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ARISTAMAM ` ` Building Inspectors Initials..... ` lk0 8 20"1 �In��� - Date Issued..................1..�.1. ��. ........................ ABLE Map/Parcel....lele.'....-��� TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Ad ess of Project: -� L� 1 /Y-� NUMBER TREET VILLAGE Qv�mer_s,Name: 7� O( 6 011 s� Ch `� �Q Phone Number ��� -33f a� �O E� mdss ��'� UPS 2J20�i�� GDf�I Cell Phone Number C j!r �ect post$ Check one Rer s den 'al Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: Z 'WORK © Siding Windows (no header change)# / r ❑ Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)#J (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number 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. r 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. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No____,if yes, a gas permit is required: Natural Gas Yes No , if yes, a gas permit is required. , If food is being served at your event please obtain a Health Department approval between the ho,.urs of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval A. *WOOD%COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side °O MEOW NER_S.LICENSE EXERTION 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 Town7"49 stable. Signature Date 71—CANT'-S-&'GNATURE Signature ' Date All permit applications are subject to a building official's approval prior to issuance. ' 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/EIectricians/Plumbers Applicant Information Please Print Le bl moO idvaI): /��U�Meus Q �_ r-C- tlSte/Zip: fir�vy� P�Q /� ©o�G3o�Phone#: Are you an employer?Check the appropriate bog: 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 constriction 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 El Building addition [No workers'comp.insurance comp.insurance. required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. A 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, §](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 subcontractors have employees,they must provide their workers'comp,policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy 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 certify under t andpenalties ofperjury that the information provided above is true and correct Si at�e: � Date: s . •' 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 1 sub-contractors nam s ,address(es)and phone number(s)along with their certificates)of necessary,supply ( ) ) insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(UP)with no employees other than the P members or partners,are not required to cant'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 beingrequested,not the Department of y .lm +1, 1 iu.arerPrnTrP,d�n Afnin a wnrkers' Ir1dLiSt'lad P cciaerlis. Should yoLt haveaLy�ucsuvu�__s rc�;nFLL.,�g_e.u�'cr uf S..o -F, compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike 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 CQMMGUWealth of Massachusetts Dgwtuient of Dadustciat Accidents Office of Investigations 600 Washinton Suet Roston,MA 021 It Tel,#617-727-4900 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 4-24-07 wmass,gav/dia C�� ���J � � 3o �i`�� �l�l ' J I TOWN OF BARNSTABLE Building201204889 BARNSTABLE, Issue Date: 08/30/12 Permit 9 MASS. �A i639• Applicant: MASS BUILDING SYSTEMS rFG MAC a Permit Number:. B 20122099 Proposed Use: SINGLE FAMILY HOME Expiration Date: 02/27/13 Location 33.BENT TREE DRIVE Zoning District RC Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 168034 Permit Fee$ 35.00 Contractor MASS BUILDING SYSTEMS Village CENTERVILLE App Fee$ 50.00 License Num 158588 Est Construction Cost$ 6,000 Remarks. APPROVED PLANS MUST BE RETAINED ON JOB AND RESURFACE(SHEETROCK)EXISTING FINISH LOWER SPLIT LEVEL THIS CARD MUST BE KEPT POSTED UNTIL FINAL INTERIOR ONLY! INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: PANITZ,THEODORE&PATRICIA BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 33 BENT TREE DR INSPECTION HAS BEEN MADE. CENTERVILLE,MA 02632 Application Entered by: JL Build it Issued By: jai THIS PERMIT CONVEYS NO RIGHT:TO OCCUPY ANY.STREET,ALLEY OR SIDEWALK ANY P T THEREOF;EITHER"T 0RARILYJ PWENttY. ENCROACHMENTS ON PUBLIC PROPERTY,NO SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED B S CTION. STREET OR:ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAYBE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF .PERM LEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLESUBDNISION RESTRICTIONS .... .- .. MINIMUM OF FOUR CALL INSPECTIONS REQUI 0 LL NSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE T VEL BEFORE FIRST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMP T RIOR TO FRAME INSPECTION. 4."PRIOR TO COVERING STRUCTURAL MEM S(RE DY TO LATH). 5. INSULATION. 6. FINAL INSPECTION BEFORE OCCU CY. WHERE APPLICABLE,SEPARATE P MIT ARE QUIRED FOR E C PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROC UNTIL SP TOR HAS APP ED VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME LL ID IF CO TRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS'OF DATE THE PERMIT IS ISS D AS NOT ABO PERSONS CTING WITH EGISTE D C TR CTO S DO NOT HA AC SS TO GUARANTY FUND(asset forth in MGL c.142Aj. ` .. BUILDING INSP ION APPROVALS PL ING INSPECTION PPRO LS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health ,3 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1 � Map Parcel 3 Application # Health Division Date Issued l Z Conservation Division Application Fee Planning Dept. Permit Feee--``�� Date Definitive Plan Approved by Planning Board L.J 0/1 z6v4-1 Historic - OKH _ Preservation / Hyannis Project Street Address -3-3 Village e n-�°€� v Owner 6&4) e �11 v Address Telephone — !r / — 3916 Permit Request We <�zl� � /� �. �; N �•� •s Z, w e 4, 5'o I,,✓-C 01 (Shtybd®t k� �d► r J e F 0 h l v Square feet: 1 st floor: existing �proposed..,� 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o Q 0 Construction Type Lot Size_ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-FaZo units) Age of Existing Structure `� d H' toric House: ❑Yes On Old Kin 's Highway: ❑Yes ❑ % 9 9 � g Basement Type: ❑ Full ❑ Crawl Walkout ❑ Other Alt, � �� � a µ.me Basement Finished Area(sq.ft.) o 47 A�/ Basement Unfinished Area (sq.ft)an i Number of Baths: Full: existing 7, new Half: existing new Number of Bedrooms: _ existin _new ? Total Room Count (not including;bthn,): existing 7 new First Floor Room ount Heat Type and Fuel: ❑ Gas il ❑ Electric ❑ Other 6 `� Central Air: ❑Yes 0<o Fireplaces: Existing New Existing wood/coal stove: ❑Yes/No ❑ existing ❑ new size0 existing ❑ new size _ Bares' ❑ existing ❑ new size_ Attached garage existing ❑ new size _Shed.,(existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 2`No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name-' �� ;,� '' u�� Telephone Number : J 1K J✓ q 7 Address �� C� �a •-� sh �, ��/e, License # = �' 0-7-6-0/ Home Improvement Contractor# 'g 5 ' Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING ROM THIS PROJECT WILL BE TAKEN TO /t,117 A SIGNATURE / �� DATE 7 r. FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED i MAP/PARCEL NO. - ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' FOUNDATION FRAME x _ INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL s . FINAL BUILDING - DATE CLOSED OUT ', ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents - : Office of Investigations 600 Washington Street Boston,MA 02111 4 www.massgov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ) /Please Print Legibly Name(Business/OrganizadowIndividual):. ��A'�s 5 64 i C�r ✓; �1 t r'i� Address: '7—�e 54 f7_11 in C, I_,; City/State/Zip: / V n 'OZ.s o.J Phone.#: �ro Ff�7_.7 t —: 79 'j 1 Are you an employer?Check the appropriate box: Type of project(required):, 1.❑ I am a employer with 4. ❑ I am a general contractor and I �mployees(frill and/or part time).* have hired the sub-contractors 6. ❑ construction . 2.V 1 1 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' co ;nsrrrance.#. -9. El Building addition [No workers comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.❑-Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions . myself. [No workers' comp. right of exemption per MGL . 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ 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 the policy and job site information Insurance Company Name: Policy#or Self-ins.Lic.#: h/c 7> /S` 3 17 7._✓ n +- Expiration Date: Job Site Address: S 71 City/State/Zip: C'el,h �r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signafore: • Date: J 1 Phone#: -.5-0 <2r, Official use only. Do not write in this area,to be completed by city or town official.- City or T. Permit/License# Issuing Authority(circle one): .L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Pex-son: Phone#: . r EVE rowti Town of Barnstable Regulatory Services' 9IIAMST.4214�` Thomas F.Geiler,Director 0.19. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, d %�.- � �. �',t/ , as Owner of the subject property hereby authorize ,��-e n r�b</ /a� to act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) t **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 O Si ature of Applicant � � PP 047 �, �� > �z���y66,X b Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012 ��t r Town of Barnstable Regulatory Services * BAMSTABLE, Thomas F.Geiler,Director MASS. 1659. A.�� Building Division EO NIA'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 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. 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:forms:homeexempt Office oous merir�"s Xc Business egu a"Cion"" License or registration valid for individul use only before the expiration date.. If found return to: HOME IMPROVEMENT CONTRACTOR Registration: ,;,158588 Type: Office of Consumer Affairs and Business Regulation Expiration: 2/1,1%2014 Partnership 10 Park Plaza-Suite 5170 Boston,MA 02116 M BUILDING SSTEMS STEPHEN BOBOLA 24 ST.FARNCIS CIR HYANNIS,MA 02601 Undersecretary Not valid without signature he ment of dub u5etts. Qe� ulat ans aka�� a Massach Bull t rw►rir rp j ; rd o� oa r�n9�� , 87 Lun. S }s License:C 00 { 24 SN' A 021\ c tto� E 4 XQt�2p1 Mm15s-,00er 1 3-� i " G }o i XJ s n 64 �'wEYs' -`1A x. L3 f � 1j1 j f.� /VG CA4H --Cs 0 e �o rk T � rov-e-0' ke v-� x 71 4 iz 4 CA 00, 'z I t 33 /�CA--b 4---y�� // 0.W- �a.� % =2 �>/"1�,s ��, o��,�9 S 0 IT r 7`7 - g 9 71 1T7e Sdjee b6ac.� 002"S F Town of Barnstable F *Permit# o . - 6 m {rs jrvxt issue date Regulatory Services- F Thomas F.Geiler,Director S / /�// TO3WN �OrEc:ntp�� � � . . ®� ; i1 STABLEBuilding Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us "-Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not-V410 without Red-X Press Imprint f p - r Map/parcel Number -bet J P O-A-e y '� I I e 1 aab 3 a Property Address Residential Value of Work" � Minimum"fee of$25.00 for work under$6000.00 Owner's Name&Address -Fed PC ri I�Z Contractor's Name O r dd(I kme T-V--'0rey-e-M e-rj Telephone Number 0V— -7-7 S`Q,'7$ Home Improvement Contractor License.#(if applicable) 10 3 '15 7 Construction Supervisor's License#(if applicable) Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am-the Homeowner. (�Thave Worker's Compensation Insurance Insurance Company.Name n _ 1" , C� �dx�Ci G� Zn l.cS 44 Workman's Comp.Policy#" P U) -7 W 9 4 3 61,2-60!j Copy of Insurance Compliance Certificate must accompany each permit, Permit Request(heck box) Re-roof(stripping old shingles) All construction debris will be take n:to Re-roof(not stripping. Going over existing layers of roof) , ❑ Re-side r #of doors Replacement Windows/doors/sliders.U-Value . 3. (maximum.44)#of windows�S40 r 1►1 . .. *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. t op me Improvement Contractors License&:Construction Supervisors License is SIGNATURE: Q MPFILESTORMSUilding permit forms\EXPRESS.doc i Revised 090809 Tti Town of Barnstable Regulatory Services Thomas F.Geller,Director Ft16`� ]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 �Y ProP e Owner Must . . Complete and Sign This Section If Using ABuilder I, -Te A �a tQ t-}'-Z ,as Owner.of the subject property he-mby ai ttionze R r lea e E31CYa C m j ah6w act on my behalf, - in all matters relative to work authorized by this building permit application for. . .(Address of rob) Signature of Owner ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption.Form on the reverse side. Q:FO RMS:O WNERPERMISSION 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 Aaalicant Information Please Print Leeibly Name(Business/OrganizadoNlndividual): r,6IL14 We__ (OVe.MeA� Address: l99 t' rr1S �oI2 City/State/`Zip: i1 i5 Oa(o0 Phone#: 0's- 715 - !-1 g Are youan employer?Check the appropriate box: Type of project(required): 1.l.� 1 am a employer with R 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am.a sole proprietor or partner- These on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g; 0 Demolition working,for me in an capacity. employees and have workers' Y P tY ; 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions t 3.(] I am a homeowner doing all work officers have exercised their l I.❑ Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t - c. 152,§1(4),and we have no employees.[No workers' 13.0_Other 601�Lv",-- 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 subcontractors have employees,they must provide their worker'comp.policy number. I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and job site information. n 1 Insurance Company Name: F-i SS�C.1 Q. S�nclu5�fiC,S Y��t Policy#orISelf--ins. Lic.#:A(AJG -76o q 9 U011ovin Expiration Date: nt Ol Job Site Address: 33&Vi IV hriVe, 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 tine 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 insurAinwcoverage verification 1 do hereby ce ender e • s and penalties of perjury that the information provided above is true and correct, Si nature: Date Z't5 10 _ Phone#: 75- IT)ik Official use only. Do not write in this area,to be completed by city or town offlclaL City'or Town: PermitiLicense# 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#: Ro CERTIFICATE OF LIABILITY INSURANCE OP ID DS 7DATOEI(MMIDDtYYYY) `SPRIN-1 /05/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden'6 Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 . Phone: 508-775-6060 Fax:508-790-1414 INSURERS AFFORDING COVERAGE ��NAIC# INSURED - - INSURER A: Associated Industries:oE to INSURER B: S rinkle Home Improvement Inc. INSURER C: 139 Barnstable Rd INSURER D Hyannis MA 02601 - INSURER E:- 1 -. COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMIDD� ATE(MM/DD/YYYOY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY " PREMISES(Ea occurence) _$ CLAIMS MADE D OCCUR MED EXP(Any one person) $_ PERSONAL&ADV INJURY $ iGENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER:I ( - - PRODUCTS-COMP/OP AGG S POLICY PRO- n LOC PRO- JECT AUTOMOBILE LIABILITY I COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) T ALL OWNED AUTOS - i BODILY INJURY - SCHEDULED AUTOS (Per person) $ HIRED AUTOS - BODILY INJURY - - (Per accident) $ " NOW AWNEO AUTOS � � ' III PROPERTY DAMAGE - h (Per accident) S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT S ANY AUTO OTHER THAN EA ACC S AUTOONLY: - AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE - $ - OCCUR-- CLAIMS MADE AGGREGATE $ S DEDUCTIBLE S RETENTION S $ WORKERS COMPENSATION TORY LIMITS IT AND EMPLOYERS'LIABILITY ER A ANY PROPRIETOR/PARTNER/EXECUTIV .Y�,N� AWC70049:43012010 O1,/01/10' 01/01/11 E.L,EACH ACCIDENT S 500000 OFFICER/MEMBER EXCLUDED? — — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE s 500000 If es,describe under - - - - SPECIAL PROVISIONS below - E.L.DISEASE-"POLICY LIMIT S 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES LEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER- CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SPRNKHO DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10, DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, :Inc. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax -#508-775-1350 REPRESENTATIVES. Margo Mack AUTHORIZED REPRESENTATIVE 199 Barnstable Rd; Kelley A.Sullivan. annis .MA 02601 ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 A �Iii;;at h:u.etis=.I)elrai tMent of 11tiltlic 1 Bmird i)f Bitiitlin, its "ul_iitiCuis anal Stafld ii.i1< Construction Supervisor Ucense License: CS 6643 �. Restricted to: 00 ~r BRAD K SPRINKLE,,,, 190 LOTHROPS LANE;" W BARNSTAB:LE, MA 02668 - r Expiration: 10/8/20.11 i firri ui, i+icr Tr=: 5478 Restricted to• 00 00- Unrestricted 1G_1 2 Family.Homes + Failure to possess a current edition of the L. ..Massachusetts State Building Code is cause for revocation of this..license., i. Refer to: WWW;Mass.Gov/I)PS i Tk ilding 11dhfg iea�i o� ooacxc�utdeEld $oard of$w Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regist �.103757. --- �- 9l2.010 Tr#. 271033 • - 61',aFl 1�J0 Ba?rtstab"Ye.Rd µ L FRnse.. r regis r lieforeahe expiration date .If found return'.to hoard of)3uhdlpgAeg dations and Standards rte Ashburton Place Rnt 1301. , r,::gbStota,. U.02 :08 Not aand wit oltt sing Luxe