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HomeMy WebLinkAbout0034 UNCLE WILLIES WAY �Jv 4 r r 8 E P i .,'.Y .._�':.�, �, s;:M��.k�`��,.:^.wiH3•"..�,,.*iia.�:>, "akQC�k u' Town of Barnstable Final Inspection Affidavit f Dat G� Building Division 200 Mair��,Street Hyannis, MA 02601 RE: Insulation Permits Dear This affidavit is to certify that all work com le ed at: Streets QW L-Q� Village: has been insp 4 t by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds federal and state requirements. Permit application �umber&—/ gyp— 3�3� Issue date: Sincerely, Francis Sheehan President Frontier Energy Solutions, Inc. 502 Harwich Road Brewster, MA 02631 Office: 774-237-0410 Email: fssfrontierenergy@gmail.com `V ,yC J�� /10 Town of Barnstable Building Department ;: ,,R OF THE TOE q.0 Brian Florence,CBO Building Commissioner sAxNSTAs 200 Main Street,Hyannis,MA 02601 yQ MASS. Op 1639• �0� www.town.barnstable.ma.us TED MA1 A Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: --t HOME OCCUPATION REGISTRATION Date: Name: Phone#: Address: Village: Name of Business: Type of Business: Map/Lot:0 d -1 Ed INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,..vibration, smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials, or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home _ Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. 1,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: 7-7/1, �191�— ,� jG(, Date: fir} -0 S Homeoc.doc Rev. 10/17 % Town of Barnstable. j Building Department Brian Florence,CBO Building Commissioner,. 200 Main Street, Hyannis, MA 02601 www.towu..barnstable ma us Pre-application for Business Certificate Date Map -10� Parcel�0)�FtL Applicant Information Applicants Name ° Applicants Address L/ � �mail Address Telephone Number Listed❑ Unlisted El Business Information New Business? � ` -- -a� P-- QiCI[ld_� .......... --- - --- Yes No V Business is a registered corporation? ------------------------ Yes If yes Name of Corporation Does business operate under the registered corporate name? Yes Is the business a sole proprietorship or home occupation? ---_-- -_6yes No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business A, Business Address Type of Business t°�Dn�n►mn Building C mmissioner Office Use Only Conditions ' C/ Building Commissione -U - Date a S� /a Clerk Office Use Only TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION OWN Off; BARNSTAB E Map Parcel Application # Health Division ':� ' : ) Date Issued Lh-rih 4 Conservation Division Application Fee G{ Planning Dept. Permit Fee U,_.5 •06 Date Definitive Plan Approved by Planning Board r�1t ' Historic - OKH _ Preservation/ Hyannis Project Street Address 3l (AAje W7E LA.AQ Village �4 k ,�, Owner Qbe r / a Address Telephone 73 hAKAukr 0094 Permit Request q3(o,&Qj�T Dap QAJ.Q!g=- E, P,0­0 OCR 0LCbCTDPTVC4 NY_�C 0 Pf"--I( 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: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing .❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes Ulo If yes, site plan review# Current Use Proposed Use `APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Nam C Ls Telephone Number Address: _`j'' � License # Q c f C4-1 Home Improvement Contractor# EmailmVl Compensation ALL CONSTRUCTION DEBRIS RESULTING ROM THIS PROJECT WIL BE TAKEN TO iq aADA ff �A SIGNATURE t Qw DATE FOR OFFICIAL USE ONLY i APPLICATION # DATE ISSUED .t MAP/ PARCEL NO. l ADDRESS VILLAGE � f OWNER i DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE , ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL x k GAS: ROUGH FINAL r `�• FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. DATE(MM/DDIYYYY). A�� CERTIFICATE OF LIABILITY INSURANCE 04/05/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND.CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.-THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER + - CONTACT NAME: Krystal Doyle ROGERS &'GRAY INSURANCE.AGENCY, INC. A/C o,Ext): (508)398-7980ONE n/c No: ADDRESS: kdoyle@rogersgray.com 434 RT. 134 - INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AIM MUTUAL INS CO 33758 INSURED - INSURER B FRONTIER ENERGY SOLUTIONS INC INSURERC: " INSURER D: 502 HARWICH ROAD INSURER E BREWSTER MA .02631 INSURER F: COVERAGES CERTIFICATE NUMBER: 42389 REVISION NUMBER: THIS IS-TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLTYPE OF INSURANCE INSD WVDSUBRI POLICY NUMBER MMIDDIYPOLICY EYYY MFF M LICY EXP LTR IDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ AMA RENTED J CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) . $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: . - GENERAL AGGREGATE $ POLICY❑JECTPRO ❑LOC PRODUCTS-COMP/OP AGG $ PRO- OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ _ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident . , $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A AGGREGATE - $ DED RETENTION$ $ WORKERS COMPENSATION XJ PER I STATUTE EORH AND EMPLOYERS'LIABILITY - ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEMBEREXCLUDI NIA NIA NIA VWC10060153152016A 03/14/2016 03/14/2017 (Mandatory in NH) - - E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Frontier Energy Solutions IncACCORDANCE WITH THE POLICY PROVISIONS., 502 Harwich Rd AUTHORIZED REPRESENTATIVE C Brewster MA 02631 _\-- • ..:;'`�.. Daniel M.'Crowjey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r ?f�,, r.,'t,o.trUt�tf.�rt�f/` , I �.»_rE:�t�.:��i - _ . - J, License:or reg str�tion Valid for-indieidaal use only office of Consumer Affairs K f3usruess Re�ulannn before the expiration date lf.found return to: ! y� HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and:Business Regutatio:n # it s e; Registration','h160854 Tye' 10`Par1:Plaza-Suite 5170 "4+rz , ?: 1 Expiration 9l812018 lLC Boston,.'V1, 02:116 ter. . 3 FRONTIER ENERGY SOLUTIONS'" .. - £ FRANCIS SHEEHAN � 502 HARINIGH RO - — ...........�....... . BREWSTER;DAA0201 Ld'nde�secrete�ti N- tval' itbou t nature s Construction Su ervisor Specialty Restricted to: I Massachusetts Eepartment of F'ubi�c Safety CSSL-IC- Insulation G'ontractor Hoaid of 8ucidin' lie u4atezns an,i Sta,ncircls 9 L4cesse CSSL 10594.1 constructi€�rt Stt,sru sir Saec .ity s 1 , # FRANCIS S,SHEEHAN' 502 HARW)CH"RD pREINST.EKMAA-2631� Failure to possess.a current edition of the Massachusetts for revocation of this license. State Building Code is cause ,..<. DIPS Licensing information visit:VVViW.MASS.GOV/DPS `{ �c t�rtt sioti r 02/17l201$ t The C:ommotrivealth,of rklassachusetts Department of lttdttstrial Ac(:idetits �c 1 Congress Street, Sttile 100 Boston., rA 0.2114-20.17 liom Mays:. oW(f a Work-ers' (:'tmrpen'safion insurance Afrtct:tvit: ..Builders/Contractors/Electricians/Plumbers. TO BE FILET) WITH THIr,PERMITTING AUTHORITY. Ap�licnt lnfornratiou _ _ _ _ Please. P_,rint L.e�ribly NarTle (l3usiness/Organizationilntiividualj: �l�' `.` 1 pp ✓ tZ t�G U l Address: ,U City/State/Zip: �� . ._ Q.�.(� S l Phone lt: 11� 7 � - C Are you un emplover?Check the.approprixlc hnx: --- --� �— -�- -- Type or project (required): I.�am a employer with__! ©_,empioyees(full uncllor pnrY•iimc).' 7. New 2.[][am a sole proprietor or p:vtnrrsh'i:p and have,no employees working t'nr me.in StrUCt70t1 $. [ I Neew co Conn Remodeling any capacity[NO workers'comp.insurance required.) r�-J� I am'a homeowner doing all work myself.IVo workers'comp.insurance.required.]` 9 l_ Demolition 4.01 am it homeowner and will tic hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or arc sole I I.O Ltlectrlcal repairs or additions proprietors with no employees. I?.Q Plumbing repairs or additions 1 am a general contractor and I hove hired the sub-contractors listal on the attached sheet. These sub-contractors have employees and,nave workers'comp.insurance.; 13. Roof repairs }}� 6.❑We an;:a corpnrtti'on and its�a(ltce.rs have rzi rcisrd(heir l,gltt otexemption per�tF;L c. 14. Other 'L t C\ j 152,¢I(4);and we have no employees.(No workers'comp.insurance required.) 'Any applicant thut.checks box ell roust also till out the section below showing their workers'compensntion poi—icy information. ^ t Homeowners who submit ihis Ttfidavit:indicating they arc ruin;all work and then hire outside contrtctors musi submit a new affidavit indicating such. �Contr:iciors that check this box must attached an additional sh"I showing the name of the sub-contractors and AMC whether or not those e;uities have employees. If the sub•contruclors havc cmploy'ccs.they nwsr..pmvuic dttir workers'comp.policy number. Lath an employer that tt provi(/in workers'compensation imvilrancefor my enTloyees. Below is the policy rind job site information: -{ Ituurance Company Natne: 1�k Policy 9 or Self-ins. Lic. _._._ . . ..: ......_..---_-____ Ex INation Datc ----�. .. 2_c17..._._. Job Site Addres P*j attach a copy of the worker9' compensation policy dcelaration pahe( howin the policy n t.t er and expiration date Ftiihue to secure coverage as required under MGI,c. 152, 2.0 1 § Sn is a criminal violation punishable by 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. A copy of this statement may he forwardmi to the Office of Investigations of the D1A for insurance coverage verification. i 1 do hereby certify under the paths n hei of perjury that the infornratiitn prnvirlerl above is rue and correct. j Siignat.ure: __ .-� Phoney ti: 714. 1 , Official use ortly, Do not write in this area, to he completed by.city or town trfficirit i City or•town: --------- Permit/L,icense H - Issuing Atitl ority(circle one): I. Board of Health 2. B.uilding Department 3. C ryrrnwti Clerk 4. Electrical [us 6. Other .pet for S. Plumhinh.[nspector Contact Person: Phonc g: [to, HOMEOWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER, 1 0 E /9- hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: zz!e The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather stripping; air sealing;attic& basement insulation; exterior wall insulation; ventilation measures In consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give permission to Housing Assistance Corporation the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for,no more than five (5)years after the weatherization work is completed, I have read the provisions of this agreement and give my consent. Home Owner(signature) Home Owner email: Date: Agent:(Signature) Date: Weatherization Contractors: Adam T Inc �C All Cape Energy CErQntiPr Fn�rav Solutions Alternative Weatherization Lohr Home Improvement Building Science Construction Tupper Construction Cape Cod Insulation Re ory Services VE Thomas F.Cefier,Director BIIIIdIIl—DIVISIOIl g Tom Perry,Bmlding Comn icaio:oer cc16 .200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 APProved Pee: .. Permit#: HOME OCCUPATION REGISTRATION �aten�yl j91 i� • Name: Phone#: Address: Village: Name of Business:—�W 'L& Type of Business:_ INTENT: It is the intent of this section to allow the residents of the.Town of Barnstable to operate a home occupation within single family dwellings,subject to die provisions of Section 4-1.4 of the Zoning ordinance;proNaded that the acti<aty shall not be discernible from outside the duelling: there shall be no increase mi noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration math the Budding Inspector,a customary home occupation shall be permitted as of right subject to.the following conditions: • The activity is carried.on by the'permanent resident of a single family residential dwelling unit,located within that dwelling unit •. Such use occupies no more than 400 square feet of space. • There are no external alterations to the dv�elling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flare able or explosive materials, in excess of normal household quantities. • Any need for panting generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,'other than one van or one pick-up truck-not to exceed one ton capacity,and one.trailer not to exceed 20 feet in length and not to exceed 4.dres,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation_ • If the Customary Home Occupation is listed or advertised as a business,the street-address shall not be included • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit 1,.the undersigned,have read and agree with the.above restrictions for my home occupation I am registering. Applicant Date Homwc.doc Rer. 1 3/08 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$4000 far 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St.., Hyannis. Take the completed form to the Town Clerk's Office, 1 st. FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: `>� G 3 Fill in please: s APPLICANT'S YOUR NAME/S: © CV1 :�, I j BUSINE S YOUR HOME ADDRESS: - x TELEPHONE # 4 amerTelephone Number NAME OF CORPORATION. ' NAME OF NEW BUSINESS: - ' TYPE OF BUSINESS V 1 4 . 1S THIS A HOME OCCUPATION_ YE NO ����,l!��c,,�� ADDRESS OF BUSINESS E? Ct 5. ' u 11�fAP.PARCEL NUMBER a� (Assessing) 9) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street). to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING C MMISSI ER'S O cE MUST COMPLY WITH HOME OCCUPATIO[(` This indivi e r1 of any p m't require ents that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO A s ized n tr. COMITY MAY RESULT IN FINES. C MME S• f4e U0t rMAJVA1-;d3 2. BOARD OF H LTH This individual has bee f r d of the permit requirements that pertain to this type of business. MUST XMPLI'WITH ALL Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS(LACE SI LACENSI AUTHORITY] This individual has 14n inf ed f he licensing requirements that pertain to this type of business. Authorized Signature* = COMMENTS: e °Fj ram, Town of Barnstable *Permit# Expires 6 months rom issue date JULRegulatory Services Fee sA"Srns v� 1639. a� Thomas F.Geiler,Director PIED MA'1 A !/ Building Division OC j �`>a#o IPerry,CBO, Building Commissioner 9, 7 7100/)v 2009 g200tlMain Street,Hyannis,MA 02601 ���� www.town.bamstable.ma.us Office: 508-862-4038 "%,3 li�� Fax: 508-790-6230 EXPRESS PRRLMT APPLICATION - RESIDENTIAL ONLY C Not Valid without Red X-Press Imprint Map/parcel Number (c Property Address V. ❑Residential Value of Work ! 000 0 inimum fee of$25.00 for work under$6000.00 Owner's Name&Address ; 0 , C( Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor M I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) b _ . ( Re-roof(stripping old shingles) All construction debris will be taken to sp k Lf z) i 'Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *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&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORM uildi g ptiemui form�s\EXPRESS.doc Revised 090809 The Cornmonfvealth of Massachusetts Department oflndustrial Accidents �' Lr Office of Investigations ►'_ 600 Washington Street Boston, MA 02111 y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 4 Please Print Le ibl r Name (Business/Organization/Individual):_ i Address:TL� � t/ t` tom` �/ Xk City/State/Zip: ,; f t �' -016LI Phone Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me.in any capacity. employees and have workers' 9. ❑ Building addition. [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their 11.0 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' 13.0 Other comp.insurance required.] 'Any applicant that checks box 41 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 or not those entities have employees. if the sub-contractors have employees,they must provide 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: 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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trice and correct. Si atu l m Date: o V /0!? Phone#: Official ttse 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 Linder 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-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 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 V Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia THE Toh� Town of Barnstable Regulatory Services �saxrvKASS. Thomas F. Geiler,Director F16 9;. Building Division Tom Perry,Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using 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) s . Signature of Owner Date . Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Town of Barnstable P' o Regulatory Services • Thomas F.Geiler, erector =ASNS ABLE, tFt.nss. 9�A 1639. a,�� Building Division rfD MA't 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 nn Please Print DATE: V JO B LOCATION: E ;\ num er street village "HOMEOWNER": ®� C 0 9.,-8 " 5—��4 j name home phone# J ✓�wwork phone# CURRENT MAILING ADDRESS: ��(�! 1 C� � ' I fh �S L2 I L T Mal city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and engage an individual for hire who does not possess a license,provided that the owner acts as to allow homeowners to 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 re rements. gnatu om omr 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 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 fonn/certification for use in your community. Q:\WPFILES\FORMS\homeexempLDOC 4 m (h I t--� - 61 pl }o � Q.o.W. 1d..00 d 7 1. rAti Q .s-j Ip4 3ai 4 t18,BK� / m I tea.. .6 � - �s � •� 3 .m UO � 7 r j co ro 7 Iv .� 24 ._ Li, �s too.oo ; $ u .. 4 I p Oc'v5 SF s Q vr=mo c-- c.a _ m 0.10 7 101.32. k C : ?S 20 -ZS'E- , \ ? CO ci 0 �I I di a di S 1.5 zo 2s '. s �S: 2� 2s° m � Q a 0 d l 0 335 0 jO Oda sue: d pA&rl 3 a ,. > - ` tl 2S I-- 3 te o odo sF ai co E- 1 V' i V. .4 Lo tU o AAAs_ t, t .co m 8 0 w jI t TOWN;OF .BARNSTABLE 2Q422 3/15f 7; r` Permit No. --------------------------------- Building Inspector lAa»TAK Cash -------------------------- °""Y�� OCCUPANCY PERMIT Bond ----------------- ��► �7Y "No building nor structure shall be erected, and no land, building. or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to J. A. Bassett, Jr. Address 8 Skyline Drive, W,Yarmouth lot`#21 34 Uncle Willies Way, Hyannis Wiring Inspector Inspection date p_ Plumbing Inspector Inspection date Gas Inspectort�-�'1 n �t� � Inspection date Engineering Department , Inspection date /3tj /75 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. E 19. ! � R ...............r r. _ ......... . ... . Building Inspector Id m aq ...... e Assessor's map and . lot number .. :. .. ........ ..... . SEPTIC SYS'TElti INSTALLED •IN COP1NCE "•` WITH ARTICLE I I STATE Sewage Permit number ............................................................. �ANITAI� �uY CODE`AN® T®VVN TWE T t -µ TOWN OF BAAX�YAM . d� o• 37 e� o B9SHSTABLE. " 039 a Bl1I-LD [H�G ] NSPECTOR �p • Ll ti c APPLICATION fOR .PERMIT TO ..... ff../.15#0 4f...... /.ix ./z/k........44.l?72 A.......................... . TYPE OF CONSTRUCTION ..................I. c?®la...... ............................. ....................................... n ........... ........ee...............19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for paypermit according to the following information: Location ......�...7..........��+].............Qva.� 1.�4......I .L1-4A......!- .Ir:y................R:141VN f.....................�........ ProposedUse ........... &Y... .../ ! n,............................................................................................. Zoning District ................................................. ...................Fire District .....If,(14 t1.4>'t'.aI................................................... Name of Owner ...- .. .r.. 7 ... ��............Address .....D........ ��� ......bo�r�� ..;�!.. . Nameof Builder ............. .e.....................................Address .................................................................................... Nameof Architect .......... .� ?: ....................................Address .................................................................................... Number of Rooms ���........................ .........................................Foundation ...........ftr...�.......��.�.�.�,f.................... r� Exterior ..:I �.1.'r. rr-.... 4ki l.l:....' � �/ ` Roofing ..:..... ? �+'��-. ................................................... Floors ...........A.M.4....1 ...............................................Interior .........hgl .Y....U)AZ.L................................................. Heating [.. �CC 'fa �V ft 7F g � ��...��.�l�f.�........ oC�...... Fireplace ....../e.....4.1. AQ!e:►.........................Approximate Cost .........ad.4-050....................................... Definitive Plan Approved by Planning Board -----------_______-----------19________. Area /.?.f�...... :.. ...... Diagram of Lot and Building with Dimensions Fee : l .........�� SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... .. .. .. ... ... .... ................................ r Bassett, J. A. Jr. 2t1�22 No Permit for TlS.t.ri!&ir.&m bin gle..f gmlt ,........ . .... %..dF7el.l.3,Ag.................... Location .34..1ITXQ1C..W4.W"Y..W,a - HyaAuls.............................................. Owner ......Jo.. ..................... { Type of Construction -wood ` YP tame................. _ ....................... .................................................. f Plot .......................... Lot 421........................ r a Permit Granted ...March.45..................19 78 ` Date of Inspection .��J G/ .. ....... 19 Date 'Completed ... .. ..L..�...� r PERMIT REFUSED .......................................................... ... 19 ..... ........ ....................... :a . .. ........ .../. .................................... ...... ................. ..... .. .... .......................... . . f ............................................................ z Approved ................ ............................... 19 ............................................................................... IM Assessor's map and lot number .......... ........................:..:.. SewcNge Permit number o�TMETo TOWN OF BARNSTABLE r � Z BAE 5TADLE, i "b q BUILDING INSPECTOR APPLICATION FOR- PERMIT TO .....I ................M&.•q^ ...... .�?� ............................. .v1, TYPE OF CONSTRUCTION .......................... 1...... ........;�.rA�........................................................................... .... `. ........�..................192.R TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......�—�?...r......... . 1 ...........Qi & ...........:...............:........................................................:.................:.� f......... Proposed Use ..........:��'.�A1c/ ..... ;?! •.��......h a. ................................................................................................... r' ZoningDistrict ........................................................................Fire District ................................................... Name of Owner ...-T A— ccs 7~y .....�T� ..............Address .... ...... /a�>:�..... 1l7 I / .... L/H,e., Nameof Builder .............`r...rr?.............................................Address .................................................................................... Nameof Architect ....................................Address .................................................................... Number of Rooms ...................... .......................................Foundation AUr-,e—"X ......r, �("�f 7"s Exterior ...t!.)! T3:.... 1c,rc' ,t1r1��L C Roofing .......t �.0 1./ 7 Floors ... I. ]rr� ..............................Interior .......! ) /e.................................................... Heating C _ '......... I ir, %� CI(I r 7 Fib f 1� 'h .......................................................Plumbing ............................. . .. ........................ ..................... Fireplace ......6fii.............11l ll...... ......�® +...........................Approximate Cost ........ ...................................... Definitive Plan Approved by Planning Board ________________________________19________. Area /L1/.d s4 )T ...;........... .... Diagram of Lot and Building with Dimensions Fee ........�-3/`-7 ,5� 1 ..................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH /Iq i r S -I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................ .................................................................... Bassett, J. A,, Jr. M-292 L324 20022 No .......I........ Permit for .......•,constructing single family dwelling ► ._ ' Location 34..Uncle..Willies. . . .'.......Y................ Wa .... ....... .... ....... .. ... 1 Hyannis r ............................................................................... Owner J. A. Bassett? Jr. ..................... Type of Construction .. ::,god fr,Me............•.... ....................................... .................................. l Plot ............................ Lot . .. !` �...................... Permit Granted ...,* March 15 .................................1978 Date of Inspection ..... .....................19 Date Completed .+.......... 19 P € PPER/ITREFUSED ................. �...... ..... 19 .......... /..../..... .............. f ••............................................. . .......................... iApproved ................................................ 19 SOIL LOG \XtiY�•(U KYl\Y • ry!/M c�rf,i.ivcfi�,.v�/i•�WiA,�x � - / / r 2'.PEAS TONE LOAM B FILL 12 MAX sV� � s a ,90 ° I 4 C. I. D I S T. BOX � r ° oo °• °O 01( 7;—,3T 1� ,24 MIN • /O YIN. 1000 I, 0, o ° 1000— GAL. ,01 y PRECAST OR SEPTIC 6 BLOCK TANK BLOCK TAN(NK I�°, ° ' i SEEPAGE PIT °° z� ys6 I eo 20' MINIMUM o,' '• �a� _ _ _ _ O q H tS FOUNDATION I I %z" WASHED STONE ELEVATION SKETCH r= 10 PERC. RATE Is <•, ti -X Z.,.,���bc�' SCALE : I"= 4' TEST BY : � ���/r,: ,��•� ''nhC"t_"cx TOWN INSPECTOR: LE-4=1c- Tr BACKHOE OPERATOR TEST MADE ON z 7 i 5 A �:G T ci.�L .�-=�dG-L.D .5�.�✓t/ a•./ J.av L 7 !9 7$ `pk 0 it of fit, 4' 1 " ROBERT r ` DAYLOR 0 = No. 20108 �J' io3 a TA - f Paz - No --7-� c o . 0,' --- �� 1 ( 1 ✓� �16rtJ F+I�tiU 2 'X O _ 2s.G Cw,f7 G I % � :� � �_1I _. isX�4N ✓N I � � L.EAGN •�llrr �t��A PQo°✓i�erD � `� �J` � �g'� a s�k X2. / 21�, c s A:t:Qo•C ARGA }- I[,� I3CA7 Roos 44 , C f 7Z6 F'IT �OT 1 ics L/ 01.Zi ` NIS '���frs�r F1LG3 e^+F=• �'Dy�lN � \�� �' � n �/r�G`�•" Ls.�•'i G c� ;Es � G.°.i ..d y �I/o • LJ . b c:: — r�rt•v.�.�-r� /oZAJ 5 ' /o/ x 33 j ELEVATION SCHEDULE PROPOSED SITE PLAN I. INV. AT FOUNDATION SEWAGE SYSTEM DESIGN 2. 1 NV. INTO SEPTIC TANK = p'' 41 IN 3. I NV. OUT OF SEPTIC TANK = !d2,79 �� �i•.c-G�= ^-'" ` �`"� �e1. y 4. INV. INTO DISTRIBUTION BOX = OZ•ryf SCALE: I°= zo 19 'a �FALt0��\� 5 1 NV OUT OF DISTRIBUTION BOX = Oa'3 C— d �� ROBERT �r F. m 6. INV INTO SEEPAGE PIT cn CAPE COD SURVEY CONSULTANTS a OAYL ROUTE 132 No.23741 O • 7. ]BOTTOM OF PIT _ 9(i.10O\�G,",� HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. s f 8. BOTTOM OF STONE LAYER = c •9 + T