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0046 STUDLEY ROAD
'�"� � r r i r r. y TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION. Map Parcel` Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee l Date Definitive Plan Approved by Planning Board Historic OKH Preservation / Hyannis Project Street Address Village Owner M&hel% l b2Od SChl<�e/ Address Telephone Permit Request lkajy--�, Square feet: 1 st floor: existing/2SO proposed 2nd floor: existing proposed Total new Zoning District Flood Plain. . Groundwater Overlay Project Valuation 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: —3 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 stoyq: ❑Yes ❑ No � C Detached garage: ❑ existing" ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑e i isting `o nevus size_ Attached garage: ❑existing ❑ new size _Shed: ❑existing ❑ new size _ Other: A Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ C, -� Commercial ❑Yes ❑ No If yes, site plan review# �: Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1"l jCrie`'� �"v `r r Telephone Number O -��� p Address L101 &q�_er OT License # 02,/29 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE t• 't If' FOR OFFICIAL USE ONLY (APPLICATION# DATE ISSUED MAP/PARCEL N0. ; ` ADDRESS VILLAGE ' OWNER f rT DATE OF INSPECTION: Y �s FOUNDATION _ FRAME f INSULATION u 3 FIREPLACE •; ELECTRICAL: ROUGH FINAL — y;� PLUMBING: ROUGH FINAL F . 'GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT f ASSOCIATION PLAN NO. r F r The Commonwealth of Massachusetts .fment o Department Industrial Accidents P Office of Investigations a 600 Washington Street t Boston,MA 02111' www.mass.gov/dia Workers}Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information A � J� Please Print' ibl Name(Business/Organizati.on/Individual): Ui,p '[J e K-,, ' Address• �/f� �l City/State/Zip: � � �t/� a hone.#: l —. 2 4 Are.you an employer? Check the appropriate bog: .Type of project(required):, 1.❑ I am a employer with 4. [] I am a'general contractor and I • have hued the sub-contractors 6• ❑New construction . ..employees(full and/or part-time).* �, Remodeling 2.[] I am a•sole proprietor or partner- listed on the•attached sheet. g ship and have no employees These sub-contractors have g, Demolition employees and have workers' working for me in any capacity. 9, Building addition [No workers' comp,insurance comp, insurance,$ 5. We are a corporation and its_ to jj� Electrical repairs or additions required.] ' 3.� I a homeowner doing all work . officers have exercised their 11.[A Plumbing repairs or additions ' myself,[No workers' comp right of exemption per MGL 12,❑Roof repairs insurance.required]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp,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 a new affidavit indicating such, $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether arnot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 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.Lic.#: 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 a 152 can lead to the imposition of criminal penalties of a fine tip 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 Investi ations of the DIA for insura=e co era a verification. I do hereb" ce ify un r ains s ofperjury that the information provided above is true and correct. Si ature: Phone# rcial use only. Do not write in this area, to be completed by.city or town officiaG or Town: ' TermitUcense# 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#: Massachusetts 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 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 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. However the owner of a dwelling house having not more 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 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 ehapter...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 complianci e 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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members'or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have 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 appropriate1ine. 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 applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"alllocations 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 that a valid affidavit is on file for future permits or licenses. 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 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,telephone-and fax number;. , e C©zxzmonty 41h of Massachusetts . � ��paent��1nd�st�a�Acczdeuts Office of Investigations 600 Washington Stet BWonx-MA Q2111 TeL ##f 17-727-4900 ext 40f or 1-877-MASSAFE Fax##6.17-727-7749 Revised 11-22-06 w.mass.gov/dia �oF z r � Town of Barnstable Regulatory Services BARNSTABLE ; - - - Thomas F.Geiler,Director - MASS. 9g, 165g.. ,a� Building Division Tom Perry,Building Commissioner 200 Main-Street, Hyannis,MA 0.2601 vrwwAown.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / y�,Q Please Print f DATE: � `3.1'O - JOB LOCATION: number street village HOMEOWNER": (� 14Gfi' . name home phhoojne/#1 ypp� work phone# CURRENT MAILING ADDRESS: y�i! J�✓1 `i'`'! �/ 't—C�( city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that he/she understands the Town of Barnstable.Building Department minimum inspection prose es and requirements and that he/she will comply with said procedures and requirement . ign tore of Home'owu Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt.from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor. Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor.(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness otlen results in serious.problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responnbili ties,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor.-On the last page of this,issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your Community. Q:for -is:homeexempt IHE r, Town of Barnstable Regulatory Services t. BARNsrABLE y HAEB. �, Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 0260.1 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: - Address of job) ) 1 . Signature of Owner Date �• Print Name If Property Owner is applying for pern-it please complete the Homeowners License Exemption Form on the reverse side. n•cnD�,rc.ncxn.r�p ncv�,rTcc�n�t DIME r Town of Barnstable Regulatory Services y� M$ Thomas F. Geiler,Director i6gq. a Division vision ��OCj3/ • RFD MA'1 " .Tom Perry,Building Commissioner PH 4: �1 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us �V/S/08D Office: 508-862-4038 Fax: 508-790-6230 C n NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR owner of property located at kofn,�. Aq hereby certify that a ; nG is no longer Construction Supervisor listed on the application for the project under construction as authorized by building'permit-# oo'— , issued on /20 00 I understand that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. _ PROPERT R DATE q/forms/newcontrowner reference R-5 780 CMR rev:011608 �FtHE�p,,� it The Town of Barnstable BAR SS`E N a , Department of Health Safety and Environmental Services f�,r fib 167A. �00 7"fEO Mpg' • Building Division 200 Main Street,Hyannis, MA 02601 Office: 508-862F4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspe pfion F _J Location /4(0 S Permit Number Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: 5 � „ x V-0 C 4774 - S'TU S ZA u P, S a9p Ac o S S L u LS-rE L OK- GD q r` � L c_ r, PEAcc_ 66�- c 8Fr CW 577W4 S-/#r2S 'Do o96 Arc'- L't7 P OU k(556=C7 �L �� I�, � ', ) v 57 MEN �aLA7eS D,,O -Ob A P (;_ /�( (-) A--` i oC� L- v L P 6 S 7— /M`G-- �P-a 04 RA SLIM cr /if Please call: 508-862=40038 or re-Inspection. Inspected by Date i e d i i j I f TOWN OF BARNSTABLE BUILDING PERMIT,APPLICATION Map d(0 Parcel". , m� Application # 01 Health Division _ ` Date Issued `f+ .-.2 Conservation'Division - r Application Fee Planning Dept. Permit Fee o25 Date Definitive Plan Approved by Planning Board Historic OKH _Preservation/Hyannis Project Street Address Village , '041-Av ! s Owne;V_A'VeAll S `� �`�� .r Address Telephone �� i — 3.9 V '- // e� Permit Request r 4 t 6 ' Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: 0 Yes ❑eNo If yes, attach supporting documentation. Dwelling Type: Single Family-,;u Two Family ❑, Multi-Family(# units). Age of Existing Structure istoric Hou ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ alkout Other Basement Finished Area(sq.ft.) -shed Area (sq.ft) Number of Baths: Full: existing w Half: existing new Number of Bedrooms: existing _J/w 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 ❑ No If yes, site plan review# Current Use Proposed Use • za APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name/ ,,;;// Telephone Number` S [� Address License# 'Y e Home Improvement Contractor# Worker's Compensation #0/foamg Z� ALL CONSTRUCTI N EB ESULTING FROM THIS PROJECT WILL BE TAKEN TO 4""/4 */,,/0, -0 0 SIGNATUR DATE �� FOR OFFICIAL USE ONLY APPLICATION# ' DATE ISSUED t MAP/PARCEL NO. i ADDRESS VILLAGE OWNER ' ` DATE OF INSPECTION: G .p 4 FOUNDATION 'FRAME -o sr, INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f 03/17/08 11:23 FAX 617 252 6563 PATHOLOGY SERVICES INC. Q 002 Town of Barnstable Regulatory Services eiaee, �¢,` Thomas F,Geiler,Director Building Division T0111 Perry,Building Comauissioner 200 Main Sirdet,Hyannis,MA 02601 wWWAOWn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 NOTICE TO THE BUMIDING bIVISION OF CBANGE OF LICENSED CONSTRUCTION SUPERVISOR / , owner of property located at (S' hereby certify that t ..is no longer Construction Supervisor listed on the application for the project under construction as authorized by building permit# ,issued on ��}' 20 63. I understwid that the project under,aonstl-uadon must cease ulatil a successor licensed Construction Supervisor, is subzuitted on the records of the Building Division, 4 PR P YY&-4AZ q/furrris/�weontrowaer � ` refaraoc R-S 780 CMR rcn011608 I a °FWE T° Town of Barnstable Regulatory Services ` E MAS& ' Thomas F.Geiler,Director Mass. � _ Building Division _ Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-8624038 °Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF t LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY s I, r , Construction Supervisor License. # , hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit#r , issued to (property address) on (� �� , 200 The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemp ' n fo (if applicable) copy of my Home Improvement ntr for re 'stration (if applicable) Commonwealth of Massachuse s W ers' o ensation Insurance Affidavit. Road Bond(if applicable) I NSE OLDER JbATE q/forms/newcont b ./<t.6 "C/�a))7/1)tO421ls2fLLC/a a�.��G2JJlX,f.72cc681�6 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:.:.133862 One Ashburton Place Rm 1301 Expiration: g/20/2009 Tr# 132800 Boston, 02108 Type: DBA GRANGE CONSTRUCTION NIALL HOPKINS 118 LAKEFIELD RD.S.YARMOUTH,MA 02664 Administrator. Vvalid thout signature Board of Building Regulations%and „Standards d Construction Supervisor License 1 license CS 84916 = Expiratwo q/212009 Tr# 12392 a _ Restnction MALL J HOPKINS BOX 231 -� SO.YARMOUTH,MA 02664 �a Commissioner NOTICE N W yOTICL TO o TO EMPLOYEES EMPLOYEES `a. • O,9M Svg The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS . 600 Washington Street, Boston, Massachusetts 02111 617-727--4900 — ,http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by ' insuring with: HARTFORD UNDERWRITERS INSURANCE COMPANY NAME OF INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06183 ADDRESS OF INSURANCE COMPANY (6S60UB-5685C66-0-07). 09-08-07 TO 09-08-08 POLICY NUMBER EFFECTIVE DATES MARSHALL K LOVELETTE INS 396 MAIN STREET "— PO BOX 836 WEST YARMOUTH MA 02673 NAME OF INSURANCE AGENT ADDRESS PHONE# GRANGE CONSTRUCTION INC 21 FRUEN AVENUE UNIT G SOUTH YARMOUTH MA 02664 � EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER.(IF ANY) DATE MEDICAL. TREATMENT , The above named ,insurer-is required in cases -of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and.medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the-First Report of Injury must be given to the - injured employee. The employee may select his or her own physician. The reasonable costof the services 'provided by the treating physician will be paid by the insurer, if the treatrrient is necessary and•reasonably connected to the work related injury. In cases requiring hospital attention. employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS 006784 W20PIG02 TO BE POSTED BY EMPLOYER The Commonwealth'of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street ' Boston, MA 02111 www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual)' Address:, City/State/Zip: Phone.#: Are on an employer?Check th appropriate bog: Type of project(required): 1.) I am a employer with 4. E] I am a general contractor and I 6. ❑New construction employees(full and/or part-tune).* have hired the sub-contractors , 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. VRemodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 ❑'Building addition [No workers'comp.insurance comp.insurance.t required.] 5. We are a corporation and its - 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.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 a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name . ` ?� �` 1�S' ® �I• Expiration Date: °°'®9 ` ®� Policy#or Self-ins.Lic.#• t��' ^ � � ®� Job Site Address: ek City/State/Zip Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to sec co erage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1 00 0 d/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$2 .00 against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investi ati ns o D for insurance covers a verification. I do hereby un er the pains-and penalties of perjury that the information provided above is true and correct Si ature: Datee�4JI171aO _ Phone#• Official use only. Do not write in this area,to be completed 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts 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 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 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. However the owner of a dwelling house having not more 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 building appurtenant thereto shall not because of such employment be deemed to be an employer." '�"^- �`, y'` �"'',� .., •.'. .,fir? :. � 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 e uirements of this chapter have been resented to the contracting authority." requirements P P g tY 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 certificate(s)of insurance. Limited Liability Companies*(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have 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 Investigations1as to contact you regarding the applicant. Please be sure to.fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications�in any given year,ineed 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 that a valid affidavit is on file for future permits or,licenses. 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 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,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-490..0 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass..gQvfdia - - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION- Map 30.fo Parcel D 16 ' Application # `Z l Health Division Date Issued Conservation Division "" Application Fee z Planning Dept. Permit Fee b Date Definitive Plan Approved by Planning Board : Historic'- OKH Preservation/ Hyannis Project Street Address Village 16"ylis Owner ?�o�i'� f� SC�i`�`�� Address �� S `'�, Xo&d AfAW n/Ir Telephone Permit Request Square feet: 1 st floor: existing%2proposed _2nd floor: existing proposed _Total new Zoning District Flood Plain Groundwater Overlay Project Valuation DOO Construction Type U>odcf Lot Size 30D Sy Grandfathered: ❑Yes Z o If yes, attach supporting documentation. Dwelling Type: Single Family, .� Two Family ❑ Multi-Family(#'units) Age of Existing Structure Historic House: ❑Yes 0'I Igo On Old King's Highway: ❑Yes 0'60 Basement Type: mull ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing_ new _ Half: existing l new Number of Bedrooms: existing new Total Room Count (not including baths): existing new First Floor Roorrl Count Heat Type and Fuel: 2"G- as ❑Oil ❑ Electric ❑ Other Z". Central Air: ❑Yes C"No , Fireplaces: Existing New Existing woodeeoal stove: ❑Y.es ❑ No Ln Detached garage: ❑existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ fisting Qneq` size c: Attached garage: `existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ca r� cn M Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review# Current Use *-,e s i-d,.Lr 1 lr6 ` _ -- Proposed Use p� APPLICANT INFORMATION (BUILDER OR HOMEOWNER) "'Name ISKL0004 )&e ac_. �c��`l��rs Inc-Telephone Number Address IS- CA�t4 Mi i`�oct al License # C $3 a 0 A 026 ;L Home Improvement Contractor# Worker's Compensation # ivG ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C l OL SIGNATURE DATE 0�15 IPOD% t FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL }s PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ^Z) l I DATE CLOSED OUT ASSOCIATION PLAN NO. r ors �� �,,,�,,` �-�, NOTES JOB NO. 807-06 1. LOCUS IS A.M. 306, PARCEL 16. Schiller.dwg 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992. �� 4. OFFSETS SHOWN ARE TO THE CORNERBOARDS ON EXISTING ®� BUILDINGS, OR TO FOUNDATION ON NEW CONSTRUCTION. 0- a � ^ 0.9'f 83,p• : VE cy M W M LOT 2 ttsf , u � 'O±S. F.- co P yh N/F MCLAUGHLIN o :N � , 4 r..::...:: ` tt.s f CVS PROPOSED :::.12,�' Np G NpVSE `Jt24't 23' X6' ADDITION %.. 1S40�S 6 MOVE SEPTIC - N/F TANK 10' FROM M o CROWLEY PROPOSED ^ ADDITION CBUILD zo OVERSUTO o .:::.::.23. 3 6" BELOW d -� t26'.* GRADE w o NOTE. EXIST. SEPTIC TANK M d �'- -� LOCATED IN FIELD BY R.J. CADILLAC. D-BOX AND LEACHING ARE APPROXIMATE FROM ASBUILT NO. 99-304 83 0• rr STv BR6/DISC FND . E Y I CERTIFY THAT THE LOCATIONS SHOWN ON THIS PLAN WERE MEASURED IN-THE FIELD « ASBUILT PLAN o;OF AA FOR 3 r RON DMAD K ' SCHILLER n LOT 2, 46 STUDLEY ROAD, HYANNIS, MA DECEMBER 5. 2007 SCALE: 1 =20 11 RONALD J. CADILLAC, PLS, RS, P.C. ��77 a PROFESSIONAL LAND SURVEYOR do REGISTERED SANITARIAN �i D P.O. BOX 258 WEST YARMOUTH. AAA 02673 REV. 12/17/07--PROPOSED TANK ©2007 BY R.J. CADILLAC (508) 775-9700 The Commonwealth of Massachusetts Department of Industrial Accidents UTOffice of Investigations 600 Washington Street Boston, MA OZlll www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information / Plea/se Print Le gib Name (Busincss/organizalion/lndividuan: o ro `Lu-�A a Lv/ lal"�,✓s �.�G ' • Address: (� ��n. $1�vt/°�� �� - City/StateJZip: G /j'IQ O Phone.#: `l'� 6- A��I an employer? Check the appropriate box: Type of 'oject(required): 1. m a employer with 4• ❑ 1 am a general contractor and I 6. New construction . employees(full and/or part-time).* have hired the stab-contractors 2❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub contractors have g, ❑Demolition employees and have workers' working for me in any capacity. t 9. ❑Building aAdition [No workers' comp.rnsrrranCC comp.insurance. req)rrrr�] 5. E] We are a corporation and its 10.❑Electrical repass or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions Myself[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required_]t c. 152, §i(4), and we taut no 13.[]Other employees. [No workers' corg.insurance required_] +Any applicant that ehml5 box#1 mart also ffl out the section below sbDWing their workcn'eomapcnsat;on policy information. t Homeowners who submit this affidavit indicating they arm doing all work and then biro outside crmtractors must submit a new affidavit indicating such. !C--Mtractor3 that ebcck this box must aftcbrd an additional sheet showing the name of the sub-contmar,t and state whether or not those rntitits have employees. If the sub-conhactars have anploycca,they must providb their worico=rrs'comp.pobry number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: ��°. 7'"( /" d Policy#or Self ins. Lie.#: d/ Expiration Date: Job Site Address: 6 .5iat(k � City/State/Zip:�(/�/�f,�/g!j�6�1 Attach a copy of the workers' compe ation policy declaration page(showing the policy number and expiration date). Failure to sccurc coverage as requircdunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment, n 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 statamerit may be forwarded to the Office of Investigations of the MA for incnrancc coverage verification. I do hereby cc un r pa' s penalties of perjury that the information provided above is true and correc4 na ' Si attzre: Date: Phone# Offuial use only. Do not write in this area, tb be completed by city or town officlaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.My/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: Massachusetts 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 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 two or more of the foregoing engaged in a joint enterprise, and including the legal representative's of a deceased employer, or the receiver or trustee of an individual,partnership, association or other Iegal entity, employing employees. HOwcVcT the owner of a dwelling house having not more 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 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 Iocal 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 amy applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL ohaptcr 152, §25C(7) states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work uatil acceptable evidence of compliance RZth the in-surance: requircmcnis of this chapter have been presented to the contracting authority." Applicants Please Ell out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if aecrosary,supply sib-confractor(s)name(s),address(cs) and phone numbers) along with their certificate(s)of incnrancc. Limited Liability Companies•(LLC) or Limited Liability Partnerships(LLP)with no employers other than the ncmbers or partnct-s, are not required to carry workers' compensation insurance. If an LLC or LLP does have ,roployees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial kccidcnts for confirmation of insuranme coverage. Also be sure to sign and date the affidavit The affidavit should ie returned to the city or town that the application for the pert or license is being requested,not the Department of ndustrial Accidemfs. Should you have any questions regarding the law or if you are required to obtain a workers' :ompcnsation policy,please call the Department at the number listed below. Self-insured companies should enter their cl-g_insuranre license m=bcr on the appropriate line. ;ity or Town Officials 'lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom ,f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant -lease be sure to fill in the permitllicense number which will be used as a�refcrcnce number. In addition, an applicant rat must submit multiple permit/license applications in any given year,need only submit ono affidavit indicating eun-ent olicy information(if necessary) and under"Job Site Address" the applicant should write"all locations in (city or Ywn).'-'.`A copy of the affidavit that has been officially stamped or marked by the,city or town may be provided to the pplicaut as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each ear.Where a home owner or citizen is obtaining a license or permit not related to any business or conmr-rcial venture _e. a dog license or permit to btim leaves etc.) said person is NOT required to complete this affidavit he Office of Investigations would 111m to than you in advance for your cooperation and should you have any questions, [case do not hesitate to give us a call is Department's address, telephone-and fax number. .The Commonwealth of Massachusetts Department of ladustrial Accidents Office of Investigations 6.00 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext4-06 oar 1-877-MASSAFE ;d 11-22-06 Fax# 617-727-774.9 www.mass.gov/dia ACORDM CERTIFICATE OF LIABILITY INSURANCE 08/05/2 08 PRODUCER (508)997-6061 FAX (508)990-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern InNLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Insurance Agency, Inc.Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Roycroft & Kuehne Builders Inc INSURERA: Arbella Protection Insurance 65 Eben Smith Road INSURERB: Merchants Insurance Group Centerville, MA 02632 INSURER C: INSURER D: INSURER E: GRANITE STATE INSURANCE CO COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRADD'INSRdTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY 8500022738 08/01/2008 08/01/2009 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYF_j PRO- JECT LOC AUTOMOBILE LIABILITY 7AM0277014095 10/18/2007 10/18/2008 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ P_ 1,000,000 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN _ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC 990610 08/06/2008 08/06/2009 X WC STATU. OTH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,OOO E ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL TOWN OF BARNSTABLE 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ATTN BUILDING DEPARTMENT BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 MAIN STREET OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. HYANNIS, MA 02601 AUTHORIZED REPRESENTATIVE Joanne Bretton ACORD 25(2001/08) FAX: (508)420-1947 CACORD CORPORATION 1988 • F ' , r 'Ile-, r-11641WAW1ll n��. lta�Xre%ufe�t6 Board of Building Regulations and Standards ii Construction Supervisor License dy m ra • � "`a M ' License: CS 83280 Expiration: 11/29/2010 Tr# 5313 Restriction: 00 SEAN J ROYCROFT 65 EBEN SMITH RD CENTERVILLE•MA 02632 Commissioner . ' ✓/tS Z1697L77Z01Z1/12CUA/1.O�✓GLQt13CZf,011[6CK6 - Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 141225 Expiration: 1/22/2010 Tr# 262207 Type: Private Corporation ROYCROFT&KUEHNE BUILDERS, INC. Sean koycroft 65 Eben Smith Road Centerville,MA 02632 Administrator • �oFTMEt, ToWn of Barnstable Regulatory Services r � i�uss� $ Thomas F. Geiler,Director. °TFnru•+° 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 ThisSection If Using A Builder. as Owner of the'subject property hereby authorize �� �C � to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) f 1XnZu .10 � . Signature of Owner ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable ti���of THE Tphy.. Regulatory Services • Thomas F. Geiler,Director Building Division PTED M�iA Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 www.town.b arnstabl e.ma.us free: S08-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: a JOB LOCATION: number street village ..HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"h0niedw1aers"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINFrION OF HOMOWNER Persons)who owns a parcel of land on'which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a iwo-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department ' and that he/she will comply with'said procedures and 1- minimum inspection procedures and requirements uements P�' P requirements. Signature of Homeowner Approval of Building Official Note: -Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions -f this section(Section 109. A -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such +ork that such Homeowner shall act as stnpwisor." Many homcownas who use this exemption ai>;unaware that they are assuming the responsibilitics of a supervisor(sec Appendix Q, .ules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly ,hen the homeowner hires unlicensed persons. In this ease,our Board cannot proceed against the unlicensed person as it would With a licensed upensor. The homeowner actin as Supervisor is ultimately responsible. e. To ensure that the homeowner is fully aware of his/her responsibilities,many communities regvnthi as part of the permit application, at the homeowner certify that hc/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by Ycral towns. You may care t amend and adopt such a fomn/ccrtification for use in your community. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Applications# J / Health Division Date Issued; Conservation Division Application Fees Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village LL �� Owner ', _fi( 5 n�116 4a,4 1,1[ dress Telephone �$ ?1 (o0?;27 Permit Request ` '. 64q 2 0 Square feet: 1 st fl r:existing proposed iiri 2nd floor:existing -- proposed Total new Ow Z*d Zoning District V 12 Flood Plain •, _ Groundwater Overlay WYA ems. Project Valuatio ��'V Construction Type ���0 Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. c Dwelling Type: Single Family !' Two Family ❑ Multi-Family(#units) Age of Existing Structure IT7 2) Historic House: ❑Yes 1l0 On Old King's Highway: ❑Yes YNo Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 125D+ Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new TotalRoom Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes )(No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new ,size Attached garage:Vexisting ❑new size ShedXexisting ❑new size Other: Zoning Board of Appeals Authorization _❑ Appeal# — _—Recorded❑ —!a Commercial ❑Yes Xo HIf yes, site plan review# o s. Current Use roposed Use w. z 1 BUILDER INFORMATION Name Telephone Number—� 2 . ftZ Address � License# (,n �J fX 2.87 Home Improvement Contractor# /!T-Dg Worker's Compensation# = d ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE `2•Y.07 z FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED y MAP PARCEL NO. ADDRESS VILLAGE - OWNER F DATE OF INSPECTION: FOUNDATION i ► - ' FRAME _ r INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r • r DATE CLOSED OUT ASSOCIATION PLAN NO. r JOB Se.tA L 01 JAYLOR, DESIGN ASSOC., INC. SHEET NO. OF P.O. Box 1313 FORESTDALE, MA 02644 CALCULATED BY ........................................................................................................-......-.....-....-.....-.....-................................................................................................. .....-..................................-...-....-.-...-.-...-....-....-.-...-.-..-...-.-..-.-..-.-..-.-..-.- .-..-....................... ...............................--...-......-....-...--....-..-.-.-..--..-.-..--..- -.. . ......2...... .- ;!,-iI X-- L 7 6....-...... s....... ................... ..................6...- ..................... ..... ............. ...................-.---..-.-.-..-..-..-..-.--.-.A-.- .............-...-....-..-..- .....-....-...-.-..... .......................... ............. ................ .-A--..-.-1..-..-..-. ..-.7.-..- .-.- 1 .-..-. ----l-f-------- --c.- ....�-I-..-.....F.-........-...........-..�L.-.. -...w.-.... .-.....-.........-.....k.....-....-.....-....-........4-.-..-. w.. ..- -.-..---.'-.---.T.---..----.- E TEL./FAX: (508) 790-4686 CHECKED BY 4- t SCALE --- ----' -_p .......... ..... ..... --- .--- ---------------- ----.---.-- -..-..- -.-.-.-..- ...-....--.............-........-........-............-.....-........-.......-........-.........-.. a 0 ------ .. ... ....-......... -..........-.........- .... . ...............j........ ......................... .....j . . .. . ----- ..... ..... . 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I .... .... -- .. - --- ----- ..... - .......................................... ....I............ ... . 17 - - - 7 ---- .. .. .......... • c.T rt .......................... - ---- ... ..... ---- ---- .... . ---- -- ...... ...... .... -... ........................... .. ................. ... . T ..... ...I........... . . ---............................................................--.-..-............................................................ .............. ---------- .c.. ...............................I.................. . ..... .................... ........ ... ...... ... ............. O ......... . ...................... ............. . .. . .l.......... ..... l ....................... ........ b Vct— ..... .............. .......... .... ........... ..................... .......... .......... .............. .................. ...... ------- -------------- ---------------------- ........ ........................... ............................ ........... ................... .....................------------------ ................. • - JOB l L.i... 'fL Crl/. TAYLOR,DESIGN ASSOC., INC. 6C.. SHEET NO: � OF r` P.O. Box 1313 FORESTDALE, MA 02644 CALCULATED BY anrE 4 2� l- 0 7 TEL./FAX: (508) 790-4686 CHECKED BY DATE d tr. SCALE . -.. .; - .... ---- --- _ r .�' .. - -.t t c �..,,� t. _ . 3� ... ......... t ............. � _ ps.`_. . :. 3. .... z �.�. . r ... 3� x `� - t _..t.t .. 3.. ?........ ..........- ` i 2, 3 > -�cj�5 - —_ , .. i JOBAN9 TAYLOR DESIGN ASSOC., INC. �` SWEET NO. � OF P.O. Box 1313 FORESTDALE, MA 02644 CALCULATED BY_ DATE aZ l- 07 TEL./FAX: (508) 790-4686 CHECKED BY DATE L S SCALE ..... .__. ....._..._............................. ... .;......... ...........[.... ._.i:... ....i.... ........ ..., _ ..............:..... ... .. ......... -_.... F _................ . .. .. . . .......... ---l ...... t-a. ...... .............. ............ — - ...................._... 1 -t- 1 �B. Cf.7 s ............>....................................._...._... _.. ...... ...... ..... - — — _ s i _ tic. t� 7� -,v.- J..............._= -._ _...... - - ...... :.....................__.._.......... . ......... ------ . _ .__-- .--..-- _._ _.__ -- _ ...... ..... _ ..... .... _.... 4 ... _ ;.._._.__.. ............. - - ...... - .rt- _..__..._ 7_G .... Z c ... ...... _....... ..... ...... ........... ................. ..... _. ... ... _. t . .... ..... ... ... ._.......... ._.. . .... .._.d .... La.. .. [.Z ._.......:.... ....:. l s O.Zs Z. l Z c � .. . o .s . o_ ,� c ........................ ........--...... . . .... — -__ _ .._.......:... I o ; Z =. ..... ........:....._.__.. - - - ............_......................_ - ..... _ .. _. ............ .. _ _....... ...._n.. 3 L t�'(-r t 1.4 , L6 _--------..>............... - .......................... ............... 4------- ....... ._..................... --..`..... ". -r"�.:.rc7 _...... -------_..............._..........._..-....... _....... ..._ .. - _ . _..........................:._........._:.............<...._._...;._........__. - -- ---- .. r-- t.-...,..- c3tr..Jr-�. ..J / ii C.-A.�a j JOB TAYLOR DESIGN ASSOC., INC.- SHEET NO. OF P.O. Box 1313 FORESTDALE, MA 02644 CALCULATED BY DATE TEL./FAX: (508) 790-4686 CHECKED BY DATE SCALE 12/06/2007 08:04 5087904686 GREGTAYLOR PAGE 01 o- JOB N � TOLOR DESIGN ASSOC., INC. SHEET NO. OF P.O. Box 1313 DATE—tT-r FORESTDALE, MA 02644 CALOuuATEo SY Gry TELJFAX: (5081) 790-4686 CHECKED BY OATr d t t cL'AO -jry (- SCALE t I 'y................y ....._.........._. ............. d........... ..... 1.._......... .'.......__ ' .. i1_...............,.........I ............ ............. .....y....... 5.............:.........................i...... __...... .....-............i............. .. .... ...._. ... .. .... .........._. ........... ............p _ _........ ... ..............._......... ............._..................... .................._..y...._........... IN 1 ! i .... ... ... i I 1 i ! i � 1 i a i . i i ; .+ i 18 ' �.-� ; c- .... . ..... .... .;.... r : ; ; ! r ; � i ; ' ...b.... .. 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I I - ' r r • ......I___ .j...: i ..........d.................. i h q........ p ... .. .... ... ... ... _....l..... ... .... I. r i t ' � 1 .........a.........4..........i.........d....... ' L J.... :.�... .. q .. ..._...i............I.._.. f k t .. .... , i r ............. ............ q.......... o.......................:..........o....... ............. ........ .....__...........I d.. .............. ..._..P......... ..... ..... ... _.. .... ....; : i ' I i ... m4-1(�8l�Tl Vaww) 02/20/07 11:17 FAX 617 252 6563, PATHOLOGY SERVICES INC. 9 003 { ,TOOWN OF B STABLE LOCATION �6 Pv le SEWAGE li 9p`3 ASSESSOR'S MAP at LOT_ `�6 INSTALI.B US NAME&PHONE NO. � � �� SEPTIC'TANK CAPACITY LEACEANG FACU TY: (type) a y (siu) /d riC3� NO.OF BEDR BUILDER O OWNER` PERMTfDATE: 'Ly COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted GroundwaterTable to the Bottom of Leaching Facility s Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) A/,* Feet Furnished by •02/20/07 11:18 FAX 617 252 6563 PATHOLOGY SERVICES INC. 11004 - ------------------------- �. Say J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Aigiooal Spotem Conotruction Vermit Permission is hereby granted to ) ✓ Upgrade( )Abandon( ) System located at y� .5Ir e l✓f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completedwithin three years of the date of this 't. Date: Approved by —— r. — ---ice �� ��w•+rr r. —,a ..� THE COMMONWEALTH OF MASSACHUSETTS 306 0 BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS IS TO ,that the -site§ewage Disposal System Constructed( )Repaired( &-j/Upgraded( > Abandoned( )by at been constructed in accordance with the provisions ofTftle ,and the for Disposal System Construction Permit No. m dated Installer igner14 The issuance of this permit a guarantee that the syste on as designed. Date Inspector !'t Permit# Permit Date REScheck Software Version 3.7.3 Compliance Certificate Report Date:12111/07 Data filename:C:\Program Files\Check\REScheck\Reports\Schiller.rck Energy Code: Massachusetts Energy Code Location: Hyannis,Massachusetts Construction Type: 1 or 2 Family, Detached Heating Type: Other(Non-Electric Resistance) Glazing Area Percentage: 11% Heating Degree Days: 6137 Construction Site: Owner/Agent: Designer/Contractor: Michelle&David Schiller Gary Ellis 46 Studley Road Northside Building Consultants Hyannis,MA 141 Main Street Yarmouth Port,MA 02675 (508}362-9802 Ceiling 1:Flat Ceiling or Scissor Truss: 1503 30.0 30.0 26 Wall 1:Wood Frame,16"o.c.: 3058 13.0 13.0 130 Window 1:Metal Frame:Double Pane with Low-E: 248 0.330 82 Door 1:Solid: 20 0.086 2 Door 2:Glass: 81 .0.330 27 Floor 1:All-Wood Joist/TrUSS:Over Unconditioned Space: 1380 19.0 19.0 35 Compliance Statement:The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the Massachusetts Energy Code requirements in REScheck Version 3.7.3 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist.The heating load for this building,and the cooling load if appropriate,has been determined using the applicable Standard Design Conditions found' e Code.The HVAC equipment selected to heat or cool the building shall be no greater than 125%of the desi oad as spe i in4 Sections 780CMR 1310 and J4.4. c ja, &U�&V r Bui der/Dfner Company Name D e Page 1 of 4 REScheck Software Version 3.7.3 Inspection Checklist Date: 12/11/07 Ceilings: ❑ Ceiling 1:Flat Ceiling or Scissor Truss,R-30.0 cavity+R-30.0 continuous insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-13.0 cavity+R-13.0 continuous insulation Comments: Windows: ❑ Window 1:Metal Frame:Double Pane with Low-E,U-factor:0.330 For windows without labeled U-factors,describe features: #Panes Frame Type Thermal Break? Yes_No Comments: Doors: ❑ Door 1:Solid,U-factor:0.086 Comments: ❑ Door 2:Glass,U-factor:0.330 Comments: r .. Floors: ❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-19.0 cavity+R-19.0 continuous insulation Comments: Air Leakage: ❑ Joints,penetrations,and all other such openings in the building envelope that are sources of air leakage must be sealed. ❑ When installed in the building envelope,recessed lighting fixtures shall meet one of the following requirements: 1• Type IC rated,manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated,in accordance with Standard ASTM E 283,with no more than 2.0 cfm(0.944 Us)air movement from the the conditioned space to the ceiling cavity.The lighting fixture shall have been tested at 75 PA or 1.57 Ibs/ft2 pressure difference and shall be labeled. Vapor Retarder: " ❑ Required on the wane-in-winter side of all non-vented framed ceilings,walls,and floors. Materials Identification: ❑ Materials and equipment must be identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. ❑ Insulation R-values and glazing U-factors must be clearly marked on the building plans or specifications. Duct Insulation: ❑ Ducts shall be insulated per Table J4.4.7.1. Duct Construction: ❑ All accessible joints,seams,and connections of supply and return ductwork located outside conditioned space,including stud bays or joist cavities/spaces used to transport air,shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions.Mesh tape may be omitted where gaps are less than 1/8 inch.Duct tape is not Page 2 of 4 permitted. ❑ The HVAC system must provide a means for balancing air and water systems. Temperature Controls: ❑ Thermostats are required for each separate HVAC system.A manual or automatic means to partially restrict or shut off the heating and/or doling input to each zone or floor shall be provided. Heating and Cooling Equipment Sizing: ❑ Rated output capacity of the heating/cooling system is not greater than 125%of the design load as specified in Sections 780CMR 1310 and J4.4. Circulating Hot Water Systems: ❑ Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: ❑ All heated swimming pools must have an on/off heater switch and require a cover unless over 20%of the heating energy is from non-depletable sources.Pool pumps require a time clock. Heating and Cooling Piping Insulation: ❑ HVAC piping conveying fluids above 120 degrees F or chilled fluids below 55 degrees F must be insulated to the levels in Table 2. Page 3 of 4 Table 1:Minimum Insulation Thickness for Circulating Hot Water Pipes Insulation Thickness in Inches by Pipe Sizes Heated Water Non-Circulating Runouts Circulating Mains and Runouts Temperature("F) Up to 1" Up to 1.25" 1.5"to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-160 0.5 0.5 1.0 1.5 100-130 0.5 0.5 0.5 1.0 Table 2:Minimum Insulation Thickness for HVAC Pipes Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range("F) 2"Runouts 1"and Less 1.25"to 2.0" 2.5"to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate(for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water,Refrigerant and 40-55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD:(Building Department Use Only) Page 4 of 4 NOTES JOB NO. B07-06 1. LOCUS IS A.M. 306, PARCEL 16. Schiller.dwg 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992. 4. OFFSETS SHOWN ARE TO THE CORNERBOARDS ON EXISTING '/1`J O C� BUILDINGS, OR TO FOUNDATION ON NEW CONSTRUCTION. ER0.9.t DRI 83 VE 0' : Cd w +� M co M LOT 2 8300± S. F. N/F MCLAUGHLIN PROPOSED s t .. EXIST/NC No 2 23' X 6' N0. 4g VSE 4 ADDITION 1S40�S F . MOVE SEPTIC 0�.. Ni N/F TANK 10' FROM o CROWLEY PROPOSED ADDITION N :� BUILD UP 20 o `....2.3 COVERS TO 6" BELOW d _� 12.6 f GRADE N C NOTE: EXIST. SEPTIC TANK LOCATED IN FIELD BY i d R.J. CADILLAC. D-BOX AND LEACHING ARE APPROXIMATE FROM ASBUILT NO. 99-304 8,3.0' S , TUDLE BRB DISC FND Y R I CERTIFY THAT THE LOCATIONS SHOWN ON OAD THIS PLAN WERE MEASURED IN 1NE FIELD ASBUILT PLAN �ZH OF MgSS 111h cP�ItA OF Mqs FOR O2 _ALL) _ s9°tip DAVID H. SCHILLER S JAM S - y Jr,M LOT 2, 46 STUDLEY ROAD, HYANNIS, MA 1 I ' u6A �x 9 DECEMBER 5, 2007 SCALE: 1"=20' �SGISTE?- .`'` ,. � ESS\ Q 4NITAO' f O SURVE"0 RONAW J. CADILLAC, PLS, RS, P.C. 11 7 I 1 PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN 1 P.O. BOX 258 WEST YARMOUTH, MA 02673 REV. 12/17/07-PROPOSED TANK ©2007 BY R.J. CADILLAC (508) 775-9700 NOTES JOB NO. B07-06 REFERENCES: PLAN BK. 116, PG. 111 1. LOCUS IS A.M. 306, PARCEL 16. Schiller.dwg in PLAN BK. 86, PG. 113 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992. 04 U ^ K 4. OFFSETS SHOWN ARE TO THE CORNERBOARDS ON EXISTING /�`J O BUILDINGS, AND TO FOUNDATION ON NEW CONSTRUCTION. 0) R D.8't S 7jyD, D E* D ^/ 83 t I�. VE ,_H M M LOT 2 N/F 8300±S.F. MCLAUGHLIN I � N O N 4s.r ' ::••::: r _ *CAUTION: LOT 2 HAS AN ERROR OF CLOSURE ::.12.•fi� NG HQ --j124, OF 0.12' S 12'47'30" W. NO, 46 USE REAR OFFSETS SHOWN .� �S40fs ARE APPROXIMATE. iy: -H A COMPLETE PROPERTY 24.1' rn NE'z `��::.:.: ,a`. o LINE SURVEY IS NEEDED 2 9QUNp o cv TO ESTABLISH REAR PROPERTY LINE. ; :. M � 12.T �j � NOTE: EXIST. SEPTIC TANK LOCATED IN FIELD BY 7s R.J. CADILLAC. 7p' `r A Pro M _�172 96. H i from Asb_rr, J_n _ TO ANG 830a. ta;lt:g9 ; CROWLEY HELD _ LE POINT �pB 116 p SUDLE )r , G 1 1137RB DISC FND. T , B / N 7 . fi ,715� 374 W 13 M — fAS. ' \ N 77. I CERTIFY THAT THE LOCATIONS SHOWN ON O A 15 W — " 1 THIS PLAN WERE MEASURED IN THE FIELD _ D BRB/CENTER ON 10/4/07, 11/30/07, 3/20/08 & 3/24/08. ASBUILT PLAN FND. 1..N of 4yM FOR RONr.L s Will) H. SCHILLER ME '.�A C� LOT 2. 46 STUDLEY ROAD, HYANNIS, MA DECEMBER 5. 2007 • SCALE: 1"=20' �Nosu �B RONALD J. CADILLAC. PLS, RS, P.C. PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN P.O. BOX 258 REV. 03/24/08--EXISTING TANK & NEW FOUNDATION WEST YARMOUTH, MA 02673 REV. 12/17/07--PROPOSED TANK ©2008 BY R.J. CADILLAC (508) 775-9700 i Monda ,Decemb 10,2007 i TO: Town of ernstable,Massachusetts FROM David Sc 11er r ADD SS;46 Shidley Road,Hyannis,MA 02601 I,Da,V Schiller, uthorize Crary Ellis to be our agent to seek Permits for Renovation for 46 StU ey Road, I fyarmis, MA. Sign d chi 1 ; s, i i TOO/T00'a 09LT# SUOISSnNI W90q�) S)[VgOEV9 OFttTE9LT9 DZ:OT LOOZ,OT'0SIa °FZHE To,,, Town of Barnstable Regulatory Services gsaaMA�ie� Thomas F.Geiler,Director �'prFo;9,. A'� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax:- 508-790-6230 Property~Owner Must r; " Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, w . in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the r Homeowners License Exemption Form on the reverse sided Town .of Barnstable �OF 1HE Tp�� Regulatory Services " Thomas F.Geiler,Director t BARNSTABLE, y MASS. g 9,A 16yg. p�� Building Division rfD � Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ------------- HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s).who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.' A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rul(;,&Regulations for Licensing Construction Supervisors,Section 2,15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fomm/certification for use in your community. _ ✓�ie U/07lrinO�I2UJP.pL//L 0�../!/CCWdl�CfZl[6P.�6 -g"_ BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number. CS 015833 Expires:02/07/2008 Tr.no: 19624 — - —— Restricted: 00. GARY A ELLIS W. 141 MAIN ST 1 YARMOUTH, MA 02675 Commissioner Board of Building,Regulations and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 y: Hoifne Improvement Contractor Registration Registration: 136832' Type: Private Corporation Expiration: 9/4/2008 NORTHSIDE BUILDING CONSULTANTS IN 9 . GARY ELLIS 141 MAIN STREET ` YARMOUTHPORT, MA 02675 ` Update Address and return card.Mark reason for change. PS-CA, 0 soM-osios-Pceaso k � Address ,� Renewal .Employment !� Lost Card ,,. ✓d� r ie �arnnno�ui�ealC� ry�./l/faaaac�ivae� - ° Board of Building Regulations and Standards License or registration valid for individul use only - - HOME IMPROVEMENT,CONTRACTOR before the expiration date.'If found return to: Board of Building Regulations and Standards 3 Registration: 136832, >one Ashburton Place Rm 1301 Expiration: 9/4/2008 Boston,Ma.02108 . Type: Private Corporation' s ' NORTHSIDE BUILDING CONSULTANTS INC. GARY ELLIS F 141 MAIN STREET ' - YARMOUTHPORT,MA 02675 Deputy Administrator of vali ithout signature ♦"� F _ ' The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbe.rs Applicant Information Please Print Legibly Name(Business/Organizationtbdividual): 4�� Address: 14�144 `il/1 City/State/Zip: Phone.#: you an employer?Che the appropriate box: ;Type ofproject(required):, 1,` I am a employer with 4. 0 1 am a general contractor and I employees(full and/or p time). * have hired the gab-contractors 6. ❑New construction . 2111 am a'sole proprietor or partner- listed on 1he'attached sheet. 7. El Remodeling , ship and have no employees These sub-contractors have g, (]Demolitions Sorkin for me in an ca aci employees and have workers'. g y p ty. 9. ❑Building addition comp,insurance. [No workers comp.insurance 10.❑•Electrical repairs or additions required.] 5. ❑ We are a corporation and its • '3.❑ I am a homeowner doing ill-work . officers have exercised their 11.❑Plumbing repairs or additions ' myself.[No workers'comp. right of exemption per MGL 12.[]Roof repairs insurance.required.]t c, 152, §1(4),and we have no ] employees. [No workers' 13.❑Other ' comp,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 hue outside contractors mutt submit anew affidavit indicating'such. $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 provida their workers'comp.poicy number. .[am an employer that is provlding workers'compensation lnsurance for my employees. Below is.the policy and job site information. Insurance Company Name#: XPration Date: 67 E i _��' Policy#or Self-ins.Lic. �— lob Site Address: lot I City/State/Zip: Attach a copy of the workers'-compensation olicy declaration page'(showing the policy numbs and expit 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the.Office of Investigations of the bIA )rinsurmoocoveraiza verification. Ido hereby certify un the pains enalties ofperjury that the information provided above is true and correct. .07 Si afore: Date: Phone#: A(f-2, Official use only. Do not.wrlte in this area, to be completed by.city or town official City or Town: Permit/License# Issuing Authority(circle one):.. .'1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ' WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company Burlington, Massachusetts NCCI NO ao959 (800)876-2765 POLICY NO. WCC 5003374012007 ITEM PRIOR NO. WCC 5003374012006 1. The Insured Northside Building Consultants Inc&Kitchen Tune Up Mailing Address: 141 Main Street Yarmouth MA 02675 (No. Street Town or City. County State Zip Code . ❑ Individual ❑ Partnership ® Corporation ❑ Other FEIN 03-2387290 Other workplaces not shown above: 2. The policy period is frorri08/07/2007 to08/07/2008 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part_Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A D. This policy includes these endorsements and schedules: SEE SCHEDULE 4. 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. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual of .Annual Remuneration Remuneration Premium INTRA 100680 SEE EXT NSION OF INFORI 4ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 2,588.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 2,684.00 ® Annually ❑ Semi Annually El Quarterly ❑ Monthly MA Assessment Chg. $2,289.50 x 4.1920% $96.00 This policy,including all endorsements,is hereby countersigned by 06/08/2007 Authorized Signature Date GOV GOV KIND PLACING CLAIM NAME SAFETY ' STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boston Insurance Brokerage Inc MA 5606 17 504 24 Federal Street 4th Floor WC 00 00 01 A(11-88) Boston,MA 02110 Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. APPLICATION FOR PERMIT TO INSTALL AND REQUEST FOR ELECTRICAL SERVICE rf- Inspect r of Wires Cj I �-, Wiring Permit #�COM/Elec 'c # 311 86 ,Town of7:rXA4 ddSr_A4 XR Massachusetts �/ Building Permit/ # Date .Z , Customer: A'111.i1/ - /-!� /-i� S on (Street #) 7�v / o Lot# in the village of ,�l���ed /G► utility pole number or underground number Customer's billing address Temporary New installation Change of service y Starting date Job description r Service entrance voltage /'241 /2 d,-o Amperage d b Phase. Wire size(cu.or.al.) ne2okConductor per phase Number of meters C Water heater Off peak: YesNo— Estimated load: Electric heat kw,lights kw,Range dryer Motors,H.P. & Phase Ready for first inspection L — Ready for final inspection Electrical Contractor Ax WAP /��1.L 1T.1� L zz L!� -s_t .Lic. # , 0/.Z-?/ l� Telephone# -7_12 Address Z" 4 6 Additional Remarks: Do Not Write Below This Line ELECTRICAL WIRING INSPECTION CERTIFICATE INSPECTOR OF WIRES INSPECTIONS DATE FEE CHARGE Temporary Service Roughing in r_ Service and Meter , Off Peak Meter f f� Final Approvalf-PH I�i II I Disapproved' UU UU Uwij US Ll P w 'For the following reasons CERTIFICATE OF INSPECTION Date -•on a_:y 95� To the COMMONWEALTH ELECTRIC COMPANY. The installation described above has been completed and has this day been inspected and approval granted for connection to your service 411 w /-Inspector of Wires WIRING INSPECTOR TO BE NOTIFIED WHEN WORK-IS READY FOR INSPECTION Permit Good For One Year From Date Of Issue CA 46 INSPECTOR'S NOTICE Oaks Use Only =1 The Commonwealth of Massachusetts Pen. tNo. Depariment of Public Safcry Occupancy&Fee Chedad BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 190 Qeaveblanit) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code. 527li IN CM :00 (PLEASE PRINT IN OR =PE ALL INFORMA=ON) Date TOWN OF BARNSTABLE To the Inspec r of res: The undersigned applies for a permit to pe f m the electrical work described low. Location (Street is Number) �. Owner or Tenant 1,0C/ Owner's Address iFt 01, 4911A' �-- Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization Existing Service 46® Amps I-Le / .2 Volts Overhead 4rQ17q1` Undgrd❑ No. of Meters_ New Service / Amps %J-0 / Y� Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampaeity Location and Nature of Proposed Electrical Workj s No. of Lighting Outlets No. of.Hot Tubs No. of Transformers TKVA1 No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Batter U its No. of Switch Outlets No. of Gas Burners FIRE ALARMS 'No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of Disposals No. of Hear. Total Total Pumvs Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices_ ipal No. of Dryers Heating Devices KW Local❑ Connect ioo n❑Other Co No. of Water Heaters KW Signs BallastsBallasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: t , INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES NO [] I have submitted valid proof of same to this office. YESM NO ❑ If you have.che d YES, please indicate the type of coverage by checking the appropria a box. INSURANCE BOND ❑ OTM>FR ❑ (Please Specify) . xpiracion ace Estimated Value of Electrical Work S Work..to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME Y '... _ / LIC.•.y0. Licensee Signature / LIC. NO. Address �S Bus. Tel. No. Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that a Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. . PERMIT FEE S Signature of Omer or Agent • r 1 1 • ® ":1 1 1 1 � �• 1 ' i s`Iy T ♦ /t�' r r- s. ` � III �� \ i•a-F�- �� � , - Fill - Lill 11-1 Nuo 4 jI , IS PRO i Jul In .. ., i ®�Ida® in I ®KIM i6 fx� i /' ,s �i i /i• ®s � > eye: ,rs s s/ s 1`: ,y � ♦ - ... s yr -- . /. r /.- r, ♦' _ �. ` r o :. . . z Y -S t ., , ♦ : 3 i :.. - _ - q I y -Y ' _ r �, .:-_ ". ;> a ,.. �,:-:,...�.,I.l.,,�,bI�,,i.,.�:�:�-,I,...1,"";.I.I.'._��,t�:,I....,,�";.:.I1.,',;.f,i I:Z,-."�_'�.... .. ~ . [4 R / } .r 1 ) . : 1I. . .1 f.1�",:1.;"�,,,:n:17.,.�wt*,-,..-.�.;,,'.:-. . V .. }::'. z � . ( Y �' �a .. „: 5 ��� w u r + 1 2V . . .-. _ Y } ,r t 1 C �. .: <2 '. .. 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