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0027 BELDAN LANE
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Hyannis,MA 02601 Re:Perrnit# lLL�/y r Nilla twoT The insulation weatheriza ' tion.work at - && - )?a5 been completed;ir ; GCOrdance with• 80CMR::" - Regards; ,':::'•'..^ Timothy Cabral, President CSL-105454 58 DIMNSON STREET I FALL RIVER,MA 02721 (608) 567-,4240 I ALTERNAI IVEWEATHERIWON@GMAIL.COM y - -,..Application number ..I ..................... .... z.... ....................................... Date Issued..: �...... ........ Building Inspectors Initials ...... ........... TO FC0 ..� ......... 201 TOWN4�T BARNSTABLEv{ �I EXPEDITED PERMIT.APPLICATION: T0kh N ROOF/s1ml GM /WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION ,. PROPERTY INFORMATION Address of Project: c2q7 &LdaZ2, 64 /% ER STREET V]- AGE Owner's Name: �/ tea. /S Phone Numbers 2 o - Email Address:,,Sff t4orme ea",,F�. f( Cell Phone Number Project cost$ 42751441-IV. . Check one Residential Commercial ,OWNER',S AUTHORIZATION As owner of the above property I hereby authorize o7v to make application for a building permit in accordance with 78 MR Owner Signature: Date: TYPE OF WORK 0 Siding �-Windows(no header change):# -Insulation/Weatherization © Doors(no header change)# Commercial Doors--require any.inspector's=review 0 Roof(not applying more than 1-layer of shingles) u Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name i& c— Home Improvement Contractors Registration(if applicable)#L (attach copy) Construction Supervisor's License# (attach copy) � /• adwt _ Email of Contractor Q,lty-,1a,h- e,UQ_Q�.ZC1 7t-1U Phone number s�U� ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE,SUBJECT PROPERTY IS IN. A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APP C T'S SIGNATURE Si ature Date /f1 All permit applications are subject to a building official's approval prior to issuance. f Permit Authorization ash save Form , Site lD: 3562346 Customer: Sheila Curtis I, V l e, J r ,owner of the roe located at: C'G ���.) property rtY (Owner's[Name,printed) 27 Beldan Lane Centerville, MA 02632 (Property Street Address) (City), hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatheriiation work on my property. Owner's Signature: \ Date: l —� FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project:. Participating Contractor Date Name: RISE Engineering y Phone: 401-784-3700 Email: Page 1 of 1 For Office Use Only Rev. 102015� ,� _ The Commonwealth of Massachusetts Department of Industrial Accidents a 1 Congress Street,Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): ALTERNATIVE WEATHERIZATION, INC. Address: 2 LARK STREET City/State/Zip: FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.[D I am a employer with 16. employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.a 9. ❑Demolition I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10 Q Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole l l.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.r7 f am a general contractor and I have hired the sub-contractors fisted on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 14.❑✓ Other INSULATION 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether 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: LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#: XWO(19)58888671158 Expiration Date:6/8/19 Job Site Address: � &Idaltl L7 . City/State/Zip: &4JAr e- 114 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u d ain a p lti s jperjury that the information provided above is true and correct Signature: Date: Phone#:508-567-4240 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#: AC�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)o6/11/18 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: PNE Anthony F.Cordeiro Insurance Agency AHc No.Ell: 508-677-0407 FAX No): 508-677-0409 171 Pleasant Street ADDRESS: HSouza@Cordeirolnsurance.com Fall River,MA 02721 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Liberty Mutual INSURED INSURER B: Ohio Security Alternative Weatherizatlon INSURERC: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 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 PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR RUUL 5UtSKI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �OCCUR PREMISES Ea occurrence) ccurrence S 300,000 MED EXP(An one person) S 15,000 A Y Y BKS58867158 06/08/18 06/08/19 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY❑PRO- ❑ JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ee aBINEDISINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED Y BAS58867158 06/08/18 06/08/19 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/08/18 06/08/19 AGGREGATE S 1,000,000 DED I I RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? NIA XWO$8867158 06/08/18 06/08/19 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under . DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA its direct and indirect parents,subsidiaries and affiliates is added as an Additional Insured for General Liability on a Primary&Noncontributory basis per the terms and conditions of form CG2001 (04/13),for Ongoing Operations per the terms and conditions of form CG2010(04/13),for Completed Operations per the terms and conditions of form CG2037(04/13)and Waiver of Subrogation applies per the terms and conditions of form MEGL0241-01 (04-11) Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02/16) Excess Liabilitv is a following form. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENT �} f ©1949--2015 ACORD CORPORATION. All rights reserved.; ACORD 25(2016103) The ACORD name and logo are registered,marks of ACORD 4Vw Curl trtxi€ark S.rtvisr fAWit1YI R t 1A -� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Mr4Z,2nutsractor etts 02116 Horne Improvem Registration Type, Corporation f Registration: 175683 ALTERNATIVE WEATHERIZATION, INC r, Expiration: 05J28I2019 2 LARK ST FALL RIVER,MA 02721 _. w i9 Update Address and return card. Mark reason for change, Q..Adciress.. ravraL_.C� lc++rntnvm+nt n��± _.... .._ Office of Consumer Affairs&Business Regulation '- HOME IMPROVEMENT CONTRACTOR Registration va1lt9 for individual use only TYPE:Oration before the expiration date. If found return to: ftg, atlon gx2irabon Office of Consumer Affairs and Business Regulation f756$ 05/28/2019 10 park Plaza-Suite 5170 a ALTERNATIVE WEATHERIZATION,INC. n,MA 02116 TMOTHY CABRAL 2 LARK ST FALL RIVER,MA 02721 Undersecretary ti'v o m� I r. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r. Map pp Parcel V Application # Health Division Date Issued Conservation Division _ Application Fe8L . Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board p Ic 9/ Historic - OKH _ Preservation/ Hyannis Project Street Address 7 ®N 00 e Village Owner ,� ���/.� (fag— IC Address .?7 Telephone 7D H63 Permit Request �' /Noa7 Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiof,-Z tY6 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, atta�tf upporti i�q do nenta#ion. p Dwelling Type: Single Family ' Two Family ❑ Multi-Family (# units) Age of Existing Structure 5� Historic House: ❑Yes ®'No On Old Kings Highway: ❑' s CJ NO Basement Type: �dFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq;.ft) jV-' 7ejTJ Al Number of Baths: Full: existing new Half: existing new c Number of Bedrooms: f existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: WIGas ❑ Oil ❑ Electric ❑ Other Central Air: &�,Ye_s ❑ No . Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No p g 9 Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ �) Attached garage: 2txisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial_ ❑_Yes- _ ❑ No If yes, site plan review# Current Use Proposed Use - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name � Telephone Number -,-Address ,_A4 dAJ L4� icense # C.!;-' CPS-TS-1 - oasaj Home Improvement Contractor# I I ,ai I ° � u A,Cr,sZ-_S,t1.C® Worker's Compensation # Cow ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO teAzilb SIGNATURE DATE „'IO/3 ����� FOR OFFICIAL USE ONLY -APPLICATION# DATE ISSUED, d _ MAP/PARCEL NO. ADDRESS VILLAGE OWNER 1 DATE OF INSPECTION: t s FRAME ,x -...INSULATION:-. t FIREPLACE ELECTRICAL:,,,.,, ROUGH FINAL I PLUMBING: ROUGH FINAL a' GAS: ROUGH FINAL .y 'k FINAL BUILDING ` DATE CLOSED OUT a ASSOCIATION PLAN NO. • The Commonwealth of Massachusetts ;k Department of IndustrialAccidents 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 CN ame(Business/Organization/Individual)::;Rkg6j yie,`, 0�/ '� �,,� 24l; �1 ?rs�//-�— Address: �fJ(J 2t9 j�i�,l City/S eaSi23, Phone#: oIX 917 f Are you an employer?Check the appropriate box: Type of project(required): 1.El am a employer with 4• 0 I am a general contractor and I * have hired the sub-contractors employees(full and/or part-time). 6. ❑New construction � 2. I am a sole proprietor or partner- listed on the attached sheet. 7. El.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.inmrrance comp,insurance.* required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp, right of exemption per MGL 12.❑Roof repass insurance required.]t c. 152, §1(4),and we have no 13.El Oilier employees. [No workers' comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,8rey must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,50.0.00 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 certi under the pains and penalties of perjury that the information provided above is true and correct. Si ature: Date: 2K�LG 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#: I 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 ffisurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of JavectigatioAs 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 f Town of Barnstable 0 ` Regulatory Services a RARNGTART.F. v n�►ss g Thomas F.Geiler,Director i6g9. 1� rD, 659. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 - - Property Owner Must Complete and Sign This Section If UsiLig A Builder I, 1ne,4C ,as Owner of the subject property hereby authorize_F (� �GU l2 1 C T to act on my behal� is all matters relative to work authorized by this bmlding permit (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. Signature of Owner Signature of Applicant Print Name Print Name Date QFORM&OWNERPERMISSIONPOOL•S 62012 Town of Barnstable Regulatory Services RARZZS Al Thomas F.Geiler,Director Building Division �En M►•t� Tom Perry,Building Commissioner 200 Main Street Hyannis,MA 02601 www.town.barnstable.ma.us Office: 50 8-862-403 8 Fax: 50 8-790-623 0 A HOMEOWNER LICENSE IIMTTON Please Print DATE: JOB LOCATION: number sh-eet village `IONMV, IIZ": name home phone 1€ work phone# CURRENT MAILf IG ADDRESS: city/town statr rip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow r omeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFIl MON 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 respgnsible 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 heJsbe 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 persons)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decon\.kppDatEL\L.ocal\M=soft\Wmdows\Temporary Internet Files\Contentoudook\QRE6ZUBN\EXTRESS.doc Revised 053012 I - lic safety -= Department Ot Pub s and standards achu5ett ulations ass eq M ildinq R Board of Bu en . Sap en '� Construction -085933 ,: kjcense- CS ERT I' PELT�R ' 5XVON DR .02563 SAN�wI�IVIA � �Jssioner &2. 1par���u racaeaC a�C��czaaa�uaeCt. rOffice of Consumer Affairs&Business Regulation License or registration valid for individul use only..: ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: e;gistration: 163404 Type: Office of Consumer Affairs and Business Regulation iration:_6L16201;5_ Individual 10 Park Plaza-Suite 5170 L Boston,MA 02116 ROBERT L PELTIER f M1M1L ROBERT PELTIER x, k 5 AVON DRIVE SANDWICH,MA 02563 Undersecretary 40t valid without signature i Ala : ►, Ott. E r Town of Barnstable Permit# U W Expires 6 moot/s fro issue date Regulatory Services Fee s MAM , ; ��� Thomas F. Geiler,Director Building Division z 7/1911 Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY l / Not Valid without Red X-Press Imprint ii Map/parcel Number `oq J L WZ Property Address Z-3 PjF_ct n)AM X,'Residential Value of Work �j3Q�_p a Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address S x` k Contractor's Name Lt-6 �1^2�. (� t f}�1 4 t✓L Telephone Number_ Home Improvement Contractor License#(if applicable) i O < 1 d Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance X PRE_- PERMI T Check one: _. r)ii j f �I am a sole proprietor S� �� t ❑ ] am the Homeowner TOWN OF �AR��T���.❑ 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(stripping,old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is Ah-wired. SIGNATURE: Q:IWPFILES\FORMSIbuilding permit for4s RESS.doc Revised 070110 Wf , 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 Le 'bl Name (Business/Organization/IndMdual): L Address: City/State/Zip: ry .ZM 6 v' Phone #: S O�S'__7 (b —'A-7 Are you an employer? Check the appropriate box: 1.[l.I am a employer with 4• ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. 7.'0 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.$ 9• ;0 Building addition required.] 5. ❑ We are a corporation and its 10.[❑Electrical repairs or additions 3.❑ 1 am a homeowner doing.all work officers have exercised their g 11:[]Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees;they must provide their workers'comp,policy number. I am an employer that is providing workers'-compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins, Lic:>#'. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy'number and expiration;date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify er the ains and penalties of perjury that the information provided above is true and correct Si a e: 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): I.Board of Health 2. Building Department.,3. City/Town Clerk, 4.Electrical Inspector 5. Plumbing,Inspector 6. Other Contact Person: Phone#: PROPC AL Page No..of- DESCRIPTION-OF JOB ARCHITECT .. .. DATE OF PLANS - PROPOSAL SUBMITTED TO: roe ADDRESS :1"_�� .;It _ _. CITY STATE ZIP PHONE DATE WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: al_,t_. o:_ i2r i- ii 3/z,,,7- ' 1 t'.' _`)11c,*�itn7, �ii:L�ii -ir iV ^:�lY 3i��3`i i':'1.«•? ?w31'4 L`. ?v 2+1 >il'ft3 Z ,a' i S1=2n j f`i �;-3 it ryi_� . ..?:-.o1 Z� ,'a'1'S ...% i '� :!:n.. i ... 'J. . .+.--!.� We hereby propose to furnish material and labor, complete in accordance with above specifications; for the sum Of Jj :C ; :`tf>„_ ? - '- '-`"r': ''- dollars - L5 with payment to be made as follows - ' All material is guaranteed to be as specified.All work is to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from specifications Authorized { involving extra costs will be executed upon written orders, and will become an:extra Signature s' ' charge.over and above the estimate.:All agreements contingent upon strikes; accidents be with or delays .beyond our control:'Owner.to 'carry fire, tornado:' and other necessary Note.This proposal may drawn by us If not accepted insurance:pur workers are fully covered by Worker's Compensation Insurance. Within days .t Acceptance=of Proposal The Labove prices, s'peclfieatlons and"condr-- tions are satisfactory and are hereby accepted. You are authorized to do the work ass specified. Payment will be made as outlined above. p Y Signature Date of Acceptance;" Signature t� " ✓/ae �oryvnaooxcuea/l! ✓�aaexc/zcrae�a Office of Consumer Aft-airs&Bfisiness`Regulation icense or registratiop valid,"for individul use only HOME IMPROVEMENT CONTRACTOR 1 before the expiration date. If found return to: Registration ry05530 Type: Office of Consumer Affairs and Business Regulation Expiration 7[17/2012 DBA 10 Park Plaza-Suite 5170 s• ' Boston,MA 02116 MI AEL A. BINNALL ADQITIO.N.&REMOLD Mic;ha lh.Binnall 25 6heva Road South Yarmouth,MA 02664` Undersecretary Not valid ithout'sig tune -21 Ylassacbusetts- nePart►trerrt of Public . Board of Buildim" Rc„ -s rfet, Construction Su `�'lations ;irrtl Shrnd:u'ds One and T PerviSor License I wo-Family Dwellings License: CS 45408 MICHAEL A BINNALL I 25 GENEVA RD J S YARMOUTH, MA 02664 ' 11 i (u......ones Expiration: 4/22/ I - -20,3 The Town of Barnstable • e�cerierest.E. • . 9e MAW �m�' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner SHED REGISTRATION a Location of shed(address) F�roperry owner's name Telephone number Size of Shed Map/Parcel# ignature Date istrict. wad st ion? Conservation Commission(signature required) THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg 31-14 3 \ 6.3 . � 1 1-7 31-15 54.3 -6 58 }/ 59.1 -5 5 31-16 154 3 \/5 26 i\ 55.0 / 9.4 �\ 51. 1-17 .2 \, 2 X4 i\ 57 --� i\ 27 l v 34 X 5:9 ""53.- i i� r i .T 6 '. ,•\ ,c .2 �6 55 .6 r 56. 5 58 " 55.3 i/55.5 4.1 ------- O% r' 56 �� � oc .� Assessors map and lot number, ...V.... ........J....... ........ .,•;� ofTNEto Sewage Permit number ........ 7 .' 711—;N ..... Z EAMSTLUE, i House number. ..... ._.,.. /�.!y. i4�u?.~.... ,,� P ,d�/lQ 9� "AM TOWN OF BARNSTAB.LE BUILDING INSPECTOR APPLICATION FOR PERMIT TO A .... TYPEOF CONSTRUCTION ................................................................................................................... .... .�t.............191:s TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locationc�.:.� ./7r7.,S C........................................ ................................... Proposed Use r)..*ri-:L�z<,.,....z'a:.t 9 i2 o.cr-n.F...... ................................................................................................................. Zoning District 1/\F'S�c�Pr/,!„� A- -...................................Fire Districtz. Name of Owner ,�7 1 �'�F':,:7�� 1? , ., �/�?�2 l.�xa!AC...Address r?.7... ap Name of Builder n ua .........................................Address .....: ........................... Nameof Architect ............ :.......................................Address .................................................................................... Number of Rooms ..............'...`. �'......................................Foundation�.l�;,,^��p.(�„�,�r,c;/P�p ��, ...... ... Exterior �, :-�-S..)?..�r �j��...5..................Roofing /.7................................................ Floors .......... R. ✓ :. ?� .............................................Interior ......... ........................................................................... Heating ...................'e�r..`:::.................................................Plumbing ........... .c'r s ..................................................... Fireplace .................: s;r `.............................................Approximate Cost ........ ............................r.�.. Definitive Plan Approved by Planning Board -------------------_-----------19_______ . Area �_ 41 Diagram of Lot and Building with Dimensions Fee c.... .�c........................ SUBJECT TO APPROVAL OF BOARD OF HEALTH 35 F I �c� e Uj A-LA �-o a.s C 1 J, N OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS l I hereby agree tot conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �, Construction Supervisor's License .................................... MARZINZIK, THEODORE 9 9-3/ No Permit for ...additian...to.... dwelling (breezeway & (breezeway......... Location .......2.7....Be.lda-n...Lane..................... .. . .... .. .... .. .. ....... Centerville MA ................................................................................ Owner ....&'...MP,:rY..xAr..z;Lnzik Type of Constructioin, ...frame.......................... ..................................................:............................... Plot ............................ Lot. ................................. Permit Granted ...... ...... 1........ 1985 Date of Inspection ....................................19 Date Completed ...................................19 ,Assessor's map and- lot number _ I 4: ikA 'SEPT1C SYSTEM MUST - 'P Sewage Permit number ...... .�� ." .�....... ........ MS�'ALLE� �� �O6 P 8 °w 1 �p �r �!i"B �1�il� t = BARNSTATILE, i House number-/..... F?.! ,� r�.-�.e.'7.�P ..l�il� EIWWRO 9� 1 T TLE 9�p M6& AL CODE f �' TOWN 'OF BARNSTABLE BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO )).:...QIY.... 14)...................�rt- ..Y........ .......... ...ti..?/./t. .,. .......:.. TYPE OF CONSTRUCTION ..( f✓VAD.................:................................................................................................. a TO THE INSPECTOR OF BUILDINGS: The undersigned.hereby applies for a permit according to the following information: A Locationt .as............................................................................... Proposed Use (Ixt 9. 6(�.....6 �9.(mr ........................ ................................................................................................. S<Q'F l`r R r Zoning District .. .. P...........%?.................................................Fire District �!?......�!�i��.'-'.��5'.�'�ScJ.r��............. Name of Owner /./1. vj0.1[_.7C)V .A..�/ ��<.�t l.&.Address aZ.7.. ��� .. +�?. �..........Y.l...... .tl�� . Name of Builder ........0 C.<,.)..4..C': ......................................Address `,S d.k..Vt.Qy......A .....!�.�� d-Q. ........................ Nameof Architect ............ ......................................Address .................................................................................... y- l Number of Rooms ..................................................................Foundation pa-fz.r:ed Exterior .64. ..........�5'..k ... . ... .......:' Lr��.r.....................................................�.. .. / � rt�l��.�.............. Roofing Floors .!?.�1 �'` ..................................................Interior........... ........................................................................... Heating .. l ! ..............................................Plumbing .......... . ................................................... Fireplace ............Approximate. Cost................................. .............../.. . Definitive Plan Approved by Planning Board ________________________________19________ . Area ......... - ................. Diagram, of Lot and. Building with Dimensions Fee OOJJ �S SUBJECT TO APPROVAL OF BOARD OF HEALTH r A OCCUPANCY PERMITS REQUIRED FOR NEW-DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .. ......... Construction Supervisor's License .....:.............................. MARZINZIK, THEODORE A=31-2 -4; N 0- 2.7-6-7.4.... Permit for Addition-to....... dwelling (breezeway ... g�k?�A.gg) I . ...................... ........................... Location ..2..................1 Beld..a..n.....L-a...ne....... .................... ......................................... -IA ...... Cefiterviile'...� ...... ........... Owner- .Theodore & Mary Mariixmijs:.................................................... Type of Construction ...... ...........f;l�. ............... % ............................... .............................. .......... Plot .......................... Lot ............................ _4 Permit-Granted ..............Ap.-f 1...;L....... 85 .9 Date of Inspection .....................................1.9 Date Completed .......................J.....19 (S TOWN OF BARNSTABLE Permit No. ------------------------- ,ARXn.n, Building Inspector rua � Cash ---------------------- °e OCCUPANCY PERMIT Bond __-------__ "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to 6reeraoi:ier Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ...................................................... 19--.-... ............................................_................._......_........................_.......... Building Inspector �Y;Assessor's map and lot number �./�G Glit/) : �y �A � Q Bpi TN E. Sage Permit number, ...�6..� 1 �................................ SEPTIC SYSTEM MUS INSTALLED IN COMPLI STABLE, House number AM � STA WITH TITLE .5 °°Aj�1639'a�e� ENVIR NM L CO C3E AP. .. m TOWN OF , BARNSTMOr&LATIO&I'S BUILDING' INSPECTOR APPLICATION FOR PERMIT TO ^J�1.1../�4 S� �; �eja .TYPE OF CONSTRUCTION ................. .. . ....................................................................................................... ....................19SQ 1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for as /per it according to the follow_in/gin information: Location 1. .....yll.c(.� /�.....,/�/On L�/lY<...". !�/���4.:.... ............................. . ProposedUse .........In A ............................................................................................................................. Zoning District .........../..` .0................................................Fire District .. �T Name of Owner L�/� � �ti.....w..�.�...t .........Address �L� C�/(/f Name of Builder .......5—�Qm..0 .........................................Address ..........✓.. P....................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .................�.......................................Foundation ................. c Exterior ......... ..................................................Roofing ..... ��✓�.1.. . •• FloorsiQT,J�.e .. l✓�N�/........................Interior ........1������ ............................. Heating. /J': 10... .4?.................................Plumbing .... c ... �w. ................................ Fireplace 7�U ..,..�/ (.. .................Approximate Cost ........ Ao() ......... .............................. j. Definitive Plan Approved by Planning Board _ ----------__19 Area .....?60 , Diagram of Lot and Building with Dimensions �Fee ..................... .................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 0 I.1L./ I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........... ................ ........ ......... ' GREENBRIER DEVELOPMENT a` No ZZ2 6 3..... Permit for Two S t ) Frame Single Family Dwelling ................................................. i Location ...Lane........ ' Centerville .......................................................... + Owner Greenbrier DevelgPMPX1.t,,,Gorp, Type of Construction Frame............................. ......................... ..................... Plot ............................ Lot ................................ k t t - , Permit Granted June 12, 8 0 i r 19 ............. . Date of Inspection19 r Date Completed ................... ,. ..19U� PERMIT REFUSED ....... .. . ... . ..................................... 19 .......... �. . ......�6... ................. . ....................... ....... . z................................................... , ........ y . ............................................. . ................................................ I� Approv.,ed,:'.............................................. 19 i ............................................................................... i ........... . ....................................././......................... C Assessor's m.. , . . .... . . . ...,. . ap and lot number .... ............. - CFTHETO SeNAgge Permit number ..�! :.1. ................................ . Z B9HB9TABLE, i House number .................... ..... j�.............................. 900,0,14AS �00Cb 'F0 YPY a TOWN OF BARNSTABLE BUILD.IHG . INSPECTOR APPLICATION FOR PERMIT TO ........:......... ...............................................................:......:.......................:.......:.. TYPE OF CONSTRUCTION ;!.............................L .............................................................. + ' ".�. ............ .y. ............................... Fw TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: 1 Location ...... /=� 1- '.�-"`:... . f� f'/1/ '?!`�L� ................ ............. ...�Yf' '.......................... ProposedUse ......... ... .:...................... .................................................................................................................................. Zoning District ...............................................Fire District .. ...... ( �j .................... .. .................................... . Name of Owner ...............Address :..!:!� "...:5 ��..... k'!P�::� `.t �................. .Name of Builder ....... �.r h).�................................................Address ................'' .....:...................................................... Nameof Architect Address.................................................................. ................................................................................... .. Number of Rooms ................. .........................................Foundation �!✓..!l.�:c�l.�:..?. r =!;.r !� ' c.. .....................: Exterior ..........{..:��.. f.. ..........................................................Roofing ...... � S.z:'..j�:. f.. .......................................... Floors ��.�: . . ...........`" r //L"L/ fit.......................Interior. ....... > !. ........... ..`.............................................. .... ....... r )�/7 .................................Plumbingaf�i Heating J :........ :...,..........L.................................. Fireplace ..............C. !!:.'n: .y �..: r .....�. {.!..t(.................Approximate Cost ....... "�.? ..: ................................ :.. „ Definitive Plan Approved by Planning Board _%`__' _ __________19C1 _1. Area = �? `K'��...... .....r.f........... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH ) z I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..'/.... r 2: ... ........:.... � `'............. GREE0BIlIEfl DEVELOPMENT A=I89-31 ' �� . . . ' yl/l �� . . Two St«»r - No ��'---- Permit. -------~---- ° i l ' ��. .�5��,�����----. ' Location ...�ot...#3..�,-)7..���ldao..I�g���_.. � ______��g le__________.. ����������� Corp. � Type of Construction .4ame........................... ' � Plot ...................I......./ Lot ................................ � Permit Granted ~~'~ Completed ' ' - ------'.19 PERMIT REFUSED � � __ -.. lV -----------. / | / ........................... .....----...--.----- . . -----~^''`-^'---~'~---~--'-^-'-''' L . --------^--'-'---^'--'-^'^---^-' ^ . ' Approved ................................................ lV � --------------~.-----.-----.. � .............. ------'---^----~^''^^'-'-^' � � � f ems'- LS`i#Hz �""f w rri} ,t s* ikt _ 'a„2 !"..$ ,� .s:�r 3.""" s � � r u `Y * ` f k fir :'- , 7v r s n4 F iA ..,�.F } ,,�.i.A . 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