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I 1, � I �XL, . - , ,,- �, - " , -, - �.. ........�! � � , , , ,- " � , -, , , , I - - , , " - - , ` - , , , ,, �, � ,- � - ., , "" � - - I I .1- ... ,, - ; .`�,�� �,,�:!;, � .,�,,�,�_,��,_,��- �,.,�,,,,-,,,,,,�.���4",�",.L",'"'.�,�,-., � 'I i ­��-­1141o��%�:,�-,I �:-­ ,,--�,� ",-':� "'. , " , '��.��-,-'�,-t���-,�',,t,.,-,,,;��,,�,,,,�,,,,�.',����.""-,��,��,,-����,���,�,,�,-'-,�,,,-,,�""I�,,,��..-�,�,��.,." , ��'_ " �'!_ k L2.�,�,,!� ", _,��,4:,`,�`-',�,­',.,:� , � "� � 1 ,'�'�'ll'�.,�u�,�",WiittiyL.0041?0 0 � ""',�,�,�,,,,',,,�""_,� :_",,,, �,;� '_ ,, ,�,�� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 7 "'Application Map— Parcel 'A pp icatioh, IV" Health Division "Date Issued Conservation Division Application Foe Planning,'Dept. ,,.Perm'lt Fee Date Definitive Plan Approved by Planning Board Historic OKH Preservation Hyannis Project Street Address Village �LltiL �(ll(� -e 71--4 Owner Q7a Address C� Slone,4 C`r L1607,q Telephone Permit Reauest lev-,-or A,m o 4 &eLo V-Y- i-o b29 Square feet: 1 st floor: existing ZI Oproposed 2nd floor: existing—proposed Total new Zp'ning District' Flood Plain Groundwater Overlay Project Valuation D CvD.,00construction Type 100a L6t Size Grandfathered: LJ Yes' RI(No If yes, attach supporting cLqcumentation. C> Dwelling Type: Single Family ,4/ Two Family U Multi-Family (# units) Age of Existing Structure virs. Historic House: U Yes UfAo On 010::King's Hig�jvay:�]Yes ia No Basement Basement Type: U/Full . U Crawl LI Walkout U Other Ul Basement Finished Area(sq.ft.),- Basement Unfinished Areaisqft) Number of Baths: Full: existing- new Half: existing ne UT Number of Bedrooms: existing A new Total Room Count (not including baths): existing � new I First Floor Room Count Heat Type and Fuel: O/Gas LJ Oil Ll Electric Q Other Central Air: Ll Yes ZN o Fireplaces: Existing New Existing wood/coal stove: Ll Yes 2r/No Detached garage: Ll existing Onew size—Pool: Ll existing Linew size Barn: Llexisting Unew size Attached garage: 5d"e'xisting U I new size —Shed: LJ existing LJ new size Other: Zoning Board of Appeals Authorization U Appeal # Recorded LJ Commercial Ll Yes U No If yes, site plan review Current Use Proposed Use APPLICANT INFORMATION Cf 04 (BUILDER OR HOMEOWNER) Name .6 L&&tj Pxxlt ,e, Toy-Telephone Number Address 15 Eb-e4A 5 1U. License # CS .8 3=5 6 2-t Home Improvement Contractor# Worker's Compensation # 7q,953eq� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO &!5 5-C,l 1 CL S"dA,,(,d W i 6A, SIGNATURE DATE— r i ` FOR OFFICIAL USE ONLY " APPLICATION# i i' DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE s OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL + PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. k� f Town of Barnstable regulatory Ser(fices F " W,ASS, Thomas F. Geiler, Director :6�q �0 P, Building Division Thomas ferry, CBO, BuBding Cora=ssioner 200 Main Street, Hyannis,MA 02601- www.town.b ax iu-ta b l e.m a.us Offices 508-862-4038 Fax: 508-79O=6230 PLAN REVEEW Owner:- �. 01H 41= 1 L- Map/Parcel: C a 6.(9 Project Address X UC te- /e P tf L�p The following items were noted on reviewing: o SUPP�—\l AL.L 5-pEc 5 Reviewed by: C Date: Q:Forms.'Plnrvw PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Southeastem Insurance Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 641 Main St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Hyannis,MA 2W`I COMPANIES AFFORDING INSURANCE e COMPANY A GRANITE STATE INSURANCE COMPANY INSURED RoycroR&Kuehne Builders Inc. 65 Eben Smith Road Centerville,MA 02632-0000 THIS 18 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING 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 THE POLICIES DESCRIBED HEREIN 18 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. w LIM TYPI OP NBURANOI POLI07 NUMBIR POLI01rlPPROM DAIN POLlOY 11P�111T10N DMl AANDEMPLOYERS'LUBILITY LIMITS E PROPRIETOR, PARTNERSIEIIECUTNE OFFICERS ARE. TATUTORY LIMITS NCL a EXCL 0 T435328 6/06/2009 8/06/2010 THER Coverage AppllwtoMAOpwdonvOray. ACM ACCIDENT S 100,00 I&ASE POLICY LIMIT S 500.00 ISEASE-EACH EMPLOYEE S 100,00 DESCRIPTION OF OPERATIONSNEHICLw5PECIAL ITEMS CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN:BLDG DEPT EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 14 200 MAIN ST DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT BARNSTABLE, MA 02601 FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATNES. AUTHORIZED REPRESENTATIVE eug. I 2009 �:"ATIFICATE OF LIABILITY INSURANCE' 2440 P. 2/7/2009 VK�„r OS/17/2009 PRODUCER 508.997.6061 FAX 508,990.2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 N. Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE NAIC# INSURED Roycro t & Kuehne Builders Inc INSURERA: Arbella Protection Insurance 41360 65 Eben Smith Road INSURERB: Merchants Insurance Group Centerville, MA 02632 INSURERC: INSURER D: INSURER E: + 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. INSR ADD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRA LIMITS - LTR NS TYPE OF INSURANCE DATE PRAIDDIMM DATE GENERAL LIABILITY 8 S00022738 08/01/2009 09/01/2010 EACH occLrd ENcE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence $) 100,0001 CLAIMS MADE a OCCUR WED EXP(Any one person) $ 5,00( A PERSONAL&ADV INJURY $ 1.000100( GENERAL AGGREGATE s 2,000,OO GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00( POLICY PRO- JECT LOC AUTOMOBILE LIABILITY 7AN0277014095 10/18/2008 10/18/2009 COMBINED SINGLE LIMIT ANY AUTO (Es accident) $ 1,000,00 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per ecadenl) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY ALITO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIAO LITY EACH OCCURRENCE_ $ OCCUR CLAIMS MADE AGGREGATE s DEDUCTIBLE $ RETENTION $ WC STATU- Ulm $ WORKERS COMPENSATION TORY LIMITS ER AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICFRIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION : NY MOULD A OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS W UMN Town of Barnstable NDTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Building Department IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main Street REPRESENTATIVES. Barnstable, MA 02601 AUTHORIZED REPRESENTATIVE Joanne Bretton ACORD 25(2009101) O 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 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 j� II Please Print Legibly Name(Business/Organization/Individual): � (°�(�04 ('�V 1t�'1r[`, . &U Address: 42b32 a City/State/Zip: Phone#: AFairn on an employer?Check the appropriate box: Type of project(required): 1.. a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees. These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' y p �' 9. ❑Building addition [No workers' comp.insurance .: comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑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 thepolicy and job site information. Insurance Company Name: a' � Policy#or Self-ins.Lic. Expiration Date: l6(�01 D 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 ce un er e p i nd penalties of perjury that the information provided above is true and correct Sigaafore: Date: �- l Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/Liceme# 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 REScheck Software Version 4.3.0 Compliance Certificate Energy Code: 20061ECC Location: Barnstable,Massachusetts Construction Type: Single Family Project Type: Addition/Alteration Heating Degree Days: 6137 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: 20 Buckskin Path Jim O'Neill Steven Cook Centerville,MA 02632 20 Buckskin Path Cotuit Bay Design,LLC Centerville,MA 02632 43 Brewster Road Mashpee,MA 02649 i 508-274-1166 steve@cotuitbaydesign.com Compliance: Maximum UA:98 Your UA:92 Ceiling 1:Cathedral Ceiling(no attic) 572 38.0 0.0 15 Wall 1:Wood Frame,16"o.c. 584 21.0 0.0 27 Window 1:Vinyl Frame:Double Pane with Low-E 84 0.320 27 Door 1:Solid 18 0.140 3 Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 528 25.0 0.0 20 Compliance Statement: The proposed building design described here is consist ith the buildingfications,and other calculations submitted with the permit application.The proposed building has b designed e CC requirements in REScheck Version 4.3.0 and to mply with the mandatory requirements liste he RESch ;�Xklist. veli Gor-- 9 `�dsojep- z ZQ4(C Name-Title - Signa u Date l Project Title: Report date: 12/14109 Data filename:C:\Program files\Check\REScheck\joneill.rck Page 1 of 3 REScheck Software Version 4.3.0 Inspection Checklist Ceilings: ❑ Ceiling 1:Cathedral Ceiling(no attic),R-38.0 cavity insulation Comments: Above-Grade Walls: ❑ Wall 1:Wood Frame,16"o.c.,R-21.0 cavity insulation Comments: Windows: ❑ Window 1:Vinyl Frame:Double Pane with Low-E,U-factor:0.320 For windows without labeled U-factors,describe features: #Panes—Frame Type Thermal Break?_Yes—No Comments: Note:Up to 15 sq.ft.of glazed fenestration per dwelling is exempt from U-factor and SHGC requirements. Doors: ❑Door 1:Solid,U-factor:0.140 Comments: Floors: ❑ Floor 1:All-Wood Joist/Truss:Over Unconditioned Space,R-25.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints,penetrations,and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed lights are either 1)Type IC rated with enclosures sealed/gasketed against leaks to the ceiling,or 2)Type IC rated and ASTM E283 labeled,or 3)installed inside an air-tight assembly with a 0.5"clearance from combustible materials and a 3"clearance from insulation. Sunrooms: ❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U-factor of 0.50 and the maximum skylight U-factor of 0.75.New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Vapor Retarder: ❑ Vapor retarder is installed on the warm-in-winter side of all non-vented framed ceilings,walls,and floors;or it has been determined that moisture or its freezing will not damage the materials;or other approved means to avoid condensation are provided. Comments: Materials Identification and Installation: ❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ Insulation is installed insubstantial contact with the surface being insulated and in a manner that achieves the rated R-value. ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R-values and glazing U-factors are clearly marked on the building plans or specifications. Duct Insulation: ❑ Ducts in unconditioned spaces or outside the building are insulated to at least R-8. ❑ Ducts in floor trusses above unconditioned spaces or above the outdoors are insulated to at least R-6. Project Title: Report date: 12/14/09 Data filename:C:\Program Files\Check\REScheck\joneill.rck Page 2 of 3 Duct Construction: ❑ ' Air handlers,filter boxes,and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. 0 All joints,seams,and connections are made substantially airtight with tapes,gasketing,mastics(adhesives)or other approved closure systems.Tapes and mastics are rated UL 181A or UL 181.B. Building framing cavities are not used as supply ducts. Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. ❑ Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the Intemational Mechanical Code. Temperature Controls: Thermostats exist for each separate HVAC system.A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor is provided. Circulating Service Hot Water Systems: O Circulating service hot water pipes are insulated to R-2. Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Certificate: A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R-values;window U-factors;type and efficiency of space-conditioning and water heating equipment. NOTES TO FIELD:(Building Department Use Only) Project Title: Report date: 12/14/09 Data filename:C:\Program Files\Check\REScheck\joneill.rck Page 3 of 3 ` r _Y 2006 IECC Energy Efficiency Certificate Ceiling/Roof 38.00 Wall 21.00 Floor/Foundation 25.00 Ductwork(unconditioned spaces): Window 0.32 Door 0.14 NA Water Heater: Name: Date: Comments: ' '•``` - ��c ' -uariiraiuuiuirl� o�� Ir:jrc�ra;ella ..z4 Board of Building Regulations and Standards Construction Supervisor License License: CS 83280 Birthdate: 11/29/1964 Expiration 11/29/2010 Tr# 5313 Restriction: 00 SEAN J ROYCROFT 65 EBEN SMITH RD CENTERVILLE.MA 02632 Commissioner y • ✓1e lno�,r,»ta�auaal!/r. o�':ll�:uac/r.wetGi License or registration valid for individul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: 1t�1 HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 141225 10 Park Plaza-Suite 5170 Expiration: 1/22/2012 Tr+x 291967 Boston,MA 02116 i Type: Private Corporation ROYCROFT&KUEHNE BUILDERS,INC. Sean'Roycroft 65 Eben Smith Road Centerville,MA 02632 -.Undersecretary Not valid witho t Sean Roycroft 508-420-1947 p. 2 r ti Town of Barnstable Regulatory Services Mug- ' 'Thomas F.Geller,.Director bra16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.ba rnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject PmPerry ycr g ue. .13L, I de r S bEereby authorize �f"CLy1 5 I�C,YC i 'f to act on my behalf, in all matters reh ive to work authorized by this binding permit application for. (Address of robs A/� S* tine of Owner ate OZIJI Print Name - If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERM W0N Town of Barnstable *Permit Expir s 6 ont f from iss ate Regulatory Services Thomas F.Geiler,DirectorERM � � Building.Division 1 /�o%� Tom Perry,CBO, Building Commissioner ��a� 200 Main Street,Hyannis,MA 02601 NOV -- 9 www.town.barnstable,ma.us o la Fax: 508-790-6230_ • EXPRESS PEPIMT APPLICATION •- RESIDENTL4,L ONLY Not Valid without Red X-.Press Imprint Map/parcel Number 0 I Property Address El/Residential Value of Work -4 `-r M v y D M!nimum fee of$25.00 for work under$6000.00 Owner's Name&Address d cdf�-rl UF UGO-W Contractor's Name Telephone Number ` Q ``T( Home Improvement Contractor License#(if applica le) Construction Supervisor's License#(if applicable) 1 ❑Workman's Compensation Insurance CheslC one: - _ • I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp,Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Whcrc rcquired: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. .. ***Note: rope wner s gn Proper Owner Letter of Permission. - A py of the H rfie rove Contractors License is required. SIGNATURE; I Q:Ftm u:expmtrg Revise061306 - The Camrrtonwealth ofMassachusetts ' Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston',MA 02111 www.m ass..gov/dia Workers" Compensation In suranceAffidavit: Builders/Contractors/Electricians /Plumbers Applicant Information --�7 Please Print Legibly Name (Business/organization/Individual);• `J�� Address: City/State/Zip: 6M 15- M� C 2 U o I Phone.#: ��Q `f S FIAx-reYOUemployer? Check the appropriate box: employer with 4. ❑ I am a general contractor and I 'Type of project(required):• ees (full and/orpart-*q).* have hired the sub-contractors 6•,❑New constructionole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling have no employees These sub-contractors have g• ❑Demolition working for me in any capacity.* employees and have workers' [No workers'comp.insurance comp.insurance.$' 9• []Building addition required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing ill work officers have exercised their 11.❑Plumbing repairs or additions amyself [No workers' comp, right of exemption per MGL insurance required.]t c. 152, §1(4),and we have no 12•[Koofrepairs employees. [No workers' .13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section belowsbowing their warkcrs'campcnsation policy information. t Homcowners who submit this¢davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors that cheek this box must attached an additionalsheet sbowing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors lave employecs,they must pravidt:their Workers'comp.policy number. ram an employer that is providing workers'compensation insurance for my employees Below Whe information. policy and Job site 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.Oo 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the I r uranc vera e verification, I do he'reb certi :rn er th ains• n aloes ofperjui3,that the information provided ov is true and correct: Sienatarc: �I 1 Date: Q�. Phone #: — Official use only. Da not write in this area,'tb be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one); L Board of Health 2.Bu_ildingDepartment 3.Ci(y/Town Clerk 4.Electrical InspectorLSJ'luim�binuspector 6. Other Contact Person: Phone#: . tipf1HEt, : Town of Barnstable. Regulatory Services i SARNSTAHLE, + ' y MAM Thomas F. Geller,Director sb � Building Division h Tom Ferry, Building Commissioner 200 Main Street, Hyannis,MA 02601 wfvw.town.barnstabk.ma.us Office: 508-862-4038 Fax: 508--790-6230 Property Owner Must Complete and Sign This Section rf Using A Builder as Owner of the subject _—�J`�� ``,n, _ • � property herebyautEiorize J UL to act on my behalf, in all matters relative to.work authorized bythis building permit application for: (Address of Job) ; gn ture of Owner Date Print Name QTOMMS:OWNERPERMIS SION Bdaf�o1 i'ng`fegulalio�s a� an ar License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 124310 Board of Building Regulations and Standards Expiration: 6/1/2011 Tr# 284683 One Ashburton Place Rm 1301 Type: Individual Boston,Ma.02108 - - James Curley -- James Curley 287 Fuller Rd. -- Centerville, MA 02632 Administrator "Not valid without signature t�lussachusetts- Department of Public Safety t Board of Building Regulations and Standards i Construction Supervisor Specialty License License: CS SL 99138 Restricted.to: .RF,WS . JAMES CURLEY' I 287 FULLER ROAD. CENTERVILLE, MA 02632 i Expiration: 1/28/2012 c�. Commissioner Tr#: 99138 ✓fze aJair�rnoncaeczlC� b���ueac�cfu�aeG7a Board of Building Regulations and Standards License or registr valid for individul use only HOME IMPROVEMENT CONTRACTOR before the ration date. If found return to: Regist_rafon1-24310 Bo of Building Regulations and Standards •Ezpirafibn__6/4/2009 Tr# 130873 One Ashburton Place Rm 1301 Type i ndividual Boston,Ma.02108 James Curley =_ James Curley 287 Fuller Rd. 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