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HomeMy WebLinkAbout0545 SCUDDER AVENUE (8) �& 7L /D r \}r j g co mm �f s" c usetts he Me WW rmit Z MaQ,..,� Parcel d,_...�V Date: �� ��/S Permi i Estimated.Job Cost:$ S �� Permit.Fw: $ _ Plans Submitted: YES NO Plans Reviewed: YES NO q - Business License# l Applicant License Business Information: Prop _er/Job Location Information: ?Name: vt� /� ( t.�0�1�G1 Name:-69 Street: . t'G Street: 0 City/Town: � �� . �3 City/Towrt: 1 - Tele hone:. -s Q Telephone: P is Photo I.D.required/Copy of Photo I.D. attached: YES ✓ NO V->44ff Initial J-1/M-1-unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family d!!�, Multi-family Condo l Townhouses Other Commercial: Off ce tail Industrial Educational ._ Fire Dept.Approv; Institutional"Qther---- �lv Sgwfre.Footage: under 10,000 sq. ft: . over.10,000 sq.fL Number o -Stories. Sheet metal work to be completed: New Work: Renovation: IVAC eL,�Rletal Watershed Roofing Kitchen Faust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: INSURANCE COVERAGE: I have a current liability insurance policy or•its equivalent which meets the requirements of M.G.L.Ch.112 Yes U40❑ If you have checked X,indicate the type of coverage by checking the appropriate box below: A liability,insurance policy Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insura .nccoverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit appiicatia ' �this requirement Check One Only Owner ❑ Agent ❑ Signature of Owner er's Agent By checking this boxl-1,I hereby certify that all of the details and Information I have submitted(or enterI4 regarding this application are true and accurate to the best of-my knowledge and that all sheet metal work and installations performed under the permit issued for this appiiaation mli be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO l'rts ems,c�s_�gctions Date Comments I � I Final.In4 ecn ts'an Date Comments J Type of 'cense: 3y Master rite ❑Master-Restricted =iiy/Tawn ❑Joumeyperson > ,eignatureensee ! �erriit# ! � � ❑Joumeyperson-Restricted License Nurnber., — 1 =ee$ Check at •�ovtdnl i nspector Signature of PermitApprovat The CommonveaUh of M'assaAuselts Deparimgd of lndusttid Accidentss Office of hwatigations, 600 Washington Street Boston,MA.02111, www.mass gov1dia workers'Co'ensation Insurance Affidavit:Builders/ContractorslTlectlicians/Ptnmbers Applicant information Please Print g Name(Business 0rganiiefionitndividuat): JU 9 F Address: 1 City/State%Zip: Are you an employer?theck the appropriate box: -Type of pioject(required):; a employer with t(� [] I am a general contractor and 1 d. New construction . employees(hill and/or part-time).*. have hared the sub contractors 2.❑ 1 am a'sole proprietor or partner- listed on the-attached sheen 7. []Remodeling , slow end have no to ees These sub-contras*:ors have 8. �Demolition � Y ( io ,s and have workers i working forme in anY capacity. ' l'e` 9. (�Bldtg addition [No workers'camp.msurance comp.insurance.* 0.[1 Electrical repairs or additions required) 5.❑ We are a corporation and its 3,❑ I am a homeowner doing all work officers have exercised their _1.[{Plumbing repairs or,additions myself('No workers'comp. right of exemption per MGL� 2. ' Roof repairs insurance regt:ired.1 t c.152,§1(4),and we havens 13.❑Other employees.(No wo�r}ka}e{rps(__J'�SS< - LA�p,T1QraTATCP,rem °Any appji ant that tbwks box#1 rwst also fin out the swfion below stowing ftii'workcre camFmsabon Policy mfors260- T iion=w=m who submit this affidavit indicating they arc doing all work and theca hn outside conUwtars trust subnuta nevr affidavit indicatiag such. lCon=to-s that check this box must attsctacd an additma sttett showing the name of the subrcontraetors and state whether arnot those entities have anployees, if the sub-=tr=ft s haveemployees,they must prvvidc their work='comp.p0bCYnaa3ber. lam an employer thct is providing worms'compensation insurance for my employees Below is the polity and job site inforntatiom / Twmm ce Company Name: 7 v del Policy#or Self-ins.Lin.#: b 0 0 M' L �o 6 i T Expiration Date: job Site Address: 5 CL.dlt 2 k°k-i City/Statomp. Attach a copy of the workers'compensation policy declaration page-(showing the policy number and expiration date). Fail=to secure coverage as required under Section 25A of MGL C.152 can lead t0 tire imposition of criminal penalties of a fine up to S 1,500.00 and/a:one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to S250.0o a day against the violator. Be advised that a copyof this statement may be forwarded to the Office of Investigations of the DDA f t insurance covers a verification. Jr do#ereby ce a the p ' and penalties of pedwy that the in provided suave is true and tarred Si Date..:, Phone g: `V61?j 0 tcial use o»ly. Do not write in this area,to be corVieted by city or town official City or Town: Permit/License.' Issuing Authority(circle one):. 1,Board of Health 2.Building Department 3.City/Town Clerk 4.Llectrical Inspector 5.Plumbing Inspector ti,Otber Contact Person: Phase tt ' ® DATE(MMIDDIYYYY) ACO 0 CERTIFICATE OF LIABILITY INSURANCE 3/5/2015 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 endorsement(s). A PRODUCER NA CONT ME:CT Debi James AX Leonard Insurance Agency, Inc PHONE AIC. (508)428-6921 FAIC Not,(508)420-5406 683 Main Street E•MDAl_E ,S,debi@leonardagency.com Suite B INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURERA:Travelers Indemnity of America 25666 INSURED - INSURER B:Travelers Cas & Surety of IL 19046 1 Bourque Heating and Cooling Inc. INSURERC:Travelers IndemnitV Co. 25658 B&L Equipment LLC -INSURER D: PO BOX 770 INSURERE: Marstons Mills MA 02648 INSURERF: COVERAGES CERTIFICATE NUMBER-Master 2016 REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE A SUBRI POLICY NUMBER MM`DDIYYYY MMICY EFF LDDIYYYY ICY EXP LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A'PREMISES ( RENTED 500MERCIAL GENERAL LIABILITY ' PREMISES Ea occurrence) $ r000 A CLAIMS-MADE aOCCUR 680SB790617-15-42 /17/2015 5/17/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,On PCOM GENERAL AGGREGATE $ 2,000,000 GEN1 AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident S 1 000 OOO ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED -8B791085-15-SEL /17/2015 /17/2016 i AUTOS X AUTOS BODILY INJURY(Per accident) $! NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident) - Medical payments $ X UMBRELLA LIAR X I OCCUR EACH OCCURRENCE $ 3,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED RETENTION$ C UP-BB791269-15-42 /17/2015 /17/2016 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY - ANY PROPRIETORIPARTNERIEXECUTIVE� N/A E.L.EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? ' (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Insured does have workers comp coverage. You will receive a certificate directly from Continental Casualty. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Bourque Heating & Cooling Co. Inc. ACCORDANCE WITH THE POLICY PROVISIONS. B&L Equipment LLC PO BOX 770 AUTHORIZED REPRESENTATIVE Marstons Mills, ,MA 02648. Tina Boulos/LEOTBI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD Rightfax N2-1 6/23/2015 5:23:21 AM PAGE 2/002 Fax Server CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD YYY) n612TM La. T IFICATE 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 E ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESE TrATIVE R PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject he terms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rlgh to he certificate holder in Ileu of such endorsemen s. PRODUCER CONTACT NAME: LEONARD INS AGENCY PHONE FAX 683 MAIN STREET SUITE B . . (A/C,No,Ext): (A/C,No): E-MAI L OSTERVILLE,MA 02655 ADDRESS: I 286XR INSURER(S)AFFORDING COVERAGE NAIC rY INSURED INSURER A: CONTINENTAL CASUALTY COMPANY BOURQUE HEATING&COOLING CO INC INSURER B: INSURER C: INSURER D: PO BOX 770 INSURER E: MARSTONS MII LS,MA 02648 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: -THIS 6 TO CERTIFY THAT THE POLICIES OFIINSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTA 4D9NG ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO.WHICH THIS CERTIFICATE MAYBE ISSUEDOR-MAY PERTAIN.THE INSU ANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND,CONDniONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCE[ BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (L MIDDIYVYY) (MawyYYY) LIARS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE` OCCUR. PREMISES(Ea occurrence)'- ED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PROJECT LOC 1 PRODUCTS-COMP:OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per Person) BODILY INJURY $ HIRED AUTOS (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $. (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION 1i $ .A WORKER'S COMPENSATION AND X WC S7ATUi0AY-;O7HEfl EMPLOYER'S LIABILITY Y/N UB-5B39530A-15 05/17/2015 05f17/2016 UMITs ANY PROPERITORIPARTNEWEXECUTIVE a N!A - E.L.EACH ACCIDENT $ 1,000000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000 000 if yes,desaioe urger E.L.DISEASE-POLICY LIMB Is 1,000 000 DESCRIPTION OF OPERATIONS Wow DESCRIPTION OF OPERATIONS/LOC4TIONSNEHICLESIRESTRICTIONSiSPEC1AL ITEMS, T M REPLACES ANY PRIOR CERTIFICATE I'SDED TO THE CERTIFICATE HOLDER AFFECITNG WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION CAPE ASSOCIATES INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEZXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 203 WLLLO W ST STE B IN ACCORD E WITH THE POLICY PRO AUTHO E!t RESENTATIVE YARMOUTHPORT,MA 02675 4*� ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD .1988.2010 ACORD CORPORATION. All rig ese ed. li i Town of Bar0stable g Regulatory Services ' Thomas F. ,Director s ThomaseBuilding i sion Tom Perry,Building C4wmissioaer ` 200 Mainz Street,Hymais,Kk o260i .towa,bargable ma:us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sim This Section f Us. A Builder C l y :�V� as whet o f the subject property hereby,authm ire-LLB`Tot + 0 li 1 to act on my beha in.all matters relative to wotk authorized by this building permit Sys 3CU& 00- UnkV G a 6, (Address of Jab) 1 *Pool fences and alarrns are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized u til ali.final inspections are performed and accepted. Signature er =- a Applicant - . Print Name Pint Name Dat- - Q:Ft�S:aWW��I0 - \ L5 s miil�sio+tiovm•rs•�oeo . a FSS1 5 a tQW Mr .L I31 EX,ETER,;i�© �;;: n F Parcel Detail Page 1 of 3 c� Cyr-. , Yl - � •..t6ayL Logged In As: Parcel Detail Tuesday,August 18 2015 Parcel Lookuo Parcellnfo ___,,.�.....•_�_ _. ......... Parcel'287 019-10E 1 Condo,UNIT E„n.,,..,, ID unit.. , Cond wilding Com lef Location1545 SCUDDER AVENUE Fronts rw«. -- - Sec Road'LAKE AVENUE Se Front villagelHYANNIS oistriir ',HYANNIS Town sewer exists at this address NO IRoa 1440 nteractly w ' Ma Owner Info _ _ ..... _........ ....... .......... owner ICONLEY,JOSEPH_TR I owner�1-!4URIE J.WATSON S H streets;F710 PENACOOK ROAD I streetz City CONTOOCOOK I state NH« ,... � I zip 03229-6000 I Country Land Info .. Acres use Condominlu MDL-05 I zoning RF-1 I Nghbd 0001 Topography I Road Utilities Ar, I Location Construction Info ' ......... ......... ......... ......... .......... ........ ....... ......... ................ _......._ ................ ........ Building 1 of 1 9� �� � w Year r20 „ Roof�—`� - _ Ext ' Built Struct Wall ««..« ., ., ,, 4 .< Living`2098 Roof AC iCentra� Area Cover: Type style lCondominium « I"t Drywall Bed Bedrooms Wall Rooms Model Res Condo Floor Carpet Rom 2 Full-0 Half ...«. �.r�. � �, ��, .,• Grade 4 Heat IHot Alr Total�4 Rooms f Type Rooms d . .,« Heat:,- ,T,,,-_ Found stories,2 Stories J Fuel jGas anon poUred ConC. Gross 9 Area- .. Permit History Issue Date Purpose Permit# Amount Insp Date Comments 5/21/2015 Repair Work 201502886 $13,500 REMOVE AND DISPOSE OF SHEETROCK, INSULATION AND WOOD FLOORS ON THE 1ST http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=102980 8/18/2015 Parcel Detail Page 2 of 3 AND BASEMENT FLOORS DUE TO WATER DAMAGE FROM H2O CONVERT STORAGE 2/12/2015 Condominium 201500740 $37,269 ROOM IN BASEMENT INTO A BATHROOM Visit HistorY .-. Date Who Purpose 7/30/2015 12:00:00 AM Tony Podlesney In Office Review 11/21/2013 12:00:00 AM Tony Podlesney In Office Review 7/16/2012 12:00:00 AM Denise Radley In Office Review 2/10/2012 12:00:00 AM Tony Podlesney In Office Review - Sales History .__ Line Sale Date Owner Book/Page Sale Price 1 10/27/2011 CONLEY, JOSEPH TR 25788/86 $1 2 10/27/2011 WATSON, LAURIE J 25788/84 $1 3 3/30/2011 WATSON, ROBERT J & LAURIE J 25347/309 $565,000 4 1/28/2004 GULLIVER, WILLIAM & E PATRICIA 18166/108 $610,000 5 12/19/1997 CHATHAM REAL PROPERTIES, INC 11125/75 $15,000 Assessment History Save Year Building XF Value OB Value Land Value Total Parcel # Value Value 1 2015 $504,900 $23,100 $15,000 $0 $543,000 2 2014 $525,700 $22,200 $6,600 $0 $554,500 3 2013 $525,700 $22,200 $6,800 $0 $554,700 4 2012 $569,400 $0 $0 $0 $569,400 5 2011 $593,200 $0 $0 $0 $593,200 6 2010 $639,100 $0 $0 $0 $639,100 7 2009 $688,600 $0 $0 $0 $688,600 8 2008 $688,600 $0 $0 $0 $688,600 10 2007 $688,600 $0 ' $0 $0 $688,600 11 2006 $622,100 $0 $0 $0 $622,100 12 2005 $620,900 $0 $0 $0 $620,900 Photos hgp:Hissgl2/intranet/ptopdata/ParcelDetail.aspx?ID=102980 8/18/2015 » . a Parcel Detail paeJoJ � y . . . . . . « h#p%!bq 2in#anetp o d la/Parc 1/6(mpx?ID=10 980 . ' . . 8/182015 4 SCHOOL HOUSE POND CONDO ASSOCIATION 297 NORTH STREET HYANNIS, MA 02601 Phone: 508-775-9316 Fax: 508-775-6526 . 1 August 21, 2015 To Whom It May Concern, This letter is to notify you that School House Pond Condo Association authorizes Bourque Heating&Cooling Inc. to perform work at School House Pond Condominiums, Condo E, 545 Scudder Avenue,Hyannis MA. They will provide the Association and the owner of Condo E with certificates of insurance. If you have any questions please contact me at the number listed above. I cerhryn Kolka Vice President of Operations TOWN OF BARNSTAB�LSE BUILDING PERMIT APPLICATION Map / Parcel 0< & ' , Permit# t" 0� { o 'I Health Division � ��� �?/�f� �'�°L � � '� )Date Issued Val Conservation Division 0 Application Fee Tax Collector_ C) Permit Fe r� Treasurer 1. l ( CIPTIC SYSTEM MUST BE Planning Dept. ��. Q IN COMPLIANCIFF "TITLE S Date Definitive Plan Approved by Planning Board R ,:� =*" 4T .CODE ANO r �� `R Historic-OKH Preservation/Hyannis � b >GUL�`3�lV Project Street Address C r v Village --9A n Y1 o S Do *A �o Owner 5 a%3 Address 1!0 SC-0 64 ye- Telephone Ct�rl- (095-SCAb? Permit Request l td!( 50seC becl m000n c ` o t Ti le Wog►c%6) ® Square feet: 1 st floor: existing goo proposed ® 2nd floor: existing Irco proposed 6 Total new Zoning District Flood Plain Groundwater Overlay Project Valuation LV® Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Cl Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: D Yes ❑No Basement Type: J Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) ®® Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new I Number of Bedrooms: existing new 0 Total Room Count(not including baths): existing new First Floor Room Count � G Heat Type and Fuel: Uk Gas ❑Oil ❑ Electric ❑Other Central Air: QW Yes ❑No Fireplaces: Existing New Existing wood/coal 6'e: ®Y% Gild to cn Detached garage:D existing ❑new size Pool: ❑existing O new size Barn:❑exis� D newmsize Attached garage:❑existing ❑new size Shed: D existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes O No If yes,site plan review# Current Use - Proposed Use eT, BUILDER INFORMATION 60 Name Telephone Number v T 7 5_1 Address 47 C'a,,v A n License# (itl a �!1��,►,n Lr rJ �✓I A ��� _ Home Improvement Contractor# _10 b 6a I Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO AIA N h n - SIGNATURE DATE 1 y� t FOR OFFICIAL USE ONLY ti PERMIT NO: DATE ISSUED = , ' 6 'MAP/PARCEL NO. t ADDRESS VILLAGE- C, OWNER DATE OF INSPECTION: _ l FOUNDATION IT FRAME INSULATION FIREPLACE �. . ELECTRICAL:. ROUGH ) FINAL . PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r os , _ The Commonwealth of Mirssachusetts Department of Industrial Accidents' = 660 Washington Street - 1 Boston,Mass. 02111 - Workers'.Com ensation.insurance Affidavit-General Businesses name: - At addre r rI` I tan.✓ • i •�� � � zi hone# 1 ����- ���70 ..1 state: City work site location full address [@�I am.a sole proprietor and have no one Business Type: []Retail[]'Restaurant/Bai/Eating Establishment working in any capacity. [] Office 0 Safes (mcluding Real Estate,Autos etc.)' ❑I am an em to er with .' ein to ees full& art time: ❑Oilier :: / //%%//%%��%/ %%�/�///%%///�////////////%%%% I am an employer providing viorkers' comvensation for my employees working on this job. r, com"ari`•Haines. ,,: - 't. ;.,_ ;tip.:{•. :.r;:, •:a•. ..;>,:: ..s.• - =....,', •.x... '• • . hone:#:• '.,,:.. Snsiiratice.cos 1 `' I am a sole proprietor and have hired the independent contractors listed below'who have the following workers' compensation polices: COMPan'aamec <. •rY. •a — ,.1., ':ldi...;_ Y�:9i .. vt .,t:i �'•, 1. .. •. �ioiie`�s. : .' s... �;....; . fnsurance'co.: -5:1 1. addresse. �• ,,.•.• , ci. �one W. 40. •°'',:o ii; +.,:`•: '•e •.:'` - :is Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of crimfhal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that R copy of this statement maybe fo ded to the Off e o Investigations of the DIA for coverage verification. I do hereby erti under the ins an erjury that the information provided above is true and correct , Date Sig�aature - .- Print name 1-1 F6.n Phone# official use only do not write in this area to be completed by city or town official city or town permftgicense# ❑Building Department ElLicensing Board ❑Selectmen's Office ❑check if immediate response is required ❑Eealth Department contact person: phone#; []Other (eveed Sept 2003) Information and Instructions Massachusetts GerieTal Liws chapter 152 section 25.requires all employers to provide workers' compens_atida for•their. employees: As quoted from the 4`law", 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 individual,partnership, association, corporation or other legal entity, or any 1wo,or more of the foregoing engaged in ajoint enferprise,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. 'However.the owher of a dwelling house having.�not'inore than three apartments and who resides therein, or the,occupant of the.dwelling house of another who.employs.persons to do.maintenance, construction or repair work on such dwelling house or on the grounds or urtenant thereto shall not because of such.employment.be deemed to bean employer. building a. pP MGL chapter 152 section 25 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;neither the- con3monwealth nor.any.of its political subdivisions shall enter into any contract for the perfornnance 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 in the workers'•compensation affidavit completely,by checking the box that applies to your situation.. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 perm t or license is being requested, not the Department of Industrial Accidents. Should you have any questions regardinjthe"law"or if you are required to obtain a.wOrkers."_compensation policy,please call the Department at the number listed.below. City or Towns . 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 applicant. Please be sure to Win the permit/license number.which will be used as a reference number. The.affidavits,may.be returned to. the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank ybu in.advance for you 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 N lee of IBWBMMns . 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 exL 406 SHE r 'down of Barnstable Regulatory Services asrAarn, Thomas F.Geller,Director q 163 ,�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 , Fax: 508-790-6230 office: 508-862-4038 permit no. .' Date • AFMAVIT CTOR SUPFLEMEENT TO PERMIT Ao CATIONw MGL c.142A requires that the"reconso��o construction of an addition,to mypreexisting o�wx►er-o,c pied lon, •improvement,removal,demolition,or biding containing at least one but not more than four dwelling units or to structures which are adj scent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. C� ,� uizogted Cost t. Type of Work: /9 Z aF y'�- &a&ess of Work D ate of Apphcation:���11—� I hereby certify that: Fr strationis not required for the following reason(s): []Work excluded by law []Job Under$1,000. ❑Building not owner-occupied Downer pulling own permit Notice is hereby given that; OWNERS PULLING THEIR OWN PERMIT OR DEALING NOT HAVE CONTRACTORS FOR APPLICABLE HOME ,A,CCESS TO'THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.1�2A. SIGNED UNDERPENALTIES OF PERTURY Thereby apply for a permit as the agent of the jer. / Conhactor Name RegistrationNo. Date OR Owner's Name Y ' v RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings $100.00 Residential Addition $50.00 Alterations/Renovations $50.00 S'# Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE C square feet x$64/sq.foot= d®0 x.004-1= P lus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft._ x.0041= ACCESSORYSTRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf. 75.00 >1000 sf= 1500 sf - 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck.... ... _ .. . x$30.00= (number) Fireplace/Chimney . x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) ,f Permit Fee y�• �� , Projcost Rev:063004 . t r HE,� Town of Barnstable Regulatory Services 1 BARN5PABM Thomas F.Geiler,Director 39. 61 Building Division Tom Ferry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 509-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This, Section If Using A Builder h n ,as Owner of the subject property I, . \� to act on my behalf, hereby authorize 3c ^ad' � in all matters relative to work authorized by this building permit application for. (Address of Job) 67 signa of owner ate Print Name Q..FORMS;OWNERPERMISSION A IJ �CPr ..__._.._. _ ... - - A 00(15 a � 4-6 V \T/ .GpNG1 II _� : •�'P(-chi• -- - ' t— I:Z � CoL.— P• ' �' ', ,, � ' x e I. a �t" ". {1, • +w'i JVL iL Ur s