HomeMy WebLinkAbout0218 SUDBURY LANE 1v I rb Sc{cP 64e� ,aike
-f
Town of Barnstable *Permit fl. 30 G
Ex ises 6 m t/ss r m issue date
Regulatory Services Fee
-P- � S PERMIT Thomas F.Geiler,Director
OCT - 4 2007 Building Division
Tom Perry,CBO, Building Commissioner
TOV°d,4 twit"BARNSTABLE 200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERNIIT APPLICATION - RESIDENTL4L ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number �� 30
i
Property Address , t 1E� -. L UL 1
i
k ... Residential Value of Work,0 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address �U �C j-_1[ _,&_1J
Contractor's Name Z �¢X' 1 /� _ Telephone Number 5� J 1�
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) 2.1
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I e Homeowner
have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate.must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
eplacemerit Windows/doors/sliders. U-Value . 3;�— (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required.
L
SIGNATURE:
�:Fomu:expmtrg
Revise061306
Boa
W "qq f44.0/-
HOME IMPROVEMENT CONTRACTOR License
License or registration valid for individul use only
RelgistratidA:, before the expiration date. If found return
" lug
I ,118352 Board of Building Ex irate Ii to:
P 3/2/2009 g Regulations and Standards
Tr# 127328 One Ashburton Place Rm 1301
' TYpe Indwidual Boston t frh >Ma.02108
PHILLIP S. KEENE ;;
PHILLIP KEENE .1
2 PIERRE VERNIER DR
� 02
SANDWICH;MA
� 264
�.�.--' �• Adminish•ator __.____ .
t:
- Not valid ithout signature —
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a
RE
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1
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,M4 02111
www.mass.gov/dia
Workers" Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'by
Name (Business/Organization/Individ
Address: �!s 77
ity/State/Zip: __SAP®r I Phone.#: �� 6
Are you an employer? Check the appropriate bog: Type of project(required):•
1.❑ I am a employer with 4. 0 I am a general contractor and I
have hired the gu.b-contractors 6. ❑New construction .
employees(full and/or part- �
2 I am a'sole proprietor or partner-
listed on the'attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 9. Demolition
working for me in any capacity. employees and have workers'
insurance.# 9 []Building addition
[No workers' comp.insurance comp.
required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l 1.❑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 most also fill but the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicatini9 they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors 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 providb their workers'comp.policy number.
lam 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: y t
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date),
Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DU for insurance coverage verification,
I do hereby certify;ender the pains and ienalties of perjury that the information provided above is true and correct:
Sienature: 4-� Date: —
Phone#: v; l
i
L
al use only. Do not write in this area,'to be completed by city or town o WciaZ
r Town: Permit/License#
g Authority(circle one):
rd of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
erct Person: Phone•#:
�oF tHE�p�y
Town of Barnstable.
Regulatory Services
BaaNsrasLE, +`
y asasa $ Thomas F. Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
"w.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�r � � to act on my behalf,
in all matters relative to.work authorized by this Building permit application for: .
y
Address of Job)
0
Signature of Owner ' Date
Pant Name
QTORMS:OWNERPERMIS S ION
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION.
Map 9�-7 Parcel � zo ! A lication# G ZZ
pp
Health Division Date Issued-
Conservation Division Application Fee
Tax Collector Permit Fee
Treasurer. I 0
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservati Ion/Hyannis
Project Street Address A 1 k S{v bur. LiO
Village_ inn W M I s `
Owner Do te ►' A t`1 i s V_e-►- X Address a Sl S v b y.i L ry
Telephone 5 0 S - 7 5's.1
Permit Request W r__ uM Gv ► 8 by o td a c4 ect4 i1�1 -Tl,a j,e a v- 04 TIN6 hu0J C.
To V -e 12 .,C- c C a w. CK cl ec. an 4, t 0o-t�tD7,—T
I CC
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed = fiotal neiii�
T:'-dcumentation.
-0Zoning District Flood Plain Groundwater Overlay wProject Valuation Construction Type cn
Lot Size Grandfathered: ❑Yes ❑No If yes, attach suppo
Dwelling Type: Single Family wr" Two Family ❑ Multi-Family(#units)
Age of Existing Structure 20 )t rarr.S• Historic House: ❑Yes CR o On Old King's Highway: ❑Yes Flo
Basement Type: Dull ❑Crawl ❑Wlalkout ❑Other
Basement Finished Area(sq.ft.) N I'A - Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name IAA r r y 1Le ( e— Telephone Number 7 > — � ) `�
Address 9)( 1 5- 0 License# ci k-f q H
SO 0 d LU �� M Gt Gd-o,3 Home Improvement Contractor#
Worker's Compensation# A W C 7®22 2 19 O �
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS,PROJECT WILL BE TAKEN TO_C s C 11 CL .
S rvtC -Sc,il duUic- 4 0iot . CY4s'&3
SIGNATURE DATE
FOR OFFICIAL USE ONLY
a
-APPLICATION#
DATE ISSUED
MAP/PARCEL N0.
.�• t y
ADDRESS VILLAGE
k �
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION ;
FIREPLACE
ELECTRICAL: ROUGH FINAL
► PLUMBING: ROUGH. FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
^i.
The Commonwealth of Massachusetts
•y Department of Industrial Accidents
Office of Investigations
r ,
a 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):. AQ Y 1^ IL e e 11 f—
Address: � A x 1 1 -7
City/State/Zip: S CA M c1 w i c'" .heat 'W-�-(, 3 Phone.#: ? D 3 l - `/
Are you an employer? Check the appropriate bog: Type of project(required):.
LvJ 1. I am a employer with 1 • 4. I am a general contractor and I
. employees(full and/or part-time).* have hired the stab-contractors 6. ❑New construction .
2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
These sub-contractors have
' ship and have no employees • 8. �emolition •
workingfor me in an capacity. employees and have workers'
Y P h'• $• 9. ❑Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work 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.�ther .
comp.insurance required.]
*Any applicant that checks box#1 must also fin 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.
tc6ntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance far my employees. Below is.the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: A W C_•7 O Z 2 Z 1 g Q Expiration Date: 2- — 11 — 016
Job Site Address: e' .b U V-�j L►%J • '`City/State/Zip: H y 0 K1 N! I
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct:
Sim ature: la- /C Date: — 9 _0?
Phone# 9/ — F3 i — Y G
Official-use only. Do not write in this area,to be completed by city or town ofjIciaL
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#:
t
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 dwellinghouse 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."
1vIGL chapter 152, §25C 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
have been r esented'to the contracting authority."
requirements of this chapter p g
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,it
1 sub-contractors names address es and phone number(s)along with their certificates)of
necessary,supply ( ) _( )�address(es)
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 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"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
Dgpartment of Industrial Accidents
Office of Investigations
600 Washingtoii Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
-vww.mass.gov/dia
P�p,*VE, yo Town-of BArnstable
Regulatory Services
* BAMSPABEX Thomas F.Geiler,Director
s MASS. g
En.19. Building]Division
Tom Perry,Building Commissioner
200 Main Street, Hyamus,MA 02601
Office: 509-862-4038 Fax; 508 790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: G Estimated Cost GG
Address of Work: 1 S U d— �u Y�/ M A.
Owner's Name: O ei y i J )V t o V_C v S[vJ
Date of Application: -7
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
❑Job Under$1,000
Building not owner-occupied
❑Owner.pulling own permit
Notice is hereby given that: '
OWNERS PULLING THEIR OWN PERMIT OR DEALING NVITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORD DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES.OF PERJURY
I hereby apply for a permit as the agent of the owner:
7 - o ff - 0,7 ,Za v ,-j V eeo e, ► so 3 6 3
Date Contractor Name Registration No.
OR
Date Owner's Name
Q:fmTm:hcmeaffldav
die � '2O'�'"`e" t ndards ' , Licens+ or registration ate, If found reti.rn to'-
t tea rd of BuilaIag Regulations antl5 a beft,re the expiration d ;:
N 7 CQ4JTRACTOIt boa;ci of Building Pegulat►ons a�d andards
IMPRCSVle11E. ce Rm 1301
_ F�OME . cane At,burton Pla
_ Registration 1063 Bes?on;Ma.021Uf3
pp
Exiratwnc 3I2712008
TYPe 8A 1
�f KEtrIE=:CONSTRUCT ION
RR`f.KEEtdE ,ealict Without s�grature` rj
—z 611
BA UE. � {
84 KNOTT AVEN
pgiut); d�ninstrator
$AND ICH MA 02563" y
r h ` fie -�aav�nahulealt! o�./�aa�activaelta
`'I BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
i• ,
Ngmber:•,C'S,.. 049941
j
Birthdate„M05/29/1944
i Expires`05/29/2Q08 Tr.no: 25217
_ Restricted °'-1Gt '
BARRY M KEENE
84 KNOTT AVE/PO BOXY]517
iI SANDWICH,'MA.02563: y`%_
C Commissioner. �.
tioF ' ti Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-852-403 8 Fax: 508-790-62-3 0
Property Owner Must
Complete and Sign This Section
if Using A Builder
I, D G u id 1U 1 G vS G IJ , as Owner of the subject property
herebyauthorize f�a CCLI to act on my behalf,
in all matters relative to work authorized bythis building permit application for. .
(Address of Job)
Sigriatiire of�Owner� � - ,��, .Y
Al e- k69 v j s
Print Name
QTOPTY?S:0 WNE.RPERMISSION
41
Pry G vy p C b�k. Ci YJ rcC,�,Y " e.•�'� W 0 u!L L GCS
------------
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�✓ CERTIFIED PLOT PLI
RUBEI,3T G / r
BRUCE
N� W CONSTRUCTION ONLY .. . .EL .RE �- /L/-(./-/S
OP OF FOUNDATION, IS�.,._._,. FEET .k !`.TES �� IN
BOVE LOW POINT OF ADJACENT. sum .��,� ".� �a �1
1;0AD.
C �4 'mGE ENGIII(EERWe 1 CERTIFY THAT THE L"
SHOWN ON THIS PLAN 13 LO
Town of Barnstable *Permit#_a lva�
Expires 6 mont m issue date
Regulatory Services Fee a
Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PEPMT APPLICATION_ - RESIDENTIAL ONLY
•� (� Not Valid without Red X-Press Imprint
Map/parcel Number 76 "/O
Property Address a:1 3 C! 01 CA 0 2: ( U 1
a/Residential Value of Work 5 d-O C)) Minimum fee of$25.00 for work under U000.00
Owner's Name&Address ►J t C Q
Contractor's Name Lr �Le e f C- Telephone Number
Home Improvement Contractor License#(if applicable) -I !'d 3(o 3 -
Construction Supervisor's License#(if applicable) 0
❑Workman's Compensation Insurance X-PRESSPERMIT
Check one:
I am a sole proprietor
❑ U N 007
J 122
❑ I am the Homeowner
O�K have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name A S - 1\A
Workman's Comp.Policy# \jV C; '7 010 f
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to C r s -e (1 C,• 5 G,H L.' C 1;1 V�gal
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U Value (maximum.44)
11
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.eist�ionsrvation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is require0 :C �j
SIGNATURE; /6e,7 tee-
Q:Forms:expmtrg
Revise061306
The Commonwealth of Massachusetts
Department of Industrial Accidents .
_ Office of Investigations
d 600 Washington Street
"= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance. davit: builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name(Business/Organization/Individual): &Y y-y -IL P P t^ -e—
Address: P,)(,
City/State/Zip: CA 0 l.0 r c,1^ 1)v,4 OJ f 6 3Phone.#:
Are ou an employer.? Check the appropriate box: Type of project(required):.
1.[ I am a employer with 0 4. ❑ I am a general contractor and I 6. ❑New construction .
employees (full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- = listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P t1'• $ � 9. ❑Building addition
[No workers' comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.❑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.t[ oof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' .13.0 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 hire outside contractors must submit a new affidavit indicating such.
lContractors 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 prcvide 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: 4 S sG • -I nl C) 1M Cc S S�
Policy#or Self-ins.Lic.#: Expiration Date: A — 1 3
Job Site Address: 01 g -5 u �uv Ln� �`/ GtnJ1t31 S City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties osperjury that the information provided above is true and correct
Si ature: Date: �-
Phone#:
Official use only. Igo not write in this area,to be completed by city or town of ccial.
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."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s), addres (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 ibis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. -The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to'fill out in the event the Office of Investigations has to contact you regarding the 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"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.
Deparinient of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-72.7-4900 ext 406 or 1-877-MASSAFE
Revised 11-22-06 Fax 4 617-727-7749
www.rnass.gov/dia
JUN-12-2007 09:01 INSURANCE AGENCY OF CC 15088330909 P.01i01
A4VKU (;I:K 111-I�iA 1 C Vf LIABILITY 11 URANC� u.+ialmmn.wrrrrl
rr 06/11/2007
PRODUCER 0110888.2766 FAX ( 0 )8 -0909 THIS CERTIFICATE IS ISSUED A R OF INFORMATION
%#.lhsurance Agency of Cape Cod Inc. r ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
480 Rte 6A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P 0 Box 964
E Sandwich. MA 02531 INSURERS AFFORDING COVERAGE NAIC 0
MOWS Barry Keene INsuncRn Associated Industries of-Mass
BOX 1517 t INSURER 6: —
Sandwich, MA 02563 INSURER C: ,
INSURER D:.:
1
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMCD 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.
LTR NSR TYPE OF INSURANCE POLICY NUMBER ' w�pptTE MMIDDArV DATF MMIOLICY �m w LIMITS
GENERAL UABILITY EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY ... - PRPMMEB EB NTED rce S
CLAIMS MADE OCCUR _ MED EXP(Any one pereon) S
PERSONAL&ADV INJURY S -
GENERAL AGGREGATE G EGATE b
GEN'L AGGREGATE LIMIT APPLIES PER: _
PROD r
TS-
COMPIOP AGG S
POLICY JECT PRO+ LpC
1-1
AUTOMOBILE umuTY I. . COMBINED SINGLE LIMIT
ANY AUTO (Ee awaenl) g`
.� ALL OWNED AUTOS BODILY INJURY w�•m ".
SCHEDULED AUTOS. ` (Per person) $
HIREDAUTOS
p 80L)n.Y INJURY $"
NON-OWNEO AUTOS I r _ (PersociAWd)>
PROPERTY DAMAGE
(Per acemem)
GARAGE LIABILITY ✓ - AUTO ONLY,CA ACC NDENT d -�
ANY AUTO + - OTHER THAN - EAACC S
H - 'AUTO ONLY: AGG $ _
EXCESSXIMBRELLALIABILITY EACI4OCCURRENCE $
OCCUR CLAIMS MADE- AGGREGATE S
DEDUCTIBLE $
RETENTION S
WORKERS COMPENSATION AND, WORl"GINAL CERTIFICATE TO 02/13/2007 62 13/2008 TORVLBnITs Eq
ENYPRORIETORISl Iu7Y SENT DIRECT BY COMPANY E.L.EACHACC.IDENT S 100,000
A ANY PROPRIETpRIPARTNERIEXFCU7IVF, ,
OFFICERIMFMBEREXCLUDED7 PROVIDING POLICY # E.L.DISEASE-EA EMPLOYEE,SM 100,D00 0
If yes.dnwibo under
SPECIAL PROVISIONS WOW °7(,/a F.L.DISEASE-POLICY LJMR S 500,000
THER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLU6101116 ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
r
CERTIFICATE HOLDER i CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES OF CANCELLED BEFORE;THE
k <
EXPIRATION DATE THEREOF,THE ISSUING INSURER WLL ENDEAVOR TO MAIL
- MIOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Town of Barnstable. Bl dg• 'Dept BUT FAIL E TO L SUCH NOTICE u IMPOSE NO OBLIGATION OR LIABILITY
200 Main Street
Hyanni s, MA 02601 OF KIN INSURER.IT AG OR REPRESENT ES. .
AUTHORI D RB 1'
ACORD 26(20011b8) FAX: (508)775.7763 XN�ACORIOICORPORKrOWASIIII
4 TOTAL P.01
Town of Barnstable.
Regulatory Services
MkM 'g Thomas F.Gener,Director '
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
WWW—town.b arnstable;ma.us
Office: 508-862-403 8
Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using ABuilder
lV d C ei(Cc&y s-A ,as Owner of the subject property
hereby authorize (Z6Zy J I to act on my behalf,
in all matters relative to work authorized bythis building permit application for,
- (Address of Job)
Signature of Owner g
Date
Pint Name
O FORtvI S!0`i T.�•?ERMIS S ION
,� ✓fie i�a7+vrnarcurea�i;o�'✓�.t.�acsu.selt t
-� Bdard of Budding Regulations and Standards License or registration valid for individul use Only {
NbME IMPRC}Vt=1 ENT GO;ITRAGTQR } bpfure the expiration elate .If found return to. =
Hear.(]of Building Itegulations.ird�,4+andards
Registration,.t6Qg3 1:' one Ashburton Place Rm 1301..
,firation-_7 ,
1; BoAon,.Ma 0210r3
KEENE CONSTRUCT IONS + Ali y
�. EiARf2'Y
84 KNOTT AVENUE .� ._ �
1<< e�altd without s� rature y
l SANDWICH MA 02563 p iuty Aclmm�strate►r 1 g
•t�
%
Assessor's map and lot number .........'7 :1...?!. °1 .. . `
_ CF TII E T0�
Sewage Permit number ......................................................�..
33A HMTADLE, i
House number ........................... .........A.......... «./ 90 Mnea
t pow 1639' `00
�FD mix a•
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ....,.Construct Si ngle Family Dwelling
TYPE OF CONSTRUCTION ..........Wood Frame.................................................................................................
Nov„„ember 22, 19....83
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location .........Lot # 4.6 Sudbury Lane.,.................... Hy
.................................
ProposedUse ......................................................................................:......................................................................................
Zoning District ..R.B. Fire District Hyannis, MA...0...2.....60...1..... .. ..............................
Name of Owner •Capricorn Realty Trust Address 765. Falmouth Roads Hyannis, MA
: ...................................................... ..... ..... .................
Name of Builder .Franco Real Estate Deer. Cgddress 7.65 Falmouth Road, Kyannis.....MA...
.......... .. Y 21C.
Name of Architect ....................Address
3.
Numberof Rooms .....SAX.....................................................Foundation ...P.C...................................................................
Exierior ClapUoard and/or shing........................Roofing .Asphalt shingles
Floors Carpet Sheetrock
.......................................................................Interior ....................................................................................
- -�= GaS- F.-W.1A. Two Copper.
Heating ......................................................Plumbing ..................................................................................
Fireplace None pp �40,000.00
.............................................................................Approximate Cost ....................................................................
Definitive Plan Approved by Planning Board -------------------_-----------19________ . Area "4-OS sq.ft. �,�}'`,�
..............o....................
Diagram of Lot and Building with Dimensions Fee �~
SUBJECT TO APPROVAL OF BOARD OF HEALTH
J ' x
I
n
1
lti
1
i
/1
1
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
r Name 4rA4f.Ae,. ... !/ /Jil!(` Z e s.
4.
} Construction Supervisor's License ......000989..............
CAPRICORN REALTY TRUST A=270-229
%
16058 One Story
No ................. Permit for ....................................
Single Family Dwelling
...............................................................................
Location ..Lot 46, 218 Sudbury Lane
...........................................................
Hyannis
...............................................................................
Owner ..Capricorn-Rea.1ty.1rust.................. ...... ...... .. ........
Type of Construction frame.......................................
..
................................................................................
Plot ............................ Lot ................................
February 8,
Permit Granted ........................................19 84
Date of Inspection ....................................19
Date Completed ...................19
/00 70,
7o oq
moo. TOWN OF BARNSTABLB Permit No. 26058
Building Inspector
sau Cash -
9.
°" OCCUPANCY PERMIT ►- Bond
Issued to CagriCor 1 pba_ItV'Z'r'ils f' Address y1
Lot 461 218 Sudbury•1aner •Hyannis ~
Wiring Inspector I �%' Inspection date
Plumbing Inspector . Inspection date
y Gas Inspector ate , Inspection date
X Engineering Departme t,�. e t,�ff --,d,- ...,Inspection date ^ C
Y � '�g y�pL,�
Board"of'Aealth
Inspection date J
�7 �d"6l� iyi
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE f
BUILDING CODE.
ff.. ..........................._, ............................................„.. ...
Building Inspector
FROM y;.A
�— - TOXIN OF BARNSTABLE k
W. Francis Lahtei a .-. 7. BUILDING DEPARTMENT
367 MAIN STREET HYANNIS, MA 02601
Tcm C3erk � � �� � � r �
Phone: 775-1 2p i
SUBJECT:
FOLD HERE _ • ,
DATE -
22 1984 MESSAGE
irk has Yin cxled' Fe�mi. 26( 8Caaricx�rn Realty- Trst . J {
�+�r-.s:7+° d• ao x-.a haze<>�;,a .�_. a. .a•..,�.,.- w,
Please release`Bond; 01
JPIGNIVD
.DATE -
` • -
• REPLY
.. SIGNED
N87-RMi „ • - -• - .: " RECIPIENT: RETAIN;WHITE COPY,RETURN PINK COPY
• - - PRINTED IN U.S.A.
SENDER: SNAP OUT YELLOW COPY ONLY.SENDA WHITE AND PINK COPIES WITH CARBON INTACT.
%j / -
Assessor's map`and lot number. ..4�. 7U.'.a. °1..
e � THE TOE
Sewage Permit`- MUST CONNECT TC TOWNS
r ........................ ... t •
E.
House number ..... ......... :. .f�. NAB b AD LeO�
r 9�p 9. \
TOWN : OF BARsNSTABLE
t .
4 B0110,1HG 471 SP E C IN 0 R
'APPLICATION FOR PERMIT TO ...,Construct Single Family. Dwelling
..
=TYPE 'OF CONSTRUCTION Wood Fram-e.TION ........ . .......................... .....: ..............................................
November 22, 8
... 19.......�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location .......:.Lot #..46......SudburX..hane.,. :....... Hyannis, M ...
ProposedUse ........ ........ .:.................................. ............ ........ .. .................... ..............
R.B. ' H annis, MA, 02601• '
Zoning District ........................................ ..............................Fire District ...... '.............. .................•........ ................:.......:
Name of Owner.,Capricorn Realty Trust Address 765 Falmouth. Road, Hyannis,„MA.
..................................... ....
Name of Builder .Franco Real Estate Dev. C9Rddress .�.65 Falmouth Road Hyannis.,.; MA.•.
Z'ric.
Name of Architect ...........................:..:. .Address '
t
Number of Rooms Six Foundation P•C '
....... ................... ...........,. . r. ...........F.... .... ...... ..........
Exterior ..Cla..board. and/or shingles••••••.. „Roofing .Asphalt .shingles,
Carpet - . Sheetrock
Floors ...............................Interior
Ga S r W A ^--- — _._ w__ _
:........Plumbin ....Two: *Copper
'
Heating ....... . ............................ ' g ..............................................
None $40, 000. 00
Fireplace ..:..........................:........ ..........................:.::..,.........:Approximate Cost ........... ...............................................ki
Definitive Plan Approved by Planning Board _______.____ �q •------- --------1 9--------. Area .... ............0�......... .
Diagram of Lot and with Dimensions Fee ......./.... !....I......................
SUBJECT TO APPROVAL OF BOARD OF HEALTH `• 1�Q�� ,
LA,
A.
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby'agree.,to conform to' all the:Rulesand 'Regulations of the Town of,Barnstable regarding the above;
construction. `
t Y Name . ..:. Pre s
A
- � 0009.89..` Construction Supervisor's License ............
CAPRICORN ;REALTY TRUST
I.j `x_ r -c,'.
;..No .2.6053...:. Permit for One.. t. zY................
S'ri le Family i aellin9............. .......: �.
Lot 46 218 S "
Location .................i................Ll 1Li>y....Time
Owner Capricorn..Re4j.ty..'SxU�k.. ....:...:.
..
ype f Construction .....Frame .
r
Plot ....... ... Lot': .......:.................. t
M
Perm lGranted .....ebrua.ry"81..............19 84
•DatemilyInspection ................ ...................19
r'i > r 7
Dateoimpleted ..... .. .. .. ••;.................19��,! . r
r
{
W
Y ,
—
t
NS
cr
wo
1 T 4 Gcc
�$,Gu uJArr+ d
Ioi.3 y
o w4_&At s
CERTIFIED
Jo
PLOT PLAN
rJ�l ,ROBERT
. c�ucE Gt� 7- ¢6 . su�3v.eY w
N" 1fVCONSTRUCTION ONLY
'OP OF FOUNDATION IS -TO IN
� Ild
BOVE LOW POINT OF- ADJACEW.T s A - r
GOAD. A9h3 fABLj4 A,
I SCAM
DATES
DATE= z;/�/ 4
1. CERTIFY THAT THE
CI�II�PIT .., $N01#IN OW THIS PLAN 19 LO
EGISTERED REAI9TLREG y� :,. ""�""`' CATIM
E: 7.
CIVIL LAND t --- ON THE `GROUND AS INDICATEp. �tI�D '.
NAINEER SURVEYOR �t,;�lYa I i CONFORMS .TO -THE ZONING LA1dfI;� g
OF SaRNSTAt�LE MASS,-2
712 M A I S T'R E ET R L'6 .;QaYa r
H Y`A N fi I S M:A 5 5. WA .BMEERED. I;AND SU SURVEYOR:' .
777777.1
As etsor's.map and lot number ...o?.. a.''..--�!��..... ,,...f
SINE
t0
'Sewa a Permit number e�P
Z IDA"STADLE, i
",House number ........................................................................ ro rnea
039• 6�
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .............................. x..L �. ........1��.., C
��U.a�!e...............................................................
TYPE OF CONSTRUCTION .................................................... �� //,,��''
................L �Y.Z1...11''JJ
......19..
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
�i
Location ................. ..9.......... ................... ......... ?;e .. .............•....•...... ...... ............................................
Proposed Use f— � t�l ... cr... ..`.:.........................................................................................................
........... .. ..
1::..6
1--�/
Zoning District .................... ... ...............................Fire District .........7 .......................................................
Nameof Owner .W. ....... ...............Address ....................................................................................
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ..................................................................Foundation ..............................................................................
Exterior .................!!` . .... ........ �..... /........................Roofing ............................................
Floors ..................................Interior ....................................................................................
Heating ..................................................................................Plumbing ...................... ....................................................
Fireplace ...................................................................Approximate. Cost Definitive Plan Approved by Planning Board ---------------_---------------19________. Area ... +?.. .. ..................
a�
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. /
Name .`�......./ /....,c?..:� !.... .... ../.` .. .. -�
Construction Supervisor's License ....................................
NORTON, VOMA A=270-369
X7 0�
r Add Deck
Nib -.28040.... Permit for ....................................
!'.........Single Fam
ily-uidly Welling
............. ...
Location ... ...$.u&Vr -. nJ-a. .,y ..........................
....................HY
............................................
Owner ......... NQK.tQYl..............................
Type of Construction .......Frazee.......................
................................................................................
Plot ................ ........... Lot ................................
Permit Granted .... ..................19 85
Date of Inspection ....................................19
Date Completed ......................................19
Av
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .....................—_.. �..oJ--. \ C.. __..________,..
� .
TYPE OF -------�`—.-�. .� -----_______.________
. ' '
6�*� �
^ ��� l�� � -~ �. ' -----° ��--.. —.—
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for o permit according to the following information:
,_��/ �_ ka,0,0-
...iocotiun ...—..--.'`�«—�..x--.�����!���.tjIL41. .. `------.�—L-^(----..,------------
-- _/P,oposo6 Uoe ---... ��.��1�z]��--`=� �./......-----------------------------------
Zoning District ................... .----------Rne District ---I.l'�—.-----------------.
�
� Nome of Owner --- .-----A66,eo ---����.���........-----------------
Nome of Builder ----------------------'A66nesx ----------.-----.—.---.---.---.. '
�
Nome of Architect ----------------------A66reo --------------.-------------
�
Number of Rooms ----------------------Foun6otion --------------------------
�
Exle,io, -----' -------.RooGng .................... --.........................................................
Floors ........................--........................................................Interior ----....................--------__________
( Heating ----'---- -----------------'Plum6ing ...................... |
Fireplace --'�.~_ ---------------------.App,oximoteCoo ................. ^
Definitive Plan Approved by Planning Board l9-------- ' Area ' At— ,`-----
� �^�� c, ��
Diagram of Lot and Building with Dimensions , Fee ......
Fee
SUBJECT TO APPROVAL OF BOARD Of HEALTH
( �
�
�
`
'
�
'
�
� . .
'
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
�
| hereby og,aa to conform to all the Rules and Regulations of the Town of 8ornohz6|e regarding the above
construction. �
.�
Nome --...1v—^.a.���.�rL��...x�....,���.���..���—�
'
Construction Supervisor's License ------------
�
NDRION, WANDA
No .... Permit for ..ADD DECK...............
j• Sincrle Family Dwelling
........................................ ....................
Location .........21.8...Sudbury..Lane....................
......................H.....va.......nni..s
..........................................
Owner .Wanda Norton
.................................................................
Type of Construction T4Z ..............................
................................................................................
Plot ............................ Lot ................................
tr
Permit Gr
anted ..June 17, 85
......................................19
Date of Inspection ....................................19
Date Completed .............................. .....19
I.L-0
f
i4