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HomeMy WebLinkAbout0005 AUTUMN DRIVE .. _� ��� - _ _ _ � �. . . � _ _ . r .. . . :. C .� r 'Y C r :. ,:. ... .... '.ti .. :. :.. _ �::. _ � ... � a ,�� _ -. �. ��. ., :. a �.� � _ .,a a, ._ _ ': a. - .r. .. s ' ". Y Town of Barnstable Building a � �DvPos#This CardSoThat its Visible FromFthe Street-Approved Plans"Mustbe Retained on'1ob and thisCard Mustbe Kept 04 Posted Until Final Ihs ection Has Been_Made Pe yam • Where a Certificate of Occu anc' �s Reruired,,"such Buildm shall Not be Qccu red until a Final Iris iect�on has been made ,.. .,�p 4 . . -. .�.gap_.. x : p ._ ,. .. .. Permit NO. B-20-13 Applicant Name: EARL BROWN Approvals Date Issued: 01/13/2020 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 07/13/2020 Foundation: Location: 5 AUTUMN DRIVE,CENTERVILLE Map/Lot 167 005 Zoning District: SPLIT Sheathing: 211-4zo --Sax Owner on Record: GOULET, RAYMOND A&AMY T TRS Contractor Narri,e ,,EARL BROWN Framing: 1 -!-1 LO (y Address: 5 AUTUMN DRIVE Contract'ar License 1-731 11 2 CENTERVILLE, MA 02632 Est. Project Cost: $55,000.00 Chimney: Description: add a 18x30 3 season unconditioned room to rear of house. remove Permit Fe : $330.50 existing deck. add smoke/carbon detector Insulation: _' / =Fee'Paid:,' $330.50 Project Review Req: Date 1/13/2020 Final � Plumbing/Gas C Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized byths permit is commen ed within siz`months'aftelPIM&We.Official Final Plumbing: All work authorized by this permit shall conform to the approved application"ana theapproved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street.or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work ` "# -1.Foundation or Footing Service: 2.Sheathing Inspection s , 3:All Fireplaces must be inspected at the throat level before firest flue lining is installed ' Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Finals 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Rough , Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in` MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT �� Final:�< Application Number.......... ... .v,... `.. ......... BARNWASM : `v MASS. � Permit Fee.......................................Other Fee:....................... 1639. Total Fee Paid ': TOWN OF BARNSToABL � Permit Approval by......4��..............On......1.�!,3�.2:�..... BUILDING PERM — ...............z.6...?..........Parcel. ....41.5........................ APPLICATION Section 1 Owner's Information and Project Location - Project Address_ Village C ; t ; p �Vllf Owners Name Owners Legal Address S City State Zip Owners Cell# E-mail Section 2 —Use of Structure Use Group �L�o ❑ Commercial Structure over 35,000 cubic feet Ell' l' Commercial Structure under 35,000 cubic feet tom" Single/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm [ build El Deck Apartment El Sprinkler System Addition ❑ Retaining wall . Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 - Work Description. A & at /? :K 30 -3 S e.c,.S O A U"V�CO►nCA e � i cAe1 e_ r � r 7, T.RCt 11nr1Rted- 11/1 inni R ti Application Number.................................................... Section 5—Detail Cost of Proposed Construction Square Footage of Project 55Jo Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist esign Section 6—Project Specifics inng ❑ Oil Tank Storage Smoke Detectors { 'i ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney 'j ❑ Add/relocate bedroom Water Supply 2Public Private Sewage Disposal ❑ Municipal On Site 1 g P P Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I amusing a crane.C Yes © No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information i ` r Zoning District QD-1 ' Proposed Use Q I Lot Area Sq. Ft. Total Frontage a 5t Percentage of Lot Coverage 1G #of Dwelling Units(on site) 3 Setbacks Front Yard , Required 3U Proposed � 0 Rear Yard Required / 5 Proposed Side Yard Required 10 Proposed oZ 7• Has this property had relief from the Zoning Board in the past? ❑ Yes . LJ No Last updated: 11/15/2018 Section 12 Department Sign-tiffs Health Department` D Zoning Board(if required), Historic District El Site Plan Review(if ) 0 Fire Department G� c Conservation C For coaimadal word please lofts your pkns di tty to the fire deprr mmt for upproraL Section 13 Owner.s Authorization I, .y= , as Owner of the subject property herby authorize r1 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature WOwner 4 date Print Name Lest updated:11/1 S12o1 8 r - vc 1 1 s Y 1`�,�•�c:.c.t_[v.. _...._ - ._.. / G ,�i-r��� ,�r�i {ter trig Se JAMES y C. MOORS No.33263 WIST '� ✓fee �a�zou�au�f'0�✓//6tu'�1¢d�ii�ef,�i Office of Consumer Affairs&Business Regulation HOME IMPRENT CONTRACTOR Registration valid for individual use only T<MRIndividual before the expiration date. If found return to: Expiration Office of Consumer Affairs and Business Regulation -71 09/03/2020 1000 Washington Street-Suite 710 EARL BROW i — 'r d Boston,MA 02118 EARL BROWN 76 HOLLY LANE �. 3= R Not valid Without signature CENTERVILLE,MA 02632 Undersecretary s, Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons�t�rtt1%tSiSpgrvisor CS-004650 - E.Spires: 04/13/2020 I EARL E BROYVN { 76 HOLLY LN�. .. CENTERVILLE MA 02632 ii t Co mmissioner 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/Plambers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): IF Address: r76 City/State/Zip: + I Phone#: L F6 Are you an employer?Check the appropriate boxy Type of project(required): I.❑ I employer with- 4. ❑ I am a general contractor'and I ployees(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 These sub-contractors have 8. ZildZ on slop and have no-employees ❑ workingfor me in an aci employees and have workers' Y capacity. = 9. addition [No workers'comp.irorrance comp'insurance.: 10. Electrical repairs or additions 5. We are a co oration and its ❑ reP required.] ❑ rP ; 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 r 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. tConbuctors that check this box must attached an additional sbeet showing the name of the sub-contractois and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Y 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.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policydeclaration 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 iIi 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 certi ep the p • naltks ofperjury that the information provided above is true and correct: Simi czcr� Date: 1,312,0-9 0 Phone#: 7 CF— Of kkd use only. Do not write in this area,to be completed by city or town oftial 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 iri 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 retained 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 mrmber 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 writs"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 Aoddents , Me of Investigations 600 Washington Street Bostort<,MA 02111 Tel.#617-727-4900 W 406 or 1-877-1ViASSAFE Revised 4-24-07 Fax#617-727-7749 www;mass.gov/dia M: Application Number........................................... Section 9- Construction Supervisor t Name ffc A `� Ib cz3�i Telephone Number ">`7 F 7 Address 114 lc-M f City rv,` State Zip 0 a6 License Number ,00 License Type Expiration Date (3 Contractors Email h ems-- - Cell # —7 7!� �14K 7 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,specific inspections and documentation re by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signatur Date 4 01,E Section 10—Home Improvement Contractor Name_ cq- 7>�d`0 c.�A Telephone Number '7�( Y 8 7 Address City v j State . Zip Registration Number 1'7 S I l Expiration Date a s h C� I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation r ' 6d b 780 C e Town of Barnstable.Attach a co Y Signsre3��AP of H.I.C... Date j(n;/V-0 -zo Section 11 —Home Owners License Exemption Home Owners 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,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Date `� 7- D i� � Print Name CL p Telephone Number 77q ?d 7 YF6 r E-mail permit to: (2- 1 2©16 0 a✓h C'A SI-o d-Ij t° Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department F Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department Conservation ❑ " r A For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's Authorization 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) Signature of Owner date Print Name i ° a _ 4 Last updated: 11/15/2018 Town of Barnstable Building x _- v -� r. ,� h. �. Mu t g pp _ In Post this-,Card=So That it is Visible From the Street A` roved Rlans Must be Retained on Job andt s Card s�be Kept 1Posted Until Final Inspecti0n Has Been,_Made ' Permit � .a Where a Certificate;of Occupancy is Required,such Bu 639- ldmg:shall Nq(be Occupied until a Final Inspection has been made -. [.. - . n _s . .. . Permit No. B-19-3384 Applicant Name: EARL BROWN Approvals Date Issued: 11/01/2019 Current Use: Structure Permit Type: Building-Deck Expiration Date: 05/01/2020 Foundation:_56 j O Location: 5 AUTUMN DRIVE,CENTERVILLE Map/Lot: 167-005 Zoning District: SPLIT Sheathing: 171 Owner on Record: GOULET, RAYMOND A&AMY T TRS Contractor Name-EARL BROWN Framing: 1 r�21 1zo 'Contractor License: 17.3111 Address: 5 AUTUMN DRIVE `' 2 CENTERVILLE, MA 02632 Est. Protect Cost: $ 15,000.00 Chimney: Description: Remove existing 18x24 deck and build new 18x30 deck with Permit'F e: $ 110.00 � Insulation: benches Fee Paid:1 $ 110.00 ff I Final: 11°�t�Lla Project Review Req: Date. 11/1/2019 t) — Plumbing/Gas Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuan a yfficial Final Plumbing: All work authorized by this permit shall conform to the approved application and the`approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zonin'by-laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. i Final Gas: The Certificate of Occupancy will not be issued until all applicable signatures by the Building.and,Fire Officials•are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: r� 1.Foundation or Footing Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flu 'Immg is installed, Rough: 4.Wiring&Plumbing Inspections to be completed prior to frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Application Number........................... .q.................. ELARMAEL% • TOYM, OF BAP K;1L.A9t ........................ .........Other Fee,....... MAM F 1639. ............. TotalFee Paid................................................................. ... TOWN OF.BARNSTABLE Permit--Approvai by.......J- ......... 1J ......... BUILDING P.ERNUT .............Parcel...............5...................... Map........................... APPLICATION Section 1 — Owner's Information and Project Locatioii Project Address S­ i/R.- Village iet v', tl:e Owners Name. =TA.IJ T Owners Legal Address City—(�e- State vWc, Zip Owners Cell# E-mail Section 2 —Use of Structure Use Group_ El Commercial Structure over 35,000 cubic feet EIII�C'ornm ial Structure under 35,000 cubic feet a--s'ingle/Two Family Dwelling Section 3 — Type of Permit ❑L New Construction E] Move/Relo'cate Ej Accessory Structure ❑ Change of use El Demo/(entire structure) ❑ Finish Basement El Family/Amnesty ❑ Fire Alarm Rebuild D--'Deck Apartment El Sprinkler System ❑ Addition ❑ Retaining wall F❑J� Solar Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 - Work Description — !R P-VYI 0 vt S CK in d T.Pzt iminted- 11/1 SnOl R i ` y Application Number.................................................... 1 Section 5=Detail Cost of Proposed Construction Square Footage of Project .5-l( Age of Structure Dig Safe Number I S� # Of Bedrooms Existing 3 Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method A❑ MA Checklist ❑ WFCM Checklist ❑ Design 1 Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage m 6 :❑ Smoke Detectors j ❑ Plumbing ❑ Gas ❑ Fire Suppression j ❑ Heating System ❑ Masonry.Chimney ❑ Add/relocate bedroom i Water Supply .Public ❑ Private Sewage Disposal ❑ Municipal On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: ��G�J two.a J � G( I am using a crane EllYesL o Section 7=Flood Zone Flood Zone Designation 1� Within or adjacent to a wetland, coastal bank? Yes ElNo E Section 8—Zoning Information Zoning District ° Proposed Use �e_.c1� Lot Area Sq. Ft. .y /hea/eS Total Frontage Percentage of Lot Coverage 0 Me #of Dwelling Units (on site) Setbacks Front Yard Required 1f Proposed Rear Yard Required Proposed 1 q P .7(9 ` c Side Yard Required Proposed _ Has this property had relief from the Zoning Board in the past? ❑ Yes L No Last updated: 11/15/2018 �R vanaawuasconn v maaaaa.��uactta - Division of Professional Licensure Board of Building Regulations and Standards Const%ttifUmbpprvisor CS-004650 Expires: 04/13/2020 1 EARL E BROWN 76 HOLLY LN O CENTERVILLE MA 02632 gyp] A Commissioner 404 j office of Consumer Affairs&Business Regulation HOME IMPROXEMENT CONTRACTOR Registration valid for individual use on ly Individual before the expiration date. If found return to: Expiration before of Consumer Affairs and Business Regulation 09/03/2020 7 1000 Washington Street-Suite 710 EARL BROW !X _ v1 Boston,MA 02118 r EARL BROWN 76 HOLLY LAN CENTERVILLE,MA 02632 Undersecretary Not va ld without signature 2�00 1 f r Z'. ,.,: . ti -.... T _t,, ...yP.. l1, lN JAMES C. No.33MPG�ta+l c� ��'A{ t�!►��' �G -�-- 3/gyp`�`� The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass govMa Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive(Business/Orgmization/Individual): Fo.&, tP�v� Address: `7 G U MA City/State/Zip: ' Phone#' ` _ t- & �- Are you an employer?Check the appropriate box: Type of project(required): 1.El kim 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 8. ❑Demolition working for mein any capacity. employees and have workers'. 9. ❑Building addition [No workers'comp.insurance comp.insurance.: r ed 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.❑Roo airs insurance required.]t C. 152,§1(4),and we have no 1 _ er comp. C employees.[No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most 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. , 1 am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. i Insurance Company Name: Policy.#or Self-ins.Lie.#: _ 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 cerWynder the pains and penalties of perjury that the information provided above is true and correct Signstore: Dater d g I Phone#• Qf)Tcial use only. Do not write in this area,to be completed by city or town of iicia[ 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#: 5 E 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 constrict 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 firtare 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 Industdat Accidents ,Office of bVestigations 600 Washington Street Boston,MA 021.11 - Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www:mass.gov/dia Application Number........................................... Section 9- Construction Supervisor Name 2.:: c...).n Telephone Number -7-7 — Qj -1 Address ' City �', State_���� Zip 0 3 License Number LS. O o (�o 0Zb License Type OI VI 2e sir,e o xpiration Date Contractors Email p ��MCAS� Cell # 7 -t�j—q 0_`7+ 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,specific inspections and documentation req ' b 780 rMR and the Town of Barnstable.Attach a copy of your license. Signature Date 10 Section 10—Home Improvement Contractor Name 6 U%A^ Telephone Number �:a Address City C-Q_A4e_,w,rl 1 _State Zip �-- Registration Number 1 13 1 I i Expiration Date Cl I '3 � .;k,6 O I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. -I understand the construction inspection procedures,specific inspections and documentation req ' �70 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signatur Date ! V 1 Section 11 —Home Owners License Exemption Home Owners 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,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Date j Print Name ® LAJ Telephone Number E-mail permit to: e �' 65 C(D V-VAC C�S�- Last updated:'11/1'5/2018 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ .v Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's Authorization I, c� , as Owner of the subject property hereby ' authori ��, ��� n to act.on my behalf, in all matternre ative to work authorized by this building permit application for: A CLmn ILrg CAP, C o -�t 4 (Address of job) rIq Si a of Owner date _,Ce 7-- Print Name Last updated: 11/15/2018 ` er....... ./ Sd1191)ApplicationN�b . .............. * s M Pemit Fee..... .1...O...............Other Fee........................ Total Fee Paid.....:...�.:.:..: ... ............................................. TOWN OF BARNSTABLE Permit Approval by..: ...........o�... .` ? l. ...... BUILDING PERMIT .f(,� ,. .per Qom- MV........ ....... ...................... APPLICATION Section 1 — Owner's Information and Project Location Project Address allisA tti ` �'. Village- Owners Name Owners Legal Address City State zip ll# 61-7 ,-q E-mail Owners Ce Section 2—Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commeercial*St=ucture under 35,000 cubic feet Single/Two Family Dwelling Section 3—'hype of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) `❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar Renovation ❑ Pool El insulation Other—Specify Section 4 -Work Description i T Act undated_2/92019 -� F� i .............. r , Application Number. .... .... Section 5—Detail Cost of Proposed Construction �62 OD Square Footage of Project Age of Stivcture L,kw kwWw"^- ' , Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method- ❑ NV k Checklist 0 WFCM Checklist ❑ Design i Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage u ❑ Smoke Detectors ❑ Plumbing ❑ Gas .❑ Fire Suppression ❑ Heating System , { ❑ Masonry Chimney -. ❑Add/relocate bedroom Waxer Supply ❑ Public _ _ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District a ❑ Old Kings Highway Debris Disposal Facility: C✓ '}'� 6-3-Co I an using a mane ❑ Yes EKNo Section 7—Flood Zone { R Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No Er--- Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard 7 Required, .Proposed, Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No j ` 1 Last imdaied--2/9/2019 Y F �ol is aSki "IN ROM NO � l 6 'z• ui � h ��� ��� '� �3 rim � � E• Fla � - ''-� ��� a , � v a r u�€ �S 4 �-7-7, as RMO _ e m ,a �5 h d '3„�� � d Z 9 � � •.pY 41�� „ys _ �' k � 3 c • 3 n � .:����.'dv � � �^ a ��.. �t 3 4 � �� " `' � GYP 3 z r .sv'-. $ yµ P 3 s , n rsb " ,xni ,,�: f r,, y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): (� LG�J2�✓j — Address: - City/State/Zip: )O 02-loa I Phone#: 609 0`f 0 Are yo 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.❑ 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.[1 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. tContractors 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. Insurance Company Name: f Policy#or Self-ins.Lie.#: >"//`� Expiration Date: y�Lrrf Job Site Address: ftwi� l1�N�l2 � City/State/Zip: Lii�t� A 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 der a pains d penalties of perjury that the information provided e is true and correct. Sinstore: Date: i 1 Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written.". An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),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 permittlicense 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 Dgwrtment 4Industrial Accidents' Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia i CEDARWORKS, INC. EXTERIOR CONTRACTING POB 1229,Brewster, MA 02631 508 648 6117 chriVerkes l @,yahoo.com www.cedarworksonline.com 8/15/18 Ray and Amy Goulet 5 Autumn Drive Centerville,MA 617 429 4422 oug let.ray pmail.com Dear Ray, Thank you for considering Cedarworks,Inc. for your siding renovation project. We have many years experience in exterior remodeling. You'll be pleased to know the job will be supervised by the company president, and we never use subcontractors. Cedarworks, Inc. is a Cedar Shake and Shingle Bureau(CSSB) and Maibec shingle approved cedar installer, a licensed HIC & CSL in MA, and fully insured. Please visit www.cedarworksonline.com for references and to view recent examples of our work. SCOPE OF WORK: Install new siding on main house. Job includes permit, labor, equipment,materials and all cleanup and disposal. SHINGLE SIDING,THREE SIDES: Remove and replace white cedar shingles on house (see below for options). Install shingles with 1 1/4"galvanized staple fasteners over typar weatherproofing paper. Maintain approx. 5"course exposure to the weather. Match to windowsills/headers where possible. Does not include re-creating rake edge shingle detail on gable ends of house. Do not re-install shutters. Includes adding two lightblocks for front lamps. Rear side of house was re-shingled recently;therefore no options are included for the rear side. One-coat colorstain shingles have a 10-year finish warranty;two-coat colorstains have a 20-year finish warranty. THREE SIDES OF HOUSE,NOT INCLUDING REAR SIDE (front, left and right only): A. Natural extra A white cedar shingles: $10,900 PRICING NOTE,8/15/18: $10,900 price has been reduced to $10,600, as a reflection of a tandem discount with Hall.No cornerboards included at this time. NEW PRICE: $10,600 NOTE: All extra work in addition to this contract, such as rot repair, or any other work not listed in this contract, shall be billed at our standard rate of$65/hr/man,plus materials (+20% on mats). TERMS: I require a signed contract copy and a deposit for one-third of the job total. • Additional 1/3 progress payment required at job halfway point. Final total payment is due at the completion of the job. Any balance remaining 30 days past job completion date will be subject to 5%interest fee. Thanks again for your consideration; I hope we can work with you on this project. Thank you, Chris Yerkes, President Cedarworks,Inc. CONTRACT AGREEMENT: We agree to the job description and rms as set forth by Cedarworks, Inc. SIGN DATE ' SIGNED DATE *Note that all invoicing is done via email. Please let us know if you prefer paper. Application Number........................................... Section 9--Construction Supervisor Name C/k,4.5 ,Rid Telephone Number Address 12 City £�1State Zip 02�3 License Number �� ;t �� License Type Expiration Date I Contractors Email Cell#` I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusjb7 Buu1 ` Code. I understand the construction inspection procedures,specific inspections and documentation r d the Town o amstable.Attach"`a copy of your license. Signature Date -- q— Se tion-10—Home Improvement Contractor Name Telephone Number • �p 1� �p�� Addres 'Z ' City {' i�>`i"'64,jState_ Zip ,o Registration Number �/�75/ Expiration Date.; . I understand my responsibilities under the rules and regulation for Home Improvement Contractors in accordance with 780 CMR the Massachusetts S uilding Co . I.umder`stand the construction inspection procedures,specific inspections and documentation re 78 Town of Bamsfab h a copy of your am.. Signature Date I ec ' n 11-Home Owners License Exemption Home Owners 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,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APP ICANT SIGNATURE Signature Date f Print Name Telephone Number E-mail permit to: CP4GLru-e'Yk5 010 T-..r ,in At i o - Section 12 —Department Sign-Offs _ Health Department ❑ Zoning Board Cif required Historic District ❑ Site Plan Review Cif required) ❑ Fire Department" r❑` : ,, ` t Conservation ` '� ❑ , . ;.�f ;' :, For commercial work,please take your plans directly to the fire deparbnent for,approvd Section 13—Owner's Authorization I, Sl as Owner of the-subject property hereby authorize 'r� to act on my behal f in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner � i 4" r �; 11 „ _ Print Name •9 Last undated:2/9/201 S <<-TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel C�8 S� �(. Application # / ,;2 S 3 Health Division � � Date Issued. ^q `6 4� I Conservation DivisionP0_-Application Fee Planning Dept. SO. Permit Fee Date Definitive Plan Approved by Planning Board C � Historic - OKH _ Preservation/ Hyannis Project Street Address C5% A ) Village Owner Pa Ul Address 6_ Telephone Permit Request NEUD , _Square feet: 1 st floor: existing LOUproposed �_2nd floor: existing proposed Total new Zoning District Rb --• 1 4 good Plain b Groundwater Overlay Wc> Project Valuation �WWo. —Construction Type i Lot Size o Ll(.P Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 3"" Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes Cho On Old King's Highway: ❑Yes U1 o Basement Type: YFull ❑ Crawl �❑Walkout ❑ Other Basement Finished Area (sq.ft.) �S 1 Basement Unfinished Area (sq.ft) � Number of Baths: Full: existing_ new CD Half: existing new (� Number of Bedrooms: existing ()new Total Room Count (not inclWing baths): existing new 0 First Floor Room Count Heat Type and Fuel: M"Gas ❑ it yp O ❑ Electric ❑ Other Central Air: ❑'S'es ❑ No Fireplaces: Existing—,—New 0 Existing wood/coal stove: ❑Yes S No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: M existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning,Board of Appeals Au orization ❑ Appeal # Recorded ❑ Commercial ❑Yes no If yes, site plan review# n Current Use QP� ��(�[1c-2 Proposed Use PS APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 9(xr l ��d LN�A Telephone Number 7� U VY6. Address 76 hik Letme License# oe / J1 l�Q MR-IN Home Improvement Contractor# J Email -� (� cr�f" Worker's Compensation # —. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO LA v ST+ca SIGNATURE DATE c� FOR OFFICIAL USE ONLY APPLICATION # D-4TE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE } OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION Im�I.o�l6 pr- r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT I ASSOCIATION PLAN NO. � ,.,o��u..,,w�....� .,..ru,.,,,..,,..., , «•,,,•• •,•,,•.•� Elie`fp'omrnoouuP,a./.�o�'C�/f/lctae�cc�auaet7a Board of Building Regulations and Standards �. Office of Consumer Affairs_&Business.Regulation. License: CS-004650 , OME IMPROVEMENT CONTRACTOR Cons#rikcti.on.Supervisor 1,PExp egistration \1)73111 TY.p._e:- iration �-1 Individual EARL E BROWN P 76 HOLLY LN EARL BROWN CENTERVILLE MA 02632 f EARL BROWN 17 76 HOLLY LANE _ �F 'fix+, ;='.:,,; � .-.��•�. //�� _ENTERVILLE,MA 0263 -5' Undersecretary ..nn CA__ Expiration: Commissioner 04/13/2018 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10-Park-Plata-Suite 51-70- Boston,MA 02116 Not valid hout signature i i Town of Barnstable Regulatory Services sARNarA=S, Richard V.Scali,Director 1MA8& • Building Division Paul'Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must r Complete and Sign.This Section If Using A Builder I c.Jl ,as Owner of the subject property hereby zutLonae to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of:Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized.before fence is installed and all final inspections are performed and accepted. C�E-2 tL4e of ApplicantSignature f Owner - . , Print Name Print Name Date. , Q:FORMS:OWNERPERMISSIONPOOLS Town of Barnstable Regulatory Services 5 Richard V.Scali, Director Building Division s � IMMINSTAXIA ` Paul Roma,Building Commissioner MASS 63 `�� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: citytto state zip code .The current exemption for"homeowners"WIKextended to inc l a owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who do not possess a license,provided that the owner acts as supervisor. DE �,a011 OF OMEOWER N ' Person(s)who owns a parcel of land on which he/sIA resi es or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detache s ctures accessory to such.use and/or farm structures. A person who constructs more than one home in a two-y. period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official o: a)form acceptable to the Building Official,that he/she shall be res onsible for all such work performed under the b 'din ermit. (Section 109.1.1) The undersigned"homeowner"assumes respondLity for c\harli e State Building Code and other applicable codes,bylaws,rules and regulations.. The undersigned"homeowner"certifies tha a/she understBarnstable Building Department minimum inspection procedures and requir ments and that with said procedures and requirements. - Signature of Homeowner r Approval of Building Official ' i Note: Three-family dwellings containing 35,000 c 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 Iicensed 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 permi t 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 to amend and adopt such a form/certification for use in your community. • 17W Camnromveaht ajfMassarJr=etfs L-� Derarfilimt a'rudzufrid Acddews fl)ite 00M..WMIgat�a:ts. 600 Wadiur beef J. Bastotr,MA 02HI 117vaumassgm/dia . Warlmrs' CumpensatianInsuranceAffidavit Budder-s/CenfractarsdEle�cfriciansJPhmhers AppEcant Inform-afrag Fuse PFiut E Address: , Lim citgfgevPh�ae 7 — Are you an employer?Check the appropriate be= Type of project(required). I_❑ I am a employer with ❑I am a geral eontoctar and T ogees(full an&or part-time * have ltisedtfze salt casidracfoss �- ❑Ides oonsfrucEi Z.RrPj am a sale pmpzietoa or Partner- listed onthe attached sheet: 7- ❑Reemodeling slip and have no employees. These sub-conf actors have " S_ ❑Demolition wadi ng for me:m any capacity. employees andhave woks' g_ ❑Bail addition [Na i4'C 6MM'comp.i„vx-anrm comp-fiLSu ►n required] 5- ❑ We are a corporation and its 16-❑Elechical repairs or adatious 3-❑ I am a homeorumer doing all word€ officers have exerts-ed their 1 L❑Plumbsug repairs or add tiam ' mpsdf[No warkers'comp- TigU of egempfiou per MG— 1?❑Roofrepaiis inc►mac a c-152 j 1(4),aII - emgloyees_[No workers' 13-❑other �A"aPPFiaate a,check,iws rl mast alsn fiIIwEthe seetsoaheiozvsiinivag�eazuos3cecs'rnmp�•mA,..Poycgi��rsa� �ameovraerstrh6 saL�Bt f�ii5 a�daru in ca>iag$wy wig doing ag WCai<sad$en htze outsider,.+,,,rc,,zbmst submit a new affidaeit inA' rM fCaatrsciu6 lagr —Tr tYs bout must attached sa sdditi®al sheet shaurmg the name of the mb—cmitz,+mrs and stste whedm ornot these ewes hne employees.Ifthesuittaat�dash>tce emgIoSi afieyimtstgms�de the srurl<e3*,'frm . P Pow mm�Irez . I arrr all errip r t7irrf is praxzairirg nrrrkets'.oar rsr iarrr irrsurartcs f yr irty emp �ee� Dcloav it floe policy and jab site Frr�orm¢lian Insumnce Campany Name: � Paficy 4 or Self-ins.Lic., EspiratioaRafe: Job Site Address: City tafel Aft2ch a copy of the workers"compensationpolicy,declaration page(showing the policy number and expiration d:at* Fail=to secure coverage as requireduuder Section 25A o€MGL c.1P-can lead to the imposition of rtirnix,ai penalises of a fine up to$UOa OG amVor one-yearimpFiso Rs weil as ciO peualiies is the fo=of a STOP WORK ORDERand a#� of up to$250_D{I a day a6gaiilst fhe violafar_ Be adzdsed that a copy of this sWement maybe forwarded to the Office of Imrest�o ofttie DJA far insurance.average yedficatian �do hemby csr1F�fi r a pairs meal Ms t!f]Ferjra q the f7ta irrf atfiza€imj-PMiiW abo'd A bus and correct afur : �/ Date- Phone dk 7 O�aL use ranF�: ,pa aa�vt Errita irr tFra+s aFretr,far be carrrlgliete�d hg citp artaavrr a,�crat City or Town: Pe-rmifiLiceaase Issuing Aufl rite(carIe one): L Board of Healift 3.BWEffing Depm meat 3.City1Town Clerk 4-Electrical Fusp .tor S.Plun-biig Inspecter 6.Other Coact Person: Phone#: amaan actsc ORS ' - I � ens�ion far their e¢g�Ioyees- . ��� e#in Ge neaal Laws r 152 all employ="D provide w�'� u an ee is defined as¢eYay pers6 .in$a a seavi ce of another under any co�xact of b�. P this sue, �103' m prr=or bnplz&cL oral or vziffm -„ • associafian,corporation or other legal eat Y,°r any two or more An e sloy�is defined as an m�vidnz P , Wives of a deceased employet,or the of the fnregomg eT,gag rd m.a joint eo=przse,andinch�g�legal reples employing empl°Vees- However the rmei=or trustee of an individ��P �ass°ciai=or otherlegal entity, notmoretiisn threeapffi�neuts and who rc=L-Stherein,or the occolan of the' - owner of a.dweIrmg horse havnzg com5h7aCdan or repair work.on such dwnDing house dweffiag house of roofer who employs persons to do man�ce, or on the grounds or btaldmg aPP ��=tD sh3nnotbecanse of such employroW d medto be an employer. sf�e or local ficeasiog agehncy shall withhold ffie issaance or 1_�IGL cbaptet ISZ,§25C(6 also sites every ru the commonwealth for any reuewa-I of a ficease or permit to operate a b•asiness or to construct buHffkgsm ce coYeX age required" applrcantwho has notproduced acceptable evidence of covaprnaacewth nor Political sub&Visions shall Ad.ffionally,MCs`L cbaptnr 152.§25CM sfa-tns 2Tetherthe iiancevYljh theTnenranc6. enter iota any conir'ar fiortlzepm -W 0f.Pab °nicunfnl acceptable eYidr ace of camp meets of this chap to hav r been presented to 13ae co g auiho Y APPHcants eusation affidavit completely,by g the boxes that apply to your situation-and,if Please El oiaf the wont' comp �)�phone numbers) alongwhth then cer�cate(s)of s°b-co�r(s)��s), ees other than the insurance. ace. L=rb P s )withno =aploy insm'�ce Limited Liability�P���C}or I,imifed I.iabnTxtY- (� to qay wonjeers' compensation?„era = I an I LC or IJ2 does bava members or parts,are not be m)lmi ted to the Department of Industrial e�loy=s,a.policy isrcquiie B0advisedfiaatthis afS aY¢may Aeeide�fs for confim on of -anre coverage: Also be sure to sign and datethe afIIdVid. The affidavit should be retnnned to the city or tnwnthat the application for the permit or license is being regIIes � not the Department of n have any qaP�°ns fhe law or ifyov are repaired to obtain a worms' I�sixial�4-_ecide� Shanldyo antes shonId enter their compensation-policy,Please call fihc Departmemt at the mm�ber listed below* Self-insured�P . s elf-m S*=c ceia&e IIumbm as the app�Iiae. CTtg or Town Officials - Ie�and - Iegahly. The Deparimmthis provided a space at,ti�bottmn Please be sure the o tDfMaffida it is Gfho P has to con i~tyonreg�g the applicant_ of the affidavit for you tri frIl o�rt in the event the Office'of InYestigatiuIIs Ju.addidon,an applicant Please b e sure to fill in pe /license nu,nber which will be used as a refere o ce�it m affidavit ind cafin cat �must submit multiple p�Iiceuse aPP club h in any��yam,need only policy mfornatian.(if necessary)and under"lobe lsdch ess"the applicantshould.wt�"all locatvons in ( Y°S. ed or mmk_-d by the�-Y or gown may be provided in the town)-"A copy of the-affidavit thathas been officlaIly or licenses A new affid � be fM opt each applicant as•proof tbat a valid affidavit is file for fofnre.p „siness or commercial 4e�l year.-Where ahome owner or ctiiZen is obtatL ining alicense or permitnotrelai>;dto anyb erson is NOT�edto comPlete ihisaffidavit Cie_ EL dog license orpe�mt to bum leaves etc-)said P . • The,Of oilnTrrsdo runs wouldli Ietn thankyouin advance for your cooperatam and.shovldyoahave my qmf-.5ftcms, please do not hesiitm to gIV"Ts a caIL i The D cp art nmf S address,telephone and fax nmnber- 00=mmWW �E O.ffM=ach Depaci"mt of 1nd A CULI- ^.' -Ti�_L.4 G1T-727-490G=t406 car 1-& MASSAFE Fax 0 617`27'749 xeYised4 24 07 - IWWma g1Ta APR . ..016 Town of Barnstable *Permit r7 A es 6 mo m issue date T®WN VT BLE Regulatory Services g rY saaxsxasca . Mass. <. _ _• ' . AM Richard V.Scali,Director � i4 rl-d><ng - Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PEWMT APPLICATION - RESIDENTIAL ONLY _ Not-Valid without Red X-Press Imprint Map/parcel Number__ Z 6 76 6 5 ;zdential Address41 Value of Work$ 5 Q6 t Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address "C' d Contractor's Name Telephone Number 2 7 y 9$7 y F14, Home Improvement Contractor License.#(if applicable Email: Construction Supervisor's License#(if applicable) ' ❑Workman's ompensation Insurance Ch k one: 7I am a sole proprietor ❑ 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) ❑ 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) ❑ ide Replacement Windows/doors/sliders.U-Value 2(/ (maximum.32)#of windows #of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 O r Letter of Permission. A cen of e o e Improvement o tractors License&Construction Supervisors License is qui SIGNATURE: QAWPFILESTORMS\building permit forms\EXPRESS.doc Revised 040215 T cJIle w0wMwauuea&1b 01' Q 66ac/ccae6t� j License or registration valid for individul use only Office of Consumer Affairs&Business Regulation l 1 before the expiration date. If found return,to: OME IMPROVEMENT CONTRACTOR U'PRegistratiow.%17,3111 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 xpiration:-_9/406.z -; Individual Boston,MA 02116 EARL BROWN j '" EARL BROWN I 76 HOLLY LANE I CENTERVILLE,MA 02632 Undersecretary Not valid Whout signature j Massachusetts Department of Public Safety Board of Building Regulations'and Standards License: CS-004650 Y+ , Construction Supervisor . + EARL E BROWN 76 HOLLY LN -1 , t, CENTERVILLE MA 02632, 1 Expiration: - Commissioner, 04/13/2018 � f Tlie Comm-olriveakh of-Vassachusetts Depaphneart o,f Industrial Acciderds Ofwce of Imwsfigadons 600 Washington Street y Boston;; 1t'fVt#:112fi .goWdlll 'Workers' compensation Insurance davit;BnildersiContradurslEIect cians(Plumbers Applicant InfGnnafion Please Print Legib Name(Iluudiame �OrganizatioJfn l} Address: ��✓1/l�1 �. o� cityfStatel ip: Phone -7 7 L/X-7 Are you an employer?Check flte appropriate box: Type of project(required):I,El am a employes With 4 ❑I am a general contractor and I loyeea(fu11 atrdlor part-time).*, have hired the sub-coax 6. tzactozs ❑Nevv construction 2.al am a sole proprietor or partner- Hsted on the attached sheet. 7. ❑Remodeling siup and haze no emploryees. . 't These stab-contractors have g_ ❑Demolition wo3ting far me in any capacity. employees and have woadcers' s[No odmrs, comp.inu=e comp-insurance.# 9. ❑Building addition - requiired_] 5. ❑ We are a corporation and its 10,❑Electrical repairs or additions 3.❑ I am a bomeoumer doing all work . officers have exercised their,. 11_❑Plumbing repairs or additions , my&-If[No ivorkers'gip_ rightof exemption Per MGL 12.❑Roai repairs. insurance require&]F c.I52, §1(41 andwe have no employees.[Na wrarkers' 13.❑'Other - comp_msurance required-) 'Any appUcam that der'ts box P1 must also falarutthe section belawshawing fl eirwoslsens compensa azipoRU infnn nodm T Romeawners who submit this affidaut=diratmg they are doing all soak and&m hire autd&contractors nmst submit a new affidavit indieatiey such- fCaatzactors tbar chedY this ba x mast attached sa additinnai sheet showing the natant of the sub-commcmas and state whether or=those entities haue employees.Ifthesubtaatx=mhive employees,they must pm ride thzir n^arkexs'camp.policy number. lam an eutploper that isprotad&g workers'coitgmrsatiaii insurance,f br uzy enrp£a y�eea: Below is flee policy and jab site informafiom Insurance Company Nam: Poll #or Self-iris-Lic.4. e Policy ExpirationI]ate: Job Site Address City/State/Zip.- Attach a cagy of the workers'compensation policy declaration page(showing the policy number and expiration date).' Failure to secure coverage as required udder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500-00 andf'or one-year imprisonment as well as civil penalties.in the farm of a STOP WORK ORDER and a fine of up to WO-00 a day against the-violator. Be adtdsed that a copy of this statement may be knvarded to the Office of Investigations of the DIAL for insui ce coverage verification Ida hereby cerli a per the rdprnahYes of,. - diatfbe ia,fornza&n pm ided abmw is tnw artd correct $mature: Date- 61 Phone (� Offrcial use only. Do not write in this area,to be campleted by city ortoorn official City or Town- PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityl Town Clem 4.Electrical Inspector S.Plumbing Inspector 6.Other Contaact Person• Phone#• Information and lnstruefions M�ec husetis General Laws chapter 152 requires all employers to provide wom3cem'compensation for their employees` pm suantto this stake,an.W471oyff�ff is defined as"_-every person in the service of another under any cuift, 1 of hire, express or implied,oral or wrifteaf 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,partnambip,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 - dweIIing house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building ng appvrC-en.ant thereto shall not because of such employment be deed to be an employer" MGL chapter 152,§25CC,6)also stains that"every state or local licensing agency shall withhold the issuance or renewal of a ficense or permit to operate a business or to construct buildings in the commonwealth for any applica.ntwho has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MCrL chapter 152, §25CM states"Neither the commonwealth nor a'ny of its political subdivisions shall enter into any contract for the performance ofpublic work unfil acceptable evidence of compliance.;with the fiisuranCO.. refairements of this chapter have been presented to the rant-acting authority-" AppHcarrts Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their Bert Ecaf-(s) of ;is-E once. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no encipIoyees other than the members or partners;are not required to cagy workers' compensation i s rmce. If an LLC or LIT does have employees,a policy is regnned. Be advised that this affidayit may be submitted to the Department of Industrial Accidents for confirmation of mi s rran Ce coverage. Also be sure to sign and date the afudavit The affidavit should be retnmed to the city or town that the application for the permit or license is being requested,not the Department of h2dustrial Accidents. Should you have any questions regarding the law orifyou are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-hmu-t-d companies should enter their self-fiisu ancB license number on the appropriate line. City or Town Officials Please be sole that the affidavit is complete;and printed legibly. The,Department has provided a space of the bottom of the affidavit for you to fillout in the event the Office of Investigations has to comrfaet you regarding the applicant P leas e b e sure to fill in the permait/icense number which will be used as a reference number. In addition,an applicant that must submit multiple p=itlhcense applications in any given year,neexi only submit one affidavit indicating current policy inffbmation(if necessary)and under"Job Site Address"tie applicant should write"aII locations in (cry 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 Bitare pe ud. s-or licenses. A new affidavit must be filled out each e owner or citizen is obtaining a license or mrri t not related to any business or commercial venture year.Wh ere a home own taming P ( ie_ a dog license or permit to bum leaves etc.)said person is NOT reqo:ircd to complete this affidavit The Office of Investigations would hike to frank you in,advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Depar(menfs address,telephone and fax numnber- 'I�he Commm Wealth of Massaohusi-,tts _ Depa:rimant cuff liict ial Aocidents Office 4f lvesfigatio= �Q4 T�asbingtQn� dos Elul 11 ... Tel. 6l ' -4Q 4€a6 or 1-� ' -IAAF Fax 617-727 7M Revised4-24-D7 `4OF�toiy, - ti � t * BARNSrABLE MASS. ,.� -.-Town-of Barnstable Richard V.Scali,Director Building,Division Thomas Perry,CBO Building Commissioner, 200 Main Street, Hyannis,MA 02601 4 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: ' • S /'�U �11�K1�1 I��`1 V'e y (Address of Job) - '' .. l�✓+I ski - , � Signature of er .Date ' IOU Print Name If Property Owner is applying for permit,please complete the Homeowners-License Exemption Form on the reverse side. to n , QAWPFILES\FORMS\building permit forms\EXPRESS,doc Revised 040215 ' 1 f , r I Town of Barnstable Regulatory Services ��rtHE to�'ti Richard V.Scali,Director Building Division sAMSTABM Tom Perry,Building Commissioner v� MAM 200 Main Street, Hyannis,MA 02601 ArEO www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures.'A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,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.t,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 form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms=RESS.doc Revised 040215 C CCAPE COD -F BA INSULATION RNSTABL IIRIR Ol33 U.MSIS5 SPRAT IOAM SUSPIN0IU RRTTS OUTT 1 RS INS UIRTION CSUINOS 1-800-696-6611 Town of Barnstable Regulatory Services Building Division 200 Main St Hyanpis, MA 02601 Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cocl Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements, Property Owner Property Address Village F ►MeKr� f �I,r�y fit i94 u"'I't 3 oeI.% C ,•�ry L(o Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( ) ( ) ( ) ( ) Slopes Floors ( ) ( ) ( ) ( ) ( ) Walls �er 6VOr ll )ror��,o/ Sincerely I 2Hr E ssi r, President Ins ation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- I Parcel O 0 Application �4 26 Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Stree Address Village V� Owner �� Address Telephone �" u vqq - I` p Permit R uest kywv�:4 90,KV10-- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District (� Flood Plain Groundwater Overlay Project Valuation U u Construction Type �� Lot Size J 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 -. F Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood coal stove: -0 Yes=;❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ riew size rw Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Au orization ❑ Appeal # Recorded ❑ ' Commercial ❑Yes o If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name V Telephone Number Address U License # �Vb Home Improvement Contractor# Email Worker's Compensation # ( 4")I a U ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WIL BE TAKEN TO SIGNATURE DATE 6 19 FOR:OFFICIAL USE ONLY APPLICATION# DATEISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME a INSULATION FIREPLACE ti ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL t GAS: ROUGH FINAL i FINAL BUILDING r . DATE CLOSED OUT ASSOCIATION PLAN NO. a_ /4 * Mass�whusetts - Department of Public Safety :Board of Bullding Regulations and Standards Canstrnctinn Super�is(ir License: CS-100988., V%I..i.` HENRY E CASSP 8 S*H1D ROW . WEST Y ARM OU'FH (� 0 I � ✓,�..� /J 'I I'� Expiration Commissioner 11/11/2015 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Con,tra'ctor Registration Registraliom 153567 Type: Private Corporation Expiration'. 12/15/2016 Trlt 259188 CAPE COD INSULATION, INC HENRY CASSIDY - - - - 18 REARDON CIRCLE -- S0, YARMOUTH, MA 02664 -----_ Update Address and return card, Mark reason 1'o CA I �:', zoM•osn t ❑ Address Renc al employment L_I Los! Cs!: V/ie ai�h�aa�itue�r�<�c`'CJr'/C�uJJ�cc�ueeC� \ Office of Consumer Affalrs& Buslness Regulntlon License or.regislrntion valid for individul use only -I OME IMPROVEMENT CONTRACTOR before the expiration date, if found return to: egistratlon; 1,53567 Type: Office of Consumer Affairs and Business Regulation xplratlon:,„;A:21:15/2b:1,6 Private Corporatlon 10 Park Plaza •Suite 5170 kr, Boston,MA 02116 CAPE COD INSULAT1,0,N:;INC;:i iENRY CASSIDY :'.•`:.: 18 REARDON CIRCLE'°;';;• 1 ; � ^ 50. YARMOUTH, MA 0266 ' zr - _— Undersecretary N validwi ut sign e .- ti The Commonwealth of Massachusetts Department of Industrial Accidents 4 W Office of Investigations w d I Congress Street, Suite 100 Boston,MA 02114-2017 °1M °y6� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ��jj � Please Print Legibly Name (Business/Org 'zation/Individual): C4 A LV�f�;�C�VL/ Address: 1 s��(r ��. 6v City/State/Zip: 1. Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.5'I am a employer with 'Z 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' [No workers' comp. insurance comp. insurance.$ ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] 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 requited.] / *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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �' G �� � Policy#or Self-ins. Lic #: L UUob Expiration Date: Job Site Address: City/State/Zip: - '.vc --- 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 n r pains and penalties of perjury that the information provided ab ve is t ue and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: From:Rogeis&Gray hisuraFax: To:+15087785735 Fax: +1 508 7 785735 Page 2 of 2 03130)2015 10r04 AM i_ :. �!�� CAPECOD-27 BDELAWRENc;E 14 FDATE(FAMIDUfi't•IY) - - �� CERTIFICATE OF LIABILITY INSURANCE 3/3012015_ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TI IIS 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(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condltions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). PRODUCER CO T NAME: Rogers&Gray Insurance Agency,Inc. PHONE Fa/c -2 15G434 Rte 134 o Ext: No: (877)816 South Dennis, MA02660 EMAIL ADDRESS: INSURER(S)AFFORDING COVERAGE tJrU(.a INSURER A:Peerless Insurance Company•see LIBERTY MUTUAL INSURED INSURER B:SAFETY INSURANCE COMPANY 3945d , Cape Cod Insulation, Inc. INSURER C:Endurance American Specialty Int. Co. 18 Reardon Circle INSURER 0:ATLANTIC CHARTER INSURANCE GROUP_ South Yarmouth, MA 02664 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY Pt- .:F10) INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICI I I i fl!.' CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE: EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE PO Y EFF PO IC E P --'-` — LTR POLICY NUMBER MM/DD/YYYY IAMIDDlYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ !^�I,000,OOQ CLAIMS-MADE D OCCUR CBP8263063 04/0112015 04/01/2016 PREMISES Ea oc0 1_o .v —100,UL_ !)UV MED EXP(Anyone person) -----=5,000, PERSONAL&ADVIN•,URY 2 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE T 2,000,000 X POLICY D PRO- ----- JECT LOC PRODUCTS-COMP/OP AGG t 2,0,00,J�%( OTHER:AUTOMOBILE LIABILITY EOMBINlEeDtSINGLE LIMIT $ 1,000,00U B - ._... ANY AUTO TBD 04/01/2015 04/01/2016 BODILYINJURY(Perperson) $ l ALL OVMVED X SCHEDULED BODILY INJURY Per accident) AUTOS AUTOS ( ) hION-OWNED X HIREDAUTOS X AUTOS PROPERTY DAMAGE Per accident ) X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,DUO,000I „ C EXCESS LIAR CLAIMS-MADE EXCl0006635000 04/01/2015 04/01/2016 AGGREGATE DED X RETENTION$ 10,000 A re, ate 9 9 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE __ERR_ D ANY PROPRIETOMPARTNERiEXECUTIVE �1 WCE00431900 06/30/2014 06/30/2015 E.L.EACH ACCIDENT 1,000,000 OFRCERIMEMBER EXCLUDE Do u N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 2 1,000,000, _ _ II yes.describe under ---- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000, s DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached Ir more space Is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement With the Ceilificate,Howe, -CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORF Cape Cod Insulation, Inc. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN [ 18 Reardon Circle ACCORDANCE WTH THE POLICY PROVISIONS. South Yarmouth, MA 02664 AUTHOR12EO REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved, ACORD 25(2014/01) - The ACORD name and logo are registered marks of ACORD • 4' . �ifs�fi�' mass. save �� PAI ICIPAnNG sorirp errorpyaltidemV c�aNTltacTOR PERMIT AUTHORIZATION FORM I, RAY GOULET ' ,owner of the property located at: (Owner's:Name;printed} 4 . 5-Autumn Dr CENTERVILLE 4'A (Property Street Address) (city) hereby authorize the Mass Save Energy Services Program: Participating Contractor listed,_ . below to act on my behalf and obtain a building permit to•perform insulation and/or,weatherization work on my property: X Owner's Signatu Date FOIR CSG.OFFICE USE ONLY. Conservation Services Group has assigned.tlie following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating-Contractor . Date; v t Foi Office Use Only , - ...ram � • - - -_-_ ��� Rev.12132011 �f'M�� ki Town of Barnstable ,�TME Regulatory Services Thomas F.Geiler,Director s a • s '"R"AM ` Building Division 1639. 39. s` Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# c�I FEE: $ SHED REGISTRATION 200 square feet or less ;4 , Location of shed(address) Village N Property owner's name Telephone number 0 a � 1 , 66 Size of Shed Map/Parcel# Can t,e M S� y) ,Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:304:30 � PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMNUSSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION . FEE. PLEASE SEE THE APPROPRIATE COMiVHSSION FOR DETAILS. s, THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN C 41"K` 0a Q-forms-shedreg REV:042911 Town of Barnstable Geographic Information System May 21,2013 4 168040 168032 #8 #3 144009 #0 — AiV r4VWN QR 167055 167004 '� #21 #16 167005 Q1 168089 �� 1 r 01 167029 167006 167007 #836 167001 #18 #822 #3 � 0 27 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:167 Parcel:005 boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel 1•=100'may not meet established map accuracy standards. The parcel lines on this map Owner:GOULET,RAYMOND 8 AMY Total Assessed Value:$286800 are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.46 acres .Abutters boundaries and do not represent accurate relationships to physical features on the map Location:5 AUTUMN DRIVE �,f �- .rJ such as building locations. Buffer `u Town of Barnstable *Permit#�� 36 Expires 6 months from isme date t • t Regulatory Services Pee z4KAM , 9. ,�' Thomas F.Geller,Director 0�) g'36 112_ atAld� Building Division �C-PRESS PERMIT . Tom Perry,CBO, Building Commissione 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us AUG 2 9 2012 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY j ff Not VaUd without Red X-Press Imprint TOWN OFMRNSTABIF Map/parcel Number Property Address ` 66 ZResidential Value of Work Minimum fee of S35.00 for work under S6000.00 Owner's Name&Address Contractor's Name ZiC'l�l (��� Telephone Number ��, Home Improvement Contractor License#(if applicable) ' / a;'f'.. Construction Supervisor's License# if applicable) _ ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name ,� lA �,,ram Worlanan's Comp.Policy# L;rr z x_ V-41 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ► ,/�Jtj� ' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.-U-Value _ (maximum.35)#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 req red. SIGNATURE: Q:1WPFILESTORMSIbuilding permit fotmslEXFRESS.doc Revised 081911 Office o Co> me A fairs&B s�oess RegulationLicense or registration valid for individul use only before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: -,,100497 Type ! 10 Park Plaza-Suite-5170 Expiration 3/25%2014 Private Corporation Boston,MA02116 DA D COX INC ,- David Cox F 19 LAVENDER LN W.YARMOUTH,MA 02673; Undersecretary 1 Net valid without signatur - - ;Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 63537 DAVID R COX 'f W PO BOX 401 � S YARMOUTH, MA 02664 ` Expiration: 10/15/2013 Commissioner Tr#: 4314 c C r oflndusai d Accidato /Mitre af'giohes Wohington Sfy"t Win,MA 0?2HZ WWMMaMSVWA0 Yinetacc Please Ott Iota Addmm- Ci .. one : Are Vau an Chwk the appropriate be= Type of idea(r 1.VI am employer With_,� 4. C3 1 aura ca n6 ar and I 6. ❑New emsbuction eu*oyaw(f&afar part4n=).* have hired the Z.❑ I aaa a sole pm or parkw- Ihftd an fire a#wbed sheet. 7• ®Rmodeliag sho and hone ffo emplayees T have g_ ❑Demo7i*= waking far nne in any may. employeesand#lave wow' 9. B g addition [No woodw s'cep.if>suna e � 10.0 Electrical or�a�tiow -� 5. [] Far am a cca�acrrtrtiaa a�its repairs 3.❑ I a=a hommovnxr doing all wmk officerabeveemaciseddmir I I.[ Plumbing repain ew aMdoms MYW1t[No water' of nPerM(3L 12.VRwfrepairs i„ mace require&1 t C.15Z 11(4),and we hwm ao 13,0 Odw [No ' coup.wsnrance requim&] •Any iae r�aPdss hoes kf=wa sh o M o u t e sKd=bataw saua**sr wcd=e compemiloopolkyinftoodaL Hammwamwbe sty d&WZd@ t is gtltay bradoWS vB wwk aae d=hua coMuleconUxonz=a&bwk&newaffkIn&WAzan mvJL Zaoaaca=Om e>aeet Ma boat=matt damW i m s t bxod sbaet this name of&e wa u,ma sum what"or am own moddes bye avWjaL IEtfta ad?-saamactan base a * d"mobs[pm ula d m&tom'cmkp6pofty wnibaL lam an vw is dWPVdiey aaWJob dts aR,fa�eaaEan. pert or Seff4m.Lic. map oa D9e: 1 �.� Job Si ram. %1 ,�J L: cityPSfawzip: Attach a copy of the gibers'compenzatica policy derlaratioa page(shag the ply uumber asrd,erpimfion date). Fail=to a cm coverage as vxpsired under Sectin 25A cf MM c_ 152 can lead to Ow impossfion of aximmal penalties of a fine up to$1,500.00 and/or ane-year imp6smunak as well as civil Penalties in tip fbm of a SMP WORX ORDER and a fir ofup to$250A a day against the violator. Be advised fftat a copy off statement my be fasarerded to fa Office of lavesligafim of 2w DIA for insmance eoveaag a vufficad= I do keroby ewo a tll-PAW and ofps*7 dbad Ike ® abo w Ex bw and cvrra t Pak QOt-tisl xse only. Do mt wt*In Ah area,to be compdetead by dV wr down. i C3q or Townt. Pereaftlldc�se# 'taste��'Y Csirsle�me?: 1.Bowd of idwhd& 2.BuMuS Departeamt 3.CltylTawn Clerk 4.Electrical Lupectur S>Fhmbing h apector 6.Mar r ct PWBM PhD=p: 6 �u.r au rp veuu,n r axiu, image 2 of 2 Date:7r19r2012 11'43 AM?59e:2 of 2 ~� DAVID-2 OP ID:KG � Rn CERTIFICATE OF LIABILITY INSUMNICE DATE(MmloDMMr; 07119na THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$ NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOU NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED By 77+IE FOLICIES BELOW. TIMES CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sj AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT, If the cartlf sate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to the term and conditions of the policy,certain policies rr;V require an endorsement A statement on this certificate does not confer rl6hts to the oefdfloste holder in lieu of such endorsements. PROOLIVIR 509-771-1632 NCONIACT AME: Nora rm)od ins.Auenc ,Inc. — 340 M n Pre.�t,, Ite I5N-393.2939 NE )e Ne �— Hy s,MA OaB01 as: INSUREP'9 AFFORQUi6 C0IYIRAO! NAIC+I INSURMA:Travelers Insurance Cam an David Cox Inc -- --- INBuREIRB:Prg mssive Casualty Ins.Co P.0.Box 401 ---- 3 Yarmouth.MA 02664 RF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLK'IES OF INSURANCE LISTED BELOlh HAVE BEEN ISSUED TO THE INSURED,4AMED ABOVE FOR THE POLICY PERIOD INDICATED, NOT0VITHSTANDINO 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 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SLICH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAiMS. _ Type OF INS _ POLICY NLWOER �'(14A91DDMfYY _LIMITS "'� •. `6111110tALLIABLlTY 1,000,00cl A COW:-RCIALMMRALLIAN.IT'' I BSM48IM796 03/14/12 103M4/13 I DAM Pfldi�rS 7EN tv a; s 300, wm I I +_eh1e$s LAIMSMMADE +T OCCUR MED eKP(.A y on-t gown) i'> S, X BU Owners I - w..�..------- ` PERSONAL E AW INdLFV S 1,000,00 II GENERAL AGaREGaTc S 2,000, GINLAGGREGA-1J)VI'APPLI_SPf;: IfI I ' — ;^S t 'PP.pfl 4CTS•C9M^rUPyAG(; : Z OOO� AWO L!LK114J Y T Ea .6d9rt S ANI ALI'o j �05747783.5 04119A 2 04M 9113 BODr_Y IN.U;TiV;Pa,peyy,l, i$ ��� ALL OWNED SCHEDULE r — AUTOS X AUTOS I I I B�DI.Y-N. Y(Aar accdanil t100 X N!R_D AUTOS J( .NON CwraED ! TEA —"'�M t1,00 AUTOS 10 I ( Per acrwenu S. 5 UiteR@LLALIAe OCCUR i• I I EACH O"-J7iCV:"..E 5 EXCESSLIAN7H AGGREC'+TE t� D I �=T 1-13N 6 Is II me C0 olNMTIDN v y" 707-4. I AND tIKlLOYlRe'LtA61U1Y YIN i ! _ _ -ER A ANY PROPR MR1PA..RT1$s^�'E3 ZJr1'V! r,'F-ViRftNaEF ex.cLuEvG1i �'NIA ! El EAC►ACCICe l S 100,00 (�11y19e0de�eve5.an41 I I •IBKUi9910XT42212 07116A 2 07N 6/13 E•L.G:SE 13E•c a EwPt OrEE s 100, DEtetGTION OG O ATIONS lMw j E L.DISEASE•P1, I I t 'TION OF OPMATIOM I LOCH noble I vat#=$(Attach ACOIW!L1,Addlttonal Ramorha sehadvb,:f more apace is r*9,w%,4l h-avid 0= is not covered by the Workers Co®p. policy CERTIFICATE N2LDER CANCELLATION TOWNNlAR SHOULD ANY OF YNG ABOVE DRSMIDED POL ICIae e8 CANCIE:LLLD oEFORE Town of SerrivAble THE EXPIRATION DAYS raff f, NC ICB WLL al Dit.MEniD IN 230 Main StMt ACCORDANCE Miff"YNE POLICY PROVION& Hyannis,NIA 02601.; AUrNMRII6D REPRMSENTATIVII 01066-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2D1010111) The ACORD name and logo are registered marks of ACORD 1 Was Town of Barnstable' Regulatory Services Thous F.Geiler,Director Building-Division Thomas Ferry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstablemia.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A. Builder k ;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: ZZMA ��, (Address of Job) Signature of o wnez Date Print Name If Property owner is applying for permiti please complete the Homeowners License Exemption Form on the reverse side. Q:IWPFILESIFORh0build ng permit fbmu\EWRESS.doc Revised 051811 i R. Town of Barnstable *Permit# Expires 6 months front issue date Regulatory Services Fee '? ITThomas F.Geller,Director BuildingDivision Vi$i®II MAY — t 2007 Tom Perry, CBO, Building Commissioner 0 200 Main Street,Hyannis;MA 02601 TOWN OF BARNSTABLE www.towm,barnstable.ma.us Office: 508-862-403 8 ax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint ap/parcel Number/6 Z`&6_S operty Address v U Q M!t) �/z . Residential Value of ork_7'14�v0 Minimum fee of,$215 00 for work under$.6000.00 N,ner's Name&Address 619�-ZS�4 V � N CS 17 )ntractor's Name C) ' Telephone Number. C7 1 (� ome Improvement Contractor License#(if applicable) M_Sti3cti 'S lVisoi-s-Lizense-,-�-if-apphtable-) ]Workman's Compensation_Insurance. Chec I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance surance Company Name 'orkman's Comp.Policy# spy of Insurance Compliance Certificate must be on file. .rmit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) "Where squired: lssuan:6 of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservztion,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, �iA c y of the e Improvement Contractors License is required. 'LGNATURE: Forms:expmtrg Mse061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Y ' 600 Washington Street . Boston,MA 02111 W www.mass.govldia Workers' Compensation Insurance Affidavit: ]builders/Contractors/Electricians/Plumbers Applicant Information . Please Print Le ibl Name(Business/Organization/Individual): . Nj .Address: City/State/Zip: � Phone.#: � Are you an employer? Check the'appropriate box: Type of project(required):, 1.❑ �asole yer with 4. ❑ I am a general contractor and I ull and/or.part-time). * have hired the sub-contractors 6. ❑New construction . 2. roprietor or partner- listed on the,attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp, insurance.$ 9.� ❑Building g addition required.] 5• ❑ We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their , 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL. 12.❑Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ 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. lam an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy andjob 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 Gerd under a pains an naIdes of perjury that the information provided a v `is true an correct. Si attire: Date: Phone# /�,� [✓ Official use only. Do not write in this area,to be completed by city or town offrciaL City or Town: Permit/License# Issuing Authority(circle one): �I 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or,implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiv nttti�stee 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-confractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or.license.is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lin6. 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 Depart memt of lndustrW Accidents Office of Investigatiow 600 Washington Street Boston, MA 02111 Tel.## 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 VAtw.mass.gov/dia i Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building,Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 026C 1 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner .dust Complete and Sign This Section If Lasing A Builder 1� R o\uA y Q y L e� , w Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building pernait application for: 1 (Address of Job) Signature o#Owner Date �d► �d U L Print Name I:'Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:114'PPILESNF0R.MS\building pemsit fomu\EXPRESS.doc Revised 051811 °pIME ro Town of Barnstable. ti Regulatory Services XA-Sa Thomas F.Geiler,Director a639 �� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 5 0$-790-62.3 0 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 bythis Molding perrnit application for: , (Address of Job) Signature of Owner Date Print Name Q FORMS:0-9vrr,MRPERMIS S I0N ROY Brawn Home Repair Co. Estimate Home Repair, Maintenance, Renovations Date Residential and Commercial Licensed & Insured 4/10/2007 Name/Address Mr. and Mrs. Raymond Goulet 5 Autumn Drive Centerville, MA Project Description Total ESTIMATED LABOR AND OTHER COSTS TO FILE AND 125.00 PROCURE BUILDING PERMITS, This is billed @ $75 per hour plus any fees incurred by the town in filings, and is not refundable ALLOWANCE FOR LABOR TO STRIP EXISTING CEDAR 1.068.50 SHINGLES..LOAD INTO TRUCK AND REMOVE FROM PROJECT SITE...INSTALL HOUSE WRAP ON ALL EXPOSED AREAS..APPLY NEW WHITE CEDAR SHINGLES 5" TTW...CLEAN SITE AN REMOVE ALL DEBRIS AND DISPOSE..PS TYVEK HOUSE WRAP..PER ROLL..300SF 98.00 WINDOW FLASHING..PER PC 8' 22.00 R&R WHITE CEDAR EXTRAS..PER SQ 600.00 STAPLE FASTENERS 30.00 DISPOSAL FEES FOR CONSTRUCTION DEBRIS 150.00 u THANK YOU FOR YOUR CONTINUED BUSINESS Total $2,093.50 Signature 7 ROY BROWN - 34 Horatio Lane. Centerville. MA 02632 Phone: 508-775-6582 * Fax: 508-775-1836 J Sta�Jar,s s a�`� pR v �ebu`a��oGpN�aP�,� , Gf t hoar ME tN`PNO 126`'6p008 Np t<yV00. 6j2112 µe9`s �N�{OM�N�pP PJ�`�,Stra�or O l P vg�RRP�\O�N MP02632 34\,O RA\k�-S' G�NTE gVILDjNG REGURVISOR BOARD pF TION soPE Licen$e' CONSTRUC 065525 Number: CS 42 02,12119 16902 BI thdate- It. no: Expires;0211212008 Restricted: 00 R BROWN 34 HORpT1O LN MA 02632 Gommisswner . CENTERVILLE, r. INGHOUSE, P.c malling: P.O.Box 182 ye Mashpee,MA 02649 NMOl O� p ia�n�[aie Bid Dept.- Mashpee 3"11Udg �® oh9rn: 18 Steeple Street Barns[able Commons Mashpee, MA 02649 O Ndf .structural design. phone: 508-221-2980 .Approved b,v: • ingenuity emall.• jensen(Oln ouse net q�11 f18 web: r.inahouse.net Permit #: � , Z42 s �'`e ING19128 -10OFM 5 AUTUMN DRIVE, CENTERVILLE, MA- LARSJENRE � LARS JENSEN AL No.50602 xld� �p DL=15PSF ROOF AND �F��sT nn O �iO. FLOOR SYSTEMS E A �..� c�w, �� ,l - — EST L-L-=40P-SF(1_ST:FLOOR), .� 92 019 Pg=30PSF, Pf=25PSF Vult.=140PSF, EXP."B" 9TH EDITION MA BLDG. CODE FOR ONE-AND - TWO FAMILY DWELLINGS _ REVIEWED BY: �.. L:JENSEN -.:.. ._k ,. .. CANNED. r. REVIEWED ON: ro. 12-31-2019 ZI I'..° N 1 Z A Z OZO TOTAL OF (5) PAGES { n I w ' .' '.. w•.wi .�. y :. ..v.- -�: ... . '".E a a. a , • z N a .. .. 'xV. .. .� .. .. a i ::.. - r v ,e' r• Mitt-sw. .. v r ii[[[i[iyyyy LA N,.Ey v yti] V ST IN A: pg1 12/ 1 .9 4 O U LE �' 5l� 1' U DR INGHOUSE 12/31/2019 GOUTLET-3-SEASON PORCH ADDITION, 5 AUTOMN OR,, CENTERVILLE, MA Page 1 of 5 INGHOUSE, Pc 104OF �s malting: P.O.Box 182 �ANNED Mash MA 02649 Pee, LARS JENSEN , oliice. 18 Steeple Street STRUCTURAL y i_ JAN 2 .12020 Mashpee Commons N0.50602 y R Mashpee, MA 02649 structural deli gn phone. 508-221-2980 ingenuity emall•, Iensen(MInahouse.net web., www.inghouse.net .1 1/2A'9-- _;• o ROOF RAFTERS: - -- _. P.T._2X12 @ 167' ox. typ. _ I � r I v A- , I' ------------- IT L4 _ 3 EX TING G X IS TING V UET AUVN INGHOUSE 12/31/2019 GOUTLET-3-SEASON PORCH ADDITION, 5 AUTOMN DR., CENTERVILLE, MA Page 2 of 5 INGHOUSE, PC mailing: P.O.Box 182 Se Mashpee,MA 02649 �0 offlCe. 18 Steeple Street. nail roof'Sheathing Mashpee commons Mashpee,MA 02649 - W/ 8d common nails at 4" O.C. at - structural design P+Te: 508-221-2980 a ingenuity email.- Jensen0i.nghousenet panel perimeters g Simpson "H2.5A" HURRICANE web �rrMnrinahouse net and-4" o.c. infield, CLIPS AT EACH RAFTER TOP & '`` a.NNED typ• BOTTOM, TYP. ate- r� x - 1 -,..r.r .,r_—�.�+•A _ - " � Q:'.` �_.:J-. yr �li. • ]M�•�U Le.r+... RAFTERS: P.T. 2X12 @ 16" O.C.- tYP. 3 Simpson "H2.5A" HURRICANE t CLIPS AT EACH RAFTER, TYP } �- —O -IKoaOW RS JENSEN STRUCTURAL No.5M2 © �FolsT nail zwall sheathing w w/ 8d common 1/2011 ati �ti c� ' nails at 4" o.c. of panel perimeters ' and 8" in f eld block !^ t. t --�--, .ALL CONCRETE c H AVE MIN. all joints;'typ F� SHALL H F'C=3,000PSI u ` E F ,KSe. ii s,�; (28DAY COMPRESSIVE STRENGTH) Simpson "LUS28", fill all holes w/ -- -- 10d common wire nails P.T. 2X12'@'12"' o.c. tyP. - - -----LL - - -- ,►Ate- `���� -- G_ - 12 floor joists � Simpson "LUS28", fill all holes w/ ' J - °° L Note: Where clear span of /'� 9. • ---- 10d common wire nails -9 3 - ' gists is 15'-6 or less,joists may be spaced at 16" O.C. as -�--— UP�f__tg Q e.5 6 Q L t s • - ss L- to 12 dia. concrete son. Ubes atop ti C r _ 28" dia. bell footings (e.g. bigfoot Ledgerlok screws nn R bottom of footing at 4'-0" in each row spaced Y� } T . footings), , T _ o c?�Sc below grade for frost protection, 5 " r. ' � S �"° . ._. Page 3 of 5 _ tNGHOUSE 12/31/2019 GOUTLET-3-SEASON PORCH ADDITION, 5 AUTOMN DR., CENTERVILLE, MA a SCANNED 41 JAN 2 12020 INGHOUSE, PC �cHoaM� mal#ng: P.O.Box 182 0. �GJe c Mashpee,.MA02649 -LARSJENSEN y�� a : olfli e. 18 Steeple Street S?RUMRAI -+ i- Mashpee Commons. No.50602 Mashpee MA 02649.. structural design phone: 508-221-2980:., e ' 6 ingenuity emaJ/.•' iensenMnahouse.net web.• www.inghouse.net 1 1/201g JL rCA P.T. 2X12 @ 12" o.c h/P• +� t �1n rc } ; ; ha ;'fir �fi � ° A -- floor JO1St5 ,, atr cht c 7 a �t o e: Where clear spamof, joists is,1:5'4',or less, joists maybe spaced at 1'6",o.c: �; _ (07 3 lJ t. { .12".dia. concrete sonotubes atop.28" dia. bellfootings (e.g. bigfoot footings); -- bottofn of-footing at'4'-0''below grade for ' — ► �, . w �., ;M_.__Vol ' frost protection, (5) typ• _A P Q� . i y. T Cs , . OUL o "LUS28 fill all holes wl a �Simps n ,k C bps c S�. 1 ' ,.� : 10d common wire nails � el A a r , . ..A _ `St 1` 0 �I Ledgerlok screws 3 SE AC R �0 G ~ f - . w spaced ' at 8 o.c. .. .....P� ,~ �i�ei(Vj i1i1�.:....�►'�;�.�biQ,�:�lr��1.��_,__ ' , - INGHOUSE 12/31/2019 GOUTLET��S FiCIRCH ADDITION, 5 AUTOMN DR I, CENTER�ILLE, MA Page 4 of 5 tl `` r J rip f4. �structural Mashpee Commons Mashpee,MA 02649 design phone: 508-221-2980 £ ingenuity email., jensenDinohousex web: www.inahouse•net ° ING19128 - 5 AUTUMN DRIVE, � CARSJENSEN CENTERVILLE, MA o STRUCTURAL No.50602 ti DL=I5PSF ROOF AND �F�,ST � FLOOR SYSTEMS,,, E W E s LL=40PSF (1 ST FL R) 0?9 Pg=30PSF, Pf=25PSF Vult.=140PSF, EXP."B" 9TH EDITION MA BLDG. ', s CODE FOR ONE-AND TWO FAMILY DWELLINGS --- - REVIEWED BY; L.JENSEN ... --- - REVIEWED ON: 12-31-2019 TOTAL OF (5) PAGES C` ! 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