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Home My WebLink About0193 BUCKSKIN PATH C�z oa pa:6 ' . Town of Barnstable Buildin Post This�Card`So That rt is Visibl'AFrom-the Street "Approved Plans°Must be Retained on l9 ob and this Card Must.be Kept MAWPosted Until'Final.Inspection Has Been Made �. q' WH"ere a'Certifitate of Occu anc" `fis;Re wired,°such Buildingtj shallrNot beQccu"iedilunA'ttil:a;Final Ins ect�on hasbeenmadeIQM a e r It �a Permit No. B-19-3506 Applicant Name: KEITH C. GILMORE ENTERPRISES LLC. Approvals Date Issued: 11/13/2019 Current Use: Structure Permit Type: Building Addition/Alteration-Residential' Expiration Date: 05/13/2020 Foundation: Yp g -U)"9 d f Location: •193 BUCKSKIN PATH,CENTERVILLE Map/Lot 170-068 Zoning District: RC Sheathing: Owner on Record:F MOBERG, ROBERT&,KIMIt Contrractor Narne: KEiTH C GILMORE Framing: 1 Address. '193-BUCKSKIN PATH. ,. ' Contractor License CS§098047 2 CENTERVIL'LE, MA 02632 , EstgProlect Cost: $4,306.00 . Chimney: Description: construct a new portico roof cover and landing 5W!,to existing side Permit Fee: $85.00 entry door location F '. insulation: a ee Paid`' $85.00 Project Review Re Final: q: Date 11/13/2019 : A, - ' y Plumbing/Gas Rough Plumbing; - zR _ _ M. •; ;§ This permit shall be deemed abandoned and invalid unless the workauthonzed by this permit is commenced within siz,months after iss"An tticial final Plumbing`: . All work authorized by this permit shall conform to the approved appl cation.and the approved construction documents.for,which this permit has been granted. All construction,alterations and changes of use of any building and structures=shall,be in with the local zoning by laws and codes. Rough Gas This permit shall be displayed in a location clearly.visible from access street orroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ' _" Final Gas: The Certificate of occupancy will not be issued until all applicable signatures ey the Building and Fir eOff_icials are provided on this permit. Electrical Minimum of Five Call Inspections'Required for All Construction Work. : ' 1.Foundation or Footing z Service: 2.Sheathing Inspection ; Rough: 3.All Fireplaces must be inspected at the throat level before firest flue Irving installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members,(Frame Inspection) Final' 6.Insulation , 7.Final Inspection before Occupancy Low Voltage Rough: Low Voltage Fi Where applicable'separate permits are required for Electrical,Plumbing,and Mechanical installations. o n al- Work shall not proceed until the Inspector has approved the various stages of construction. . _ Health "Persons contracting,with,unregistered contractors do not have access to the guaranty fund"'(as set forth in.MGL c.142A). Final Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT' Final: HE Application Number...... .........-55O.G........... 8 ELARNSTAKE, 1JIL MASS. D11VG DEpT Permit Fee..............lffl ?..................Other. Fee:............:.......... s639. OCT 1 8 Fee Paid.............. ................................ TO Total F W1 1 ................ ...... /V OF 8 LE , IhAc� , TOWN OF BARNSTbErE? Permit Approval by....... .....................On.....f ........ BUILDING PERMIT map............4.7.0...............Parcel..................... ........... APPLICATION Section I —Owner's Information and Project Location Project Address I ' h3VCY-S �1-,'Q 1p;qT4 Village &1t,1*%+rf Owners Name- �'vv\, Ko bay Owners Legal Address j g S h>u JOAV, City State lAA Owners Cell# 565 -Zoo - -7-7.31 E-mail k;vnwxA-6q 9 t owe CxS+ Section 2 —Use of Structure Use Group_ Fj Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single Two Family Dwelling Section 3 — Type of Permit ❑ New Construction ❑ Move/Relocate pEr Accessory Structure E] Change of use El Demo/(entire structure) El Finish Basement El, Family/Amnesty-, ❑ Fire Alarm Rebuild El ,Deck Apartment Sprinkler System ❑ Addition Retaining wall Solar El Renovation ❑ Pool El Insulation Other—Specify Section 4 - Work Description o v frry c,+ o, A14,W aot),,&M 0// T.Pqt imdqterl- 11/15/701 R 2 Application Number..................... Section 5—Detail ilk • P e 0 Cost of Proposed Construction � �� Square Footage of ProJec• t Age of Structure Dig Safe Number -� # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design -Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public ; ,_❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ "Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility:' I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage # of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed , Side Yard Required 'Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 Commonwealth of Massachusetts Division of FRee�lations and Stansional Licensure dards � Board of Building a� N rvisor Cons 11 �ires.0711512021 CS-098047 KEITH C GILMORE q' PO BOX 17 CENTERVILLEE'MA \` Commissioner 0/9 Z Z a�- Office of Consumer Affairs and Business Regulation E 1000 Washington Street - Suite 710 Boston, Mas husetts 02118 Home Improvemeractor Registration Type: LLC ;, Registration: 134443 KEITH C.GILMORE ENTERPRISES,LLC ` i°o 3 m- Expiration: 11/15/2021 PO BOX 17 CENTERVILLE,MA 02632 wy Update Address and Return Card. SCA 1 0 20M-05/17 ` VFfze (PG i77/�/ZOnU1P�LLfL O��z[t6ed _ Office of Consumer Affairs&Business Regulation , HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only IX-PE:LLC before the expiration date. If found return to: Rggistrat ho Expiration Office of Consumer Affairs and Business Regulation 11/15/2021 1000 Washington Street -Suite 710 Boston,MA 02118 KEITH C.GILMffS,LLC. ' q 1 9 KEITH C.GILMOR 28 HIDDEN VALL Not valid without signature MARSTONS MILLS,-' Undersecretary , . E i i . q # , BZ/65/19 03:51:13 BOB -> RF Connect Page 003 CERTIFICATE OF LIABILITY INSURANCE 02�05/2019'N""' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER NCAONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. PHONE 150 SAWGRASS DRIVE 877.266.6850 1 FAX 585 389 7426 ROCHESTER,NY 14620 E-MAILESS. Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIL A NSURED INSURER A- NorGUARD Insurance Company, 31470 KEITH C GILMORE ENTERPRISES LLC INSURER B: PO BOX 17 CENTERVILLE, MA 02632 INSURER C: INSURER D: INSURER E: INSURER F: ' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE 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 SUBJECTTOALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ISR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS TR INSR WVD MM/DDlYYYY) MMIMYYYY) GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS-MADE[::�]OCCUR MED EXP(Anyone person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: POLICY =PROJECT=LOG - PRODUCTS-COMP/OP AGG $ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Eaaccidant) - ALL O SCSCHEDULED BODILY INJURY LL $ _ AUTOS AUTOS (Per person) HIRED AUTOS AUaTOSIVNED BODILY INJURY $ (Per accident) y PROPERTY DAMAGE $ (Per accident) UMBRELLA LIABOCCUR EACH OCCURRENCE $ _ EXCESSLIAB CLAIMS-MADE t' AGGREGATE $ DED I I RETENTION$ $ - WORKERS COMPENSATION AND X WC STATU- OTH. EMPLOYERS•LIABILITY KEWC060351 02/04/2019 02/04/2020 TORY UMITS rR E.L.EACH ACCIDENT $ 100,000.00 ANY PROPRIETO"ARTNER EXECUTIVE OFRCEFWEMBER EXCLUDED? � E.L.DISEASE-EA EMPLOYEE $ 100,000.00 (Mandatory in NN) N N/A E.L.DISEASE-POLICY LIMIT $ 500,000.00 If yes,describe under • , )ESCRPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more apace IB required) , CERTIFICATE HOLDER CANCELLATION Keith C Gilmore Enterprises LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE P.O.Box 17 1 - THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Centerville,MA 02632 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE > ACORD 25(2016/03) @1088-2016 ACORD CORPORATION. All rights reserved. . The ACORD name and logo are registered marks of ACORD I . propozat Keith C. Gilmore Enterprises, LLC HIC#134443 _ P.O. Box 17, Centerville, MA 02632 MA CSL#98047 Phone: 508-420-9934 Fax: 508-420-9935 Date: 9-25-19 Project#MOBO1 Client Name: Kim Moberg Phone#508-280-7731 . Billing Address: 193 Buckskin Path, Centerville, MA 02632 Alt.# Fax# ,Project Address: Same as billing. Email: kimma59@comcast.net Project Description: See below. t i Project Task Items: !Design, permit and contruct a side entry portico.Landing will !be 5'x4'with Azek Brownstone deck surfacing, 8'pvc wrapped posts, roof frame with matching roof pitch to main house,.pvc roof trims, ;asphalt roofing to match existing home, pvc ceiling with wall light `relocated to ceiling flat recessed can. Total $ 4,306.00 F 3f • , i I • i f Total 4,306.00 Initials PAYMENT TERMS •The amount or estimated amount of said contract is $4,306.00. Customer agrees to pay the Contractor according to the following terms: �� Due at scheduling $ , 00 Due as invoiced in weekly production installments $1,000.00 Due as invoiced by substantial completion Description of payment terms s All work will cease under this contract if payments are not made pursuant to the terms described herein. Workmanship.issues must be documented by the Customer,in writing,to the Contractor within fourteen(14)days that Homeowner knew or should have known. i There will be no refund for special-order materials and/or any other non-stocked items after three days from approved proposal.Any other refunds shall be calculated and/or determined by Keith Gilmore Enterprises. Y The Contractor retains all legal remedies available if the Customer fails to pay including the recording of a mechanic's lien on the property pursuant to M.G.L.254,§5 to secure the payment of all labor, including construction management and general contractor services and materials, including those furnished by Keith.Gilmore Enterprises. Customer guaranties the payment of all sums owed to the Contractor. Customer understands that any debt to Contractor over 30 days past due is subject to a 1%%finance charge per month(APR 18%). Customer agrees to pay all legal fees and costs incurred in the collection of any money owed to Contractor. ' Customer acknowledges that Keith Gilmore Enterprises has a reasonable expectation of payment from the Customer for any materials furnished by Keith Gilmore Enterprises as part of this project between the Customer and Contractor notwithstanding any payments to or disputes with the Contractor. This Notice of Contract is.to be construed and interpreted according to the laws of the Commonwealth of Massachusetts. The undersigned acknowledge that they have read and understood all of the enclosed terms and that their signatures appear freely and voluntarily below: 3 Auth rized Agent' Date C 'tractor Date Page 2 of 2 Initials } LAND� Y MI FORM N KIRRANE g TERRY DEED BoOK'9511 "r 3749-912 �"---- PAGE:177 L TGAgE CORP. sa PLAN BOOK: 244---- : PAGE:67_ T KIY Y:`M08ER0 PUN.NUMBER: LOTts}2s_ REEISTERED s 1R� /14195 LAND _-SCALE:+1-"m30 REGISWTION BOOK: _ PAGe. FLOOD. CERTIFICATE`OF TITLE: HAZARD INFORMATION PLAN NUM 1PIA0Q NAP Comwxn NO.: 250001 BER:�_ L •T(9�`.per,,00T5C DATED: 08/19/85 ASSESSORS MAP N MAP:-- B1ACK: PARCEL•____ MORTGAGE INSPECTION 'PLAN .193 BUCKSKIN PATH, BARNSTABLE, MA N/F BARNARD• , "" 150.Od W LOT 23 ' 15,030 S.F. Af SCREEN PORCH o o LOT 22 LOT 24 3 7+ bxE"LIN A!* 134.10' BUCKSKIN PATH MORTGAGE LENDER = : ... .: USE ONLY N `•THIS IS THE RESULT OF TAPE MEASUREMENT, NOT THE RESULT ,;- ,-OF AN INSTRUMENT SURVEY AND IS CERTIFIED TO THE TITLE ANSURANCE COMPANY AND ABOVE LISTED ATTORNEY AND LENDER. DES LAURIERS & ASSOCIATES INC. rTHERE ARE NO DEEDED EASEMENTS IN THE'ABOVE REFERENCED 30' o 6s? 130 WEST STREET, WALPOLE, MA 02081 xib,;,DEED OR ENCROACHMENTS WITH RESPECT TO BUILDINGS SITUATED lEl, (800)287-8800 FAX (508)668-4512 -ON THIS LOT EXCEPT AS SHOWN. " § THE LOCATION OF THE DWELLING SHOWN DOES NOT FALL WITHIN Uf r= IN a�- A``SPECIAL FLOOD HAZARD ZONE. " 'THE LOCATION OF THE DWELLING AS SHOWN HEREON EITHER WAS IN COMPLIANCE WITH THE LOCAL ZONING BY-LAWS IN rd r t r �a EFFECT WHEN CONSTRUCTED (WITH RESPECT TO STRUCTURAL �Y, Za $ETBACK REQUIREMENTS ONLY), OR IS EXEMPT FROM VIOLATION EMFORCEMENT ACTION,UNDER MASS. C;L, TITLE VII. CHAPTER 40A, th14) e ECTION 7. :GENERAL NOTES. l(1) The declarations mode above ore on the basis of my knowledge, information, and belief as the result of q,moctgoge inspection tape survey mode to the normal standard of core of registered land surveyors practicing in Massachusetts. Dedorotionsaore made'to.the obove named client only as of this dote. (.l) This pion was not made for recording purposes, use in preparing deed.descriptions or for constructions. (4) Verificalions of property line dimensions, building offsets, fences• pf tok-` flgurotion may be accomplished only by an accurate instrument survey _ _ _.._ e .. Application Number........................................... Section 9= Construction.Supervisor Name kLz tt,�_ C (9 ,� t1v'-�_ Telephone Number Sot -36P Z 0(o , (o Address 1—T City e eN'v I State . Zip 1z60 3 2- -7— License Number �'ij- 0 9 S 0y7 License Type C S Z V Expiration Date I / .1 Contractors Email t �'►a y'-� �"` "r i r t s 6� c o °1 1° Cell # SDo 3to2 -0(08(o 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 req ' ed 7 0 CMR d th Town of Barnstable.Attach a copy of your license. ' Signature Date /p to I Section 10—Home Improvement Contractor y _ Name_ A& (. e r Telephone Number So-6 - 3l0 Z ;;0&S 4, P Address Q o. 5�C / City G�e�v� N'v�I I•t. State /4A- Zip 0 2 "z- Registration Number ! 3 q 1-1 N 3 Expiration Date I L 1 I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC... _ Signature Date' Section 11 Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable: ' Signature Date ' APPLICANT SIGNATURE Signature % Date• /,P Print Name Ke.t` c` Ov-C. Telephone Number 5V-5 -3Cv Z S/v E-mail permit to: �� ,}� D Last updated: 11/15/2018 Section 12 —Department Sign-Offs ' Health Department ❑ Zoning Board(if required) ❑ Historic District, ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation For commercial work,please take your plans directly to the fire department for approvab . f Section 13— Owner's Authorization i I, IN ' er of the subject property hereby authorize ;' to act on my behalf, in all matters relative to work authorize 's building permit application for: Y g P PP (Aadress of job) 1 Signature of Owner date Print Name .� a z I Last updated: 11/15/2018 Town of Barnstable RECEIPT " ` 200 Main Street, Hyannis MA 02601 508-862-4038 a Application for Building Permit Application No: TB-18-3060 Date Recieved: 9/14/2018 �ld4, _7 Job Location: �W--BUCKSKINPATH;CENTERVIL�L-E---, Permit For: Building-Addition/Alteration-Residential Contractor's Name: State Lic. No: Address: , , Applicant Phone: (Home)Owner's Name: MOBERG,ROBERT&KIM Phone: (Home)Owner's Address: 193 BUCKSKIN_ PATH, CENTERVILLE,MA 02632 Work Descri n: —Jdd door overhang CN �►i o�`i c ; i5asVL Total Valf W7 To'Be rmed: $1,000.00 ' 4( w� _ -'� Structure Size: 0.00 0.00 (� c � .00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24` hours in advance. Signed: MOBERG,ROBERT& KIM 9/14/20:18 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $1,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $85.00 9/14/2018 $85.00 114' Check ......._ ........1 ......... ... ........_. ........ ............. Total Permit Fee Paid: $85.00 p Application Nmnber.......ts�`.1.2......................................�..6 .. PermitFee..........(2.4 ....................Other Fee........................ XASIL TotalFee Paid........................................ ......................... . TOWN OF BARNSTABLE Permit Approval by.................................On.........................» BUILDING PERMIT MT..........I......�...............Pic...........5;��Y..................... APPLICATION Section I — Owner's Information and Project Location Project Address Iq3 tAd6S #I- Gt-1� Villag r�e. �ee� �--o 1 �. Owners Name Z - r ff �� 42 Owners Legal Address I�� urns�p�� W�� O ^ ®�� m, Cf� �' State ZipC a Owners Cell# � (R (n -r],76/ E-mail k n ma 5, - Section 2—Use of Structure Use Grroup ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet IFZt Single/Two Family Dwelling Section 3 --Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory StrvctLue ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System `] Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Pool ❑ Insulation - Other—Specify Section 4-Work Description T s►ct tmdsdetE 2 M201 S i Application Number..................................................... Section 5—Detail Cost of Proposed Construction ► Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ,❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics (Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing [] Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Waxer Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last imdated 2/92018 I ��'}f�i-.i-GSET l 11� � �✓� �. � CdVK?�E� �� P� P� Lauzon, Jeffrey From: Lauzon, Jeffrey Sent: Tuesday, October 02, 2018 9:59 AM To: kimma59@comcast.net' Cc: Lauzon, Jeffrey Subject:. ViewPermit, Permit No:TB-18-3060 Applicant, Please be advised the above application has been reviewed and the following is noted: 1) Application is incomplete. Construction Supervisor listed on application with no copies of Construction Supervisor's license or Home Improvement Contractor's registration. 2) No plot plan submitted demonstrating compliance with required setbacks. The:application is denied pending the submission of the required documents.And' if aggrieved by this notice;you may file a Notice of Appeal (specifying the grounds thereof)with the State Building Appeals Board within forty-five (45) days of the receipt of this notice.As always, please do not hesitate to contact the building department with any questions.. Thank you, Respectfully, Jeffrey Lauzon Chief Local Inspector (508) 862-4034 Jeffrey.lauzon(a town.barnstable.ma.us The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): f' o C.� Address: 113 B kac'e— City/State/Zip:��(�te. IVY Phone#: 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 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 8. Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers'comp.insurance comp.insurance.: ed.] 5. We are a corporation and its 10.❑Electrical repairs or additions luff 3.ErI 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-contractor;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: 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 the pains and penalties of perjury that the information provided/above is true and correct. Signafore: Date: "I -4—j 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): L 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( )states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation 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 being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia )kA l lz I�2-V rr7i 24C PA q- y a 91-2—AA ,� wXy eG 'Ors `�CSo 20 1P . Application Number........................................... Section 9—Construction Supervisor Name Telephone Number � 5 7— f 6 c Address D Ci u% to Z c�-� ty � p license Number License Type Expiration Date Coi tractors Email Cell# I d my responsii Iffies under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR,the Massachusetts State Budding Code. I understand the construction inspection procedures,specific inspections and dog,mentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signahue Date Section-10—Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building'Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CUR and the Town ofBamstable.Attach a copy ofyour ILLC... Signature Date Section 11—Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Date Print Name M. Telephone Number E-mail permit to: T e..r.....i..a�.i.11 in Ant a Section 12—Department Sign-Offs Health Department © Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ f Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire deparEment for approval Section 13—Owner's Authorization I, , as Owner of the-subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of j ob) Signature of Owner date Print Name Last wdate:219/2018 Town of Barnstable • • ' PostThiPermit s CardSo That itisVisible�From tte StreetA `roved°Plans Must be Retained on Job and this Card Must be Kept ,� k unn4 PO sted nt(Final Iris ection Has Been Made pp h - � ,Where a Certificateof O.ccu anc Is Re u�red,,such Buildinshall Not be Occupied,4u;ntilya Final Inspectionhas beenmade n - . � .: Permit No. B-18-3976 Applicant.Name: Saunders Kevin Approvals Date Issued: 12/10/2018 Current Use`. Structure Permit Type: Building-Sheet Metal-Residential Expiration Date: 06/10/2019 Foundation: Location: 193 BUCKSKIN PATH,CENTERVILLE Map/Lot: 170-068 Zoning District: RC Sheathing: Owner on Record: MOBERG, ROBERT&KIM Contractor dame .KEVIN C SAUNDERS Framing: 1 Address: 193 BUCKSKIN PATH � , Contractor License: 34$0 2 CENTERVILLE, MA 02632. Profe,ctCost: $ 10,000.00 Chimney: Description: HVAC duct Permit Fee: $85.00 Insulation: Project Review Req: Required HVAC documentation Per 201=5 IECGmust be on site Fee Paid ` $85.00 for inspection. Date t` 12/10/2018 Final: 3 �ts�,TcM Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authonzed;by this permit is commenced within six months,' er issuance. All work authorized by this permit shall conform to the approved application and theapproved construction documents 1or whichAKis permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zon ng'iby laws and codes. This permit shall be displayed in a location clearly visible from access street or goad and shall be maintained openz.for public inspection for the entire duration of the work until the completion of the same. �; r Electrical Service_ The Certificate of Occupancy will not be issued until all applicable signatures the Building and Fire Officials are'provideoQ n this permit. Minimum of Five Call Inspections Required for All Construction WorkP Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 1 IOB MAN.INSTALLC0 D.( ILDING PRODUC1;S PO SO)(7.30y E SAGAMORE DFACW 'NSULA'i"IOnj CCRI'IFtCA7"IOI-1�MA 02562 PER IC CC 303,J3A i7`{INSULATION '1.1 Cxtel-i'6r wally; �itrrer, Exteri©r walls (UthPr); 1�-VelCie: I irpc toter: tnter rpr'-vvall,Sairwt'It: - _ -- -._._Manufacturer: tiac: 1 lYicnt:Ceiling: - _•_...._ _ - �" V.• vpe: - _ ManGrfacturHr: Fiat CP,lr he,: y - ... R,Value:-- 1Yne: 1\4_. _ .... cto rcr: sta - - _tA.d Ct':itin j Manufacturer: R`Value; �. S�t1tAf tC�tV"(.FIBLf�Gf A55 LclJ R CE �-0 Cxterior:wlls Fype: :Settled 7h�cicness; �� -� ._.-_.._..Manufacturer: � Cover, Settle Lte area: d t-Value �___ _ Iristailed thicicn Nur -•••--..__ _ Instate ess - giber {Rags:" d density _. Flat ceil;n -- -_Martuf�cturer. settled ry hrckne. - R_ COVPraI�- Settled Are<,: Vattie;� �--- � ./y�C�, (nsfatl ' ~ -_ . to ed thickness; �- � Nurn 7�- brr of gags, sta?t'eiY densit _ f Y err _-_••�-._..__._..__.H., ...__.....,.. 7Yf�e J Settled Thickn -• _Manufac <'ss: �c� toter;, �•}t L'c a ��!t.,�('overage Ara - — Settled R-Vahr - �r Ins > a NUrriber' e:� j _ tns '_ tallt.d thicknetis �c of Bag,,:_.. a ed don,it Tor I1(t/4P Inst Id U"i t Ltu itd,n _ OatN g Pr du /ail jrl i . Town of Barnstable Building PostThis Card So That.�ts=V�s�ble Fromahe Street-A roued.Pla`nSMust,.be,Retamed onJob and this C. rd Must-be::Ke t , s r j Pot U entilyFinal Ins ection Has Bee IUlade � A Permit Where a Cert�fica#e of Occu anc` is Re urretlsuch Build�n" shall Not be 0ccu ied;untit a:Final In eciion has beenE.made. Permit No. B-18-2346 Applicant Name: MOBERG, ROBERT& KIM Approvals Date,lssued: 08/09/2018 Current Use: Structure Permit_Type: :Building-Alteration INTERIOR Work Only- Expiration Dater 02/09/2019 Foundation: Residential Map/Lot 170 068 Zoning District: RC Sheathing: Location: 193 BUCKSKIN PATH CENTERVILLE % Contractor Named Framing: 1 Owner on Record: MOBERG, ROBERT&KIM ` Contractor Llicense, 2 Address: 193 BUCKSKIN PATH y� '-• � „ "Est Project Cost: $15,000.00 h Chimney: 10/ �S CENTERVILLE, MA 02632 Permit Fee: $ 126.50 FLooe o 10 !o ilr . . Insulation: Description. Convert existing one car garage to family roo Fee Pald- $126.50 r�1!e�• s�F^�w•� Project Review Req: Change to conditioned space must meet 2015 IECC energy - Date. `y 8/9/2018 Final: code �� Plumbing/Gas Rough Plumbing: Final Plumbing: Rough Gas: ; This permit shall be deemed abandoned and invalid unless the work authonzed�by this permit is commenced within s&months after%suance. Final Gas: All work authorized by this permit shall conform to the approved applicatwn and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be incompliance with the local zoning by laws an'd codes. Electrical This permit shall be displayed in a location clearly visible from access street or,road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Buildmg.and Fire Officials are proNO- on this permit. Rough: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing - - Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Town of Barnstable r Building iHs!M',- sThis Card So Thai�it�is 1/�s�ble From the;Street—Approved Plans�Must be,Retai�ed on�Jpb and his,Card Must,be;Ke t „y P � : %A'': �, ? a 1' , � „ i Until Final,Inspection�Has B.�eenIVlade �� ,, ,� �* r, '::' .o , ', .a.- .,. Permit aCertifieate of e c u anc � Re"u�red such�Bu�ldm steal Notbe:Occu �edunt�l a=`Final Ins ect�on has:-been made =' ;` Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r - r > a � r I y L ' Application Number..�—�.....� �... 3..` .................... # . a W �............Other Fee.................:.. �►s8. Pemut Fee................�...... .... 163 TotalFee Paid............................................................... ...... TOWN OF BARNSTABLE PermitAWoval by.....TOWN ......... ..OIL ..........4.1..... BUILDINGPERMITMap. .................................. arcel.......... ...................... APPLICATION Section 1 — Owner's Information and Project.Location Project Address l bL C S�fYj �Ct Village � -� - Owners Name © Owners Legal Address �� ( JkA City State lip Owners Cell# -5n ALSO .`7 73 I . E-mail ki m�v t C�4�� • n� Section 2—Use of Stractare Use Group_ [] Commercial Structure over 35,000 cubic feet ❑ Commercial Structure.under 3 5,000cubic feet CD �.,� c LK Single/Two Family Dwelling j Section 3—Type of Permit _: cn ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ C e of uses ❑ Demo/(entire strizctine) ❑ Finish Basement ❑ Family/Amnesty El Tire L= M Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Re, fining wall ElSolar Renovation ❑ Pool El Insulation Other—Specify Section ork 4 W Description----�_ &I\k-& ey.i T Act undRind:2 2Q1 8 Application Number.................................................... Section 5—Detail Cost of Proposed Construction i nl�� Square Footage of Project Age of Structure ', ''f Ue—aZ5 • Dig Safe Number #Of Bedrooms Existing 3 Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics i i [R Wn-ing t ❑ Oil Tank Storage s ❑' Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating S ! ❑ Maso Chimn ' ❑Add/relocate bedroom g Yst� mY ey Water Supply ❑ Public ❑ Private Sewage Disposal El municipal. ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway j Debris Disposal Facility: I an using a crane ❑ Yes ❑ No Section 7—Flood'Zone Flood Zone Designation / Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required 'Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes No Lastmiated MOM � dw S TOWN 4F PARNSTAPl r r 0� �,�66YV1 � C-S: able Bldg. DBarnst e Approved by: F:L..- Permit #: The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston;MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. Address: �q5� �C-P.(� City/State/Zip: W Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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' Wam 'Or' comp.insurance comp.;nsnranCe# 9. ❑Building addition ed.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. I a homeowner doing all work officers have exercised their I L❑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: 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 cetrWufy der the pains and penalties of perjury that the information provided above is true and correct 20 1 Simiafore: Date: Phone#: 91 3 -6 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 tddo maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation 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 being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-n7-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia gg 1, Application Number........................................... Section 9—:Construction Supervisor N Name Telephone Number Address City State Zip License Number License Type : Expiration Date Contractors Email Cell# I tmderstand my responsibilities under the roles and regaiations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature' Date Section-10—Home Improvement Contractor Name Telephone Number Address City State Tip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town ofBamstable.Attach a copy of your H.LC... Signature Da Sew ection`_11 Home_Owners_License tiemption Home Owners Name: `K�b Telephone Number ep �� •�� '��.Cell or Work Number ,�g•��r�� 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 78 CMRa To of Barnstable. Si Date APPIL� - �SIGNATURE--� Signature DateNO �� Print Name a b6r ` Telephone Number o 7� E-mail permit to: 5 T.,..o.....i--A.11 innnr o ` Section 12—Department Sign-Offs n , Health Department © Zoning Board(if required) Historic District ❑ Site Plan Review(if required ❑ - i Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the f re deparbnent for approval Section 13 —Owner's Authorization L , as Owner of the-subject property hereby authorize to act on my behalf in all matters relative to work authorized by this building permit application for: job) (Address of ' a Signature of Owner date 4 Print Name t x r. Last uadated:2/9/2018 Town of Barnstable Building Post This�Card So That�tusVisible Fromthe.Street Approved Plans;Must;be.Retamed on;Job.and this..Card Must be Kept.= Posted Until Final lns 16 ,3�"� a �� Permit l t- Permit No. B-18-2854 Applicant Name: Approvals Date Issued: 08/30/2018 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 02/28/2019 Foundation: Location: 193 BUCKSKIN PATH,CENTERVILLE Map/Lot: 170-068 Zoning District: RC Sheathing: F�'" Owner on Record: MOBERG, ROBERT& KIM x Contractor Name.` Framing: 1 Address: 193 BUCKSKIN PATH a n :' Contractor License 2 CENTERVILLE, MA 02632 ^ Est Project Cost: $0.00 Chimney: Description: Shed 8x8 - PermitFee: $35.00 V4 It I I Insulation: Fee Paid. $35.00 Project Review Req: 8'x8'shed. must meet minimum zoning setbacks of'10'for side and back r Dater 8/30/2018 Final Plumbing/Gas IT Rough Plumbing: , Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within siz monthsafier:ssuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning bylaws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open.fo public inspection for the entire duration of the ..x r -- Electrical work until the completion of the same. '+ sit a r -- ,' J Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Bwldmg and Fire Officials are provided on this permit. Rough: Minimum of Five Call Inspections Required for All Construction Work x _ '" # s x . 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation g 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. 5 / "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT s Town of Barnstable THE r Building Department Services SDOLDIN(3 ,DEp a Brian Florence,CBO • RAENSLOM Building Commissioner AUG a 0 SI 2018 163� �� 200 Main Street, Hyannis,MA 02601 prFD � www.town.barnstable.ma-us TOWN OF BARNS-r,4 OLI Office: 508-862-4038 Fax: 508-790=6230 pF,RMTT# FEE: $35.00 SEEM REGISTRATION RESIDENTIAL ONLY 200 square feet or less `�� Location of shed(address) Village V Property owner's name Telephone number Size of Shed Map/Parcel# P Sig6turj Date Hyannis Main Street Waterfront Historic Disinc O Old King's Highway Historic District Commission jurisdiction? V You must file with Old Ying's Highway Conservation Commission(signature is required) Sign off boors for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WIT UN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q forms-sbedreg REV:08/6/17 j LOT .25 Jri LOT 22 �s- SIN J�O FND. etc° pp LOT 26 LO PORCH 6�. —__HSE v' �c s� LOT 24 RES. ZONE.- "RC" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C" Bank Use Only TOWN: �LMZ FMLLF,___ — — — REGISTRY OWNER: . ARGAREZA. LUNDOUISM DEED REF: _1 ,24Z32 — —BUYER: _RORERT__ Kl�_M—M0RF2G_ „ DATE:. 12 7�4— — — PLAN REF: 24167 — — _SCALE:1 = 30 _FT. I HEREBY CERTIFY TO B�1'Bg1Ylf� �QRT��E_�QBP—_ OF M YANKEE SURVEY -------------------- SHOWN _____THAT THE BUILDING �� '4s�o�y 'CONSULTANTS ON THIS PLAN IS 'LOCATED ON THE GROUND AS PAUL SHOWN AND THAT ITS POSITION DOES ____ CONFORM A. 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE MgRITHEW H Q " TOWN OF RA - RNSTAZ _____________AND THAT Na S2098 INDUSTRY ROADo IT DOES—NOTN LIE WITHIN THE SPECIAL FLOOD HAZARD '�GISTEa��J� MARSTONS MILLS, 02648 si s TEL: 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED-6��.68�- oh�I LAND FAX 420—5553 Com nit —Panel 250001 0015 C THIS PLAN NOT MADE FROM AN.-INSTRUMENT 16065 Eis L P R THEW P_ SURVEY NOT TO BE USED FOR FENCES ETC. Town of Barnstable *Permit d tips Ii i 6 m lli issrce dote Regulatory Services F � 9 ;} pER q�ard V.Scali,Interim Director �ArED MP'l A u SEP 16 2015 Building Division - Tom Perry,CBO,Building Commissioner TOWN OF BARNSTABLEoo Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDIEN LAL ONLY, Not Valid without Red X-Press Imprint ` Map/parcel Number 17 OZO& � Cali � V nc Propett�#Address I`3ca41rS Ki0 _ r residential Value of Work S Minimum fee of S35.00 for work under$6000.00 Owner's Name&Address I //?d Ae/'i /1nhe,, Contractor's Name_%r mA&I.e,Q;r�an,s &,a , '1eAA sc)n Telephone Numbera0- 11)2-2 q-q kzo Home Improvement Contractor License T(if applicable) /�4 ,5 Email: Construction Supervisor's License44(if applicable) EgWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name A em n au " 1t1Suco t1ce- r Workman's Comp.Policy 4 W C 9 7-80 S S 3 5 2 3 9 L-1 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side [Replacement Windows/doors/sliders.U-Value • 3 O (maximum.35)4 of windows-2- 9 of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. �Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy o the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:IWPFILESWORAMIbuilding permit formslEXPRESS.doc Revised 061313 SOUTNEW-01 PARKERNATHCO CERTIFICATE OF LIABILITY INSURANCE . °A$fl3rz` o15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS ; CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES j BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED ' REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. - 1 IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsernent(s). PRODUCER i NAME: I CONTACT W1111s Certificate Center Wills of New Jersey,Inc E PNONE 87 845-7378 c/o 26 Century Blvd E TAtc.Na Eml:( 7) LAIC Not(888)467 2378 P.O.Box 3055191 !E-MMLADDRESS: Nashville,TN 372304191 INSURER(S)AFFORDING COVERAGE I NAIL# wsuimf A_Selective Insurance Company of Southeast 139925 j INSURER 8:OneSeacon Insurance Company 21970 'i .Southern New England Windows LLC ;INSURER c:Argonaut Insurance Company 19801 OWA Renewal by Andersen ; ` 28 Albion Road :INSURER D: ' Lincoln,RI 02865. !INSURER E: I INSURER F' , COVERAGES CERTIRCATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO VI&'IICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN M SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE j POLICY NUMBER SR POLICYMI p DCP I L9AITS A X c.OMMERCUIL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,IWIMP 00 {9 AIMS MADE OCCUR ! X IS 202909' 08110/2016108/1012016 P S(�Ea ax�merae) 5 100,0" t 1 Atf1r�0fff,�MED E (Any M pe-n) $ I ? ;PERSONAL&ADV INJURY 1 ; GEML AGGREGATE LIMIT APPLIES PER: � ran t {{y ;GENERAL AGGREGATE 1$ 3,00Q,YY—f POLICY®JERCaT C LOC { j PRODUCTS-COMPIOP AGG I$I OTHER- I + s AUT'OCdDeItJ:LIABILITY ! I S tAa ED SINGLE LIMIT 3 1,0N, 000 )k X I ANYAUTO i X 'S 20294W 08/10/2015�08110/2016 BODILY INJURY(Per pesos) s ALLOMINED It��SCHEDULED AUTOS i—]AUTOS I I ! BODILY INJURY(Per acaHemt) $ X HIREDAUTOS x I AUUTOS OWNED E i I ��P DA&tAGE S ( ; s UMBRELLA LIAB OCCUR i EACH OCCURRENCE S I EXCESS LIAO CLAIMS-MADE ArADE S AGGREGATE I S j DED RETENTIONS i S WORKERS COMPENSATION i R i ff}., AND EMPLOYERS'LIABILITY Y I N� i} X STPEATUTE O !ER B I ANY PROPMETORIPARTNERIEXECUTIVE ! Dooms= !0812 1/2 0 1 5;08/21/2018 EL EACH ACCIDENT s 1,M,84 i OFFICERANEVBER EXCLUDED? N tis MIA; - yypeysRAandatt" In N i EL DISEASE-EA EMPLOYEE5 1,000,00 DExRbe udw IFi)ONOFOPERATIONSbebv I i EL DISEASE-POLICY LUT S 1,000,00 C Workers Compensation C928058352394 OB/21/2015 108/21/2016 See Attached ( i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD ioi,Additianal Remarks schedule,maybe attached IT more space Is required) THIS CERTIFICATE VOIDS AND REPLACES THE PREVIOUSLY ISSUED CERTIFICATE DATED:e/11/2015 Auto Policy includes additional insured When required by mitten contract/agreement as per policy form. HSS Holding Corporation,Ina and any,subsidiaries are included as an Additional Insured as respects to General Liability When required by written contract/agreement as per policy form E CERTIFICATE HOLDER CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELMERED IN ; ACCORDANCE W171i THE POLICY PROVISIONS. ` I }AUTHORIZED REPRESENTATIVE m ©INS-2014ACORD CORPORATION. AR rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents n Office of Investigations 5 I Congress,street, Suite 100 Boston,MA 02114 2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS ' Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#:401-228-9800 Are you an employer? Check the appropriate box: Type of project(required): 1.Q I'atrt a employer with 20, 4. ❑ I am a general contractor and I 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 g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.¢ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.El I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no employees. [No workers' 13.M Other Window Replacement comp. insurance required.] "Any applicant that checks box nl must also fill out the section below showing their workers'compensation policy information. " Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lic. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address:- 19 3 3txKsK i,n ra4-� City/State/Zip:&n Art(ie 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 25,N%V IGL 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 forInsurance coverage verification. I do Hereby certi under t/ie ' s andpenalties ofperjury that the information provided above is true and correct. Sign ature: Date: —/ ,",2O �S Phone#: 4012289800 Official use only. Do not write in this area,to be completed by city or town official. X` City or Town: Permit/License# Issuing Authority(circle one):• I:Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Southern: New England Windows d.b.a Renewal by Andersen of SNE Massachusefts-DeparttrrM of Public Safety Y Board of Building Regulations and Standards COnStr uctioa Supervisor License:CS-095707 BRIAN D DENN L96N 7 LAMBS POND lF IRS s Charlton MA 01507 Expiration Corrunissioner 09/0812016 Office of Consumer Affairs lad Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration , Registration: 173245 Type: Supplement Card Expiration: 9/19/2016 SOUTHERN NEW ENGLAND WINDOWS LL DENNISON BRIAN 26 ALBION RD - _ - LINCOLN,RI 02865 Update Address and return card.Mark reason for changes stini b 2ouosm " Address E,,Renewal ❑Employment Lost Card . .` !��•:1��:9�einoN�cc.'.1��slf<c:s.re�iiulrs mg� 21 Rce of Coaseo rr Affairs&Business Regulation License or registration valid for individul use only ' before the expiration date. If found return to: E IMPROVEMENT CONTRACTOR P Office of Consumer Affairs and Business Regulation egiatraUon: 173245 Type, 10 Park Plaza-Suite 5170 Expiration: 91192016 Supplement'ard Boston.MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON DENNISON BRIAN 26 ALBION RD — lINCOLN,RI 02665 Undersecretary Not valid without signature - . n Ili i�.� kENEWAL, a lb et rt.� 06 now .' 2G16ami.l�mu�d ► ,�. � es" f%me Fax '01.160S02 tQili' pdiV l dbd/WfJ.. tana _ •c4DSTM'41'tiK4�ANDDOORRL-NMDUMGAGRB 4`$ V fly �. •25v3vs�h�r�'ta + .� ao G.��?+odS,�.�nd�or fin. of'SouBScrr,�ti.4a 1rad�Win�caiY�'[.DCsSfl ia,!ta't'a R�a;mi_ bj,Ani uB SMd.19M Bess,Eh&nde " nn :soda the CexiEu laatl,r mdhimt arm n6a�aae d!e iE l ffi]f4;dl a ems•,�tf mI awl a al ahe a a�zpe era nG 4s� o8l��t1cY r�l'�y_. 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We—You assay,sf you w:sh"campy ugffi t}a inMradetiians erf'j Sme;oT you niay if you *4 iflroe Seder roger+d�irQg i te#T11 IlPn e4rtt afTlte goodLs'aR RFIe" 'the SdIer r egsrdt ih®redunn si►�t of the- at th A St'llrei's t�rtperrse adu3 rs"s141 ''yrw do n�nlce ehc ids aetadslbYa 5adlea'x�p se and rfisk K y^ou do neakc ttiC y�OedS avalldble ta'4he seflea=ii r Sefier dots sat,pk3r;hersi up widthi so.tlso So7ior.at►d tho'Werr*Nw toot:jptelc them,up ve�Jtldw tAassrrty of of r�r►celOat3oa4 yfau assay r+atarn t :t t�xeniy days 4f ti.e data df cnncdlal ory•you may retain or a spose the,goods.FiFf rnrt�ifnrtiteer•,otile�on 1!yodr 1'tl�pasc et�hc,,go+?Qs tvlth�t 0¢�y Ii1it�IteT a�'bq�ota.Ht�rou. [ail bo reeafo®thc g!Dodi' I e.to Die Se'llerp nor Jfyau e.l fa7l mo im alto ft govdi aiildrile t a dm Sellesr,or if you iagree': d*go.p*ta.he'Shcei and fail to ido s4 tfter yw° p.m rrturn the good.do t��t 5rfler setid a91 do so,tleeae grou 'rensain Ifeab3a for:partonnsnce rf A*bugs Ens 4WWW thr . _ Ira liable tdr ptrSormtintt m#t111�'bb$ tcisder floe: Ci"6-iA TD sanosl t%l ;arr11 aa°ddiaex a s'�ned' Co rsfraet,4o caned fls'is t�w►neG6laa,,ersail ar r7clirt r a siigreed and-dAtid G4py of thus "nce�ntian nadice *r-.My air l mired dAtea . Of tfais i n nfdtke.Or t w.-ptho.. v�i4'tats•na�rc eta'lt., t�D�ene�ia1�71andeisersol' t'vw�isocnnotit;�,o�aetcll�rauenbPt�ne�1'�;y�ru3ecs�of. SoutfeErvs!Now$ Isn_d.af1tE�AIWanRoed4.i Rl' 3..tl 26 r�,Sov�heyn t+t�r'fia drat ill�iaan Read Lleteoll. IRf 4l}Bd'S NOT u0.TER N.MIDNIGHT OF � l Nor LATER MIDNIGHT OF. � � �.1I 1C5Jl BY CANCELT4415TRACTIoNr. (Daft Fd BYGA GGE1'f}IISTSAMSAC!fI0 = .rr. tA! ...ee9ni,ilion. ,P�i:. .. +�',SFkpwiw.: 'eytaelM�se a.cr L6. 3Nd 'S6B'6 ="9dG1S '9sl:80� SM/lI :1190'T oFtMME r Town of Barnstable *Permit / pExpires 6 months orb i su4-t Regulatory Services Fee BARNSTABLE, 9 Mass.1639• Richard V.Scali, Director ' ♦0 ArFD MA'I A Building Division ' Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number � - . . Property Address �j (A GPC �_A PX RL4 _ All 0ZC- j 2-- CP/idential Value of Work$ Minimum fee of$35.00 for work under$6000.00 • 1 t . i.. Qwner's�Name`&-Ad dress-- j 1 pnbeiff (' '_ Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: qpR 4 �� ❑ I am a sole proprietor ZQ,¢ ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Names' ' Workman's Comp.Policy# Copy of Insurance Compliance Certiflcate�,-must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to '❑_Re;roof(hurricane nailed)(not stripping. Going over existing layers of roof) C e-side Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance ofthis 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 required. QAWPFILESTORNIMbuilding permit.forms\EXPRESS.doc Revised 061313 irA }i t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly (_—Mime`(Business/Organization/Individual): KI\11 `�. .L�7C'�� I1/1 GyJn4 A'ddr--e� s's- tCity/StateLZp 7' C'��!`L-�i�l Phone Are you an employer?Check the appropriate box: Type of project(required): L❑ 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 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 8. ❑Demolition working for me in any capacity. employees and have workers' " 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ 'required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions _..Pam 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 the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiQ u der the pains and penalties of perjury that the information provided above is true and correct. CSi afar-e: Phon 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#: .n Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to 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 being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Town of Barnstable , Regulatory Services Ja �; tHe Richard V.Scali, Director Building Division , RAWis'rAEOZ. ' Tom Perry,Building Commissioner Mesa 1639. 200 Main Street, Hyannis,MA 02601 Eo r www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION I Please Print DATE JOB LOCATION: ► t71—t.� G�� f'�_,� G� CJ�r,� C-l2ri - number ,. A e t `--villages "HOMEOWNER": name ++ ,,,homehone �t �'�, ;wefkphone# �y a CURRENT MAILING ADDRESS: I� L t G t k-1(/` GL.tl''L^-- 2 32— `^M....c!tyhown - �_"`"--te. state_-N zip code The current exemption for"homeown re s"`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 buildingpermit. (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 require ents. Si`a e of-Homeowner p ' 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. t - + SAWMABM • `• &619. , Town of Barnstable Regulatory Services Richard Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,'MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 /Faxr: 508-790-623(0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of-, e fthe subject property hereby authorize / to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WHILESTORMS\building permit forms\smokecarbondetectors.doc. Revised 050412 ug Town of Barnstable TOWN OF BAR.NISTABLE EVE r Regulatory Services11011p . Thomas F.Geiler,Director " MASS. Building Division Asa 1639. ,�� Tom Perry,Building Commissioner . ; 200 Main Street, Hyannis;MA 02601 DIVISION www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 PERMIT# C l 1020�"� FEE: $ _ .SHEDREGISTRATION f 200 square feet'or less r Lc ion of shed(address) Village v 3 , rl'7 9 -6 46 3 Property owner's name Telephone number SAC ® I `70 Oho (F) Size of Shed Map/Parcel# Lao ' I i , ature + Date Hyannis Main Street Waterfront Historic District? No Old King's Highway Historic District Commission jurisdiction? mc) Conservation Commission(signature is required) _� — — �.t ;5ign.off hours for'Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION:OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042911 LOT .25 LOT 22 SIN T�'p � FND. p- LOT 26 ' LO -PORCH �� - —_____ cP 2 =_ H93- _ �� iN �C� sue. LOT .24 p This MORTGAGE INSPECTION Plan is For FLOOD ZONE.• "C" RES. ZONE.„ "RC" Bank Use Onl TOWN: EffZP;Z ML A — REGISTRY OWNER. RUEEZ—A LUND�UIS � — DEED REF• —17, Z3� — —BUYER _EOBZBTLC KI -�ZMG DATE: 12. 7-,�94 _ PLAN REF: 244 2 — — —SCALE:1"= 30 ___FT. I HEREBY CERTIFY TO B�YB�1Ylf� �ORT�g�Z_�QBP_— `N of �c YANKEE SURVEY _ ___THAT THE BUILDING ti CONSULTANTS SHOWN ON THIS, PLAN IS LOCATED ON THE GROUND AS PAUL SHOWN AND THAT ITS POSITION DOES ---- CONFORM A. H '40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE N. c INDUSTRY ROAD TOWN OF B4RNSTA—BIB______—-----AND THAT �� MARSTONS MILLS, MA. 02648 IT DOES�NOT LIE WITHIN THE SPECIAL FLOOD HAZARD ' CISTEa SJ� TEL: 428-0055 AREA AS SHOWN ON THE .U.D MAP 5 C TED_6,��.1Z�— �� No FAX 420—5553 —Com nit P,ane THIS PLAN NOT MADE FROM AN -INSTRUMENT 16065 B�IS ` P LR THEW FUS SURVEY NOT TO BE USED FOR FENCES ETC. i oR, > Town of Barnstable ' *Permit# �r 4 3 2 '� XV&es 6 months from tasue date Regulatory Services FeeKAM z63 Thomas F.Geileri Director Building Division Tom Perry, Building Commissioner X-PRE S , IT 200 Main Street,.Hyannis,MA 02601 ~ Office: 508-8624038 MAY 2005 Fax: 508-790-6230 EN'RESS PERMIT APPLICATION - RESID ARNSTABLE Not Valid without Red X Press Imprint Map/parcell mber 1-70 Qe b Property Address . 1�1 3 u�c,�s V� �•,�`. C ..: I�vl� ❑Residential Value.of Work 2 SOO Minimum fee of•$25.00 for work under$6000.00 Owner's Name&Address lRo-L-2 11'1/1.D <✓r Contractor's Name i✓ W,0SO&W... _Telephone Number U& -7-7 5" 2 7UU Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) s ❑Workman's Compensation Insurance . Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [r-I have Worker's Compensation Insurance Insurance Company Name ✓ t�-- G 22 Z I t Q S 5 1 L/4 f) ! Workman's Comp.Policy# 6 2-7- Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof.(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U Value r -3 y (maiemntn.44) •Where required: Issuance of this.petmit does not exe#t compliance with other town department regulations,i.e.Historic,Conservation,etc. ' ***Note: - Property Owner must sign Property Owner Letter of Home ovenient Contractors License is r aired. 3qe Board of Building Regulations and Standards. Sigaatuie HOME IMPttOVEMENT CONTRACTOR ReglstrA_ n\100718 Q Forms:expmtrg ': -; i ,% � 3/2006 Revise063004 � ^^ V�i'L-s �, :E.� ` i; t,� Yare Corporation MOGAN&CO.,I Francis Mogan,Jr. f - 68.JOYCE-ANNER Centerville,MA 02632 Administrator The Commonwealth-o= Massachusetts _ - Department of Industrial Accidents , Office of Investigations < 600 Washington Street, 7th Floor Boston,Mass. 02111 Workers'Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors .s�Unhscntihforato� � ,t ': lest ' ) e� l +< r �b '$m ' °'J� } :1„ $ name a address city state: zip: phone# work site location(full address): - ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Buildin Addition :'i jiu.yi;.,tt;,,�,' 7j-111£{C. P, :]?.",•�,'+'.' :.:fin;x'' .�. •; . i{.�'::,q:.� ..�..e;t:', r✓-s,:; .. ...,t. $'?f`s+S,,.... �{....:.:. ''_.^!._>_;d.ei�.,.,_3•°N..q,.. 3,','as* .. 4+�+'4'+'i:> ''x7„ ,; .;tiff.ir-,'+..• k,.•,;s_ r.r°I -;tss;.F�.;F.r.:-yr'„tWT,.,,,;;y •�t,...:�..:w.� ❑ I am an employer providing workers'compensation for my employees working on this job. company name: address: A,,,` 2.9 city Vl,, phone# `27UU r •• 77 , nn insurance co. policy# Z 2 Z u f3 0 7 `Ylq 0 I _ u .. ,. .�' a � i"l+ie... ,.,.u:1J:.r........l,r•'S'�&hi.,=e":'r.�...�r>h.v`�,.b ia...r, e...: .. y.ff r. ... .,,rt. ,.�.r ..y :•t•:�u.t I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below-who have the following workers' compensation polices: company name address: city: shone insurance co. policy# q ybq`..•. 4:. �', :',}q�i.Mt'':Y.S;} .if.:sq; i _',-;s"tzy4='tJl�L7'{f o.° �•�' "•:.:?si��.m'1-+: r,4:a:.n,r `.i...� n�:•r':7o :u... - q i.F . i'�„_,. ._,ha.}:�r`'t. i st.. s yr...Yrr+f. fiS t'YM, ,:ri,, 2 < :�!•;'�.. , ('...•. -0.=r, r; `.'T•.,. Y -,. 'company name: address: city: , phone# i. . . ee7, insurance co. policy# } tlatlF ddlhorial::slt ire sad M fl t j r r lr C�)C�.f.�� 3.i .t i pmGC�}. x�tsr.r �y q. ! •'.ti,�'a wr- t b .n �y .$, X �c:-�..t.. .xs' x...fi+.d,'.u1C...�w` 9s.:a�wa�,''`�5s�°�,.r;w`�zarlta�e�E.�tE{�t'��rd<t,•� +.�k::.�?z+��2:�ldayt,.� ;&� `iI� 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$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that.a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification, I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature P``G Date 7'/d J r Print name Phone# 7 7 5 official use only• ,do not write in this area to be completed by city or town official city or town:' ' u . r°' permit/license# []Building Department ❑Licensing Board i ❑check if immediate response is required, ❑Selectmen's Office []Health Department contact person: hone#• P Ot e hr (revised Sept.2003) - . 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 employee is defined as every person in the service of another under.any ct of hire express or implied,contra p p ,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 -r trustee of an individual partnership,association or other legal entity,employing employees. However the owner of a o ,P P� g 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 section 25 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,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. «�_ =;�x.;TR - '��'?5-:- s;:,.. . �..r ��qq•^�-sa:�;:skw'; g�g� z:�" ":�:xi'f•w�,� '-i' ('"e�.tr.'{�,•z;•4��?�t.�rA,�,•�"_>'��oez;:�t�;.`s�.;�: G��5#.wtl�+��''k,� ^aa�`L�'�wr4�P'irf•� ad� ' r�7� f'tl�K -TSltu9}�'�S�x'.��i» f"',�.�r::�',W,',.i�4':�A t z 4j •�� +,^ ,i� �•'- `•�' sx�'':,r'p Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance 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. „ «w.. .. •.�..£ r�'•:-r-,.r .r•-='-.�. ' •.. - .}.o,rrs�_ - _- - ra*.:�.a� =9t. ".;r"'s�W:t p.r=nr• �'S��P:`- '=T.t4".w'-sn:i;...:j; ..`Y:'e:t^t �`r =°-4"� ��'%�, rr..�.DB;i'r .'�. ,S. ,,.Y�: .g. ?�..t Y+ .'A'.�,ter, .a,. i':�int :,�.,< :;t•;-:ii4 . r..�.,,..�.. -$h - t' Y, a� .l. ,°�.'•,.,i' f; aaT.'i}-. .'!2 .f. �fe�. '.:i oit::. .�,[:•. _ .:t •:f':•'L.Y?r•2:�... 's,I r."1i a, Y ,3't;- tr eti: .$. :.t. .,R. 'y5.al ".+3'•',.''' }. - - v1,.."lcw, .'iA. �rvrS;u L �.4� :n�: d°:.h' .�F' `°�'•_ ..{Y a.' - .:de. j ,•�.?L• �7a. f��r}'.. t' �.�'.^...: q'�F.j��:'`.di+l:•. �'. r.t'�`eA4.�.15.:.t •��.0 fla'3�e YSN i`v''N`.t..e:s�s�1cs" �'R•9jc}+br-•.. ...wnt A:t�Y fs_._;5€*.. .5�`$.. .k u'rk�. R d-16... City 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. The 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. ir:. �;C,.�. THS.:,., ':5'ytijr :.(« „ ,,,.. ,h'%:11`'•' ;lytG 4' '==:,. r. M� ee•,�5`.$' ;X,r. , 'u:.at�:•.ti',z'v,a a 4ti < L-7"4'.Pk is ' ,9'.k �' �as; `��€`'�'�:,n'i,'-'�`m��$�.`"Zh':•.�i�.F: ..:;�•'•`'�`':a r,,t.�r ti�' � ._r"�. .i,�,.`,z.�' 1 4 ,.b• ir :.i r , a xt,.•F' ti z !` c x c�'- F;:r:«::..::'!•e 3 `p�'•-✓.$'% ,.c ' i^ti ei?',o-. :k,9 Y'2 i`�. i„�:xs°�' :� xsw � �Hn 3�. fi,,.��°le^ix '�•�3�8�6t�EYs$��ts��•z"i�•a�'� �x� The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma, 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 Town of Barnstable P Regulatory Services a r Thomas F.Geiler,Director Building Division TomPerry, Building Commissioner 200 Main Street, $yannis,MA 02601 www.town.b arnstable.maxs Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder as Owner of the subject property hereby authorize:' " to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) s�23lie) s ' Signature of Owner Date Print Name n.vnvhdR•f1WTTPRPF.RMTS CiON TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION fi .Map "7 Parcel two Permit# o Health Division A4, Date Issued Conservation Division 4 5 ,, Fee T2S ad Tax Collector - �SEPTIC SYSTEM MUST BEt ' Treasurer ` INSTALLED IN COh7PANCE Planning Dept. WITH TITLE 5. .,ENVIR0H.,7EN7AL CODE AND Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village omnn}-cam ~ ; ��• s Owner PAlua e- VV " Address , Telephone Permit Request r • Square feet: 1st floor:existing - proposed 2nd floor:existing proposed Total new - Estimated Project Cost v Zoning District `` Flood Plain - Groundwater Overlay ` Construction Type Lot Size Grandfathered: .❑:Yes ❑No If yes, attach supporting documentation. A Dwelling Type: Single Family Q"' 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 Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count ' 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 O Appeal# Recorded❑ • • Commercial ❑Yes ❑ No If yes,site plan review# Current Use Proposed Use ~ BUILDER INFORMATION _ Name° Qn �, Telephone Number 5nS .p Address y flo MAiA License# 6qi C& Home Improvement Contractor# jai q p Worker's Compensation# ��,�n� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 01„ SIGNATURE bAad Q.,o Lelf k DATE as`92 H - FOR OFFICIAL USE ONLY x .•• PERMIT-NO. -DATE ISSUED". .a MAP/PARCEL`NO. '. .. ADDRESS' ` " VILLAGE ` OWNER� -' ~.Y_awprssr i ` � t S .t`", ..,, r a • } f 4 ...,f , s a ' +i " DATE OF,INSPECTION: 1 T + FOONDATION FRAME � ' �* � . •� } ryry' .A ...r i r . ' ' r er. al.. 1.• - 4♦ y. 4 1 . . r ` INSULATION ,a " • �`� • I I ;. ._ . . � "`.; ;;. .,' i , FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING:, ROUGH(" FINAL ,. f, ..GAS: ROUG-i FINAL r FINAL BUILDINGS ^s O ,' _. 3 '.•�r \ ♦ ♦ ^. kii �-� a...F }' t 't _ + r f . s r e I e �a cr DATE CLOSED OUT _° ASSOCIATION PLAN N( LOT .25 LOT 22 SIN FND. LOT 26 LOTi,� FORCH 0� = — - - = cP xx s�,e x/ 0 LOT 24 RES. ZONE.- "RC" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.- "C" Bank Use Only TOWN: SCE TLRHLIF _ — — REGISTRY OWNER: "UEEZ-A. �UNPQUISL — — DEED REF: _74Z333L — — —BUYER: _EOZZ&RTLC &-1KI9--M Jp$ERG DATE:. IR17Z94— — — PLAN REF: 244 67 — — —SCALE:1 30 FT. I HEREBY CERTIFY TO B�Y��NK�'�OBTIY��aE_�Q&P�—_ `N OF Mgs�c YANKEE SURVEY ___ __ _____ _ _ _________THAT THE BUILDING ti CONSULTANTS SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS PAUL SHOWN AND THAT ITS POSITION DOES _-__ CONFORM A. 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE MEWITHEW INDUSTRY ROAD TOWN OF ___B4RN�'.M$Z-------------AND THAT Na 3208d e IT DOES_1VOT LIE WITHIN THE SPECIAL FLOOD HAZARD �, 'PECtSTE�� MARSTO TEL MILLS,428-0553 MA.05 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_6,�.,�_.__ '�'op�IlAp�s FAX 420-5553 Com n't -Pane 250001 0015 C FAX _ ________ THIS PLAN NOT MADE FROM AN -INSTRUMENT 16065 BJS P LRITHE P SURVEY NOT TO BE USED FOR FENCES ETC. i®iiiiii■ii®■ii� C��'�:�� 1�� '��C��ii■�■■■■i ii■ii■■i■■iii�■ice■®■iiii®■i■■■■■■■■■ ■■ ii�i� ■i�i�iiii��■■��i■�■■i■ �`ii�iii�iii�ii�■■■ iiiiiii■■i■■i®i■i■■��■i■i■ii■i■ii■■ii■�■■■■■ iiiii'i■■■ii■ii■iii■��■!ii■�■■ii■■■■■■■■■■■■i ii■ii ii■i■■iii■ii® ■i■I ■ffl-! 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' ME liiiiiiiiiiiiiiiiiil� �■iii�i■ �➢��lC��t1■i■�■ iiiii■■i®iif i i■iii■i■i' l i ...: i �r..... h m- No iiiii■■i■ii■ii■■i■■i■iii■■ '� l�:l�■i■■il� �■i ■■■■■■■■■■■■■®��■�ii■J�ii■�■ %iii■i■■i■■■■■■i ■■■■■■■■■■■iiili111 ■,/yl�i■i■■■ ��■■■■■■■■ ■■■■■■■■■■■■ii . �; ■ ■■■■■■■M■ ■ ■■ ■■■■■■■■■■■ ■iiii■■■■■■■■■■i■■■ i■■■■■■■■■■ ®iii ■■i■ii■■i■■i■�■■■■■■■■■■■ ■■i■■■■■■■■■iiiii■�iii■■■■■i■�■■i■i■■■■■�■ ■■■■■■■■■■■■■i■OEM■■iii■■■■iii■■■ii■■■■■■E -lu■m■■■■■i mom ■�■■ii■ii■®■®■iii■iiii�i■i■■i iiii■i®ii■■i■iiiii■ii■■■■�■ii■�■miiii�■�i i } 1 ,. �, ,. ,; �, The Town of Barnstable • r�►susr� • 9 � Department of Health Safety and Environmental Services rEc Mop' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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. 1 Type of Work: Estimated Cost It 50 0 Address of Work: i �9 (�?A,i r Pnt�ck anITI A Jwj—tc pllnv Owner's Name: J64�C� = i� Date of Application. 6.- -.A ._ . . I hereby certify that: Registration is not required for the following reason(s): Work excluded by law [31ob Under S1,000 []Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING'THEIXOWN°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. is,�C -- Date Contractor Name Registration No. . OR Date Owner's Name g1orms:Affidav �`_-- The Commonwealth of Massachusetts ==`r;� = Department of Industrial Accidents ONCE aflnse50290fts R. s£=3 600 Washington Street u r. Boston,Mass. 02111 �at101iS+�rance Affidavit ��//,� ��i//r��i�/i��%'<,.... �ilt1C�12FitT[IOrtZL'RtttJt[✓�� %�� //rii// // / r /�/ name: location " city phone# ❑ lam a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any ca achy /////%////,"1 1/115 tiA///%/O�'/'/////////.s'/////! ��'/ ///.l�///,//////////////////%//% ��'/////////%/%/��//%G� I am an employer providing workers' compensation for my employees working on this job. compnnv name: R address: Y. city: „aA.,42:4.� LW MQ - b C Y( phone#: Sc)9-4;L insurance LEG l I) silty# 10C 0;4 ❑ I am a'sole proprietor, general contractor, or homeowner(circle one)•and have hired the contractors listed below who have the following workers' compensation polices:. companv__tt=e: ;. address ;.....:<:::;•.,•:.;,.:. dtv. phone#: inaornnce-cn— 20fty 0.. •• •• comnanv name: :. •.:•:::•::..... address: _ .. ..."`.....' .......: city- ? phone#-' ... =w .......... ..... ....:.... _ .. ..:.... ..::...v vi' is•i '"' insnrance ro. Polieva FaIIure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a ane up to 51.500.00 and/or one years'imprisonment as—11 as civil penalties in-the-form of a STOP'WORK ORDER and a dne of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Otllce of Investigations of the DIA for coverage verification. I do hereby certify udder the pails and npen alttn ies of perjury that the information provided above is true and co rrect Signature �f.n Date CF _ Print name_ t2,P44 PA&IO L k., Phone# 5�0! 9.2 9 9It D ofIIdal use oniv do not write in this area to be completed by city or town otncial city or town: petmitNcetue# ❑Building Department .❑Lleeruing Board ❑check if Immediate response is required ❑Selectmen's Ofiiee ❑Health Department contact person• phone#; ❑Other�� .... (mum 9,95 PIA) Y 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 employee is defined as every person in the service of another under any cam= 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 receive:c: 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 occup=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 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: of a Iicense 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,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 requiremenss of this chapter have bees presented to the contracting authority. . Applicants . Please fill in the workers' compensation affidavit completely,-by checking-the box that applies to-your,dwatian and-. ---_w supplying company names, address and-pho=-m=bers..along with a.certificate=of insurance-as all affidavits may be _ submitted.to-the.Deparmnent of:Industnal Accidents_foriconfirmation-ofins+ rance-coverage.-=-Also-be sure-to sign and date tfie davit:` The affidavit shou�Iabe reaiie`�d-to the city or town thaf the^application for the"permit or license is` _.: .. being requested, not the Department of Industrial Accidc=.-Shbuld.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. City or Towns Please be sure that the affidavit is complete and printed legibly. the De ce paroneat has provided a spa at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicau. Please be sure to fill in the pert it censc number which will be used as a reference member. The affidavits may be rca=ed io the Department by marl or FAX unless other anangemeats have been made. The Office of Investigations would Igo to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. ----------------------- The Deparm='s address,telephone and fax member. t The Commonwealth Of Massachusetts Department of Industrial Accidents 0mce of laliestloadoin 600 Washington Street Boston;Ma, 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 f S OEPARiMENi OF PUBLIC SAFETY • CONSTRUGLION SUPERVISOR LICENSE Ex fires: . •Birthrate �, Nunh"e C$ 0 gfl� 6`3128�2000 9R�0LCE 04GK, 4�, • � �R�' 24 OEB�I�S IN _ .. @ t '" -� NARSTOpS;JI,IIIS,::�MA 82,h64 ��,,,,,�•,..,> � ..,.` b�Qy�%THETO�yn TOWN OF BAR.NSTABLE SALFiTOIILE, i a �� s BUILDING�� INSPECTOR MP r. e APPLICATION FOR PERMIT TO .. ......c�h .. ..... . TYPE OF CONSTRUCTION ..........:..... ...... /.. :/�...r- c4� '.r;........ w ✓" ................ .......a 1......19 � TO THE INSPECTOR OF BUILDINGS: The undersigned herebyapplies for a permit according to the followin information: Location ...... ... ..............:......... ...... .... .` ......: .. �� .......:....... ProposedUse ............................................................................................................................................................................. Zoning District ........................................ Fire District Name of Owner Address ............ ........ Name of Builder �.:G...................... �' ......Address .............. ............... .................... ...................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ............................................:.....................Foundation / ... Exierior ... ... . .. ...... ......Roofing ......... ........ � �Floors ............... �� .:4 ..� .....................................................Interior ............................ ....... .... .... ............................. Heating ...............-.. .. .Yv.......................................Plumbing ...................... ................. ^-..... Fireplace ..... Approximate Cost �. ................. ......Definitive Plan Approved by Plannin Board -------------------_---_-------19________. Diagram of Lot and Building with Dimensions Pei- 7 J SUBJECT TO APPROVAL"OF BOARD OF HEALTH 'j 0 M. W Imo- U) > LLJ ♦V � � fY9 'dam ./u'`Jy LL w A 1_j D Lt.J _1 Lco V) Z, 2 < � � j < w� Lo I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable rega ng the above construction. Name ... Small, Alan E. No .17?2..... Permit for .................. „One family.........;?SOT .................................. Location ...Augkskin..P,a.th Auqkskin.Path............................... ................... sntaimills.................................... I Owner ...Alan..E....Sma.0.................................. Type of Construction .fr.&m®.............................. 4 ................................................................................ I Plot ............................ Lot2. .............................. !93 • Permit Granted ....November• 27 ••197 9 Date of Inspection ................. ..................19 Date Completed ... .............19 i Ca�rp�� PERMIT REFUSED ................................................................ 19 ............................................................................... .................................................. ........................ ............................................................................... ............................................................................... Approved .._.............................................. 19 t ............................................................................... I i ............................................................................... i I k 4 FTr 10'-7 1/8' 8'-3 3/4' LBarnstable Bldg.Dept. 6 1/2' Approved by: -3'-7 1/4' Permit#: 4,-0' 2'-4' 4'-0' o o 0 Pro3osed e n ro n co ro n evofion a Scale 1/4"=1'0" — — Client: Kim Moberg Pro iec}: Side Entry Portico Revisions: Dale: 10-16-19 P 1 O _ Keith C. Gilmore Enterprises LLC . - O O - P.O.Box 17 -9934 ilie. MA 02632 193 buckskin Path Drawn Bv: — O — P: 508-420-9934 F: 508-420-9935 E: gilmoreen♦•erprisesocomcasf.nef Centerville. MA '''t''� www.gilmoreenl•erprises.i nfo — Scale: 02632 1/4"=1'0" � ire o �ied r i wilbM the cermission of Keith C.6iFnore Entemdses 11C c I 6/12 6/12 5 1/2' '-7 1/8° o T-101/4° 12"x48" concrete tube spread footings 4' below grade typ. -�' Simpson ADU66 post bases bolted into footings using 5/8"x10" galvanized threaded rod 2x6 p.t. landing framing a 16" o.c. with Azek 5/46 decking 6x6 pA. posts with pvc trim wrap, posts secured to bases and girder using H2.5 clips 4'-3 1/2' 2-2x6 girder perimeter tied to 2x6 roof framing @ 16" o.c. 1' 0° 2x6 ceiling joists at 16" o.c. with 1/2x5 pvc ceiling planks 2'-4° Pvc roof perimeter trim. asphalt roofing and cedar shingle siding to match existing PrODOqed E -n --- Fy - P E eVCt *ion Scale 1/4"=1'O" — — Keith C. Gilmore Enterprises LLC Client: Kim Moberg Project: Side 'Entry Portico Revisions: Date: 10-16-19 P 2 O — OO _ P.o.6ox 17 Centerville. MA 02632 193 Buckskin Path P: 508-420-9934 F. 508-420-9935 Drawn Bv: E: gilmoreenterprisesecomcast.net .ir`.� .iln►,s-�.� www.gilrwreenterprises.info Centerville, MA 02632 Scale: l/4 -10 These&eians are not to be n,a MIW or COoied withouF the permission of Keith C. Gib2re Er*erorises LLC I 10'-7 1/8' 8'-3 3/4' 6 1/2' 3'-7 1/4' 4-0' 2'-4' 4'-0' Fo Dos d 5 *1de En F OF 0 1 co FFonf E evcf *ion Scale 1/4"=1'0" O&K Client: Kim Moberg Pro iec}: Side Entry Porfico Revisions: Date: 10-16-19Keith C. Gilmore Enterprises LLCP.O.5ox 17 Centerville. MA 02632 193 Buckskin Path P: 508-420-9934 F: 508-420-9935 Drawn Bv: E: gilmoreenterprisesocomcast.net Centerville, M www. ig I�r wreenferprises.info 02632 Scale; 1/^ —1�� The-deeians are not to be rtadified or co oled t without the permission of Keith C.Owe Enteiwisea LLC I _ILLI 111 6/12 6/12 5 1/2' 0 T-101/4' 12"x48" concrete tube spread footings 4' below grade typ. -e" Simpson ABU66 post bases bolted into footings using 5/8"xl0" galvanized threaded rod 2x6 p.t. landing framing a 16" o.c. with Azek 5/46 decking 6x6 p.t. posts with pvc trim wrap, posts secured to bases and girder using H2.5 clips --4'-31/2' 2-2x6 girder perimeter tied to 2x6 roof framing a 16" o.c. r 0' 2x6 ceiling joists at 16" o.c. with 1/2x5 pvc ceiling planks 2'-4' Pvc roof perimeter trim. asphalt roofing and cedar shingle siding to match existing 0 0 0 PrODOqed 1 n --- F OF I co E evcfion Scale 1/4 i — Client: Kim Moberg Pro!ect' Side IEntry Portico Revisions: Date: 10-16-19 P 2 O — Keith C. Gilmore Enterprises LLC P.O.Dox508 17 -993 vine. MA 02632 193 Buckskin Path Drawn Bv• — O _ P: 508-420 9934 F. 508-420-9935 E: dIrwreenterprisesocomost.ne� -�-f.� w-/n►e i-s www.gilmoreen{•erprises.info Centerville, MA — — 02632 Scale: l/4"-1'0" These designs are rok♦o be r,ed or copied — wi�houk the cermission of Keith C. 6ihare Enkerwises L.LC