Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1118 BUMPS RIVER ROAD
� r a `9"`yY'Lr s. ..gF ,f# M f4- �',,,u y.''yq�y�..,�c'.�.�Jk�`',�YX': •� ,'!h=i��_.'.-`.f•y.e�*"4-..t,>aM4.;...:....,tfSX"'i x,.rr _.•; 'rg�`-t'tu r:'�_c, `r:' _ _nio:` ,\`3. ,<X•::.. 't i' a .a` MAI �.' •;r.�ti'ago . H fi. O M.� .�t�sti�r� •� ,.rr,X i a � y�. .it �;�' � ,n - o u � a; u 1 . 13 1 un. r r n- w o v 1 , S� X 'L n ,a r r •.n .. n - �, ak ^ n ' 4 � a' , S.. Y , , 5`z b o , oo � , i ... ��� � o 'd `�` r 7• � i ^�.ka .. - , v f t � �4•N '- ., o� a � g� � � _ t `�1 p y I v` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel J Application I t Health Division Date Issued V0 Conservation Division Application Fee ` i Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board " �911��t•3 Historic - OKH _ Preservation/Hyannis Project Street Address UK I?tl.-4 PL1a- P,b Village �J21lZLL� Owner. L; ► Address LICE mff mce E D Telephone �0 ed I �S Permit Request Mot>E L_. C 1V1,f Ste- 111 "if1!Dek'A. Square feet: 1 st floor: existing 16b 0 proposed 6 2nd floor: existing 1660 proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation .Q OOC- 0' Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) _ Age of Existing Structure Historic House: ❑Yes Cho On Old King's Highway: ❑Yes ❑ No Basement Type: d Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Wc) ca Numb of Baths: Full: existing 3 new ® Half: existing =` `mew Number of Bedrooms: existing 0 new t i Total Room Count (not including baths): existing new 0 First Floor om CotN Heat Type and Fuel: ❑ Gas -®'Oil ❑ Electric ❑ Other � Central Air: ❑Yes -El<o Fireplaces: Existing New Existing wo d/coal stove: &Yes C71Qo Detached garage: d"existing ❑ new size—Pool: ❑ existing ❑ new size _.Barn: ❑ existing ❑ new size.-- Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size,_ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # -Current-Use -Proposed.Use- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) � �� ' Name JAI S l ����� ��� elephone Number Address &C �ru_r- License # L I ®�6SS Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN'TOS17f13G J 5T74- yO,-J SIGNATURE DATE ! l ,a FOR OFFICIAL USE ONLY APPLICATION# DATEISSUED E: ,g MAP/PARCEL NO. 4 l ADDRESS VILLAGE 4 OWNER } DATE OF INSPECTION: L •FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ;x PLUMBING: ROUGH ' FINAL F' GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. E 41 The Coninionivealth of Massachusetts Department.of Industiial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 mtvn.Mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electiicians/Plumbers . Applicant Information Please Print Le 'bl Name(Business/Orgauization(indivi(bual): F,4T 2v ST. Address: :�?U 4 1:d �1 a5 rE1(/L7.t. City/State-/Zip: .Phone#; �0 Are ylodan employer?Check the appropriate boa: Type of project(required): 1_ I am a employer with A. ❑ 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. D4t&nodeling 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.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself o workers'co right.of exemption per MGL w mY � comp. 12_❑Roof repairs insurance required.]B 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. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Conttactors that check this box must attached an addirt"sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conuactors have employees,they must provide their workers'comp.policy number. I a►n an employer titat is providing workers'compensation insurance for my eniploy,ees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.1ic..#: I��d Expiration Date: Job Site Address: P 1 M f S � �� �Zb 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 tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as vital 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. 1 do hereby certify epai►is a►td penalties of petjiiry tl►at Cite information provided aba is trite and correct i ture: Date: 7)67,1 3 cd, Phone#: Official use only .Do not write in this area,to be co►npleted by city or town gffrcial City or Tomm- Permit/License# Issuing Authority(circle one):' 1.Board of Health 2.Building Department 3.City/Tovim Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A R CERTIFICAT E 4F LIABILITY INSURANCE °"�t13/2013 '' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY OS HOLDER. THIS La [CERTIFICATE ND CONFER N DOES NOT AFFIRMA71VELY OR NEGATIVELY AMEND, EXTEND OR ALTR RTHE OVERAGE AFORDED BY THE PEOLIC EIS ELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A•CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED EPRESENTATIVE OR PRODUCEER,AND THE CERTIFICATE HOLDER. Ml'ORTANT: If the certificate holder Is an AQDITIONAL INSURED,the pollcAles)must be endorsed If SttBROOATiON IS WAIVED,subject to - the terms and conditions of the policy,certain policies may require an endorsement, A statement on Ihis certificate does not confer rights to the CeltlBcate holder in llau of such endorsements, PRODUCER co Mark Sytv►e Insurance Agency,LLC NAME: Dabble 404 Main Street FHO16 I a 508 957 21Z5 AryNe�:508 957-2761 Centerville, MA 02632 ARDBESI: !ft M-tk vle)n5urance.cOm INeIIRER 3• ( 1 AFCOROING COVE{V►CE NAIC INaUREO - IN9URERA;MOntpeler US Ins Co West Bey Management Trust INsuRERB;Travelers Insurance Co 770AMain Street INSURPRC: Ostervllfe.MA D2655 r INSURERO; INSURM E: COVERAGES INSURER F CERTIFICATE NUMBER:THIS IS REVISION NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISS9JED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OFINRMNCE POLICY NUMBER �114/2�0121" 01201 A GENMAL L[ABILnY MP0006001012633 LIMITS X COMMERCIAL GENERA,LIABILITY EACI'I OCCURRENCE g 1,000,000 CMS-MADE 1 OCCUR PREMISF LooNn.,nrpl a 100.000 MEO EXP LAnv ane ersoo3 $ 5,000 PERSONAL 3 ADV INJURY g 1.000,000 GENERAL AGGREGATE i 2.000,000 GENLAGGAFGA;E LIMIT APPLIES PER, X POLICY npR0 LOG PRODUCTS-COMP/OP AiGG b 2,000 000 AUTOMOBILE LIABILITY It M tiD SNGL uMn ANY AUTO Ee arc earl} �O�YME° SCHE.D ILED BODILY INJURY mer0erzonl t NON-OM1VEf,. BODILY INJURY IPeraOddara) I MRED AUTOS AUTOS I Y DAA4A Petec Oent 3 a . uMBREItp UAB. OCQJR exce LIAO EACH OCCURRENCE S. CLAIMS-MADE AGGREGATE S CED RETENTION B WORlcEROCOMPENSATION UB-7615805A t AND EMPLOYERS'LIABILITY YIN 323l2013 323/2014 s]AT X o ►� ,CERIMENBERF,►IANY ACLU�DED�7�Tlv�❑ NIA E.L.EACH ACCIDENT I 500,000 (Mond"In NH) — Ifyas t1951YIDe unear - E.L.DISEAySE,EAeMPLOYE- $ 500,000 OESC"RIPTION pF OPERATIONS below E L.OISEA3E-POLICY LIMB 19 500.000 DESCRIPTION OF OPERATIONS I LOCATIoNs/VENICLES(gtheh ACORO It",Addleoml R.merks SehedwIn.N mom apew la ngWlretq Residential Carpentry CERTIFICATE HOLDER CANCELLATION (508)790.6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Elernstable Building Department INC EXPIRATION DATA THEREOF, NOTICE WILL BE DELIVFRCD IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis.MA 02601 AUTNORIZEp REPRESENTATIVE ACORD 25(2010/05) ®1t�-2010ACORDCORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i OfFice of Consumer Affairs&Business Regulation• License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 152124 Type: Office of Consumer Affairs and Business Regulation xpiration: 8/2/2014 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 WEST BAY MANAGEMENT TRUST I ADAM HOSTETTER 770 A MAIN ST. OSTERVILLE,MA 02655 Undersecretary Not valid without signature Ma.machu.wtts- Department of Public Safety Board of Building Regulations and Standards Construdtion Supervisor License License: CS ti►4302 ,..• ADAM FfO& TER 770 SUITE`Al. AIN:ST. OSTERVILLE MA 62655`: Expiration: 12/2212013 Convnbdoner. Tr#: 7378 i s • 1ARNSfABLi. • MAM Town of Barnstable " Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us -Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, JM(4 Z VJ L-414 b ,as Owner of the subject property hereby authorize IW E i 1 gq:!l �J�L4 )el)S T to act on my behalf, � in all matters relative to work authorized by this building permit application for. (Address of Job) f S4&6e o Owner date a� Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\dewfl*\AppData\Local\Ncrosoft\Windows\Temporary Internet Files\ContentOutlook\QRE6ZUBN\EXPRESS.doc Revised'053012 S y �a to Ftoo� co Ve-i-T� x EXIST.TOILET HALF WALL NEW SHELVES TO REMAIN _ NEW CUSTOM ` •t 5HOWEK z v cL 6 rh 3, p NEW W DBL U T. 9ATHRO I PAN VANITY" - PRQPOSM AATHROOM_PLAN p4 �' T` C _�«._ I ~' 11 LL 114"=1'-W CBH sna13 _ : i A I f a � } TO a 051 ' r: : . f r i t I F. SE a i I , t 4 i t < i t i I , r i I I : y i I 1 : • I I . : S _ ; : , i F i 1 : ! R � � I ' r , i : : I f. , ' .i I + i • PAW VIA p stmd L.J. -.1!A • ? I � 1 1A ..�. ,{ ..... , � ...+.. •.. .mow. ¶..,..., ., .....:. .... j ... ,'. i l 1 A K 17 i fl: � ,. t q r. j I , I t c I A jyy F: kbd .1 -1. Y+- 5 1 } I F.. r : alp } l n { z+i VolZoe. I �r ...... •, a GG CCC Y� 4-1 .1 q n A i { I I ` M , 1 , {. I I ' I• , 4 1 1 4 .. .... .. 4 T-j -' , 4 { 7 1. 1_j T I vi + I t lY I i ! N > I 'd 1 J, i : I i i ' f 1 n G. 4 „..THE TOWN OF BARNSTABLE Permit No, _19913_--1/27/78 t »SrA Building Inspector . cash --------N!A --------- °"`Y�� OCCUPANCY PERMIT Bond No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Mr. & Mrs. J. Douglas Murphy Address Centerville. lot #9 1118 Bumps River .Road, Centerville Wiring Inspector Inspection data Plumbing Ins r Inspection date Gas Inspector Inspection date Engineering Department A14 Inspection date i THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ....................L. IJ. ......, 19. � ..................... .......,:. ................... .... c..... ..... _.�...._._ Building Inspector w Assessor's: map and lot 'number ...�. .�d...:...r.. `. ......4 µ t�" 1 SEPTIC SYSTEM MUST BE I;' INSTALLED-IN COMPLIANCE Sewage.: Permit number ...................................................:.. ~a "' ' + WITH ARTICLE If STATE. SANITAR COD yo�tHET°� => TOWN OF "BAR � a� o � T©�� �Q o - � ii m �Q i EAiiSTAUL JpYO s BULDIHG INSPECTOR -1 C4 :.� 1 :... t weLLa N z; A`FPLICATION FOi> PERMIT TO .... C?A? i.f:.Q._ ...�..................C(.:.................::.......................................... is h TYPEOF CONSTRUCTION ....................................... ............... ......:................................................... ..................................z..........19.. B TO-THE.,INSPECTOR...OF,,BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...........I ?}.... ....... M(�S.....QI IjE Q-.... 4 ..:".....�.�.N;IC.1�4?d.!-i�ve......................................... Proposed Use ivl?— .!�E!�t i.('� .. ...... ......................................... r Zoning District L.�...�...�imc.Alc.kk...Fire District .... teX.Su..LLlg-...................................... Name of Owner ...Ml UAYAddress Qer1+.Q-.r.Mi..UC..................: Name of Builder ... P'1 5.... ......�St��. ....................Address ....... tlP. ............................................ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ............ ..................................:...............Foundation dA)..... ........P ct.a....0. .................................... Exierior Cl� sar.ds .................... H `fit 1� ��................... ............. ................. ........Roofing .....:..��.....��.:t......... Floors WMA +o...Wmr1....................:..............:...Interior ............. �I�...�,.ZN-L:......................................... Heating �_i �r�l �1......� .L............................:.....Plumbing .............��.11-.......................................................... 1............i,? Fireplace ........... f-g...............................................................Approximate Cost — )..4O 000 v po ....�...........°.;0 .7a Definitive Plan Approved by Planning Board ---------------_---------------19________. Area !� f.. . ... .......................... Diagram of Lot and Building with Dimensions Fe / `...................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name�� sc..... .! ..�J .... � ............. 1 Murphyj-Mr. & Mrs. J. Douglas 19913 1 1/2 story .............. Permit for .................................... single family dwelling ............................................................................... 1118 Bumps River Road ........Location ......................................................... Centerville ................M..r........&....M...r..s.......J....Douglas MurphyOwner ..Type7of Construction .........................frame................. J ................................................................................ Plot ............................ Lot .........#9................... Z January 27 78 Permit Granted ......... 19 Date of Inspection ...-19 Date Completed ..........19 .......................... PERMIT REFUSED ................................................................. 19 ................................ ............................................. ................. ........ ....................................... ........... . ......................?.................... t... ............................................... Approved ................................................ 19 ............................................................................... ............................................................................. Assessor's map and lot number ... .................................... Sewage, Permit number ...................... ...................... ............ Er yOFTN TOWN OF BARNSTABLE BARNST1IDLE, AS& 639- • DU-ILDING INSPECTOR I M Af, APPLICATION FOR PERMIT TO ......... i- 1)w wiz LL'Aja ..............................................!............................................................... YS D .I TYPE OF CONSTRUCTION ....................JL)C T) P............................M r- ..................................................................................... ................................................19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... ............................................. ..... .. ........................ .. ................................................. "Proposed Use ................................................................................................................................................ 1 11"-(?.rNto�r t-j'k L-1 r-, .................... .................. r,.O.!�tk ....Fire District .....I....... ................................................................. Zoning District Name of Owner ............................................. .. ... ..,� MCN�Aciclress ......... +2............... ... .. ...... Name of Builder ... ....................Address ....... ............................................ Nameof Architect ..................................................................Address .....................................:**—,.....---....--***---*- 1 cct-cr,27M Number of Rooms ..................................................................Foundation .............................................................................. Exterior ....... .............................................Roofing ...............h5PAAR.A�t.....a"I),-,C,V-4-:- ....................................... Floors .......t-L'P,LL 4-n ......................................Interior ..............-beq Vc-)FAIt.......................... . ....................................................................... Heating .....)--..H...:J.....�... t .. (-' ...I...................................Plumbing .............;).I/--.......................................................... ► Fireplace ..................................................................................Approximate Cost ..... ..... 0.W......................... � /3a Definitive Plan Approved by Planning Board -------------------------------19--------- Area eF 0 4V/y.01........................... Diagram of Lot and Building with Dimensions J.41-9A........................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 4 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. .............................. ................... Murphy, Mr. & Mrs. J. Douglas A=188-132 1990 1 1/2 story No ................. Permit for .................................... single family dwelling f ................................... . ...................................... 1118 Bumps River Road Location ................................................................ • Centerville Owner ..Mr. & Mrs. J. Douglas Murphy L ................................. f frame Type of Construction .......................................... ................................................................................ Plot ............................ Lot ..........'..9.................. January 27 78 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED .. .�, .. �. .............................. J... v....../.11..� � ........./. ........././Y5. ... �.. f Approved ................................................ 19 ............................................................................... ............................................................................... e All ' 1v L01' JO J Lat q L 07 6 �© I PRO06A RA P o Ex ISrru� ;+ .a ' "'^ ��Qunsd�9ft�Mi �y 2� • 55/ ROAD P/. 0r PGA / j. 13EING 4077 -9 fA5 SNU6✓1V -- J N PLAN SOOK a.79 PAGE 9/ T 41Z- 26HY C,6x27'/,orY 74-IA7' TNT 6XISr- A< /NCB f 70UMPA 7-/ON L 0CA T/40nv /-,5<:VZ 'E. P "Ng-, 45 .'�'i1©!'YN aQNU_LZO'CS,_;COA1 OZI-f Wl7"q � �i;z y LC.�VY • �A;; � Ttta�£ 8U/L�/Nf� SET(3•�iC�.L��Ql1l�'�/�4f„�c/T of rA/E r'OWAI .OA �u bs1 M / ,.. Cleo Gvr : o�ry sr .Y.�t1:�.Mcr r�✓ E'r ti1,q. 4 " TOWN OF BARNSTABLE:BUILDING PERMIT APPLICATION i Map $ Parcel !3 Z . Permit# 3 :a Health Division z Date Issued t to hr Conservation Division Fee d76 Tax Collectors ' Treasurer Planning Dept. s Date Definitive Plan Approved by Planning Board' Historic-OKH Preservation/Hyannis Project Street Address 15'"A4 Village Owner /Z d y i Address s,0 d F -Telephone t Permit Request S i/Z / i-7 Square feet: 1 st floor: ' ting proposed 2nd floor:existing proposed Total new Estimated Project Cos o�-�� Zonis District Flood Plain Groundwater Overlay 1 � g Y Construction Type g Tip Lot Size Grandfathered: ❑Yes ❑�No If yes, attach supporting documentation. Dwelling Type: Single Family •❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 0 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 O Other Central Air: 0 Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:0 existing ❑new size Attached garage:0 existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use - i BUILDER INFORMATION Name 7-<-1�e C �� ���"�� Telephone'Number• -7 7 S 7 2e' 3 Address r License# ai�, 2,l Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO �'�- DATE SIGNATURE FOR OFFICIAL USE ONLY PERMIT NO. ;, • e _ e ' • ,:. k .� DATE ISSUED MAP/PARCEL NO.. ADDRESS Y , VILLAGE M •� OWNER ,• _ A DATE OF INSPECTION: s.• , . ' FOUNDATION t ' ' � . +' - =•"` , t' 9 FRAME — INSULATION ` FIREPLACE - ELECTRICAL: ROUGH FINAL — PLUMBING: ROUGH FINAL k GAS: ROUGH FINAL FINAL-BUILDINGf a DATE CLOSED OUT ASSOCIATION PLAN NO.. f t t The Town of Barnstable • snarrerw� • Department of Health Safety and Environmental Services 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. Type of Work: S' T/7 �'`-�z� `'� Estimated Cost 3 Address of Work:Owner's Name:Name: fCe 1/LW Date of Application: e' I hereby certify that: Registration is not required for the following reason(s): Work excluded by law C]Job Under$1,000 Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:fbmis:Affidav ` The Commonwealth of Massachusetts Department of Industrial Accidents Mce allomes9fadeos 600 Washington Street " " J Boston,Mass. 02111 Workers' Co m ensation Insurance davit . name: /G Ile, location: %2-G J61=�-Z /2,-,'- - city ❑ I am a homeowner performing all work myself. ❑ lamas ole apritand have no one worki>i in achy � ///%//%//G%%/% /i'////[////3///I//amZ//an employerding workers' compensation for my employees working on this job. comaanv.name.... ...........................__... ....__4....._.... ................. ................. . .... address._ _. . .. _ _ ........ ..... .... ._.., . .............. .. ...... i::i::::ii::::i::::i ::::i::::::::::^::i:(:j::::::....:::: ......:::: ?:�:::::ii::Fyi'::i'i<:::j:ii:::S;::i'::':{:}::<:L4i::::i:::{:v:..:::::±i::::::i'± i'"':::i:{::::::i:::;:::iv:i::i}n 4i:P}:^}i}T}i}i±i•: ':Yi' ::i:i::::::'::v;: v;?:i:::ii': 'Fi::i':'}i:•. }}'::..:::.:i..:i'' :::t!}:i:.i}:;.i::: :^is::.i.:::.i:.::........::.:::±}:.:^:.....:::.:}:}::::.:::%`.:::'?:.:':...i::.:::•::::}}':i'i.i::i:i::ii}ii':h.y'_ Y vi4..:}}}}}i}}}i}iiiii::::i::iy±}}}}±i:;.};•;}}i}}:•i}i:: ...........:.................. ...................::::::.:::::::::.}::::... .:.:::.. . ... . .. .............. <<> :::: ::::::.::::::::::::::.::::::::::.::::.:.:............... ..:.:::.. ::............ ......:....... .•. .:........................................:....:......................:....:.. .........................:.:..:..::.::::::... .:.... ..:::::::::. .....::..:.::..::::........:..:..:.......:......:..:::::::..:..:.::::.:::.::.::.;.:............ .. ::::..:...::.:....:.:.:::.:.::.::.:::::.:..::::::::...::::.::::::.:::.:::.........:.:.:::::.::: :.:::::.:.::.:.::..............:::::..::.::..:::...::::. .... ......... .........:......................... ...:::....:..::: .:: �":.... ... ...... ............................................... ...... ....... ...... ...::::. : :.:... ...... .. :: ::: .insurance �r _ _ tdif:v# �'�.: ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contras=listed below who have ` the following workers'compensation polices. vn:aN.w company nam :::.. ............................................:.........::::::::::.......:........::::.::.::::::....................................... :::.....:::.:::::::.::.,........::.::::::.... ..::::' ......................................:...:::.::::::...::..:::::...::..::................11",................%...............::...:::::.::::::.:::::::::.::::::::::::::.:::::::::.:::::::.; syddress.. } . . ...::.:.:...:..............:.:....:.::.::..:..:.............:.....::..::..::::::... :. .............:......:::..:.::..::.:....:..:.....:................:...........:.......... :::::.: ,........,..........::..:.......:.......... ty` b flu ............................ .,.......f-::::: ::;.:}:•}:•}:i•±:}:.::•}:•}}}:<;;.:-±:}}}±±;;:.}y:::::::.v:::::::::::::::::::.�::: ..........:.........;..:.....:..:....,::.:::::. .. :.rfi...,............. ..v:.:.......v vri vY.•:::::::::::::........ ... .......2�. 'v:±:•:{4i:•±}::•+:4•::..}\.t;.;•}.:4,.,�.......,,. .. ......................... ..... ,.......4....... .r..T...�... vs r::::x::v. ............v'v:x::::.. �A.. k•::T:nvi �: v:::::::::::::::,v::::;v.v:.:::::::±i:•.:4:.: ::::::::w: �.�.............. {..,.•' ix.v{..�S.Zr �iC�W6.U0w>n•:env:.• :: ..{.. canrosay..nam .... .4..i..:.i..;.:.W..;..:...:i....i....}...::.::.:.w..:..�.:..::.v.::... }.l..ii...i.t..i...:..{..•{...{..v•.i:..i...:..�.�.F..i...!i...?}...+}...i...±.i..i.i...:..}...:..•.i4....`Y...}...:!:'.. : � : ..::: .::::::. . . v . : }±•.}:•}y } :± :±:4±±}:4}}}}: }}}:4w:r±ri4}}}:}:i}}4}}•+{ . .. . : w 4 : . : : } }: ':ii: : :i! . : i �:i:.•i.;}.:.4:.:.•:.4:}i::r4si.}:iv ! s. .. ,: : ....... ... : .. . r::::j:::i:i.:::}::!:.•::±i.i i: . .:}.v:••.:r::.:...:vw:.•..::.:n:::.::::.:n:::::.?;.vr:::v..::..•. ..........:.::..;h:.:c: .•:.::.�}.�}.i:....s.;.>;..�.�,.:{.;h.�;`v^..:.<4.:g:.T;:F..::::< ?...�:...i>...: .� address: {':iii iiY:iSi:j: v:v:. j{•}i±:'Lii±±:y •i}:}:.....ii}:L}}}}}±T±±±}}i}}}}}±:±}::i}iiii}:hi<:i':�:�:'i::±:±=}:}`:•}}:ii};.4.:}:{.}}':{:::::::.:{:::•.}w::::v:;:•:ii:,}:vi}}}}}T}}:•}:•} is:::.i+::..^}i:;!:h:{•}::}{{4i:{•i:4i}:v �:;{4}}}:•}}}:•}}}}}}±}?±}i v.;>}}:•:+:}Y:ii}:{•}?}}:i± ............i}}±:'v}i:i:i{C!:i:viii}ii 4'3i'v'±:::.:::;:•::•.}•::•:: .v: ::::::::::::::::::::•::::: ::•.�::::::::::::.:::.�:...;.:.....;.:..........................:n. .... ......;...,::. ... ;}:{{;<;.}:;{.±±:{.±:.::::::::..::::}:,.::.,.......... .:............................................................................................................................................. .v:::::::......................................:...::.:::w;:•:::v;.. .�:: w..;.............................-........-....:::::•v::•..X........................................... .. .......n.v .. .v A .......................................... ... ... .... ............................................ :tiC{t ji'rii viiii;i>iiiJ :......}': > }..... ................................................................:....................................................... ......................................................................................................:................................................. ::::.�:::::•••:x.....-. ......................:.v:::.v;...:.:...v:::::::;..........................................:;..;...;..::......:•.:•.....:;:;..••w::nw::;;;...............'l.{;}:;}±}:; ;• ...............r......v........... nn nwv 4rx:•}}}}::{..............:: :::::::::::::::::....:::.:.:n::::::.:.::........:::::,............::. +.....T..r......:.........................:...n::. tv...... {:::::{.:y,K+•:v4:•T;{{....r.... ......................................:.;v... ......... :.......................... v:vr:::..:::::: '}•4:{;...',lC:'viX:iY}±�}:• ....:.::::::::.:..:•.................... .::.......................................... .:::::::n.... .:::::. .............:. ... .. ..............vx .......... .............................: :•:x:.v:v::rr.}}w:..ti4:v}ti:4±'.}:w: •:::v.... :::.v:::::::::.::::;{;4:t;•.....::::::•{::±+}:,.., ...M{.v.. ...A:RJ...:...... n,X3Rp ................nv.:..:......nv.................................................:.........vrvv.....:..•::J:.................. {{{•}:•}±};{.±±};:•Tv.+........xv•:.v:.::rw:•:4:{•}:^:{•}}'.;}±•.... :A;:iv}•.i'{vr}:..,,••{.}:{. nun?BnCC•ttl::}::.;:::.:':.:.:;••:::::.:•.:;:::,:;::.:._:.;•. :::.,::,:.;:.;.::.;�::.::.;:::.;:.::.;:::.;:.:.::.;::.::.;'.::::.;±:.}:. :::,. b�� :.�,,.....:..::}::.::•} •:�:. Fxnms to seems coverage as requited under Secdon 25A of MGL 152 can lead to the imposiden of criminal penahles of a Bar up to S1,400.00 and/or one years'imprisomuent as well as civil penalties in the form of a STOP WORK ORDER and a Me of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage veriBenfion. I do hereby certify the pains and penalties of p 'wry that the infornradon provided above is&w and rowed Signature Date Print name Phone# Ccheckff do not write in this area to be completed by city or town official psmitAtcense q QBaEDeputneut ❑Li nediate respanse is required e❑H phone#, _ ' OrawdMSPJA) Information and Instructions - <� .. y 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 coo -- , 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 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 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 contraoting authority. , .Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers 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 Departtaeat at the number listed below. 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 io 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. i The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston'Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat 406, 409 or 375 �`-� ✓fie C�Ja�rnm.(YyuuecrG�lt of ✓l'tcaw.�t�iuuF✓Gul � ' �... .;HOME IMPROVEMENT. CO,NTkACTORS`:REGISTRATION / s oard of Building` Regulations' and Standards One Ashburton Place - Room 1301 ; o o� ' assa .hus t;ts1�Q2108.? -- HQME :IMPROVEMENT CONT 0 -- ....,.• h�:� '-�.i. -P - ." ..:'ram r'• F " ti { d.'• .l? - Ressx;attatFe0891� >> xPrattions 8�2?/00>: T L 66v INUI TV;.QWA V` t. lx. 'S � - ) •. �T � Ct 1' 49w� '6 ' ry I �/ 8,��(`771'I/�4/fUA''/I� .i//I74fIC�(/4 .. ����.��1 �� ++r 3t>}c i i�#�.Z,�t1�"� .` /td.: .Yw., •9 -S � bk�� ��^xl � A.,� __ � r'.�, 1� HOME*IMPROWMENT CONTRACTOR Registration 106918 = �^ E~ :7J,a ., 4pe - INDIVIDUAL THEODORE L 1 HITCHCOCK Expiration 08/27/00. f PO BOX 21- /' 55 LFSA W BARNSTABLE MA 0668 t r THEODORE L. HITCHCOCK r r. . PO BOX 211/ 55 LISA LN q &.BARNSTABLE MA 02668 ADMINISTRATOR Ai �. �o�s rti Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee ALE, eU 9 MASS. Thomas F. Geiler,Director s639• ♦0 4'prEc LA Building Division Tom Perry, Building Commissioner X-PRESS PERN41T 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 MAY b 2004 Fax: 508 790-6230 EXPRESS PERMIT APPUCAVTION - RESEDENThUfflM BARNsTABLE Not Valid without Red%Press Imprint Map/parcel Number Property Address &lnps - [residential Value of Work 1 .00 - / Owner's Name&Addresses �✓/lid /�I/�r'� �� rkfij��- Ld v' T i , Telephone Number Contractor s Name_ , ,�� ,�l �rr'/1 -��� Home Improvement Contractor License#(if applicable) `• Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance - Check one: , ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name,lllr�/ ,�r 12 Coo Workman's Comp.Policy# 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 (91%!_:'P�';; (maximum•44) 6 f\ *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must si Property Owner Letter of Permission. Home Im rov -ent actors License is required. Signature ✓ '� �� Q:Forms:expmtrg r HOME IMPROVEMENT INSTALLATION CONTRACT Branch Name: Lkli - Date: Sold,Furnished&Installed by: The Home Depot At-Home Services Branch Number: 711 Job#: qH 345A Greenwood Street,Worcester,MA 01607 Toll Free(800)657-5182; (508)756-6686; Fax:508-756-2859 Federal ID#75-2698460 ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#565522 - \ ``` MA V M/����AHome improvement Contractor Reg.#126893 Installation Address: 1 2tt 112 6%ps }•{rk& Cel,�Ndl� .' 'I Wb3) City State Zip Purchasers: Work Phone: Home Phone: �e Home Address: 4�t (if different from Installation Address) City State Zip Proieci Information: I/We("Purchaser"),the owners of the property located at the above'installation address,offer to contract with Home Depot U.S.A.,Inc.("Home Depot")to furnish,deliver and arrange for the installation of all materials as described on the attached Spec Sheet# a` b 7 incorporated herein by reference and made a part hereof. Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not included in the contract. DEPOSIT PAYMENT OPTIONS (Subject to fund verification and/or credit approval.) �y') 1. Check,Cashiers Check or US Postal Service Money Order CONTRACT AMOUNT $ 1 .A e1 (made payable to The Home Depot). * 7 LESS DEPOSIT $ b -"7-'='-- 2. Credit Card*and/or other payment options-Circle One Below �- Visa MasterCard Discover American Express - BALANCE DUE Home Improvement Loan ome Depot Credit Credit ON COMPLETION $� �q11 • Available Credit:$ ) Ul-L (HIL&HDCC ONLY) *25%of Contract Amount due upon execution of this Ace L xp.Date: contract.One-third(1/31d)of Contract Amount is required Name as it appears on card:_ff�/)y for MASSACHUSETTS RESIDENTS ONLY. *By my/our signature below,I/We agree to,aliow The Home Depot to charge t e Indicate Payment Method For abo%E1 posii indicated. BALANCE DUE ON COMPLETION % oZ, DatDCCuthorization Codes Final Payment # # Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate and pay any balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder. For Mass.Residents Only: Contractor shall procure all permits required by law acting as the owner's agent. Owners who secure their own permits will be excluded from the guaranty fund provisions of MGL Chapter 142A. Unless otherwise noted within this document,this contract shall not imply that any lien or other security interest has been placed on the residence. Entire Agreement: This agreement and its attachments,including any financing agreement,contain the complete agreement between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties. f NOTICE TO PURCHASER Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time you sign. Keep it to . protect your rights. Do not sign any Completion Certificate or agreement stating that you are satisfied with the entire project before this project is complete. Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. You may cancel this transaction at any time prior to midnight of the third business day after the date of this contract. See Notice of Cancellation for an explanation of this right. There will be a service charge equal to 25%of the contract amount if the job is cancelled by Purchaser AFTER the third business day. BY MY/OUR SIGNATURE BELOW, I/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. FWE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. BY MY/OUR SIGNATURE BELOW,1 USIDE ND THAT THE AGREEMENT IS SUBJECT TO REVIEW OF MY/OUR CREDIT HISTORY AND I/WE AUTHOP 4E HO DE O VERIFY AND REVIEW MY/OUR CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGEN AND L S HEM FROM ALL LIABILITY INCURRED FROM INADVERTENT OMISSIONS OR ERRORS. SUBMITTED BY: - Date: 1 4-2 l:—J 4 H 1 •00 R C V D t Sales Cons Itant107 _ ACCEPTED BY: Date: • o caner - Date > : Homeowner . 'NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT White-Branch File Yelloa-Customer Pink-Sales Consultant - J .1-14-04 C-SC . t = E C .r 063-A-044 07-75 DH CM 6500 Renovations (NFRc Double Hunq - Vinyl Argon/Low E SC DS National Rmsoation Ratlng Coundi 1-800-746-6686 RES 97 ;. ENERGY PERFORMANCE RATINGS U-Factor(U.S./I-P) Solar Heat Gain Coefficient 0 . 33 0 30 ADDITIONAL PERFORMANCE RATINGS Visible Transmittance 0 . 49 Manufacturer stipulates that these ratings conform to applicable NFRC procedures for determining whole stip product performance,NFRC ratings are determined for a fixed set of environmental conditions and a pinformation. performance IMorma specific product size.Consult manufacturer's literature for other product _ www.nfrc.org 'I ENWMM S9W unit qualifies for Bnergp star Region(s): Northern, North Central, south Central, • southern ` fl DP • 2 5 3tD: RZIN oo/CLAss Ds/s—A25 Test size: 48 x,80 Order #:3648746010001 50708. HS �/ce �ommea�uuea`!�i of'../�aaacu,�usaeC� . Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Reg latiation:.. 126893 Expiration. 813I2004 Type: Supplement Card Home Depot At Home:Services. SO N, CONRAD J OHN _. 3200 COBB GALLERIq PtCVVY`OC26 (w. ALTANTA,GA 30339 ,� :=Admini trator of iKE r� Town of Barnstable *Permit# Expires 6 marllrs jrom issue date HARNSCABLE. Regulatory Services Fee 14� ' - - - - �b ,e& 1�� Thomas F. Geiler, Director 3 (�i� PrFd `� Building Division Tom Perry, CBO, Building Commissioner j l o � 1 200 Main Street, Hyannis, MA 0260.1 �J www.town.barnstable.ma.us V Office: 508-862-4638 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint .Map/parcel Number /3, J A , Property Address 6,-)u mns 671 y rai. V f j 4.t-) Residential Value of Work A-UDU°p Minimum fee of$25.00 for work under$60,00.00 Owner's Name& Address l�� (�'(sliP f L (Z 0`--P . . OF Contractor's Name t L(4 P-Is n!k(4 L- L— Telephone Number ? r !' Home Improvement Contractor.License 9(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance -PRESS PERMIT Check one: >�T_Iam a sole proprietor, : JUL. 15 2009 0 I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARN STABLE Insurance Company Name�� C((,a cy 2 ii Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof.(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going-over existing,layers of roor) Re-side t erner�—} ❑ Replacement Windows. U-Value (maximum .44) *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. r _v eat ContrActors License& Construct Supervisors License is required. SIGNATU Q:\WPFILESTORMS\Express\EXPRESSP MIT.D Revise060409 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 s� 'y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): ®J n-L_ Address: Sk-!� E. J O City/State/Zip:. �� p-IL.M o� �c�-- Phone.#: . �FS -—7 C o 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 6. ❑New construction e loyees(full and/or part-tim.e).* have hired the sub-contractors 2 a sole proprietor or partner listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have g, 'F1 Demolition working for me in any capacity. employees and have workers'comp. Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs insurance required.] t c:152, §1(4), and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant,that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees" If the 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 tip 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 he pains and penalties of perjury that the information provided above is true and correct Si afar Date: Phone#: Go- 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#: I j 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 of 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 conipliznce�zth 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 numbers) 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 permittlicense 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. me Office oflnvestigatiors 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 lndustri.al Accidents Office of InvestigatiOns- 600 Washington Street Boston, MA 02111 Tel. #617--727-4900 ext 406 or 1-877-MIASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia try Town of Barnstable Regulatory Services 9 ` 4BLK $, Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town_barnstable.ma.us Office: 508-'862-4038, Fax: 508-790-6230 PropeAv Owner�Must Complete and Sign This Section If Using_A Builder I, petlt�kll , as Owner of the subject property hereby.authorize at G A- to act on my behalf, in all matters relative to work authorized by this building permit application for. J ( 1 Y d5urnO?5 dcvC,,f'L 664 (Address of job) Signatur Owner Cate Pent If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side: Town of Barnstable - � _ ���t•+F r�� Regulatory Services Thomas F. Geiler,Director RARNSTAMy— 'MA S 163¢. Building Division PrfD Tom Perry,Building Commissioner . o 200 Mairi:Street—Hyannis;MA 02601 _. ... __.... vr".town.b arnstable_ma.us Office: 509-862-4038 Fax: 508-790-6230 HOl%1EOWWER LICENSE EXEMPTION Please Print DATA: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as Supervisor. DEFINITION OF HOMEOWNER Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that.he/she understands the Town of Barnstablp.Buildi..g Department minimum.inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatirr of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger,will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any bomeowncr performing work for which a building permit is required shall be cxcmpt from the provisions of this section.(Section 1 D9.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a pmon(s)for hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rulcs&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often resulrs in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicenscd 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/hrr rrspormbrilitics,many communities require,as part of the permit application, that the homeowner certify thkt hdshe understands the rrsponsibilitics of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a fonn/certifi ration.for use in your community. 92. ':Board of Buildin�io'ns.and Standards �--•-� -- - HOME IMPROVEMENT CONTRA CTOR License or registration valid for individul use only Registration: 10553 before the expiration date. If found return to: 0 Board of Buildingg Expiration /17/2010 Regulations and Standards s Tr# 271194 One Ashburton Place Rm 1301 a , r Type DBA Boston,Ma.02108 t MICHAEL A.BINNA L gDDITIONS REMOLD Michael a Binn 25 Geneva Road ` = South Yarmouth,MA 02(i64 Not vali wig It ut sig tore, , _�- .iauuissluuu .� llOZ/ZZ/ti :uoi;endx3 ;;; �! b99Z0 VIN 'Hlf10mvA S - r 08 VA3N39 SZ VNN18 V. �3dH01W a _ . n 80bSV SD.:asuaai,j ' asuaol-1 aoslAladnS uoijoni;suoD Sp.iupur.;S pur. Suoj;rin:'all luiplin8 jo paro73 �itynd.lo Iuaiulir.daQ -sIjacnyirssr.l,� '