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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
.41
Map I Parcel Application #
Health Division Date Issued
Conservation Division Application Fee /1
Planning Dept. Permit Fee V
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address a g131 aL
Village Gen �e r
Owner A e- Address_�� �U IC V Q,Ile 2 ({n k //t
M L"
Telephone g y a 163 o 9 W y 3/
Permit Request 'b reN Qn tXi s 4M o (.lo u f ;n d-n ��iA 0'0 am
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new 0
Zoning District Flood Plain Groundwater Overlay
Project Valuation 0 G O Construction Type o 0
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinishhe�LA�� ( q[fif PT.
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing Dnew MAR 10 20'
Total Room Count (not including baths): existing new ount
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name 0) 8 92Tf+R M e-La n 2 Telephone Number S"0 3 0 3 c
Address _ 3 &-c,k �/a,Il f" License#
C-en-ke, .I j l e, M O . 0 2. G :z� Home.Improvement Contractor#
Email rV\&6A to-M d a ny v orn(a.)t Je r Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO bw
c,-rn s k14A ke ku b-on w ck Re c,y L 10h 4 CZA44,r,�,
SIGNATURE 0 I ,A, �✓L� DATE
FOR OFFICIAL USE ONLY
APPLICATION #
DATE ISSUED
MAP/ PARCEL NO.
° ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME L7 G
INSULATION rQ54 SI2z7/ Yge,
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
c
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
Y
ASSOCIATION PLAN NO.
f
,fir ' ) ' ' •. s .. A. a
.T7ie CtarrzrrrorrtrerrIlrrh af?Vasstif�Tirrsetfs
D'i,}[dTt ffe-itt F)f rndusaia[Accide?dg
- r Office of1m.w gations
600 W�slrar gton Street
y. Basf-on,'MA 02111
i;t�rv�s�rrtrrr�gav�rfin ". _ ,
Workers' Campensaf cdL Insurance Affidavit:Stuldeis/C,antractu.rs/EIectricians/Plu nbers
Applicant Infhrmatinn Please Print Le��IY
Name�raein��c anizationlfudivizival} di(1.IFY e,7'
Address: 13 ��C IC ✓a ((,�, ►!
"city/statetz p (-�1.c(- v�I(e m ` oLu3 �n� 8 y 8 3•�3 ;
rr G
Awe you an employer?Clteck the appropriate.box: Type of project(requii ed)
1.❑ I am a employer U'I th. 4 ❑I am,a general contractor and I
employees(fish andlor part-time)_* Have lured the sub-contractors
6_ New Construction
�-❑ I am a sole proprietor orpartner listed onthe attached sheet. 7. J<Remodeli g
s• and have no employees. L These sib-contactors have
I. P _ 8. Demolitiotz
woddng fame in any capaci4S� employees andhave workers'
9. Buildin .addtfross
[No workers'comp-insurance comp.insurartmi ❑
required-] 5• We area corporation acid its 10:0 Electrical repairs for ad& ons
3.%F am.a
officers have•exercised their
FiamBou�ner doing all work _ 11-Q Flutnbingrepairs or additions
self o workers' right of exemption per MGL
! , �' � �P'- 12_❑Raofrepat .
im c.,15Z, 1/4 aadwehaveno 'c�rranre required.]i � � L. � 13.0 other
employees-[No workers'
comp.insurance required-1
;Any snicmttEistchecksboxPlmost also flefutthe section belowshmsingthearwDde 'compensaiia'apalicyinfon mL,
Hameoarners who submit dtis af5da«iad5mabng they are doing all W at agjj then lyde outside contactors amst submit a naw affidavit indic¢tiog such_
IC'ontra rsfttcheckibusboatmustattached=.sdditionsl sheet shoumgthennueofthem' -cu=tarcfozssaidstatevrhetherornotabaseeatitiesba2e
emp]oyees I€thesavcontactorshace employees,they=ntprauide their'worken'romp.policy number.
I am ari eatpZoj:wr that ispnwidittg markers'con,Ux-risaliian fumirance-for azy emplo Wes. ,Setow is lfie policy and job:&Ae -
inforrnrriiruz ,
Imsurance,Com.panyName:
Policy 4,cr Self-ins.JUC- ` y I�piiiatotiDate_
_
Job Rte Aiddres-s: cttylStztel7.tp_
Atta,ch a copy of the workers'compensationpolicy declaration page(showing the policy number and respiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c�152 can lead to tfie imposition,of crimimai penalises of a
tine up to$1,5Q0-Ua and f'ar oos-yearimpfisc)--t,as well as ci dl penalties is the form of a STOP WORK ORDMMd a Erne
of up to$250_00 a day abaiast the violator. Be advised that a copy of this statement maybe forwarded to the Office of . .'
Investrgahons ofdte DFA for insurance coverage verifta#iorL
Ida laerRby c rhf}�riarder tTzeprmcs aatd penaises afperjrarj'fJlatflta iaf ormadorr prayed abase is hire and carr'ect
Siffiature: ^-/"'. fVIV '-- late-
r Offlcial use icily: Do not at:rat'e in oar's area,ter be campleked by city orten-n offrctat
City or Tomm: Permiff&ense#
Issuing A.Whor€ty(circle one):
L Board.of Health 2.&uMing Department 3.Cityfrown Cleric 4.Electrical Inspector S.PPhr¢nbmg Inspector
6.Other
Contact Person: Phone#:
r 1haformatian and las tcti0),�' r
Msssachasetfs General Laws chapter 152 regah-es all employers to provide worker'compensation for theta employpar. ees.
,an this sfatufe,an mvp&yrne is defined as."—every person in the service of another under any coact of hire,
express or implied,oral or wiMmf
' ' ' axfn associaticm,corporation or other Iegal entity,or any two or more
An �Iay r is defined as an mdividnal,p ersh�,
of the foregoing engaged in a Joint a tr-T else,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 theremy or tfie occupant of the -
dcveIli ag house of another who employs persons to do mafiitmao-ce,construction or repa r work on such dwelling House
or on
the grounds or buildmg app thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also sues that"every sfafE 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
aPF licantwho has not produced acceptable evidencea of compHance with the fijs ce_coverageregnxred"
Additionally,MGM chapter 152,§25C{7)states-Neither the commonwealth nor arty of its political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compIiance with the bIs"anc6.
rttrm-gents of dire chapter have been presentE-d fo the cunt t i g anfiio3*-7
AppHcaxts-
Please fi7I out the workers'compensation affidavit completely,by checking ffie boxes that apply to your sitaation and,if
necessary,supply sub-conti=tor(s)name(s), address(es)and phone nvmbm(s) along with their c rfficate(s)of
;,rnrance. Limited Liability Compares(LLC)or Limited Liability-Partnerships(LLP)withno employees other thanthe
members or pm.-tneas,are not required to carry woikers'compensation insu-mce. N au LLC or LLP does have
employees,a policy is required. Be a.dvise-d.that this a$da.Yit maybe submi't�d to the Deparmant of Industrial
Accidents for confirmation of fi s rr an_ce coverage. Also be sure to sign and date the affidavit The affidavit should
be retnmed to the city or town that thLo application for the permit or Iicense is being regnested,no t the Department of
LodustrialAoddents. Shouldyou have any questions regarding th.e law or ifyou are rujoimd to obtain a workers'
compensation po3icy,pleasff-call the Dt--pactncnt at tha number listed below. Self-insraedcompaniesshould enter their
self-m Wince license number on the appropriate line.
City or Town Officials
r
Please be sm-e that the affidavit is complete and pri ded Iegibly. The Department has provided a space at tie bottom
of the affidavit for you to f M out in.the event the Office of Investigations has to contact you regarding the applicant_
re
Please be so to f M in the peffiitlhcensewillmrnber which w be used as a reference number. la addition,an applicantcurrent
iiort must submit multiple permitlIicwse applications is any men year,need.only submit one affidavit indicating
policy info=ation_(if necessary)and under"Job Site_Address"the,applicant should write"all IocafiLns in ( Y or
town)-"A copy of the•affidavit that has been officially stamped or marked by Ahe city or town may be provided to the "
applicant as proof that a valid affidavit is on f le for future petmi�or licenses Anew affidavit must be filled ovt each
or Pmaknotrelatedto any business or commercial4
year.�iThere a home owner or citizen is obtaining a Ir p
a dog license or permit to bun leaves eta.)said person is NOT required to complete this affidavit
The Office of Invesligat;.ons would like tb thank you in a&Mce for your cooperation and should you have any questions,
please do not hesitate to give u5 a call.
The Deparfinenfs,address,telephone and fax number. .
Tht�Gm
MMWtalft of Masse chuaDtts,
l�epar ent of Inddial A n
�ast��EMI lI
Tf,-I.#CI'-'27-4}Qg�t 4-06 or I-977-hASaAFE
Fax#617 727 7749
Kevised4-24-07 ww mass-gagfdia
r~ Town of
$at w able
RegQlaforp Services
o� r $.icIiard V.ScaF,Dl for
t E
t �csrwr�r„xrx Tom gent,$gilding Commissionner
• `� :I. 1a 200 Mao.Street Hyom3s,MA 02601
`rm ww ty-fn Ven.h us
Office: 509-9622-4038 _ _ Fa= 508-790-6230
. HOMEOTP2�LT���N
. •g[czscPrint
jolt MCKUOK: 2-R' 13 (ti C. VMap
K ll G(Ie�, (Z p C�n f�� ✓��l�C
•�ooWi�x: /Y)A(ZI 1 11A I�'1 G G n 2 ? L �?Z 9 7
- h®cphanc� •�woticphonc�r v
CURRENT i�GADDRESS• �� L 1I r� k A 11 e 4
- std= Zip CDLL— ,
The curs ent exempfion for"homeowners"was extended fo mclude owner o ec�ied dwellmZs of sie units or Iess and to aIIo�
homeowners to engage an individual for hi ewho does notpossess a license,ptoyidcd that fhc rmer
owner acts as syisor_
• . I DEFzRrLON OSHOBMOWNEB
person(s)who o W= a.parcel of Imcl on which he/she resides or mfPnds to reside,on which there is,or is intmdad to be,a one or two-
fami7y dwelling,atfachtd or detached stactums accessory to sach use and/or farm struetnm!;. A person who contacts more than one
home in.a two-year period shall notbe considrr�d ahomcownez Sach, hnmcownee shall sabmitta the BmZding Official on a farm
aucpiabhIehotheStsr7dmgOf5Lial,tbatbdshesbaIlberesponsmIeforaIIsackworkpezfnrmedund�r$hebm�dmcpert (Section
109.L1)
The undaisigned`�iameowner"a mares trsponsmMtp for compliance with the Sty Bhalding Coda and other applicable codes,
bylaws,roles and Mg-mL-d2'ons- -
'Ihe nnd�igaad`hamcowner='eatfres thatbelsbeon_d nds•6be m
Town nmdmcDeparfincutm mspecEian
procedures and requr ntsandflothelshcwMcomplywith said pmcedmzsandregasemeids-
i
Sign ofSomeas
ofBuflcrmgodffaal
• Note- Tbree faojUy dwenings conlaaii2g 35,000 cabie fret or Iargrt wMbe regohed to earls'withtbe Stal$BmZdmg Code
Section.1227.0 Caastradion C=tML
HQMEOWNE$'S EIS LION
The Code stains that oAny haiaeowaer performing workfor which a b ding permit is reused shaII be exempt
from the provisions of this secfm(Section 109-U-TImusing of constudloa Supervisors);provided tTiat if the homeowner
engages a persons)for bire to do such work,that such Homeowner sh2n act as mpervfsor."
Many hoMeOwners who nsa$his ezempfion are mmWare.that$icy are arsvozind the responsrflTities of a superdsor
(see Appendix(?,Rvles&Regulafians for Ilmnsmg Construcfion SIIperdsors,Sectinn 2J5) This iwxof awarrshess often
resalts in serious problems,pardeularly when ffie homes-Ymer hires=Tw-eased persons. In this case,out Board cannot
against the ceased person as if would whiz a licensed Supervisor_ The homeowner acting as Supervisor is
promedlately responsible.
To eusm-e•that the hommeow=is Wy aware of his/her responsibilities,many eo ifies require,aS past of the
permit apprumfion,t73zt the homwwner=rffy tit he/she undersbmds the responsibrWies of a Supervisor. On die kA gage
of this issue is a form mrren$y umd by.several towns. You may care t amen d and adopt such a fo rm/��riifi ^a for ine is
your commmziiy
Q�4�pFII�•'OB?,d5��,.,�'��Pcm�§ams��a�F�e amino
F mised 0613 13
I
Town of Barnstable
o�
` Regulatory Services
UUM $ xir�a v sc2A nireefar
Buiiclmg Division
• TamPerrp,$� Co**mainioner
200 Maim Streat;gpmis,MA 02601
www townlarnstablesaa.IIs
Office: 509-862-4038 Fag: :508-790-6230
Property Owner Must
Complete and Sign This Section
If CJsing A.Builder
as Owner of the subject property
hen'lapaz�liottTP to act on mybebA .
in all matters mhi im to work anthorized bytbis binding pftI=, aPPliration for.
(Add ess of Job)
"."Pool fences and alarms are the responsiMiL7of the applicant Pools
are not to be filed or ijgLed before fence is installed and all final '
inspections.are performed and accepted.
Signature of Owner Sk atnie of Applir=
Piiut Name Pl:i=Name
QFOAMS:oW��'ERP�r�,�neem�.rPoor� .
�IAN
�Li�t,
cw
1H
FT
go
J
............... -J.
a -
�oFtt�r rod Town of Barnstable ble *Permit# a
�'
ti
Regulatory Services Lrpires 6 months from issue(late
Fee
tfASS.
Thomas F. Geiler, Director
Building Division POZ14ESS PERMIT
Tom ferry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601 If`` ((
www.town.barnstable.ma.us ��/�
Office: 508-862-4038 OF BAR" ll F
0-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
No!Va fidwilhold Re(IX-Preys Intprutl,
Map/parcel Nurnber 74a
Property Address �,� 1�t' �i� � /. C Q VIA
Q"Re'sidential Value of Work Minimum fee orS35,00 for• work underS6000.00
Owner's Name & Address
Contractor's Name Telephone Number c�
U _—
Home Improvement Contractor License:#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ l am.a sole proprietor,
❑ I am the Homeowner
E�J"T have Worker's-Compensation Insurance -
Insurance Company Name
Workman's Comp,Policy#����� U 1
Copy of Insurance Compliance,Certificate must accompany each permit,
Permit Request (check box)
ERe-roof(hurricane nailed).(stripping old shingles) All construction debris will be taken to�c��i
Re-roof(hurricane nailed)(not stripping; Going over existing layers of roof)
❑ Re-side y
#of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .35) #of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Flistoric,Conservation,ctc.
***Note: . Property Own mud tgn Pr e Owner Letter of Permission.
A copy of t o e m ro e i t'Contractors License & Construction Supervisors License is
%f/i1�d.r l/
i
The COrtlrrloiritwea/l/r OfIfcrssaclrusells
- -- Departrrr.eril oflndustrial_4ccidents
Office oflnnestigalions
600 Waslrin ton Slre'el
t ti orlon, Atl 02111
rtl'7S'YI'.rrraSS.g01)1dra
'Workers' Campensation Iusu-Mi nce Affi.dnit: Builders/Coutnictors/Elecbi aus/PIumber•s
Ap-pbca-ut Information Please Print Le 'bly
I�at31e(Business}Orgauizaficrn'IndividE�al): Awe—
Address: 6 P
City/State/Z' � ' - Phone 9: `;( n � (o
Ave you an employer?Check the app•opriatr.boa.: [110
fproject(required):
L D—ram a employer with ?j 4. ❑ I am a general contractor and
employees(full and/or part=tim�.e).
* 1iave-hired.the siib-contractors []:New constnrc.tiou
2_❑ I am a soleprapnetor orpartner- listed on the attached slt.eet_ enodelimg
These stab-contractors have
ship.a.ncl have no employees emworking :for me in any capacity. employees and leave ivorkers'workers' comip.irts�tumace comp:insur'lace..7 uilding addition5. Vr e axe.a cor, oration.amd.itslectrical repairs or a.ddztionsrequired_] ❑ Pofficers leave e-xi-cised th�e r3.❑ :I am a hotueotivmex doing.a11 u ork umbing repairs or additions:myself. [No worker'comp. right of exemptiuu per NfGLof rep.urs
im.uT ice:requ.ifedj r c_ 152 §1(4), and.eve have noemployees [No workers' er
cocvp.:insurance required.]
'Any applicant that checks box#Lauri also Ell oat the section.below shawing tbeir wuraers'conrpema:ii.'on policy infor nitioa.
t Honieowwrs who submit this affidavit indicating they are doing all work aaad then hire o-utside canhactnrs must submit.a new.affdaz it indicating such_
rCantcacinrs that check this box inust.attachM an sdditinmal sh-e.et shoe.iug,tlie'nsme of ibe sub-coutmCars and stale whether or not those entitee:s have
employees. Ifthe sub-.contnctors:han employus,.ihey.must provide their wurkers'comp.po kynumber.
f alai are eNiploy er f/latr3pr07 LdIllg 7t"�Y tl�?r3':C07T7{TP71SatiOrt 27151;t'/arf.GB for lety e��Trplal er r. Eelotr'is tltepolicy and job site
tr fOYN[aitbOdt, '
Insurance Company Name:
Policy#or Self--ins_Lc-#: Expiration Date: �-I lb
Job Site Address: City/Stat-e4 i e•��1. 91��
Attach a copy of.the workers'couiperundon policy declaration page(shoxizng thepolicy number and expiration date).
Failure to secure coverage as requited under Section 25A of NfGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORP'ORDER and a fine
of up to$250.00 a day against the vio1� or. Be advised that a cop),of.this,state-ment may be forwarded to the Once of
Investigations of the D.IA for imuran coti ye verification.
I do lter-eby c,erti trader e p 'is and i es of perjury Lhat the ifrforttiahort pro irled a botra L trsi.a altd correct.
Si tore: Date: -) L� b
Phone M
Q�cial rise only. Do notttrite ireiltis area,io be cosipleted bj,cih'or town official
City-or Torn: Permit/License#
Issuing Authwity(circle one):
..::,:,u•;'a- [ " ..r e-, }..+P , :'•t... 5--'�pY. c�. -•.f'rr- ?_.,.,:r�:yr.-.;Pe,.,.. ...,�4, n-';t ;�• ,:x:x.;;�:Y s•44.- t 7Y4 1`i?c:<r,' .....`a_ i Y t,....
7J 6., r .,. t '.' +' , :e 4'a"P4 "e' tl r ' act - a r:a"^n `ae.,a,.tri�l�.k , as y. .
:.d .�- 'kx'CJ- s 4.,�,.7�",', ..,. ,.J ?- :,z f° - t. `Lpt _...h.+`��,"n m "3'rF i t�, 4 #. f t t K :V�
4,.4'rv,:.�i,„x: +ff '? y �:- � $,�',,.. , .5 a'ti .r.Aj1,' P`r2N§t'•^..T $it 1'�' 'nN {i4 3
.l 7 •vJ.'t� 3.1' "k' 'M i� -
;?� � � S'-'•�' ,ko- y. �
,42 ey
r r '
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, n .. .a✓� " r � �"t1 T` �{�#�.,�i 3 t �'y&k,-.4',e p Y
rfRh.
Ro
35�P�EEP70A'D ROA >
CENTERVILLE MA 03632
508 420=6216/774-238=2938
WWW.Markherbst.com ,.
u r
�r
PROPOSAL SUBMITTED TO: WORK PERFORMED AT: �
7h , n Martha Mclane +} s tf x
28 Black Valley Road Same
' Centerville MA ,
508-4208-3036
�as
, a
iu tr1 We herby propose to furnish the materials and perform the labor necessary for the completion of: �f
New Roof,
Remove 1 laver of existing shingles ti. rx
k ft Install ice&water shield at edge {
Install 8"drip edge
i(.Ke � + Ise
t, ;F install 151b.felt paper ,
Install Certain Teed LandMark 30yr.algae resistant shingles
Cut ridge&install cobra vent - s,kt
. Replace plumbing boots
k� Storm nail all shingles k '
All debris cleaned daily
Price includes material,labor&dump fees' ��
r' ,-f" .t i.g
t All material is guaranteed to be as specified. The above work will be performed m accordance with the specifications submied
L and completed in a substantial workman-like manner for the sum of 'Six•Thousand Four-Hundred
_ x z Dollars($6,400.00)with payments as follows: Full amount due'upon completion
*Any alterations from above proposal involving extra costs will be added under a separate written agreement and become an ex rah
r � k
charge over and above said proposal. s y s
3 '
RESPECTFU SUB T v CJ
r� 09120/10 J ' sir
} ' Mark Herbst
ACCEPTANCE OF PROPOSAL "
The above price,specifications and conditions are satisfactory.ji herby accept this proposal. You are authorized to do the workmat
payments will be as specified above. ;
SIGNATURE: (/ lei
�
} :. `
*This proposal may be withdrawn by said company if nQt accepted within 30 days. ,
r'
h
1
t� } Y-�..a''!" ,s„_'rJLr y 'tc?3.:..( '`tC t:: t �..y -7 i..rx .t7� y{ gzf� LxyEy _
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NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE,P.O. BOX 4070,BURLINGTON, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC 7016215012010 01/10/2010 - 01/10/2011
POLICY NUMBER EFFECTIVE DATES
P O Box 494
Leonard Insurance Agency Inc Osterville, MA 02655,. (508)428-6921
NAME OF INSURANCE AGENT ADDRESS PHONE
Mark Herbst 35 Peep Toad Road Centerville, MA 02632
EMPLOYER ADDRESS
01/11/2010
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT.
The above named insurer is required in cases of'personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be`given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury..In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL'FACILITY
NAME OF HOSPITAL t' ADDRESS
TO BE POST E- 1) BY EMPLOYER
ie �ioo�inauuealtl o�/�aaoa�ivaelta \0
Office of Consumer Affairs&Bosiness Regulation �r License or registration valid for individul use only -
HOME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Reg istration:..>12648p Type:
6/8/2012 Individual
k 10 Park Plaza:-Suite 5170
Expiration
Boston,MA 02116
MA K HERBST E t
K _ ,
MARK HERB,T
35 PEEP TOAD RID,-,,
CENTERVILLE, MA 02632 Undersecretary. Not valid wi o t signature
Massachuset Public Safety
ts.,BeRe atnonti and Standards
Board of Buildtn�, :,
Su ervisor License{'
Construction rP } .
4854.. 6 fit
License C$ x
Restnctedjto 00
MARK D 1'0ERBST
35 PEET.TOAD RD,: , E `
CENTERVILLE,UA02632
Expiration: 1/27/2012,
13699 • . ,
Commisioner
i
Assessor's offioe {1st floor): 7� i-pZ�� a
/ rt _
r Y R: ���TIC SYSTEM MU f' O*TNE,o�
i; Assessors map'and iot number ........... e
Board•'of Health '(3rd floor): b UL ED IN COMP
Sewage Permit'. number
- ,
....... s ``e .
WITH TITLE 5 t Baas E,
gineering Department (3rd floor.): a8 � ,?'!.' ENVIRONMENTAL CO 1b
House number -................ r
,`s}Y 'TOWN REGUL.ATIO ogar
APPLICATIONS PROCESSED -8 30-.9:30 A.M. and' 1:00-2 00 �P.M.-oplyy
t TOWN OF .,BARNSTABLE
I�. BUILDING 7'INSPECTOR
APPLICATION FOR PERMIT TO ..s: �.. ....... n ....'.` ...... ..........................................
T_YPE OF CONSTRUCTION .. * !.!'. f .........................:.......
.... .. .....................
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereb applies for a'permit according to the following formation:
t -
Location........................................C.F..../..�...: ..
ProposedUse .. .. . .......................... ................................................. ..................................................................................
Zoning District .:........................................:.... ................:..`..Fire District ..:..... .............:.............
........Address .. ..............Name of Owner .........,.. ..................................................................
Name 'of Builder .:.................... ............Address
Name of Architect .........::'.....'....Address ....................
Number
f . 77....R........... . ........ Cy
Foundation .... ........................................ ......................
. .............:.............. ........ ..". ...RoofngExterior . ...............................................................
Floors ..... .Interior ...... .
.... .. .
Heating ,/ ( �. Plumbing ........................ -.
Fireplace u Q ... ...........:................... e...,..Approximate Cost ....../ � .
Definitive Plan Approved by Planning.Board ___ :____19____ Area ��� .........:...............
•Diagram of Lot and Building'With Dimensions.. Fee ..............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
Y .R • Y, V i
.. .. a .. -
OCCUPANCY PERMITS REQUIRED FOR NEW•DWELLINGS i {
I, hereby agree to.conform to.•all the Rules and Regulations of the Town of Barnstable,regardi the above
construction.
Name ...... ...............
Construction Supervisor's License L/� �, ..........:...
i
SMALL, ALAN
Nof S032.4 One Story
• � Permit for
Single Family Dwelling
F _ ....................... ............ .......... c.
location Lot~#674 , 28 Black Valley NRoad
- �• f
'4 Centerville
...............,. ..........(.................... ... � v T
Owner
Alan Small........ ... ......... ' r-
Type of Construction Frame •
......... ....... .... `
Plot ...... ...`........ Lot .......................
' December 2.3 86 �^ =
a Permit Granted ... '....f9
.f 1<<
f ��f_ •'
Date of Inspectiori ....................:........:... . .
•
Date Completed ` .. Z ..... :19
aJ E•!�.
tj
z- t`
F
,
ly
Assessor's- offioe Ost floor): � � C,7,
?N E t
Assessor's~map and lot number .......................:.................. Q�oF
Bcaard of `Health (3rd floor): Q, fO� ♦�
Sewage Permit number ............ .�.. .�...!... '....... i BAHAXktAG S
.. d9T
Engineering Department (3rd floor): v�8 � 5 �ooe,039•
Housenumber ......................................................................... 'F0MAI
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
F
TOWN OF BARNSTABLE
- BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...........�.-���. e'.}�.....................................................................................................
-a,
TYPEOF CONSTRUCTION ......... .....................................................................................
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
,d ..._ye..._...•f....�:............�........; , ....�..> . :....................................Location ....................................... � ....................
f ,
ProposedUse ..... f ...'` .. .......................................................................................................................
Zoning District ................................................/.....................Fire District ............
Nameof Owner ................................ ...................
r �
Nameof Builder ....................................................................Address .......:............................................................................
• PA
Nameof Architect ............ ......................Address ....................................................................................
Number of Rooms ............. ....................................................Foundation
..............................................................................
Exterior ....t-:...,P........, ..........................................................Roofing C
Floors -,- c Interior r `� ?..r../r :-.. ..... / /....................................
- i f
Heating Plumbing
......................... :�'. ............................`- ....................................
Fireplace � ...... f' PP .........................
.� �...................
:.. ........ ...............................................................Approximate Cost ........ �.. > ,•
Definitive Plan Approved by Planning Board _________-- ________ ��___19_ Area !�� .. ...........................
f Lot and Building with
Dimensions N
Diagram o 9 -.Fee` .............................................
� f
SUBJECT TO APPROVAL OF BOARD OF HEALTH
� � ♦ rP P
P ,
i
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name - .r........ ' .............................
Construction Supervisor's License ...::................................
SMALL, ALAN A=170-222
4'No 3 0 3 2 4 permit for .,,,One Story
Single Family Dwelling
.....................................
Location'....Lot #674 , 28 Black Valley Road
.............................................
Centerville
...............................................................................
Owner Alan Small
:. ..................................................................
Type of Construction .........Frame
.................................
...............................................................................
Plot ............................. Lot ................................
December 23 , 86
Permit Granted .......................................19
Date of Inspection ....................................19 `
Date Completed ......................................19
2 Iz
Co G
18 7
t
AP
�oa�F TOWN OF BARNSTABLE Permit No. . 30324
BUILDING DEPARTMENT
Cash
TOWN OFFICE'BUILDING
'►tn ur► HYANNIS,MASS.02601 Bond .....X
CERTIFICATE OF USE AND OCCUPANCY
Issued to Alan Small
Address Lot #674,- 28 Black Valley Road
Centerville, Ilassachusetts
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN+ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
February 3, 37
............................ 19................. !.................,...................
v Building Inspector
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
TOWN OFFICE BUILDING
MAIL
g i639 � HYANNIS, MASS. 02601
�a MAY►
MEMO TO: Town Clerk
{
FROM: Building Department
�^ r
DATE: 7
An Occupancy Permit has,been issued for the building authorized,by
Building Permit # ..... .d'�» » ................. ...........................................................»................................»......»».......
_ »».....»»»...
issued to T/,,.. .»......»/.,H...................................................... .r���G ..» f1�/� C✓
Please release the performance bond.
I
�.Y
TOWN OF BARNSTABLE, MASSACHUSETTS BU.ILD"ING _rtP'ERMIT
A-170-221 DATE (31r,m Y i� 19 86 PERMIT
APPLICANT A In n Rmn 11 ADDRESS �¢- � (1 .+.L;5_z
IN0.) (-S'TF2 (CON7 R'S LICENSE)
9 t
BU"'(' UWEi111n(- -( �. ) STORY J1:1 1.c $W�BERNG UNITS
OF
PERMIT TO T E ' ii'fil�.�1 _1)f�f'' i
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)_
Lot #674
AT (LOCATION) / 28 Black Valley {Oud CGil��TV [' ZONING
CT
(NO.) (STREET)'
BETWEEN AND
(CROSS STREET) (CROSS STREET)
t
LOT
y SUBDIVISION - LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION ,
I
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: __ JG?WFI(Tf3 #86-874
AREA OR Bond
VOLUME 2160 sq. f� $ 150 000• 00 PERMIT
9 ESTIMATED COST / FEE 108. UQ
(CUBIC/SQUARE FEET) r
OWNER pil.iln. .SIYlc3.LZ
\., /..
ADDRESS Centerville BUILDING DEPT.
BY /
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR
► PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED'BY, THE JURISDICTION. STREET-OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
'MINIMUM OF. THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN
ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING_ AND -
1. FOUNDATIONS OR FOOTINGS. . MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS:
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
FINAL INSPECTION
TI TO BEFORE
FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION BEFORE
.00CUPANCY. -
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
4
2 2 2
(/ p
f�i 4__:6
3 kATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
.001
OTHER -n (�
BOARD OF HEALTH
I
WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE
TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. (I PERMIT iS ISSUED AS NOTED ABOVE. NOTIFICATION.
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