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0093 UNCLE WILLIES WAY
��. i I �i i Application number................................................ Qa �� FMQ O.r'�1R��.01 Fee�� ...........:....0 8.......-O.b..... ....�.... ... ....... ...... MAW OCT 0 12018 Building Inspectors Initials..... ................... .. Date Issued.......`..... ...°..... .................................... Map/Parcel.............:............ ...... .......................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGNY INDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET V4AGE Owner's Name: llC l<D(O-W Phone Number S-03 73 7-0/7,5' Email Address: Cell Phone Number Project cost o� Q0 _ Check e� $ on Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: ���Qc� Date: TYPE OF WORK 02(siding 2J Windows (no header change)# '� Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review IETRoof(not applying more than 1 layer of shingles) Construction Debris will be going to $ F-lCe,�, CONTRACTOR'S INFORMATION Contractor's name � S �c�rx r�l� �d (I k— Home Improvement Contractors Registration(if applicable)#_ �6,�o� (attach copy) -Construction Supervisor's License# O1 g3 (attach copy), Email of Contractor iyiC,- ai—cl i'ks btu/dl . f0M Phone number 77L/ 0036.665- ALL PROPERTIES THAT HAVE STRUCTURES OVER 7§1YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. s APPLICATION NUMBER............................................................ wi i *For Tents Only* y Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent . X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or> Yes No_____, if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, speck inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE Signature Date /C7/o/%d/� All permit applicatio are subject to a building official's approval prior to issuance. 5 i j 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 r Name (Business/Organization/Individual): �/y S ��/�/� J�YI0� Address: 2 uClecv '1-r City/State/Zip: S NA OZ6 01 Phone#: 7` / -93 6 65 Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with 2. 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.❑ 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 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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Q Insurance Company Name: Policy#or Self-ins.Lic.#: ANC`9CO,703 66/3 8 Expiration Date: Job Site Address: 23 MICA IVIJlt f-s . 61)ay City/State/Zip: �A /I MA 0260I Attach a copy of the workers' compensation policy decla ation 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 co erage verification. I do hereby certify under the pains a d penalties of pe jury that the information provided above is true and correct. Signature: Date: Phone#: 77�/ 3G '665 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#: i A 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-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 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.#617-727-4900 ext 406 or 1-877-MA.SSAFE Fax#617-727-7749 Revised 4-24-07 wwtv.mass.govfdia •Y' �a IHS9 Building and Remodeling,Inc Email:Richard@ihsbuilding.com 32 Buckwood Drive - Website: www.ihsbuilding.com Hyannis MA 02601 Phone: (774) 836-6654 —Building&Remodeling— Construction Contract This agreement is made by IHS Building and Remodeling, Inc (Contractor) and Judy YALDATEL and Ken ROGERS (Owners) on the date written beside our signatures. Contractor IHS Building and Remodeling, Inc 32 Buckwood Drive Hyannis, Massachusetts 02601 Daytime Phone Number: 774-836-6654 Evening Phone Number: 774-836-6654 Email Address: richard@ihsbuilding.com Federal Employer ID 823954399 Massachusetts Home Improvement Contractor Registration Number: 190612 Registration expires on 2/9/2020. IHS Building and Remodeling, Inc is incorporated in the state of Massachusetts. IHS Building and Remodeling, Inc will be referred to as Contractor throughout this agreement. Owners Judy YALDATEL and Ken ROGERS 93 Uncle Willies Way Hyannis MA 02601 Phone Number: 508-737-0175 Judy YALDATEL and Ken ROGERS will be referred to as Owners throughout this agreement. The Construction Site 93 Uncle Willies Way Hyannis MA 02601 I. Project Description A. For a price identified below, Contractor agrees to complete for Owners the Work identified in this agreement as the Project. The Project is described as follows: -Obtain necessary permits Roofing: -Remove 2 layers of roofing shingles and replace with Lifetime CertainTeed LandmarkTM Architectural roof shingles. Color to be determined. -Install ice and water shield first 3 feet of all eves and rakes,valleys, and pipe boots. -Use Roofer's Select®tar paper over the roof -Install new roof by storm nailing all shingles for higher wind protection. -Replace roof flashings around eves,pipes, etc. -Install extra wide metal drip edge,flashing on all eves, and 5"drip edge roof rakes for better leak protection on all edges. -Reflash skylights and counter flash chimney flashing -Install CobraTM ridge venting system Signatures The signatures that follow constitute confirmation by those signing that they have examined and understand the Contract Documents and agree to be bound by the terms.of these documents. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES'!! This agreement is entered into as of the date written below. Judy YALDATEL a Ken ROGERS, Owners OVIJA�'�01 .' (Signat ) ( te) Zia,) (Printed N e) (Sig/nature) (bate) (Printed NaMW IHS n�v emodeling,Inc, Contractor 7/17/18 (Sign- re (Date) Richard Peckham, President (Printed Name and Title) Page 9 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construction'Supe.rvisor CS-094193 E4pires: 07/29/2019 77 RICHARD J PECKHAM; 32 BUCKWOOD DRNE..''; ' HYANNIS MA 02601 N Commissioner V' — .5 . '' i���ze tPaminxa�acuealt/o�C�/��auac/u�elta - office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR TYPE:Corooration , Registration Expiration 190612 02/09/2020 IHS BUILDING AND.REMODELING,INC. RICHARD J.PECKHAM 32 BUCKWOOD DR ' HYANNIS,MA 02601 Undersecretary Constriction Supervisor Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl • n f a I i I I Z ,T- r � I OF i T 1 ( � - s i u 0 1314 1 I o � y rt s�aNAL LA " ;;, • ' "AS IPUILT PLOT PLAN TO THE BEST OF MY. INFORMATION, f�ASS. ,KNOWLEDGE, AND BELIEF THE Lor 2 �, ,F- 30� (� 9 ' v,✓ .4 rio,A/ SHOWN ON THIS , R J. O/�EAR/1/ /NC i ;PLAN HAS BEEN LOCATED ON THE SWAN RIVER PLAA GROUND AS INDICATED. 35 ROUTE 134, UNIT 2 SOUTH DENNIS, MASS. 02660 ` UATE : 7110 _ SCALE = 26 JOB NO. _.�, CLIENT: TE REGISTERED LAND SURVEYOR DR. BY : __ SHEET !0F i .I 77 yo, ! < c;'� y l Town of Barnstable *Permit#�3 - -� im mo miscue Regulatory Servicesi 6 ee fr ' MASS. Richard V.Scali,Director 059�- ► ` Building Division 200 Main Street,Hyannis,MA 02601 www.town barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS ERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address �-00( l e S A Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address -e rACS 1 . Contractor's Name ' (/;�q,f r�( e.(i[�W���'°� c F< Telephone Number —,7 Home Improvement Contractor License#(if applicable) /6 fO 15 3 �l Email: Construction Supervisor's License#(if applicable) tl- ❑Workman's Compensation Insurance ® Reset r PII ne: >..: a sole proprietor JUL 2 4 2017 the Homeowner e Worker's Compensation Insurance Tot"' ot"' O� 8A R AI S-�/iDL E Insurance Company Name F One, 4 �l l`� Workman's Comp.Policy# y�—(�/�. —G/�j® z O -31 LZ Z ,�4 Copy of Insurance Compliance must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) e-side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. _ y of the Home Improvement Contractors License&Construction Supervisors License is r SIGNATURE: l QAWPFII.ESTORMS\building permit forms\EXPRESS.doc 01/25/17 The Cawmmweahk 4Mkmzdmse& Office OfI 600'Was*gLou jrreet • wrv��ms����ra Warl ers' CaupensatimtInsm-mce Af fidavit Bml.Eler-.lCantractar-Mechidansdgm bens AgOlkant W- wmafian Please-Print Are you an eotplo�e . Checkthe apprapriate b= ' Type of project(reed}_ L❑ I ant a emplayw wi& ¢ ❑I am a general conirsctar a d I 6. ❑New cans5[mr&n emplayew(f dandforpm"me)-* 1=ehinAlhe sulr- 2. I am a saie pzvprietor arp3rtaer- Til ed oaflsE a�arbed sheet. 7 ❑Remodeung sh p and ham no employees 0 Demaltfioa en3ployeess.Chace workers' wozifimg foe.me is any capacity- c �„��$ 9. ❑Building addition [NOromp.ias�ce °mp- revim&] 5. 0 We are a cmporafianand ifs 1Q0 Electoral repairs cr ad&fi= 3.0 I mn a hQmevmw doing all wodc officets have e--P,wed thak 1L 0 Phmd3 agrepaim or ad&h ms. Mysem[No wadmre F- p� �' UZ Roafrepaim c-M¢It�andwelmmno A ��-[No13-0 other a n C°mP-inmumca MquhB&] `$apapp&�t�sccberEsbmc itaasca]samoa these oaudaW ffieawo�C�mmp�aSaupa yi ma�o� #ff�vra�wlzoVamakITrisaffidnic they ampsagw Kn4&MMoMbideca =-s#galadtaumuffdavdium SWI FCa�sacf�B�sCd��s6mcmasta�rhe3�mcaddiS�alsineetsTioaiagtLenam�of�eaodsEafe�rhei�arm2fi�nse�shs� Mvb3 mTM2snH-C�1=er�gloy s,&�ey gmsddt uanrkea'trmp.paTiryav�bet I am ari emplisr dint fs pmvidzii;nwrkecs'comperiardfea h=raurifor ray empkwes Beraly is thepaucg arrd jab zIe inforracdiam n Ias�seCamgaayl+Fame: d'— /71- 'Porwy 9 or Self ims.um e(��✓� ,DC) 70 3�Ll Dafe: Job&ta Addres 5 V ea tr ull. /io s- Ci£g/Stdazzip: 4 e eztt ( I S Af4ach a capy of the warhers'compensationpaTcydaeclaraf m page(sha ing the policy ngmmber and e=ph-A6on date). Fail to sew coverage as requinAunder Section 25A of A&M a 1572 can Lead to the imposition of eri-inal penalties of a fine to$1 41}4�az,dJor arse-gar imprison as weS as civil penalties n ffie fgan of a STOP WORK ORDER and a fine of up to$25a0a a&y against the violaiur. Be advised 9xd a copy of this statement maybe forwarded fa&M office of Ids of9m DIA for coverage Vedfication. Ida Beer y ' s attd s"�Fcr j�crF atflis ar+srafimtpnaci rl a€��att�s icg�6afrs�an d correct i—. atar� _ Bate_ < d`( C> (' `7 alai aw awoL Da not aunts in dds area,ita be compWad by dip artowt affidat t.afy er Tawn: Permit cewe ig Issming Axflmrky(chiffe one): L Board of Health .. Depa t 9.C& p1ruwaors 4.IIearical Inspector 5.Phrnbiug hVecter 6.Other Coact Person: Phase#: -- 6` afarm ation and Ins c ous �. . :. . Laws M requires as cEqAay=t3 pravide cnsatkm for their emglloyecs. &is ,an Iopee is defined as¢:eYexyPerson in a service of anafflcr ua3a any Men3r-t aflm-, ' empress or jrcg?jjc4 001 orb" An rpTayer is ddmed as wmbX ideal,Pam ,amciabc Tj6m_.�parafian or ofheS IegaI e�y,or say iwo or more off is aJ� MAi-MI�dmg =�� oft deceased employer,or the reaeiv=or trustees of an kffrvidnaL per,asociaiian or ofiieslegal MItit9,CEqiay1119 CEaF'DyD--- However file own=ofadWrDinghonsebaviog•aotmoretbMlffee-spat=ftmadwhoresides•weir,criheo affh- dweMag house of another who elmPlops P==M is do maims cc.CM=Jrad nn or repair wow Cal such&mlTmg horse or on the grounds or bmldmg a IhMcb 9nUnotbecause of such emplopm dbe deemedt o be an employer-" MGL rhapt�l52.§25CC6)also stems tTiat¢every stain ar local Iiceusmg z cy shall iihald the i�snance or rencW21 of a Dcease or permit to operate m bminess or to construct bwjRamgs iu tiie commoner for zY apglicant mho has notgrodnced acaepfahle evidence of cnmpTianc�wi&fire insuranm coverage ,q�ri'rf; naIln MCrL chapter L52.§25(M states fiTeidcrflie _ nnr�y ofitspoIitical subdivisions shall ester min any fs&C P ofpubho wcok vahl ac�tab evidence of coupIian cewith the msm-tee. req===fS ofthn dMpt=BEVO 1; �P==tndto f=confraZffng.MffaoZy:" A.PPlicants Plea fse ili ovt $se wmk='oompcusatinn affdaya compleh;Iy,by d=idmg the boxes runt apply to your soon and,if nece$s�,amply�b acmr(s)name(s), addressCes)andpbrmcnnmbMCS)aIongwrthtllea ctfrcs±F- of in3�ce. L—ixdLiabilityCompenies(LLC)orL-imitedliabii_r? s(IIP)v�ifiino euipIoyees o tbanibe members or p ere mot rbqca-ed to cosy wmi=e coxtxpensatiom iasmmzce- If m ILC or 112 does have empIoyees,apoIicpisr Bea3visedi3�tiusafBxykmaybesnbmit�totboDeFazimectoflndastial Accide�for cow of insurance coverage: Also be sore to sipz and date the afncdaQif The affidavit should bereinmed to&e city or town that the aPPlic-atian for fife Pence or license is being rrctpited,not thin D epai ccn' of Iadusttial Ascidrsfs- Shanidyoa hour any finest Lcos regmffi g the law or ifyou are wed in obtain a wo�e�' camp=saE pofiey,gleamcallfhdDepmlmeotatthenumberlisfEdbelnw. Self-insured=nP2`micsshouldcaterIieir. self-ia_��ce Iicecse mmzb�an�.e Ime. Clay or Town Officials _ Please be sine 1�tTze affidavitis complete andpxiatcdleg�ly. The DeperSnenthas provided a space at the boffnm. • of•Hie:affidavit for youto frI1 out iaf e,aye 13D Office oflnyestiaQafioas has to MdB.Ctyouregazdmgthe aPPh=at Pleasebesureinf�IlinthCp re„ beawhichwMbeusedasaref �mbmInaddition,eaaPPU•� t�must submit multiple Pose aPPhtstxm in any gmayear,need only s Dine affidaviE mdicaimg cunxuot policy kf m ati=@fneoes&ny)and under"rob O Ate"fie spphcmt shouldwafe-BU locations 5n Cc'Ly or town)"A copy of ihe•affidaviL at has bees officially stamped cr maimd by ire city or town may be`Provided in the applicant as proofthat a valid affidavit is on f In far t ure'pc®js or 1"icenses Anew affidavitmirst be fiIled Dint each ift7mm is obtaiaiing a Ticeuse or pe�itnot reTatr-din a3iy bus n=or a year�Rhene a home ownrx or c a dog license orwonitinbumIeaves efn.)saidpCE=is21C1'Treed affidavit The Office ofInvesbg3fi= h� wouldeinthankyouivadvm=foryourcooperationandsbonldyouhaveaaY4 =• . please do not hesifetn to give us a call The Department's address,telephone and fax number: - - Rmised¢24-07 g Office of Consumer Affairs&Buuess Regulation License or registration valid for individual.use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration,'-'', 166334 Type: Office of Consumer Affairs and Business Regulation l Expiration:`='-5[T3/2018 DBA 10 Park Plaza-Suite 5170 r Boston,MA 02116 , INTEGRITY HOME;SOL ffIONS�( RICHARD PECKHA�VIJ: 7r ; 32 BUCKWOOD DR``: ---- HYANNIS,MA 02601 "-�__ Undersecretary o lid out signature Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-094193 „ °w Construction Supervisor RICHARD J PECKHAM,JR. 32 BUCKWOOD DR., HYANNIS MA 02801 ?,.:�,, q (�.�n l� Expiration: Commissioner 07/29/2017 r j J ofCo timer Affairs 1 B (iine/s�Rcg c/two License or registration valid for individual.use only Office of Consumer Affairs&Business Regulation g Y r HOME IMPROVEMENT CONTRACTOR before-the expiration date. If found return to: Registration; °,166334 Type: Office of Consumer Affairs and Business Regulation Expiration:"5/13/2018 DBA 10 Park Plaza-Suite 5170 I = Boston MA 02116 INTEGRITY HOME SOLUTIONS RICHARD PECKHA -,JR-< � 32 BUCKWOOD DR , HYANNIS,MA 02601 "°="= Undersecretar y 0 lid w' out signature Construction Supervisor Restricted to: ro Unrestricted- Bwldmgs of any use group which contain less than 35,OOC cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOV/DPS Integrity Home SoCutions P.O.Box 1269 774-836-6654 � Celiter\•ille, MA 02632 Richard@illsbuilclingxoln �vww.ihsbuilding.com Building x Remodeling- Construction Contract This agreement is made by Richard Peckham Jr. (Contractor) and Judith Yaldatel & Kenneth Rogers (Owners)on the date written beside our signatures. Contractor e-N-G( Richard Peckham Jr 1 PO Box 1269 Centerville, Massachusetts 02632 Phone Number: 774-836-6654 Email Address: Richard@ihsbuilding.`com Massachusetts Home,Improvement Contractor Registration Number: 166334 Registration expires on 5/13/2018. Richard Peckham Jr. will be referred to as Contractor throughout this agreement. Owner Judith Yaldatel and Kenneth Rogers 93 Uncle Willies Way Hyannis MA 02601 Email Address: wildwomanofgod@msn.com ' Judith Yaldatel and Ken Rogers will be referred to as Owners throughout this agreement. The Construction Site 93 Uncle Willies Way Hyannis MA 02601 I. Project Description A. For a price identified below, Contractor agrees to complete for Owners the Work identified in this agreement as the Project. B. The Project is described as follows: , -Remove and replace siding shingles on the right-side gable wall with Grade A R&R.whiter cedar shingles -Remove and replace 2 existing windows with Harvey Classic double-hung new construction style windows -Remove and frame in kitchen window, repair sheetrock and siding as necessary -Prime new interior wall finish -Remove screen door to the kitchen, repair trim work behind and reattach the screen door -Repair rotted corner board to the left of the screen door NOTE:Any unforeseen rot will become an extra charge and will be fixed at the rate of$65/hour plus materials II. Contract Price A. In addition to any other charges specified in this agreement, Owners agrees to pay.Contractor. $7,300 for completing the Work described as the Project. Page 1 . Integrity Home SoCutions P.O.Box 1269 774-836-6654 �( �` Centenille,MA 02632._ Richard@ihsbuildinb.com I1HA www.ihsbuilding.com Building&Remodeling-- 7 III. Scheduled Start of Construction A. Work under this agreement will begin approx. first week of August, assuming Contract is signed and deposit is made. IV. Documents Incorporated A. This agreement incorporates by reference certain disclosures and notices required by federal and state law. The following documents are incorporated as though included in full as part of this agreement. Notice of Right to Cancel under Regulation Z (in duplicate) B. Anything not included in this contract is not included in this agreement and is not part of the Work. Contractor will be entitled to a Change Order and additional comperisation for anything in any Plans or Specifications or anything required by Law or ordinance that is not identified in this contract. V. Scope of Work A. Contractor shall supervise and direct the Work and accepts responsibility for construction means, methods, techniques, sequences and procedures required to complete the Project in compliance with the Contract Documents. B. Contractor shall make a best effort to adopt and implement policies and practices designed to minimize work stoppages, slowdowns, disputes or strikes. Except as may be specifically provided elsewhere in this or a separate agreement, Contractor is not liable to Owners for damages suffered by Owners as a result of work stoppages, slowdowns,disputes or strikes.Contractor shall allocate labor tasks among the various trades in accordance with local custom, rules,jurisdictional awards, regulations, and decisions, regardless of-any classification by the Contract Documents. VI. Compliance with Law A. Contractor and Owners mutually commit to use reasonable care to meet the Requirements of state, federal and local Law when discharging their responsibilities under this agreement. B. If Law enacted after the Contract Date changes the Scope of Work under this agreement, Contractor and Owners will execute a Change Order adjusting the Contract Price and Contract Time to accommodate the change in the Scope of Work. C. Contractor is licensed to do Work described ,in.the Contract Documents. Contractor will notify Owners of any change in that license status. Every Subcontractor working for Contractor will hold a license appropriate for the Work performed. D. Except as required by Law, Owners are not responsible for any breach of Law by Contractor. Except as required by Law, Contractor is not responsible for any breach of Law by Owners. VII. Permits and Fees A. In compliance with Massachusetts General Laws 142A, Section 2(a)(10), Contractor has: (1) Provided Owners with a list of building.permits required to complete this Work, (2)Advised Owners that it's normally the obligation of a Contractor or Subcontractor to obtain the required permits for their Work, and(3)Advised Owners that homeowners who secure permits for Work on their own homes are excluded from the guaranty fund provisions which appear in Massachusetts General Laws 142A, Section 5. Contractor accepts responsibility for securing building permits for the Project. Page 2 Integrity Honw SoCutions = P.O.Box 1269 774-8S6-6654 7 Centenille, MA 02632 1 Richard@11isbuildfi-ig.com www.ihsbuilding.com Building&.Remodeling I. Owners' Responsibilities A. Owners shall have sole responsibility to secure financing for the Project and shall pay all fees, charges, or other costs of such financing, including Inspection fees charged by any lender. The nonperformance of any lender shall not affect the obligation of Owners to Contractor. Owners hereby authorizes and directs any lender on the Project to furnish Contractor with full information on undisbursed loan proceeds when requested by Contractor. B. Owners will not interfere with or permit others to interfere with, stop,hinder,or delay completion of the Work by Contractor or Subcontractors except as provided under this agreement. , C. All materials to be furnished by Owners under the Contract Documents shall be on hand and available at the location specified,when required in the normal course of construction. Contractor makes no warrant that materials Furnished by Owners are suitable.for use in the Project and may reject such materials if installation would materially increase the cost of construction or substantially delay completion of the Project. D. Owners shall obtain all consents and approvals required from any architectural review committee, homeowners association, or similar entity having the right to review and approve Plans prior to construction. II. Representations by Contractor A. Owners have reported to Contractor all conditions known to Owners which may not be apparent to Contractor and which might significantly increase cost of the Work or delay completion. These concealed conditions include, but are not limited to, hazards on the Job Site, unsuitable soil conditions, prior Defective Work of others, latent Defects in the Plans or Specifications,earlier attempts to do Similar or related Work, and obligations imposed by government. B. Contractor affirms that the company is financially solvent, licensed, experienced, competent, and has resources necessary to complete the Work in compliance with the Contract Documents. III. Payment Plan ' A. Deposit to schedule and order materials $3,650 Upon Completion $3,650 B. Except as provided otherwise in this agreement, Owners shall pay the amount due within 7 calendar days after approval of any application for payment. { IV. Cooperation of the Parties A. Both Contractor and.Owners pledge that their relations will be conducted with courtesy and consideration in an environment characterized by mutual respect. Owners pledge to respond promptly to requests by Contractor for guidance,assistance and payments when due and agrees to extend to Contractor the deference and latitude a dedicated professional deserves. Contractor pledges to commit the skill and resources required to complete the Project in a manner that complies with both the letter and spirit of the Contract Documents and enhances the reputation of Contractor for dependability and professionalism. Page 3 Integrity .Come SoCutions P.O.Box 1269 774-836-6654 g mH- s Ceutel-�-ille,MA 026$2.. Richard@ihsbuildin .con wwwalisbuiUng.coln Building x Remodeling V. Contractor Claims A. If Contractor claims that any instruction,Drawing,act or omission of Owners or any representative of Owners, or any agency of government, increases costs to Contractor, requires extra time or changes the Scope of Work, Contractor shall have the right to assert a Claim for such costs or time. B. Contractor and Owners agree to make a good faith effort to resolve all Claims that arise under this agreement and shall seek the opinion of expert disinterested parties on the validity of Claims, when appropriate. Claims not resolved to the mutual satisfaction of Contractor and Owners shall be resolved under the provisions of this agreement covering dispute resolution. VI. Arbitration ll agree in advance that in the event Contractor has a dispute concerning Contractor and Owners mutually a p g Y ln' this contract, Contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business Regulation and Owners shall be required to submit to such arbitration as provided In Massachusetts General Laws, Chapter 142A, Section 4. (iyj JJ JJ/" "I , O nature Contractor's Signature is i . alrxre NOTICE: The signatures ab ve a ly only to the agreement of the parties to alternative dispute resolution initiated by the contractor. The homeowner may initiate alternative dispute resolution even where this section is not separately signed by the parties. I. Dispute Resolution A. Should either Party bring suit in court to enforce the terms of this agreement, any judgment awarded shall include court costs and reasonable attorney's fees to the successful Party plus interest at the legal rate. g , II. Insurance A. General Requirements 1. Contractor shall carry workers' compensation insurance and public liability insurance as required by Law and regulation for the protection of Contractor and Owners during progress of the Work. Page 4 Integrity Home SoCutions P.O.Box 1269 774-836-6654 Celltenille,MA 02632 t 1Z1CIlaI'd@111Sbu11dII1b.COI11 H- ,s v1wi6hsbui1ala.coni. Building K Remodeling Massachusetts Home Improvement Disclosures Massachusetts General Laws 142A, Section 2(a)(8) requires that home improvement contractors and subcontractors register with the Director of Home Improvement Contractor Registration.You may inquire about contractor registration by writing to The Office of Consumer Affairs and Business Regulation, Home Improvement Contractor Registration, 10 Park Plaza, Room 5170,Boston, MA 02116. (617)973- 8700. You may cancel this agreement if it has been signed at a place other than the contractor's normal place of business, provided you notify the contractor in writing at his/her main office or branch office by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached Federal Right of Rescission form for an explanation of this right. Massachusetts law grants lien rights to builders.Any construction contractor, subcontractor,tradesman or material supplier who is not paid can record a lien on the property being improved. If not discharged by payment,this mechanics' lien will become a security like a mortgage on the property. Massachusetts General Laws 142A, Section 2(a)(8) provides that,,,"No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be.declared due and payable because the holder deems himself to be insecure.-However, where the contractM deems himself,to.be insecure he may require as a prerequisite to continuing said work that the balance of funds due under the contract, which are in the possession of the owner, shall be placed in a joint escrow account requiring the signature of the contractor and owner for withdrawal." Massachusetts General Laws 142A, Section 2(a)(8) requires that the property owner receive, at the time of signing, a copy of the contract signed by both the contractor and the owner. No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. Massachusetts General Laws 142A, Section 2(a)(8)requires that this contract include a notice disclosing all warranties and the rights of Owner under this agreement. Except as provided elsewhere in this agreement, Contractor makes no express warranty. Owner waives, renounces and disclaims all implied warranties of fitness for purpose,merchantability, habitability and good construction. Page 5 Integrity Home SoCutions P.O. Box 1269 774-836-6654 Ila Centerville,MA 02632 Richard@ihsbuilding.com wwwalisbuilding.com Building K Remodeling Signatures The signatures that follow constitute confirmation by those signing that they have examined and understand the Contract Documents and agree to be bound b the terms of these documents. �' Y DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES!!! This agreement is entered into as of the date written below. Kenneth Rogers, Owner (Signa e) (Date) go I'ek-S (Pr ed Name) Judith Yaldat 1, caner (Signatu ) (Date) Jr (Printed me) Richard Peckham Jr, Contractor (Signature) (Date) (Printed Name and Title) Page 6 TM TOWN,OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel %s r Permit# � �(0 Health Division 7 Z Date Issued Conservation Division , a� Fee 45;e1*r_) Tax Collector ( l ' Treasurer — SEPTIC SYSTEM PADS T DE Planning Dept. INSTALLED IN CdRriPLIANCE - Date Definitive Plan Approved by Planning Board WITH TITLE 5 ENVIRONMENTAL CODE AND' Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address V - A11 V WALf / A Village �_' MM<1407 U K 45W3 iU Owner alsoA2Q4 AA2 DAkf f �Si��®�/��'Address Telephone V�d $ — cS(,q-C� I - Permit Request Square feet: 1 st floor:existing ja. / / proposed 2nd floor: existing proposed Total new Estimated Project Cost ��oa Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family P Two Family ❑ Multi-Family(#.units) Age of Existing Structure /5``/rs Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other r � l 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: Uk1 as ❑Oil 0 Electric ❑Other Central Air: ❑Yes 114" Fireplaces: Existing _ -�� New Existing wood/coal stove: O Yes -70 No Detached garage:Cl 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 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO CSIGNATURE DATE _ O� i FOR OFFICIAL:USE ONLY ; PERMIT NO. a... t DATE ISSUED MAP/PARCEL`NO.' _ ^ r{ r .i ADDRESS J VILLAGE - OWNER rt r DATE OF INSPECTION < i FOUNDATION FRAME INSULATION FIREPLACE ECECTRICAL: ROUGH FINAL PLUMBING: ROUGH -, : ' FINAL GAS: r ROUGH ` `- FINAL t r -- FINAL BUILDING � f5of - " DATE CLOSED OUT .+ ® m ASSOCIATION PLAN NO. t + TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION t N*w c1 Parcel 3 I Permit# � � 1 Health Division �'S — Date Issued - 0 o Conservation Division 0 Fee�,� Tax Collector ,) Treasurer Planning Dept. Che Date Definitive Plan Approved by Planning Board W" OF BEDROOMS Historic-OKH Preservation/Hyannis Project Street Address �' WA 3Y Village /� 4 1VAlZ Owner��i�� � ';�!r yC -JA (ZejW 11: ' Address < Telephone V -- " ` Permit Re uest 29 ' P Square feet: 1st floor: existing /00 proposed .5 �2nd floor: existing proposed Total new Valuation `J�(� U� Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. i Dwelling Type: Single Family,L Two Family ❑ Multi-Family(#units) Age of Existing Structure Z2 l ",�o Historic House: ❑Yes Jq No On Old King's Highway: ❑Yes"` ❑ No Basement Type: ,4Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) X 3 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 L Heat Type and Fuel: )KGas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes A DJo Fireplaces: Existing New Existing wood/coal stove:A Yes ❑ No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn: ❑existing ❑new size Attached garage:❑existing ❑new size ShedAexisting ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# --Current Use _._. -_ Proposed-Use - _ BUILDER INFORMATION 1 Nam �l A;&X'/ /��"������'���>�Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 1 '� DATE FOR OFFICIAL USE ONLY 67 i PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS ! VILLAGE OWNER i • f f DATE OF INSPECTION: •) FOUNDATION r FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH =' FINAL Y PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING j 41 x #a Ir DATE CLOSED(OUT ] ASSOCIATION?j PLAN NO. a i The Commonwealth of Massachusetts Department of Industrial Accidents T Office.of Investigations 600 Washington Street Boston,MA 02111 ••''y www masSgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/or g anization/Individual): r1t�9 i �) L ) Address: 3 ►'V ►�/ City/State/Zip: a'"�o . Phone#; CCU --7� e you an employer?Check the appropriate boz:. Ty emp*to Type of projed.(required):- 1.❑ I am a with 4. ❑ I am a general contractor and I yer 6. New construction employees (full-and/or part-time).* have hired the sub-contractors 2.111 am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees - These sub-contractors have 8. ❑ Demolition working for me in an capacity. workers' comp.insurance. 9. y p ty. El Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or.additions r uired.] officers have exercised their 3. am a homeowner doing all work right of exemption per MGL 11-0 Plumbing repairs or additions myself.-[No workers' comp. C. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.] t employees.[No workers 13.,M Other F!•U�v ' Dec)L camp.insurance required.] *Any applicant that checks-box#1 must also fill out the section below showing their workers'compensation policy information:`• t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their-workers'comp:policy information. ation. 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 Dater 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 ike form of a STOP'WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to.the Office of . Investigations of the DIA for insurance coverage verification. I do hereby certi u der,thepains andpenalties of perjury that the information provided above is true and correct: afore: Date: ~ Phone# Official use only. Do not write in this area,to be completed by city,or town off ciao City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Inspector S.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: t 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 a -.:an ind victual,.-PartaegbV ,association, oration 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 association or other legal entity,employing employees. Howov..er:the receiver or trustee of an individual,partnership, _ 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 wofk-ou such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed be an employer." MGL chapter fi52, §25C(6}also states that".every state or local licensing agency shall withhold the issuance or. Teaewal of a license or per to-operate a business or to construct buildings in the commonwealth for any71 = applicant who has not produced acceptable evidence-of compliance thhthh z insurance of olitical suberage divisions shall Additionally,MGL chapter 152, §25C(7)states `Neither the commonwealth Y enter into any contract for the performance of public work untiil acceptable.•evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants our Situatio Please fill out the workers' compensation affidavit completely,by checking the�booapp ce n if sub-contractors)name(s), address(es) and phone numb O along with g th ca e(s)of necessary, 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 wor)crs e ' compensationpolicy,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 Deparhmnt has provided a space at the botm of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be savi to fill in permit/hcense 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 :future permits.or licenses..Anew affidavit must be filled out.each applicant as proof that.a valid affidavit is-on file for 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 h`!ce 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 a Office of Jnvestiga#RnS 600 WashingEon•Street . Boston,MA 02.111.. Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia c� Town of Barnstable ° Regulatory Services ` ssraze: ¢ Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 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: D e c Estimated Cost 6 0 DO— Address of Work: �o Owner's Name: t I S! t(f Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law E]Jy6 Under$1,000 ElAuilding not owner-occupied LJOwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH.UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. / OR ate Owner's Name Q:forms:homeaffidav i 'COME r Town of Barnstable oT Regulatory Services t grAl L • Thomas F.Geiler,Director ,639, 1m� Building Division Tom Perry,Building Commissioner 200 Maier Street, Hyannis,MA 02601 www.townb arnstable.ma-us :face: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE — Z4 — G 5" JOB LOCATION,• C1 3 number + streets village "HOMEOWNELt':��� home phone# work phone# name CURRENT MAU-NG ADDRESS: A s r I!E --city/town state zip code The current exemption for"homeowners"was extended to include owner-occuyied 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 resuonstble for all such work performed under the building vermit. (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' ection procedures and requirements and that he/she will comply with said procedures and require ts. gnature H 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 tom a-Licensing of construction Supervisors);provided that if the homeowner engages a persons)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 d and adopt such a form/certification for use in your community. c P r, 4 i J I 1 I i I L v I h' ---- _ 3� { ,s OF I e ! 1 C 0 314 �q i I S��NAL LANDS N pAS PUILT PLOT PLAN, TO THE BEST OF MY INFORMATION, 'e"ov1Ti9eC 4--� AMASS. KNOWLEDGE, AND BELIEF THE lo?" t, ,F. .30,2 9 �uyi✓p•9 Tio�/ _ SHOWN ON THIS ;PLAN HAS BEEN LOCATED ON THE R d OkEARAI /NC - SWAN RIVER PLAYA GROUND AS INDICATED. 35 ROUTE 134, UNIT 2 SOUTH DENNIS, MASS. 02660 // SCALE:CLIENT. .._ : JOB NO ♦ vs TE REGISTERED LAND SURVEYOR OR. BY- SHEET Or of �> TOWN OF BARNSTABLE Permit No. 28209----------------- .,,..,r.;.. { Building Inspector cash NARMAX pull 1' 4 • -- - ,eso. OCCUPANCY PERMIT Bond __________�� Issued to Elliott K. Slade, Jr. Address N Lot 12, 93 Uncle WilZfe"s Way, Hyannis Wiring Inspector f�,i�, � i Inspection date Plumbing Inspector Inspection date Gas Inspector � r, � i L Inspection date 2 x Mo o A,S. XEngineering Department ,✓ / Inspection date Y, { Board of Health !' ._,, ., �'� Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE 'BUILDING CODE. f Building Inspector I t I i i j I i n I � � `o i I M �35. �2 I I i ; t of I c o 314 �� y ISTER�� s��NAL LANDS b,,y°'• "AS QUILT" PLOT PLAN TO THE BEST OF MY INFORMATION, MASS. I KNOWLEDGE, AND BELIEF THE Lor' � c. ,�- .34.2 �. � 9 v,✓o�T'io�/ SHOWN ON THIS I PLAN HAS BEEN LOCATED ON THE R SOHEARVER �A 41C GROUND AS INDICATED. 35 ROUTE 134, UNIT 2 SOUTH DENNIS, MASS. 02660 DATE T /o SCALE: ,�� /d 8•� J08 N0. _ .?636 CLIENT Ent�QvS DATE REGISTERED LANDSURVEYOR- DR. BY: SHEET i OF ! i � i r map and lot number .!�.p.Q c p'.. � ` �➢/C D4 /�Asykssor's , .. .........�_ r Eray Sewage Permit number ............U•..`..� /�j i� 0� ���� �� `O�Q.� y� ......4/........................ SYSTEM, �J.. ............................................... INSTALLED IN COMPLIANC t BAaaSTSDLE, House number .......... .........!. - WITH TITLE 'oo 1639 } - F=�1`k/2,Rn���vaE'NTAL CODE AND �oMAr a' TOWN OF BARNSTABtrU BUILDING . INSPECTOR APPLICATION FOR PERMIT TO .........IL ............. ..................................... ....... ............................... TYPE OF CONSTRUCTION ...... ........................ ..< ! ....... C .C........ ...G.........19.. .0 TO THE INSPECTOR OF BUILDINGS:, The undersigned hereby applies for a permit according to' the following information: Location ....k7o.. l..............�... ..... .r.C:L:.tZ--7 ...�..I L L....0 ...'........ �..�C... I..".1... Proposed Use ........ . . .... .. 0......... . .......... �..t.. f.�.L... ............... . ..C`.5..... .C. ..:. '......................... ZoningDistrict ........................................................................Fire lDistrict .............................................................................. Name of Owner.Y.�.�.�...K-S.-A`I . ?.K.....Address �. .�`.. .N......!...:....G(/L� !Y...S - r. Nameof Builder .....C..w.N r��.............................................Address .................................................................................... C Name of Architect .....(D..W...`'.../-x................................Address .................................................................................... 2� �-ud�C C(L .0 C7 cs Number of Rooms .................... ...........................................Foundation ......... .......................`: Exterior .....5. ./...��`..��....(- ........................Roofing ....:..................................................... ��AP(- /� y Rc�vD C� ( c� cLC Floors ....O.............�..., ............................Interior ..................................... .......................................... ............................ Heating- ................ Lk fW.......f.`.�. ....Plumbing .................................I................. - ........................... Fireplace 1 `�� ............................Approximate Cost 3 S i. V Definitive Plan Approved by Planning Board ________________________________19--------. Area /.. S ..................... Diagram of Lot and Building with Dimensions Fee ... .... SUBJECT TO APPROVAL OF BOARD OF HEALTH �2- y� 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 \. ........� ........ .... ................ Construction Supervisor's License... ........... ... .................... ... ........... ... ........ ..:- SLADE, 'E,LL10TT K. JR. ,Iqp 28209 1'2 Story Cj ................. Permit for .................................... Single Family Dwelling ........................................................................... Lot 12, 93 Uncle Willie's Way Location ................................................................ -Hyannis ............................................................................... Owner Elliott K. Slade, Jr......................................................I;........... Type of Construction Y."ralae............................. ................................................................................ Plot ............................ Lot ..............................I Permit Granted .........JulX 15,--•••,•-,.,,-19 85 Date of Inspection ....................................19 Date Completed ..........19F '. `t �• L lr/ q `Assessor's map and lot;numbeer-.. �� '...`" �5....:......��' ! ©/C Dt4 14,6112 o*IREto Sewagew Permit number .................. y 13AUSTABLE, i House number rasa � 4po�1639. 6� 'Ep MOX a` TOWN . OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .�L_J �&(... i� s���`l w L �u �' ,.i"WE OF CONSTRUCTION .................................... �. ................................................................................... ....................( ......................19.. u TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following .information: Location ....k7o. ...........�... ..:.. .r.C-Z-.C'........ .f L L/ �?....r........wl.....1..!. ProposedUse ........................................................ ............... .. . 5 ..... .C..... ....................... Zoning District ...................................................Fire District Name of Owner�I.l. .V ...���.S..L' JZ� .. .....Address g.�. �N.. �... ��..� 1!Y/rSr Nameof Builder .....(0 (Ai ......................................Address .................................................................................... Nameof Architect ..... .............................Address .................................................................................... Number bf.Rooms ..................................................................Foundation f. q.�7rq.......�.peey.C(2-.C:.. (;;.......... Exterior ..... ................................................Roofing .................................................................................... Floors U .R ©.�.. .........2..!e-......�y ie .. � ...Interior ...... CC1� �� `-r—Heating -.A...� .2 . Plumbing ....:..:...... .................... ..... .................. — - — Fireplace .......... � 4.........................Approximate Cost ......3..5...!.....0 ....`. ...... Fr Definitive Plan Approved by Planning. Board -----------____---------------19________. ,Area ...................�!...............:. Diagram of Lot and Building with Dimensions Ir Fee ?` ............................. f... SUBJECT TO APPROVAL OF BOARD .OF HEALTH 'fl 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. P Name ... ......... .Construction Supervisor's License ............... . .." I SLADE, ELLIOTT K. JR. A=292-315 28209 1' StPU.... No ................. Permit for ........ Single Family Dwelling•••••••,••• Lot 12 93 Uncle Wi ..ie's Way Location ........r..............................:............. .I , Hyannis r ......................................................................... Owner Elliott K. Slade, .•J ••• „ Type of Construction ....Frame•,••••......•••••••••••••••• ................................................................................ i Plot ............................. Lot ............... ` Permit Granted .....,July 15 ..........19 85 Date of Inspection ....................................19 Date Completed t.TA 9 5 1 � r t_ �01toIRE t Town of Barnstable *Permit# Erpires 6 months from issue date Regulatory Services Fed. HARNSTAELE, Thomas F. Geiltr, Director S, MASS' -17 1639. 96 Building Division rea n+a� Tom Perry, C$O, Building Commissioner 200 Main Street, Hyannis, MA 02601 www;town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �j Not Valid without Red�\-Press Imprint Map/pareelNwnber ' �`� Property Address Residential Value of Work • 2� a Minimum fee of$2S.00 for work under $6000.00 Owner's Name&Address_ h Contractor's Name J �,, �C,��'� Telephone Number 7 7 g-� 77 IV -�� Home Improvement Contractor License# (if applicable) f RMIT - _ ❑Workman's Compensation Insurance Check one: AUG 2 9 2008 ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE I have Worker's Compensation Insurance Insurance Company Name /T/ '` 4� 1 c3 Workman's Comp. Policy Copy of Insurance Compliance Certificate-.must be on file. �a 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) rd w Re-side r ] !Replacement Windows7ldoors/sliders. U-Value_b 7 (maximum..44) — ._ ,. �lLCQirri *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 Dome Improvement Contractors License is required. SIGNATURE: Q:\WPFILES\F0PMS\buildingpermit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachiusetts Department of Industrial Aeciden.ts kiOffice of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Ynsu.rance Affidavit: Builders/ContractorsTlectricians/Plumbers Applicant Information Please Print Legibly Nain0 (Businessiorganization/individual): �Es;� i / n, • AddrESS: 2'� �6 'd a n t )Z i! d" .. _ � City/StatelZip: T n„, i z 0 � _ Phone,-4: 7-7, i 7 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 6. ❑New construction employees(full andlorperrt-time).* have wed the sbb-contractors I am a'sole proprietor or partner- listed an tine attached sheet 7. ❑Rrmodcling 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' czmp.-insur=r COS' a cc orpor 10. Electrical repairs or additions rCguired_] 5. [] We are a corporation and its ❑ P 3.❑ 1 am a homeowner doing all work officers bave exercised their 11.[]Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12 0 goof mpairs insurance required.]t c. 152, §1(4), and we have:no employee workers' s. [No 13.❑ Other comp.insurance required.] 'Any applicant that chmks box#1 roust also M out the section blow showing their workers'caTnpaisafian pobcy information. t HomcownttS who submit this a$davit indicating fbcymr.doing all work and thrn hire outside contractors must submit anew affidavit indicating such. tcontractors that chmic this box anmt attached an additional sheet showing the name of the sub-contractors and sbb wher o ethr not thosd rntitirs have employers. If the sub-eonf ur-t0Ts have aaployms,,they.mumt provi&their workm-;,comp•pobry number. I am an employer that fs providing workers`compensation:Insurance for my employees. Below rs the policy and job site information. f Inniranca CoropanyNzane: Policy#or Self-ins.Lic.#: C�� Z 3 3 7 cL..�> 1 Expiration Date: 6 J o" IOb Site AdlireSS:_ (J'h C /� d ��.� A� C1ty1St&tLJZIp:4 R YI vi i t / 711 • Attach a copy of the workers' compensation policy declaration page(showing the policy number and ezpiration date).` Failure to secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penaltics of a fine lip to$1,500.00 and/or one-year i�onmcnt; 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 fist a copy,of this statrmerit may be forwarded m the Office of Investigations of the DIA for insurance coverer o verification. I do her certi. u 09r the alns�and penalties of perjury that the information provided above Is true and correct. Si c: dam" Datt: Phonc 4: a 7-7 / 9 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 rY �a 14- Phone#: OfVEr, Town of Barnstable Regulatory Services + BARNM sa LE' Thomas F. Geiler,Director 'v�p l�o,r,Hra Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize rn� ��h _ZS L A to act on my behalf, in all,matters relative to,work authorized by this building permit application for: �Z.. (Address of job) o 'Signature of6 caner Date 0ANI fI Print Name If Property Owner is applying for permit please complete the Homeocvriers License Exemption Form on th:e reverse side. V Town of Barnstable ��ofTt+e r�ti y o Regulatory Services t anxxsrwgts Thomas F. Geiler, Director 9 MAS& g, i65q. �� Building Division �TED a Tom Perry,.Building Commissioner . 0 Main Street Hyannis,20 t, y , MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5.08-790-6230 HOA'fEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: numbcr 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) assumes responsibility for compliance with the State Building Code and other The undersigned"homeowner" 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 rcquirod shall be exempt from the provisions of this section(Section 1om,1-Licensing of construction Supervisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption aie unaware that they are assuming the Trsponsibilities 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 v rith 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/shc understands the responsibilitics 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. Licensee Details Page 1 of 1 he Official Website of the Executive Office of Public Safety and Security(FOPS) Public Safety Mass.Gov Home DPS Home EOPSS Home Mass.Gov Home State Agencies State Online Services Department of Public Safety Licensee Complaints License Type Home Improvement Contractor License# 158588 Restriction Company Mass Building Systems Name Stephen Bobola Address 24 St. Farncis Circle City, State, Zip Hyannis, MA, 02601 Expiration Date 2/11/2010 Status Current No complaints found for this Licensee. Back To Search http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=HIC 158588 8/29/2008 The Town of Barnstable AS& ' Department of Health Safety and Environmental Services Building Division EO MA'S' I 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph�Crossen Fax: 508-790-6230 - Building Commissioner TOWN OF BARNSTABLE Permit SOLID FUEL STOVE PERMIT Date: t/;kl�( Fee: l. `��Q Owner: Phone: 7 78- Address: 9,2 �� '7 Village: �Q��/s Map/Parcel: Date: 0 D Stove A. Ne /�sed� B. Typ . 'ant/Circulating C. Manufacturer: o Lab. No. D. Model No.: 7- Chimney A. New �xisti' (If existing,please note date of last cleaning) 00 B. Flue Size C. Are other appliances attached to Flue? /Vy D. Pre-fab Type and Manufacturer E. Masonry: Lined/Unlined Hearth A. Materials: l'a - ST NG� ��" 0 ve-- Sr%c,� B. Sub Floor Construction: Installer Name:_,J Z/),U /Ls/ / Address: Phone: Location of Installation: % 'r r NY �C.00 APPROVED BY: Please make checks payable to the Town o f Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Stove.doc 1� -- � - ..,.. . �.� ' �' a ��� fig. � +,�k- *� • ,. �------�T- --- .. � ! The Commonwealth of Massachusetts Department of Industrial Accidents Office offosesmost/nos 600 Washington Street = �5; Boston,Mass. 02111 Workers' Compensation Insurance AMdavit name location: 5,13 u/ ti -A t,I g k/ _ city hone# I am a homeowner jeif-ornAg all work myself. ❑ lam a sole propnetor and have no one worlds in any capacity /////ff/1/////////00//, Providing workers' compensation for my employees working on this job.: ;; ❑ I am an employer.p:;;;;:<::>:} :;g;: Com anv name:. ::..:'::::::.....::':: .:'.:,.:': ss ...... ..... . ...... . :::>:: hone#: :. u _ .. . ..:...:....:.. --CV#" insurance co. ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers, comp .... ... :polices: ..... .. ,:. con anv name: ::; ::::;; .... ... :.... ... ci . ..:.:....:.............. :: :::::::::::::::::::::::::::::::::......................................................................::..................................... ........................................... ..................................................................................................................................................... ...............................................................::::::i:}}};�}i}}i:C•iii}}::i•:i::•isJ:4}ii:�}}i:4}i}}i:�:iv}}}}:�::::::...::�::..:::::. :•:.:�::::.}'.�:::.::....................... :w...... .................:.:. ...... .. .:::::::•::::::•:vr...;.......•::r•:.}':::w .�:::w.•y: v::•:...::•:::::::.�::.:...fi::::::::.�:::...:•:::.�: ::.�:::::....iid}:4:•}}}}:•};•}:i:{}ii:::i{i:::::::•:::::.:::::•:::::::::•::.::•::•:: � :.�:::::'.::.:`%:::.:::.::.:':.;:yr.�:.i'.:.:i}:r}q:i<:}::iiY4•:>_..:•:: OLty# insurance ca., ::...:..::,:•;::...::..:: ..:....: c a address ;': N. X. .............. .................................................................. ........................................................................................ . ..........::................................................................................... .. . ............................... li�o ias-z;rance . re cove as required under Section 25A of MGL 152 can lead to the imposition of crbnhw penalties of a One gaffer to secure rage up to 51,500.00 and/or one yam,Imprisonment as well as duff penalties in the form o f a STOP WORK ORDER and a tine of S100.00 a day against me. I understand that a coverage vetifieatlon COPY of this statement may be forwarded to the Office of Investigations of the DIA for I do hereby mi certify the aura and penalties of perjury that the information provided above is trw. d correct e c Date - signature Phone# Print name official use only do not write in this area to be completed by city or town official permif/Hcense if ❑Bonding Department dty or town• ❑Licensing Board ❑Selectmen's Office ❑check if immediate response is requited ❑Health Department phone#; ❑Other--. contact person: 511 (tensed 9195 P1A) I� Information and Instructions ; r Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any co=.:c 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 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 c building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renev f a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h, o P not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwe alth 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 contacting- authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the'law"or if yo are required to obtain a workers compensation policy,please call the Department at the number listed below. F City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of 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. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of fmlesdUadons .600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 e own Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-862-403 8 1 Building Commissione. 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: ��r�G Estimated Cost 0 0 YP , Address of Work: q3 U��L �� Jif WL Owner's Name: — Date of Application: '7/ A// q? I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law C]Job Under$1,000 Building not owner-occupied 0O7er pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME H"ROVEMENT WORK 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 Date Contractor Name Registration No. OR Date 4Z=Owner'�Nwn q:forms:Affidav Department of Health Safety and Environmental Services Building Division i 1 367 Main St:W Hyamtis MA=01 NAM Office: 508-962-4039 Raiph Cr0ssm Fax: 508-790-6230 Building Co�a: IIOMEGWNMLZ=MEMMFnON MUM a 99 JOB LOCATIOM: 3 (/lX eG/ F_ '/A)i l/!'&S 'Wi9 r7 �/A.yf�i�C o !mil 0,26al number sttett �� name . homaphotie# wodcpiwae# CQRRE TT MAMM d" aura zip code The ctureat exemption for was extended to includ ied dweffinn of six mots or less and to allow homeowners to engage an individual fax hire who does not p�a fie,nrnvid -d that the rnmet OEFIINIL&I (WIM, AV= pesson(s)who owns a pared of land an which he/she resides or iameads to aside,an which there is,or is intended to be,a one or two-family dwd b&attached or detached cop err l +es at cgMy to mach==&or farm stry =cs. A person who mom tl mt woe home in a two-year period shall not be eomidered a homeowner. Such .'9Lmnt:owne:""submit to the Bmldiag Official on a form saxp'table to ft Big 0f�+�h lsbe shall be ._ ,hie f 109.1.1) The made signed"homeowner*'atmmes rasponsAW far campiiat=with the State Bn9ding Code and other applicable codes,bylaws,riles and regulations. The smdersigaed n meavvad mttif=that helshe sm a=lds the Town of Bamstabie Building Department minimum hvwdm prop P Im P, and requirmwo and that helshe wM comply with said procedures and sigaaa��f Appmvai of Buiidiog OtBciai Note: 'mfn*dwdings csmhtiag 35,000 c cWc feet err imW will be required to cmmply with the State Budding Code Section 127.0 Comsmmdan Control. 'lbe code sores that 'A�homeowner perfmmmg vm*for�odCt� �is I ahau tx ao�t fin the of this soaioa(Seetim 109.Ll-"crosmg of sao:teoation S k F��that if the 600>oaoroer ea�ages a t (s)for hire to do so&wady,tbatsm*Homeowoershait art u supayboe ter homeownea who uta d ds eampdon aaa tmmm dol bef womonsft do ummMes ofasopavism in -problem (see&Q• Rids A R fw Lbcmft Cep°Snperts M Seddm 2M padadadp whm the homeowner(dies tmiiomud pesaons Ja d ds mo our Board cannot pe r, ,agw=*c=ioe=d p=oo as it world withalioaisedSupwwbw. Mwtmma0wneraetio6asSapavisatisdWo lely maap was to phu.u pact of the permit awicadou. To camthattha homeuwcier is A*aware a�f hislhar�thattheh theheta6e>mdasta�the ofaSupenim On the impageoftbis issue isaformcm *used by mvaai towns. You may care to wand and adopt such a fWzIGCIrd6CMn forum is yom amity. lob, 416�low &6Q)T y r i ..- .3 G `' �o`� rb�R �.c `�"� ���p C - G'g 4 ;� 8'� �--�` « l