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0114 SAINT FRANCIS CIRCLE
i 1� �� �� Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 11/18/15 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit 201507085 Dear Mr. Perry This affidavit is to certify that all work completed for 114 St Francis Circle,Hyannis has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey. j i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a 91 Parcel a`� I Application a, Health Division Date Issued Conservation Division Application FeeS S ?�y Planning Dept. Permit Fee 1 � Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address t` A 5 a11 n_' VJL4 ; C tl-CG`e - d Village f AAl' -? Owner a ' COCILO Address Telephone ��1 � �63� -� Permit Request �dJ R�35 cel�wto5e +c, the q-L ,`c, PrcLkSf 40 rf�� ba3eMP,n'1". P;r & ` 1kt �-�-��� n tot ��� Loane11� 0- o Ain ��— Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation d Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *0 If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Weld, oC�aS.e� �,�. a C' Telephone Number Address �1-D RytA+"n 4r# License # ZC I o a4 ?-b E• )�.rma,4N-obi , t/ Home Improvement Contractor# L �l 3 g Email Worker's Compensation # W W(- 3[3 L �m ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �g,rrrlGa4 SIGNATURE DATE L 1 S E t' FOR OFFICIAL USE ONLY I3 APPLICATION# 'r DATE ISSUED MAP/PARCEL NO. ,t �E ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION `r FIREPLACE f ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 6F FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 1= x. it a .F `' iM+eF ^a 'XX'.a,+•r ,:Tlae.Commonwealth:otkiissachusetts = Department of Industrialcct nts.A de , e.. on ..q 4 — t• A J•1 Congress Stre -Suite 1 0 ��x _ g koiton,,kA 0114-2017 q.K• -., � .' ... �..a .. w � 1YWW.�maSS. g OV�llta gay' -t^�', I '«orkers'Compensation Insurance"Affidavit:Builders/Confractors/Electr cians/Plumbers. -; I AUTHORITY. TO BE FILED WITH THE PERMITTING -Applicant Information Please Print.Legibly Name(Business/Organization/Individual) Cape Save Inc ' _ qt ter. ^.-..wee--".- �•* " -.... . 1 - Address:7-D Huntington A—venue , _ � t � .I;� rs t�~r � t f t t City/State/Zip:South Yarmouth,MA 02664 k R!Phone h.508-398 0398 ' *t 'i r; � :; e Are you an employer9 Check the appropriate box: +> Typed protect(regwred) .,.�.; • i. ✓ I am a employer with k.`-employees ❑ New construction—».�.........;4.i . y. `YS " , t `�'�,' �'3+¢'3Ti zit 4'r"' �r `i, '� .; :. i•+ E+` r�'�F} w+'fi� .�li r� r - i t 2[I am a sole prognetoror parineis}iip aril have no employees working forme m 7,-,r x l<t�r .g Remodeling any,capacity.[No workers'comp insurance required]r t .g+ �' y; r a , s s j� A P t. Y{ : t r r r :i k i"" e 9 . Demolition p e i t t i 3.❑I am a homeowner doingall work myself, mp. required.) [No workers co insurance ., . 10'[j Building additign 4.a I am a homeowner and will be hiring contractors to conduct all"work on m . g Y P�P�'- I will "'- ensure that-all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs Or additions t proprietors with noemployees ^. • r1°;r �^ .r,. t t .,y R 12.❑Plumbing repairs or additions ; 5.❑I am a general contractor and I have hired the sub contractors listed on the attached sheet. _ t These sub-contractors have employees apd,have workers'cornp,insurance,'- `; 4 13.❑Roof repairs J 1 14.[j Other Insulation - 6.Q We are a corporation and its officers have exercisedtheir right of exemption per NIGI,c.y. t 152,§1(4),and we have no employees.'[No workers'comp.insurance required] - ,,.,;aAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7i r r, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating.such. W' i +Contractors that check this box must'attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide'their workers'comp.po, cynumber; I am an employer thatis providing workers'compensation insurance for my employees Below is the policy and7ob site µ :nforinatiorti. _ _ .�. , r m= � ,,... �: -. . . M c v r - h F, Wesconsurance I Company =Insurance Company Name. i -.,.Policy#or-Self ins Lic::# C3136274 r £ ;z s.-Expirationµ '04/09/2016 tf,, ``" , r ; at D e A Job Site Address: 114 Saint Francis Circler' .• "z; it T �� y/State/Zip: Hyannis •=�°,tit t�` F � . .Attach a copy of the workers';compensation policy declaration page(showing the policy number and egpu•atian date)a Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year mprisonment;:as well as civil penalties in the form of a STOP WORK ORDER'and a fine of up to$250.00.a i -day„against the violator:A copyof this,statement,may be,forwarded to the Office of Investigations of the DIA for.insurance .. - coverage verification. tt` x w r:r.4h ti ; t^ } rn t t, 'x u, rya' t :+ 7' L E a r :: ti I I do hereby certify under th ,pains and penalties of perjury that the information provided above is true and correct: - 1 Si ature: y Date. 10/21/2015 i ' Phone#:508-398-0398 y l �iw,.e,i—-.. _ ...rt ..>.-... .w+..�.,.-w...•...r.wm�•Y.'7+•,w.w•,t:w. .wm. 2 -Official use only.'Do not write in this area;to be completed"by city or town official. ry . Y„n qrw. ,..... •-.w�.-Z.,.•..m,w..ia.h.��:,m..+«.sd�+::4w+*—.._...,. ..L»..+e..a�. w..sr_.,.y:+ ..y..w+..r....rw .. Y.w....nq. "wM!YY*.:.. �.•sr,ay.Y,..:..._•.w•w..c,...«+-�w..M.:r.;pe+...., :.a:...,.:.,.-c. u City or Town,v : ,^ter ,n�Trr;4,jV0C, ..,k i�O v4,{. PermitlLicense ,Issuing Au 'is (Circle}one).;r'-., ! 1.Board of Health 2 Building Department 3 City/lk"Clerk 4.Electrical Inspector 5.Plumbing Inspector* y_ 6.Other i. .. Contact Person: - _ Phone:#: 4 Y t.+�'G 'r':*-re,:1,10.3:s x�y • c � �. "�s.� tll , ACORLJ� DATE(MMIDDi W) CC> CERTIFICATE OF LIABILITY INSURANCE 10/14/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER-THE COVERAGE AFFORDED BY.THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT COME: Colleen Crowley` Risk Strategies Company PHCIN E (781)986-4400 FAC No:(781)963-4420 15 Pacella Park Drive EApAlLssccrowley@risk-MASS - Suite 240 INSURER(S)AFFORDING COVERAGE NAIC;R Randolph MA 02368 iNISURERA:Selective Ins. of America INSURED INSURERB:Allmeriea Financial Alliance Ins 'Co 10212 Cape Save, Inc I.NSURERC.Wesco Insurance Company 7 D Huntington Ave INSURER D: INSURER E South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER:CL.5101402127 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED E ELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR C NDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VIMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCI i AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF INSURANCE POLICY NUMBER MMI ICY EFF MPOMIDD r LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE F OCCUR PREMISES Ea LNILU occurrence $ 100,000 ' 01994480 - 10/16/2015 10/16/2016 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY. $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�PRO E r a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Es accident $ 1,000,000 B ANY AUTO ' BODILY INJURY(Per person) $ AUTOWNED X SCHEDULED AUTOS A88A46796600 11/6/2015 .11/6/2016 BODILY INJURY(Per aocident) $ X HIRED AUTOS X NON-OVMIED PROPERTY DAMAGE $ _ AUTOS Per accident $ .. X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ Nil S1994480 10/16/2015 10/16/2016 $ WORKERS COMPENSATION officers Included for X P R OTH- " AND EMPLOYERS'LIABILITY -" • YIN STATUTE' ER ANY PROPRIETORIPARTNERIEXECUTIVE Coverage E-L EACH ACCIDENT $ 500,000 C OFFICERIMEMBER EXCLUDED? �NIA (Mandatory in NH) WWC3136274 4/9/2015 4/9/2016 'E.LDISEASE-EA EMPLOYE $" 500,000 If yyes,describe under DESCRIPTION OF OPERATIONS bebw c t "' E.L.DISEASE-POLICY LIMIT $ 506,000 p n DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additions]Remarks Schedule,may be attached it more space is required) National Grid Corporate. Services. LLC.d/b/a National Grid, Action Inc, Colonial, Gas Company.and NStar - Electric are all ,i.ncluded as Additional Insureds with respects' to the General Liability coverage of Named Insured as required by written contract. CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing ASsistanC.E Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 460 West Min Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 026or, AUTHORIZED REPRESENTATIVE Michael Christian/CLC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) i t Town of Barnstable - „ ° Regulatory Services K Riebard V.Scan,Director esa� g . Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis.MA 02601 www.townlarnstable.ma us Off ce: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section ; If Using A Builder I,MA iZ LY DF Sne,i?A CoEl14 Q___,as Owner of the subject property hen;byatuhorize to act on my behalf, in all matters relative to Ilk authorized by this building permit application for. rr*�C k/VC2 A 11'5 (Address of job Pool fences and alarms are the responsIflity of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S' of Owner Signature of Applicant Prim Nalne Print Name 23 1 Date Q:FORMS:owttFF.RNnSsaormtxus C_ 01JC�I2t1�3 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration -- = Registration: 171380 Type: Corporation - - t Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. " WILLIAM McCLUSKEY --- 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 r - -- -- •Update Address and return card.Mark reason for change. sCA i 0 20M-05r1 i EJ Address [] Renewal Employment 0 Lost Card ....... _.__. ,.;., .... .....__ .. . . . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: il71380 Type: Office of Consumer Affairs and Business Regulation Expiration -042016: Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE SAVE INC. WILLIAM McCLUSKEY t. 7-D HUNTINGTON AVENUE SOUTH YARMOUTH,YARMOUTH,MA 02664 Undersecretary Not valit rthout signature I Massachusetts -Departmerit'of.Public Safety ! Board of,Budding Reguiations and.Standards a,rn��`aFiiEtiii�Ti.auri0i v iwi License: CSSL 102776 02V WILLLAM:JMC C>tu 37 NAUSET ROAD F , West Yarmouth MA Expiration Commissioner 06i=2017 N n o { r" P'f'f CA --4 m R7 o N CA CA 6f- Ca , \., N G7 CA ca rn IA w G 41 z,p CA .. 5 o M. • ` r •s t t rC a UAw 26 Nri s 4,4 3,0 F �( � J s I� • 1 AV �4 IL ``� •« fAa *�- • V y t • f 3 N•orE d 1. t �t E.s `r aoT � ti ► L�o1� Phi N RTI L"i r3 ', PLAN Y. F O A s,� i- tZ TOWN 0 F -- AB5��Ns`T-� S C A LE moo° ®_ATE ` Z -I CERTIFY THAT WHAT 1S SHOWN. ON THIS P;IA Ao -IS AS IT EXISTS SON T-HE 6AO UN.0. ANO CONFORM .HE TOWN IE61llATIONS T0. ? : Yy 0 'l ASS0CI T S FALM. UT� e Assessor's map and lot number ............... :...I.... ............1* THE Sewage Permit•number . ...........................X} ...... . ... . d � ' ` Z BABB$TABLE. i House number., �� 90 MABa........................................... p 039. 00 'ED MPY C" TOWN OF, BARNSTABLE BUILDING INSPECTOR 15014 APPLICATION FOR PERMIT TO ........................................... .................................... TYPE' OF CONSTRUCTION ........................ .r, ..131�...l ,.,. ........................................ • ................... .. .l9.9-3 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: < kLocation :....... ^C1..���.. .~f....... ... .yam .......... 1�.. ... G,,,. r`'^!Z f." Proposed Use �>.�..^r�.! -f'............ `^^' �.� L........./`-f?.A-c d ................................................... • 1. Zoning District ..................l .. ..........................................Fire Distract ................ ...................... Name of Owner �.J `•[:I.�1..�. ?arm .. d[. 1 Address .... �..C...aJ. !� .(. .... a...... � E'.! .... ... Name of Builder ...... ..+.,r�.a.�....J..../.....n........ af}."..............Address .... q.......w�.':$.1....�..�dc��....:...�� l- Name of Architect ~...... Address Number of Rooms ........Foundation 'T•..:................................... ......�.... .. ..'t'.�...................................... Exterior' ..:. .............Roofing .,............. ��� ld.i,(........:....... Floors .Interior . .............................................................. ' Plumbing ........... .. ......... .... ..... .�.......... .... Heating ....A...... ...... �1........ ..7.................... �r 1 Fireplace ...............0,�1.. ...:...................................................Approximate Cost...........,2�n.C ....................... .............. DefinitivePlan Approved by Planning Board ________________________________19________. Area (/.. .................. f Diagram of,Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH � o - JJ� \l kN1 - �l 1 , r T { OCCUPANCY .PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Bui rnstable regarding .the abov� construction. Name `h`. ...... ;//�......... ....... ./.`. . :a3 Construction Supervisor's License � ..... Cl)............. w SOUTH HARBOR ASSOCIATES, INC." A=291-229 ail_ ?,%Cl No ..... Permit for ...... ..... ...........S�gl ..Fzmi.ly. D�,el.-ling..... ............... Location .....I,.Ot..1.7....... ..1.4...St.. ...ran6is Circle. .................... f Hyannis ...................................... ...... ............................... C�wner-,...SoLith Harbor. Associates - I ................................................... Type of Constructiori ..Frarrle............................ ........... ................................................................... Plot............................. Lot ................................ Permit Granted ... ............19 84 Date of Inspection ....................................19 Date Completed ......................................19 # ii TOWN OF BARNSTABLE Permit No. __?��� - Building Inspector su.rr.a Cash --------------—-------------- 'r°"'y'' OCCUPANCY PERMIT Bond ------_ -------------- Issued ton:zih 7icc�riafi-� TnrAddress t 7:-�f-. 'i 7.���i L Cf.. '�'r�xac^�i�.:_ f"i•rnlca,. uar�rani c Wiring Inspector , ^ � Inspection date O Plumbing Inspector Inspection date Gas Inspector �,HJ Inspection date .Engineering Department j �` � Inspection date . dBoard of Health Ae , � am Inspection date f t THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. , Building Inspector l FROM TOWN OF BARNSTABLE BUILDING DEPARTMENTMr. Francis Lahteine 367 MAIN STREET FIYANNIS, MA t�21� . Town Clerk Phone: 775-1120 SUBJECT: ` FOLD HERE , DATE February 26.,. 1995 - M"E S S A G'E -Work has been completed under Building Permit .#26940 {South.Harbor Associates, Inc::), Please release Bond. DATE REPLY �� . .. SIGNED - 7 Ne7•RMI RECIPIENT: RETAIN WHITE`COPY,;RETURN PINK COPY x PRINTED IN U.S.A. , SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. ss §Sties map and lot' number.. .............:. ... .... ..... Sewage Permit; number ......... {' MUST BE ,, BABHSTABLE, i House number .' 1/..` C�{ : 4 `TALE �, Ca14,:'�.��< 'u�, 9 M�a ....................... .. ....... .. - TOWN , OF- BARN'S,� ��AB�LE ' BUILDING -INS-PE;TOR APPLICATION FOR PERMIT TO ................. .... . TYPE-OF CONSTRUCTION. .........................i ` ..C ..t ��F................ ................. .,.L . ...1993 1 , TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following inform on: r 1--e-7 - /...7 .... r Location Proposed Use ...............5..1...r ....—P,.._..... /.. ;....... 1�1 LJ l j Zoning District ..S)o ......4.:f..............................,.....................Fire District .........:..... . ... ✓.�� Name of Owner . .�`r S dc:...7.!.`7Xddress ........Cl ►...,.. G�A Name of Builder .... /4J.... ....... �Jf ...... Address .1........ Nameof Architect ........... ......Address ........:.......................................................................... Number of Rooms .:.. �..............................................Foundation � /�� �-,.�h. . ..:....:.........................Roofing ............... ......................I... . Exterior ............... ..... .. .�� • � 1r Floors .............. .... ..... .........................................................Interior .................. ,............................................... Heating .......... ... .........................................................Plumbing ............. ... .. .............................- . Fireplace ...............G. 1.. .......................................................Approximate. Cost ........... ....................... s1f.Definitive Plan Approved by Planning Board ________________________________19________. Area (............ . .... Diagram of Lot and Building with Dimensions Fee L SUBJECT TO APPROVAL OF BOARD OF HEALTH LP OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS. I hereby agree to-conform to all,the Rules and Regulations of the Town of rnstable regarding the abov construction. ,Name .. ! `... ...... . ........................ .�s, ' Construction Supervisor's License p .3�� ........... SOU12I HARBOR ASSOCIATES, INC. � y hof 26940... Permit for .One..Story............... , y Single Family Dwelling Location ......................................................l 114 St. Francis Circle Hyannis x �' +....South Harbor- Associates,...Inc. .• 'MJ �.`-`'-' .. 1 Owner;............. ( ✓" , Type"of Construction Frame r ............... ..................................... Blot`... ........................ Lot'. ...................... 1 Z Se tember 6 r Permit G"ranted P . 19 84 p Date ofT�.lnspection .... ...... .... .. :19 '.Date ,Completed xez .tea- •r..r. 1.'• � � 1n /I/� ,� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map s-;q Parcel d;9 Permit# Health Division l t��y/a s� �W.S'-OrI j Date Issued Conservation Division 1Z/Ic,/05 ' CA-66D91 Fee Tax Collector AApplication Fee Treasurer ChEgrK Planning Dept: I Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address /-1 L( S,,,q,`AJ rA,gers C Q le, Village /7✓4,VAfi S n Owner ReA.e,0 t1,jLy Address Telephone 60- ,F-©775- YO Permit Request IS r6✓ 2.r�s,�;uc� G?°Pc,� Qerct° .�P®/ �� ���ir�� .t�E� d�c� ��x/6 adja' ST7 ye_ Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation ` Zoning District flood Plain Groundwater Overlay Construction Type 4clkeZ Lot Size Grandfathered: ❑Yes ❑No If yes;attach supporting documentation. Dwelling Type: Single Family 8 Two Family ❑ Multi-Family(#units) ) � _ Age of Existing Structure Historic House: ❑Yes `Flo On Old King's Highwa�, : ❑Yes o C r Basement Type: HFull ❑Crawl UR'GValkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) !Q Number of Baths: Full: existing new Half:existing new- E� Number of Bedrooms: existing C2 new Z r r, Total Room Count(not including baths): existing new First Floor Room COL nt Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No P g Detached garage:❑existing 0 new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed: ❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ ��Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION /-3ff0 Name Telephone Number ' 77 Address^" t ce.4/s.ae %uc. r License#. S tow - `d/7 r ,amy d'e, , Home Improvement Contractor# ^ /60/07/ Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE f �,_� `~ `-` DATE ///�-0/0S FOR OFFICIAL USE ONLY a PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS- VILLAGE ' OWNER / DATE OF INSPECTION: FOUNDATION FRAME i INSULATION y FIREPLACE ' ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH i FINAL F` GAS: ROUGH = FINAL , �a r, FINAL BUILDING 0 tip DATE CLOSED OUT 0 ASSOCIATION PLAN NO. s. pF1}IE>° Town of Barnstable f Regulatory Services Thomas F:Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property hereby authorize . ee-4.0u y' �,[f< to act on my behalf, in all matters relative to work authorized by this building permit application for; (Address of Job) ig ature of Owner Date A Print Name Lo ,.'TI o N o F P ROI P E RYY LINES MAY Iq oT' B E AC U e2 TE STANDARD LEGEND --e¢e bEcic Q j,4,VJ NOTE:not all symbols will appear on a map Lf —s P,i a r F(1-4,uc S C11 Q 5 GOLF COURSE FAIRWAY 917 nt0e"MAO EDGE OF DECIDUOUS TREES MA EDGE OF BRUSH C7�lm0i F ORCHARD 0 OR NURSERY _.._._.,. ,l /7/LLS' EDGE OF CONIFEROUS TREES MARSH AREA n,� ___ . -......... EDGE OF WATER DIRT ROAD DRIVEWAY PARKING LOT 1 E--PAVED ROAD DRAINAGE DITCH ' - PATH/TRAIL c " PARCEL LINE** MAP326 E - MAP# 021 E PARCEL NUMBER •o #367 _ HOUSENUMBER 2 FOOT CONTOUR LINE —ice— _ 10 FOOT CONTOUR LINE Elevation based on NGVD29 4.9 SPOT ELEVATION y \�! -x=x STONE WALL .\ r( 1.., I, ... -X—X- FENCE .f RETAINING WALL RAIL ROAD TRACK STONE JETTY PWL-' SWIMMING POOL PORCH/DECK C� BUILDING/STRUCTURE -_' DOCK/PIER HYDRANT ___ --- e VALVE OO MANHOLE o POST O" FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N F O R M A T 1 O N S Y S T E M S U N 1 T In, SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetiia(man-made features)were interpreted from 1995 aerial photographs by The James E n TOWER 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE wK• ry P P physical I N topography,P Y g PP P ry Q �Q ZQ National Map Accuracy Standards at this do not represent actual relationships b h rcal objects Corporation.Planimetiia,ro o ra h,and vegetation were mapped b meet National Ma Accuracy Standards � LIGHT POLE O ELECTRIC BOX s 1 INCH=20 FEET* enlarged scale, on the map. at a scale of 1"=100'. Parcel lines were digitized from FY2004 Town of Barnstable Assessor's tax maps. , 1. .. - - -.,..; .. .. :... - - - ... _ ....... ... :... .:. _ - . '.:' y. FOOTING'10"TUBE 4' DEPTH HOUSE ' DECK FRAME 2X 40 STOCK 1„oowc x DECK POST 4X4 : i�se 4 r . BAL v _ , ,. , = - - b'1 8'-I. 23-7 e e�:, .,;,_ - _ iy 38 s - i: � V .,.. R , -. OWNER `t - RICHARD JENNEY 1�ECK 114�SAINT-FRANCIS CIRCLE YA H N ... NIS, MA . so o�A CONTRACTOR 3 0 :: 18 :OCEANSI .. INC . >: . N SRN�TON ;' - r .. .: , -. -. -- . - .. . - . . , a: , . . , , T��,.�,; � � � . ,, , .., . ��, ..., � .. .� ,. -:,",�.,,.- I . � x I.,I "' H S,E FOOTING 1:0"'TUBE 4'"DEPTH 1.00`ot x -I,.o,I:�.r.L.".�I?1 DECK-,FRAME 2X,10 STOCK. D T- . �n.9s' 4X4 - ECK:POS LADDER STYLE'.RAIL:WITH BALLISTERS PER MASS CODE 4 ' I. -. _, , , -:.. . ., <. ., . _ . 2 ,5.1 . 8--" _ .:_ 3'7" . ,, , M: 36'-9" OWNER ., 5- 4" - . F1 HAR o C . D JENN Y s E BECK ;_ _ 114:SAINT FRANCI . CIRCLE, HYANNIS, MA . ro DMA CONTRACTOR OCEANSIDE INC N S 11AAON 217.T DRIVE` HYAN -, .. - ,:,.,. -, - , a ,, .. 11. I� ., I �, :. - �I. I � I I: ."� . .. , .I I - I I- ,- -I ,. ,�l- -:.�I:1,�.�: .. .� � �,�., -� �. .� ; . J0;ej;S1u1ulpy 0£9Z0 VIN '919d1SNNV8 i �»✓ as 111H 3HOV 99 f ANvio M allVHOIH F b0 Pa;Oil;saa L98£l :ou �l 900Z/lZ/l0 saaidx3 I.:. (41 £4 :�a wn 0000 SO q N SNOSIAH38m NougnNISN' :asuaai1 .b oltv.ino3b oNla�Ine 10 aae0a e Board of Building Regulations and Standards License or registration valid for individul use only . r _ ,• ' = HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration, 100.121 One Ashburton Place Rm 1301 M Expiration 6/9/2006 Boston, Ma.,02108 Type; ,.Private Corporation OCEANSIDE,-1NC Richard 'Clark' *. 217 Thornton Dr Hyannis, MA 02601 , , Administrator Not valid without signature , ^ +Department of Iridastp ial Accidents " Office.of Investigations* ' . 600 Washington Street Boston,MA 02111 ' y www.mas&gov/dia Workers' Compensation Insurance Affidavit: ]builders/Contractors/Electriclans/,Pl»bers Applicant Information ]Please Print Leeilbly Name (Business/organization/individual): . Address: 417 �o�,v1 City/State/Zip: ••l4 /k/IS'f IVA, AA Iol Phone#: J!9y`2 71-,3//o Are you an.employer? Check the-appropriate box:. Type of project(required):- 1. am a employer with S 4. ❑ I am a general contractor and I ' employees (full•and/or part-time).* have hired the silb-contractors 6• ❑�,,New construction !w 2.Elu9Oid I am a sole proprietor or partner-. listed on the attached sheet 1 7• e1ing ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any*capacity. workers' comp.insurance. • 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We'are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or.additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-❑ PhuAing iepairs or additions myself.'[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees.[No workers'. 13.❑ Other camp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners•who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContracto:s that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information• lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. - Insurance-Company Name: �4 101e4 L-49 eo Xu Policy#or Self-ins.Lic.#: i✓ d230 79 Expiration Date: I 4/Z12 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500,.00 and/or one-year imprisonment, as well as,civil penalties in ttie form of a STOP'WORK ORDER and a.fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. p do hereby certify unde pains and penalties of perjury that the information provided above is true and correct. Si atur . Date: /d G9S Phone#: Official use only. Do not write in this area,to be completed by city,or town official City or Town: PermltUcense# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massaqhusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: ' Pursuant to.this statute, an employee is defined as"...every person in the servile of another under any contract of hire, express or implied, oral or written." ' , association,parporation or other legal entity,or any two or more An employer is defined aS._An Mdivi¢t�al,;p aftuers ip of the foregoing engaged in a joint enterprise,and i 6ubng the legal representatives of a deceased employer,or the partnership, association or other legal entity,employing employees. Hove er:tlte receiver or trustee of an individual,p . t more than three apartments and who resides therein,or,the occupant of the owner of a dwelling house having no dwelling house of another who employs persons to do maintenance,construction or repair woiYbn such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or -renewal of a license or permit to operate a business or to construct buildings in the•commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance coverage required." Additionally,MGL chaptq 152, §25C(7)states"Neither the commonwealth nor any of its-political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of•this chapter have been presented to the contracting authority. Applicants ; Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if. necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the carry workers' compensation insurance. If an LLC or LLP does have members or partners, are not required to car employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate lime. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided space at the bottom of the affidavit for You to fill out in the event the Office of Investigations has to contact you re arding the applicant ense number which will be used as a reference number. In addition, an applicant Please be sure to fill in tbePermit/lic that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy inform(if necessary)and under"Job Site Address"'tlie applicant should write"all locations in ' (city or A copy of the.-affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that•a valid affidavit is�en file for,future perinitss.or-1keuses.,A new affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT repaired to complete this affidavit The Office oflnvestigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts . -. Department of Industrial.Accidents () ire ofvestigations r. 600-Washington.S reet� . Boston,MA 02111.. Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-727-7749 Revised 5-2645 www.mass.gov/dia Town of Barnstable Regulatory Services BAMSTAB9 MAWI'E g` Thomas F.Geiler,Director �A 1639. 10 jEo A Building Division Tom Perry,Building Commissioner ' 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Pemut no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION . MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other'. v requirements. Type of Work: of e i'7.ac9 �e-cl1 Estimated Cost" Address of Work: y Owner's Name: o4 I 4z2;,U4-1/ - Date of Application- //1/dIlDS h I hereby certify that: , n Registration is not'required for the following reason(s): �= 11Work'excluded by law ❑Job Under$1,000' �. ,. ''Building not owner-occupied DOwner pulling own permit Notice is hereby given that: 1- OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY r I hereby apply for a'permit as the agent of the owner:` Da e .. . ContracigeName ' Registration No. O r ,. Date• x O er's Name z , , Q } p " :forms homeaffidav r r,- ., AMA ICAN HOME ASSURANCE COMPANY 69194-0000 WC 693-27-98 ------------------o� -- 3-82-0105-00 NEW YORK OCEANSIDE, INC.' 217 THORNTON DRIVE Member Companies of HYANN I S, MA 026o 1-81 o5 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# MA UI ••. ..- TPA INSURANCE AGENCY, INC. WORKERS COMPENSATION AND EMPLOYERS 10 NEW ENGLAND BUS CTR DR' LIABILITY POLICY INFORMATION PAGE ANDOVER, MA o1810-1096 INSURED IS PREVIOUS.POLICY NUMBER CORPORATION NEW OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE wc9go6io ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 0 1/0 1/05 To 0 1/0 1/06 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: AK AL AR AZ CO CT DC. DE FL GA HI IA ID IL IN KS KY LA MD ME MI MN MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI : ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications,.Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Remuneration Classifications � Code Number $100 OF Re- Premium Annual ❑3 Year muneration Annual ❑3 Year z SEE EXTENSION OFA NFORMATION PAGE - WC7754. TAXES/ASSESSMENTS/SURCHARGES $1 ,508 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $264 MA . MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $ 0,8 2 If indicated below, interim adjustments of premium shall be made: ❑ Semi-Annually ❑ Quarterly ❑ Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM. SCHEDULE - WC990612 01/30/05 PARSIPPANY 82 Issue Date Issuing Office Authorized:Representative wC 00 00 01 39967 INSURFD'S COPY I fi Town of Barnstable *Permit# Expires 6 n rsfrom issue date Regulatory Services Fee_ Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner I , 200 Main Street,Hyannis,MA 02601 �� � � www.town.barnstable.ma.us �l � 2005 Z 603, Office: 508-862-4038 � OF BARN EXPRESS PERMIT APPLICATION - RESIDENTIAL, ONLY Not Valid without Red X-Press Imprint p/parcel Number perry Address �/y ST JE(MA/C IS- LV t r Residential Value of Work �% 256%7 Minimum fee of$25.00 for work under$6000.00 ner's;Name&Address K . COV u E itractor's Name be A0 Telephone Number � �f— > me Improvement Contractor License#(if applicable) nstructio upervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I aarthe Homeowner n-fhawe Worker's Compensation Insurance arance Company Name T�'a L&A �p r irkman's Comp.Policy# 7 P aV IR 1 + 7� ` py of Insurance Compliance Certificate must be on file. I mit Request eck box) st mit R;Re-roof(stripping old shingles) All construction debris will be taken to ,�t -r-r ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. NATURE: orms:expmtrg ise071405 f COREY & COREY The Roofers bpi toottat Capp Cot %tat * 1 * 74 169.4 Falmouth Rd. #115, Centerville, MA 02632 CERTAINTEED WOODSCAPE AR -% 30 REq& ROOFING PROPOSAL October 5, 2005 DICK JENNEY 114 ST FRANCIS CIRCLE HYANNIS,MA 02601 Phone: 1-508-771-2067 COREY & COREY hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturers specifications and local building codes. Remove and Haul Away All of the Old Asphalt Roofing Shingles. Re Nail All Plywood Sheathing as needed. Supply and Install CERTAINTEED WOODSCAPE AR 30: 30 YEAR WARRANTY, 5 YEAR SURE START PROTECTION, CLASS A FIRE RATED, ALGAE RESISTANT, 245 POUND,EXIRA HEAVY WEIGHT, SELF-SEALING,-70 MPH WIND WARRANTY, MULTI-LAYERED, LAMINATED ARCHITECTURAL STYLE, FIBERGLASS BASED ASPHALT SHINGLE with New England's exclusive COPPER/CERAMIC STONES with a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT COLOR: SUNSET BRICK Supply and Install 8" WHITE ALUMUMM DRIP EDGE on All Eaves.. Supply and Install CERTAINTEEID R-GUARD (Ice& Water Shield )WATERPROOF UNDERLAYMENT SYSTEM on Roof'Eaves. Supply and Install ALPHAPROTECH-SUL SYNTHETIC UNDERLAYMENT Supply and Install SMART VENT SOFFIT VENT SYSTEM on All of the Eaves. Supply and Install SMART VENT RIDGE VENT SYSTEM on All of the Ridge. Sup�ly and Install ALUMINUM &NEOPRENE SOIL.PIPE FLASHINGS Clean and Remove Debris from work area after job is completed. i TOTAL INVESTMENT $ 4825.00 immediate)Payable PaY a u lesion. Y upon completion. POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards,Plywood Sheathing,Missing Metal Flashing,Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus 20% and Labor at the Rate of$ 50.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please make checks payable to CHARLES COREY COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 5 Years and then on a pro-rated basis for 30 Years Total if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a 70 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above specifications,will be executed only upon written orders and will become an extra charge,over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work. This proposal may be withdrawn by us if not accepted within thirty days. COREY & COREY carries Workman's Co pe ation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ACCEPTED BY: SUBMITTED BY: � r DICK K C S CO �Y HOME® ER CORE & C EY Page 2 of 2 Pages. lip 4 ✓vim° gegulations and Standards Board of Building ENT CONTRACTOR } HOME tMPoVEM Re9istratlbr 1366 Mro ENTS CORE COREY& c � ';= per,✓ ; • t CHARLES CORE �r o -���•'• 168'l FALM OUT H R SY __Administrat9r a CENTERVILiLE,MA 0263 1 ne t ommonweatrn of massacnusetts Department of Industrial Accidents t Office.of Investigations ' d 600 Washington Street Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARiplicant Information Please Print Le 'bl Name (Business/organizationa&vidual): 72 Ic Xos t rvv� Address: 'fa► ! City/State/Zip: L v �hone#: Are you an employer? Check the-appropriate bo •. Type of project(required): 1.El am a employer with 4•, am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑ Remodeling ship and have no'employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10.0 Electrical repairs or.additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11-❑ Plum�Mepairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12. ofs insurance required.] t employees. [No workers' camp.insurance required.] 13.❑ Other *Any applicant that checks box#1 must also Sal out the section below showing their workers'compensation policy information: 'E t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder Ithe 'ains and penalties of perjury that the information provided above is true and correct Signature: Date:'. to Phone#: C Official use only. Do not write in this area,to be completed by city or town offkial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4..Electrical Inspector 5.Plumbing Inspector 6.Otther - Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employeesr, °. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an�vidual,:PmUersliip;association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,Partnership, association or other-legal entity,employing employees. Howover l4e owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the er who employs persons to�do maintenance, constriction or repair woTkvn such dwelling house dwelling house of anoth or on the grounds or building appurtenant thereto shall not because of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any " applicant who has not produced acceptable evidence-of compliance with the insurance coverage required. Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable:evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their cerdficate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the rkers' compensation insurance. If an LLC or LLP does have members or partners, are not required to carry wo employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial.Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below.. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials , Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to,contact you regarding the applic t Please be sure'to fill in the pernnt/license number which will be used as a reference number. In addition, an applicant that mast submit multiple permit/license applications many given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof thata valid affidavit is on file for:future permits.oflicenses..A new affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit, The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,teiephorie and.fax number: The Commonwealth of Massachusetts. . Department of Industrial.Accidents ..Office of Investigations 600-Washington Street BostOn,MA 02111. Tel. #617-727-4900 ext 406 or I-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Town of Barnstable � E Regulatory Services Thomas F.Geiler,Director Building Division ninss. Tom Perry,Building Commissioner p39. �aim 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Approved: V. Fee: 4 0 Permit#: FIR 109 HOME OCCUPATION REGISTRATION Date: Name:(,� L C` �� Phone 4 0c- Address:0 S l r A,,-)C.( .� C k'r 4" A/V/V is village: Name of Business: ' LA�t/�5 __ q, Type of Business: Map/Lot: ;I 01 INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to theC premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single.family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home ' Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. •, No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation islisted or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree'wi e above restrictions for my home occupation I am registering. Applicant ZDate: do 610 Homeoc.doc Rev.5/30/03 7R TO ALL NEVV BUSINESS OWNERS DATE: 0 6 10—b Fill in please: APPLICANT'S YOUR NAME: BUSINESS „ , , ;, YOUR HOME ADDRESS; [lG SAtp i� ftNecS c cr TELEPHONE f Tele hone Number Hom SQ NAME OF NEW BUSINESS TYPE OF BUSINESS O IS THIS A HOME OCCUPATION? YES NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS I S AP/PARCEL NUMBER f N 3 When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the'Town of '. Barnstable. This form is intended to assist you in obtaining,the information you may need. Once you have obtained the required signaturesisted 5, 1 below,,you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall) or if you get the business certificate first you:MU$T go to ' the following office to make sure you have all the required permits and licenses.._ GO TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) and you will find the following offices: 1. BUILDING COMMISSION OFFICE This.individual ha een infor e f any permit requirements that pertain to this type of business. u horized Sin ure COMMENTS: 1 Q(-,( C].`�C� /� G� _ ((J� 1C�.c 1 �S 2. BOARD OF HEALTH This individual has b mformed of the.permit requirements that pertain to this type of business. n Authorized Signature** 1 COMMENTS: Qn 1? 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual h been informed of rf4 li s' g requirements that pertain to this type of business. Authorized Signature"* COMMENTS: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. -it does not give you permission to operate-you must get that through completion of the processes from the various departments involved. **SIGNIFIES APPRO VAL FORA BUSINESS CERT/F/CATEOft Y. �yOt?XE Tp�ye� TOWN OF BARNSTABLE = saassTss� mop �a3gM`�P MASSACHUSETTS Solid Fuel Stove Permit G I _ w DATE OF APPLICATION ... L.�.J -3 . ISSUING,PERMIT NAME (owner)� (! l/�C ......GJ��� ...: ��N� TAME (Installer) .:..,:, .Sri�.�........���..s �� owner ... .................................. ADDRESS\ ... ........s :.:.L �tiS.�.. !�PL.S mDDRESS ....., ?........ ,.... . .o ............................. STOVE TYPE.......�..�.. OQC 4. { ..{.L. ! .��................................ CHIMNEY: NEW ... EXISTING ........................ Manufacturer . ................................... CHIMNEY: Masonry ............................................................................................. Mass. Approval ............................ ............................................................................ CHIMNEY: Metal ................................................................................................... This'is to-certify that the above installer has permission to install a solid fuel burning appliance at the listed address in accordance with an application on file with the ! ...../ .... .. ...................... —Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. _ � q Issued By: ... C,Y�rS ....Title .. Date Z. Permit to install expires 60 days after issue date Stove ,{ .ei:v.c.d4 S 1 L� { ,...�r'G,J„L.4 !i w .................................................................. ... StoveClearance ......................... ..........................................................................................................................................................................................................................:........ Floor L ..............��.......... ........... .. ........................................................................................................................................................................................................................................... Smoke Pipe ................ ...............................................................................................................................................................................................................................I............................. G� SmokePipe Clearance ..................I�............................................................................................................................................................................................................................. Chimney ......................Ila.c..1/..1f..:. ..................................................................................:............................................................................................................................................... SmokeDetector .............../ ./ 5........................................................................................................................ . ................................................................................................... The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ...................................................... has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ........................................................................ Installer INSTALLATION APPROVED 1.zIzOP,3.......... BY .—eezx... .......... Title date ,.;4 I... .....(>......7 WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT rTown of Barnstable *Permit# s Expires 6 months from issue date BAMgr,,BLX Regulatory Services Fee ,' S • 4 0 °ASSsbs9. Thomas F.Geiler,Director �e�' Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w PERMIT Office: 508-862-4038 2001 2 6 Fax: 508-.790-6230 E8 EXPRESS PERMIT APPLICATION OF BARNsTABLEE Not Valid without Red X-Press Imprint ® � Map/parcel Number G'/ 1 _ 2— Property Address U � .0 t cf;QcL.-e Residential OR Q Commercial Value of Work Owner's Name&Address 2 • S l� .��vt^rS C` [/2 c L-2 �/� �vic.�S Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) MWorkman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) Re-roof(stripping old shingles) Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value (maximum.44) r Other(specify) v U G e-t 0 t✓ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signatures expmtrg �W ram, The Town of Barnstable Department of Health, Safety and Environmental Services trAsrts{reer.E. ► Building Division K. 1659. 367 Main Street,Hyannis MA 02601 �D N11►'i� Office: 508-790-6227 Ralph M.Crossen Fax: 508-790-6230 Building Commissioner Home Occupation Registration Date: / � Name: ./C%�/y/ F�7C cJ��33 J E I)E Phone #: Address: FgAAA-- IS C,0e Village: �1 Y 4-/JA)t5 Type of Business: F� �-7— C, I-L- Map/Lot: N1 INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling there shall be no increase in noise or odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of tight subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwellingwhich are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree-with the above restrictions for my home occupation I am registering: Applicant: Date: 1 �� Homeoc.doc