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CT5 � iAitNel'ABLE, � .039 Thomas F.Geiler,Director a639� p�� Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-796-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Q Not Valid without Red X-Press Imprint Map/parcel Number 1 Property Address 5 1 f \ ( 1�(1't V �\I I Ef'Residential Value of Work Minimum fee of$25.00'for work under$6000.00 Owner's Name&Address C�_I)e l y t 1 Contractor's Name J �. �j k�i O fY11Q_ elephone Number < R 77\ Home Improvement Contractor License#(if applicable) j Constru n Supervisor's License#(if applicable) C —00 b to'j:fj orkman's Compensation Insurance ��PR83 FERNY Check one: ❑ I am a sole proprietor OCT 212014 ❑ Iom the Homeowner. 91 have Worker's Compensation Insurance .TOWN OF SA R N STA S L E Insurance Company Name Workman's Comp.Policy#_ .Pr Uj ( m V,9",43'D.® � 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 v ❑Re-roof(not stripping. 'Going over existing layers of roof) ff-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 re SIGNATURE: QAWPFILES\FORMS\building permit forms\EXPRESS.doc. Revised 090809 ••••••.......rcascia vJ trJu33U,:UU3r113 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 i www mass gov/dia aticant Informationtion Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ap Please Prmt Les?>tbly Name(Business/Organization/Individual): Sprinkle Home Improvement Address: 199 Barnstable Road City/State/Zip: Hyannis, MA 02601 Phone #: 508 775-1778 Ext.10 Are you an employer?Check the appropriate box: 1•�I am a employer with 10-12 4. ❑ 1 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•❑ I am a sole proprietor or partner-~ listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' 8. ❑ Demolition [No workers'comp. insurance comp. insurance.. 9• ❑ Building addition 3.❑ required.] 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions I am a homeowner doing all work officers have exercised their myself [No workers'comp. right of exemption per MGL 1 1- Plumbing repairs or additions insurance required.]t c. 152, §1(4),and we have no 12.❑ Roof repairs employees. [No workers' 13•❑ Other comp• insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers* Homeowners who submit this affidavit indicating they are doing all work and then hire outsideconetractors nsation most suhmoit ti as new affidavit indicating such. .ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have nployees. If the subcontractors have employees,they must provide their workers'comp,policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site ,formation. tsurance Company Name: A.IN Mutual Insurance Co. Aicy#or Self ins. Lic. #: 7004943012014A Expiration Date:_ 1/0 j/2015 ib Site Address: i l y • City/State/Zip: `1 ��- ttach acopy of the workers'compensation policy declaration page(showing the policy number and expiration date). tilure to secure coverage as required under Sectidn 25A of MGL c. 152 can lead to the imposition of criminal penalties of a to 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the D1A for insurance overage verification. to hereby cert6 ar and penalties of perjury that the information provided above is true and correct ature: \ Date: 7 - one#: 508 775-1778 Ext. 10 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#: A�ORO' SPRIN-1 OP ID: DS �.� CERTIFICATE OF LIABILITY INSURANCE F 01/14/14 DATE(MM/DO/YYYY THIS CEItTi :ICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW THIS CERTIFICATE OF EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW' T S E OR PRODUCER.INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ER,AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder Is an ADDITIONAL INSURED,the the terms and conditions of the � policy(fes) must be endorsed, N.SUBROGATION IS WANED,subject:o certificate holder In lieu of such policy. $pllelea may require an endorsement A statement on this certificate does not confer rights to the PROD CER BrydeU &Sullivan ins Agency Phone: 508-775-6060 NAME:c88 —� Falmouth M BA 022660 Hy 1 Fax: 508-790-1414 ""ONE Kelley A-Sullivan E-MAIL ADDRESS: INSURERS)AFFORDING COVERAGE f VAIC0 S INSURED Sprinkle Home Improvement Inc. INSURERA:Assoclated Industries of MA _ i 199 Barnstable Rd INSURER — Hyannis,NIA 02601 INSURER c: _ —---f--- -- — INSURER D: INSURER E: T COVERAGES CERTIFICATEINSURER F: ' THIS NUMBER: NUMBER: — IS TO CERTIFY THAT TH E POLICIES OF INSU REVISION INDICATED. N0TIMTH RANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMC l EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. YSR TYPE OF INSURANCE MP�CY EFF MM/D EJ(P GENERAL LIABILITY POLICY NUMBER —-UUMITS - __J COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ oownence) CLAIMS-MADE 7 OCCUR PREMISES(Ea MED EXP(Arty one Parson) $ PERSONAL&ADV INJURY !g GEML AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ t POLICY PRO I PRODUCTS-COMP/OP AGG $ LOC AUTOMOBILE LIABILITY AN AUTO Ea .' ISINGLE LIMIT $ ALL OWNEDS SCHEDULED i BODILY INJURY(Per person) $ — HUTO BODILY INJURY(Per aodoent) $ HIRED AUTOS NON-OWNED � �—----_------.`—� AUTOS i I iPRROP R DAMAG accidentPer UMBREIlq LIAB OCCUR $ J EXCESS LIAB CAE I EACH OCCURRENCE _ g N DIED RED ' AGGREGATE g WORKERS Co AND EMPLOYE�jIABln� $ f WC STATU- OTH- (ANY PERIMEM ER EXr E HIVE YIN N WC40070048432014A �yas�InNlf)EXCLUOED9 N/A i 01/01/14 I 01/01/15 E.LEACHACCIDENT I$ 500,00 OES� OdI F OrPERATIONS below f ; E.L.DISEASE-EA EMPLOYE $ 500,00 E.LDISEASE-POLICY LIMIT $ 500,00 SCRIPTION OF OPERATIONS/LOCATIONS/VENICLES(/yhgr ACORD 101.AddlOonM Remarks Schedule,if more space Is required) ,rtificate issued dfor insurance verification purposes. RTIFICATE HOLDER CANCELLATION SPRNKHO f� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE + Sprinkle Home Improvement,Inc ACCO DANCE WITH THE POLIIRATION DATE CY PROVISIONS. E WILL BE DELIVERED IN Margo Mack 199 Barnstable Rd. AUTNORMED REPRESENTATIVE Hyannis,MA 02601 Kelley A.Suliivan ORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t Town of Barnstable _ m ° Regulatory Services Thoinas F.Geiler,Director ' En Building Division Trim Perry,Building Gornmissioner 200 Main Stxect,Hyannis,MA 02601 wnvw.tawn.batrnstalale.maxs Office: 508-:862.4038 - Fax:: 508-790-6230 Property Owner Mils ti , Complete.and Sign This Section I 1 Us in ilder �B �. i Z,. . V ANC ��� i ,as Owner of the subject property hereby authorize Sprinkle Home Improvement' Co act otxmybelaalf, i a all:aiatters relative to work authorized by this bdding.pertnit application for .(Address of job) Sign4hre.of Owner Date ,'10-e I e— �z I' Parise If ProyeM Owner is applying for permit please complete the Horneowners,Mce<Lse Exemption Form on the reverse side, llFllR t�fiSY1 WIJRR:PF,R 14iT.CC1�N r Massachusetts -Department of Public Safety Board of.Building Regulations and'Standards Construction Supervisor. License: CS406643 BRAD K SPRINIQ 190 LOTMOPS w sAMSTABLE Expiration Commissioner 1010812015 C �n iai»irn.�namallX v acleu�e/�a. Otlirc.ofConsumei Afia rs,�.BusahessltegWkoon MEIMPROVEME:NT"CON RACfOR. egtstratlPM ;A03757 TYpet. Ex}5lration r7/�9 01E Private Corp SPRINKLE HOM i�R E iMOVEIE�11,tNC, . Brad.Sp ,fin 198•Barnstable Rel: , H annis,:MVQ0 601 Y tlndersecre tary CT.27.2014 14:53 5087751350 Sprinkle #4371 P.001 /001 SPRTNKLE. HOME IMPROVEMENT , TNC . 199 BARNSTABLE ROAD — HYANNIS , .MA 026.01 . TELEPHONE 508 - 775 - 1778 FAX 508 - 775 - 1350 EMAIL SPRTNK (u) CO119[;�. (j S.L' . NE...'I',• FACSIMILE TRANSMITTAL SHFF.T Margo Matti, Office Man-aei COMPANY: DATE: - Town of Barnstahlc Building Dept 10/27/2014 FAX NUMBEK: TUTAL NO.OF PAGLS.INCLUDING C(>VT?R: 508 790-6230 Itr: YOUR REFERENCE NUMBEn: Bra.d's Slgnawre ) . II ❑ URGENT ❑ FOR RFVTP.W ❑ PILliASi CO ❑ T'T.F.ASF, RFM,Y ❑ PT.•,E-ASI; ]ZLCYCLL License or resistratiun valid for individul use only . before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 0211G - Y Not.valid witho signature I 0 Engineering Dept. (3rd floor) Map I�q Parcel ( ermit# 6 t House# � Date Issued /0 B 4.30) Fee s oor C 00 d THE►q;_ MASS � 059. �!$ rfD N1P�� A. . TOWN OF BARNSTABLE Building Permit Application Project Street Address c, Village Le 1,Q O Z 4 3 Z Owner e- � boq 11094 �aw Address a 2 �'`@ yr✓J�� �L-1 �.11/� Lvw)E+Q►zrw Telephone / — � T Permit Request e- avT— e f First Floor square feet Second Floor /ti07---kl- square feet Construction Type (��� �'�2 ►4 r..--Q Estimated Project Cost $ �/_ 'Cr Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑.No Dwelling Type: Single Family 2"' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes Sgo On Old King's Highway ❑Yes U�N-o Basement Type: Ueull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) !ti vim_ Basement Unfinished Area(sq.ft) l'G Number of Baths: Full: Existing_ 1 New Half: Existing New No. of Bedrooms: Existing 3 New Total Room Count(not including baths): Existing 6e New First Floor Room Count Heat Type and Fuel: 215aas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ttached(size) Zy ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes Q'&o If yes, site plan review# Current Use Proposed Use / Builder Information Name d6rkevl��A I Telephone Number Address �e/ lfa S e rzc f o License# C>S 7 39 y O L6 3 2— Home Improvement Contractor# // ! y 3 y Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO guw� SIGNATURE DATE 2 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) " rt C is FOR OFFICIAL USE ONLY � , PERMk NO. DATE PSSUEd _ MAP[PARCEL NO ADDRBSS. n VILLAGE - OWNED , DATE Q ISPECTI� N: FOUND''►TION FRAME INSULATION FIREPLACE t a ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH �/JFINA(L , FINAL BUILDING f Z"' I v A"�J - DATE CLOSED OUT ASSOCIATION PLAN NO. ti +` The Commonwealth of Afassachusetts Department nJ1►tdustrial.4ccidents ' 1 Office Of111=11ffMONs :Z�_ ',=�' 600 11'asinh lt ton Street �__ . Boston,Mass. 02111 `-' Workers' Compensation Insurance Affidavit 1 i at _ l c on: �� ��e.�14VL fit) phone# ZO _ VI m a homeowner performing all work myself. aam a sole proprietor and have no one working in any capacity y.... /-^+.e'.��?'_'%�.'�" .?inC!'+o!AaP+?'anRli/,Fs:'-.�'�s..^'.T't!.:.:.4......:.:, .. .. .. .:,.:r .::.^"� . �,...r•'�„ �r+.,s•.a,c� I am an employer providing workers' compensation for my employees working on this job. company name- address: ; city: phone#• - msur•tnce co policy# 7.2 0 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comliany name: iddress• city: phone#- • icy# )n�ur�ncc co ..+;��m.'z�'r•s".y.mN4��:9^T" _ _ 77.1Ffitr7 .-'-. ,..T....,+cc .,GJn:•'i7•""r�, a.•-ra-r, .•.rQ. '.•••".._ ._... ...__.ter:. ._.�._ c6mlinny name: address: city Phone#• insurance co policy # M -Attach addi_tianaFshiii if tiecess _i_ " } a< y` " pr i�i.. j£ •pry,aA ���r. _ .._ y � °;�y�y Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. !do hereby certif to •r t/re pains and penalties ojperjuty tha the information provided above is true and correct. Sienatu Date re Print name d'�e`'t"� "Iix Phone# Y z 7Department official use oniv do not write in this area to be completed by city or town oMcialcity or town• permit/license# nBuildLicen13 check if immediate response is required �SclecE31lealcontact person phone#• nOthe r'. Irevrsed 3105 PJA) 1_ Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an emplt{vee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An emplurer 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 ,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that even,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 commoirwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. 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. + t . Applicants _ Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. • %t Cite or Towns 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. - ,••,a.R.,.,.,•...............:.-�,.—•-..,.a-... ,...�..,...�..,....v,..r.�..a...,z,s�.-w- �..--�w.. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations ° 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 *THE?, The Town of Barnstable eaxrrsTABM41 ` Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires .that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: �e 2 o-z� Est.Cost_ Address of Work: �'/ rt y� ( � �� C��.L,�tiJ le Owner's Name ed�— 2 f/1�S re G✓ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: 1,4-12- ,/ 44 Is-4 1 y3 Date Contractor Name Registration No. OR Date Owner's Name MPROVEMENT CONTRACTOR b. eis�rt anon111434 INDIVlDUAL-,&' 1�` ➢a7s ' C9 .�Yc.r f`'S.a�yxt- 'v.ai. �; fl� ����� .NARBORS,IDE RENODELINfi�� �s 811 OSEMARY . �[Q�ri tq Yi�'�.e�i �i'•r�'S,,'�kry r�'� "r^ ,��_,"_}'"„{�`� �ADMINIS1FiAT0R -t?�RILLE MA 02b32 � ,- 3 ✓�ie �ooranzooz.,uea/,l< o��aaaac�iurel�t DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE . Nu�ber Expires: Restricted To 1G si Oe IS— • i 9 ROBERT G WALSH " .101 ROSEMARY A CENTERVILLE, MA 02632 . � e , TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION TO THE INSPECTOR OF BUILDINGS: The undersigfTed^^reby.applies for o permit according to the following information: ^6* Location Proposed Use Zoning District ^Fire District Name of J^^^^^^f^^iC^rT^Address Name of Builder Address Name of Architect Address Number of Rooms Foundation Exterior .Roofing Fireplace Approximate Cost Difinitive Plan Approved by Planning Board 19 Diagram of Lot and Building with Dimensions Floors Interior Heating A Plumbing j^Cssh -fee hereby agree tg conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Small,Alan E, No .,1,05?3....Permit for single fa^ly dwlli Locotlo;^/.Birphin ^ Centerville Owner .... Type of Construction Plot Alan E.Staall frame Lot m. Permit Granted 19 66 Dote of inspection 19>fc? Date Completed 19 PERMIT REFUSED 19 Approved 19