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HomeMy WebLinkAbout0064 CAMP OPECHEE ROAD r r.'p' „ a �, .: .. .. a .�:�..___ a_ _ c�, ,k �'r .: 7R �, .: � � - ,. �r �i ,�_. f •.,.4 ,.: � . �' ... ., .,, v ., -. � '. .. � ; ... .. ,} .. r � „ .. __. _ `n- r S:' t. s .. �� .. ., � �. ." r. -� �;..�� _. F G ., � � ' �. � s -.. ,',. ..�tsd Town of BarnstableBuilding �,r .` �z�. Post Th�sGard So.TFiGattt isUisible From.the Street Apraved Plans Must be=Reta�nedon3Job andth�s Card Must:be Kept �A�tNf1TASLE. ,fir M"16 Posted Until Final In pection Has BeenMade `, rWhere a CCert�ficateof Occu anc is Re ulred�su_ch Building shah Not be Occupied untt a f�nai Inspectionphas�been made Permit r,. Permit NO. B-19-1985 Applicant Name: HOMEOWNER IS APPLICANT Approvals Date Issued: 06/14/2019 Current Use: Structure Permit Type: Building-Deck Expiration Date: 12/14/2019 Foundation: Location: 64 CAMP OPECHEE ROAD,CENTERVILLE Map/Lot: 210 151 Zoning District: RC Sheathing: Owner on Record: BEARSE,JUSTIN M 4� Contractor Name HOMEOWNER IS APPLICANT Framing: 1 Y Address: 64 CAMP OPECHEE ROAD o'S ConfractorLicense EXEMPT 2 CENTERVILLE, MA 02632 Project Cost: $ 1,500.00 Chimney: Description: Building a 20'xll' Floating Deck off of the backside of"the Fiouse this- Permit Fee: $ 110.00 deck will be 22"off the ground and not attached to the Insulation: house I will Fee Paid ' $ 110.00 be using Concrete Deck Blocks Roughly Every4'to supportEthe deck r Final: all framing and matieral will adhere to standard building codes Date 6/14/2019 additional blocks may be used inside perimeter of de k�f$ne-"ded Plumbing/Gas Project Review Re ) 'JP J 4 4V Rough Plumbing: Building Official final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six"months after issuance. All work authorized by this permit shall conform to the approved application and thesapproved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structu e§shall be in compliance with the local zon ng3bylaws an'd codes. ; 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 Final Gas: work until the completion of the same. ' " Electrical The Certificate of Occupancy will not be issued until all applicable signature bythe Bu ldi g and Fi a Officials are;provided on thipermit. Minimum of Five Call Inspections Required for All Construction Works Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 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 Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT n - ------ ------ - ------- ---- _ -------- -. . Application Number.. `..... . .. ............... • SARNgPABLE, + . MASS. Permit Fee.................'. ...................Odteqee........................ s6 Total Fee Paid......:.. :!.I ........... ....................... ...... TOWN OF BARNSTABLE Permit Approval by...... . .....................:.on... BUILDING PERMIT ]] Map.......... .!.......................Parcel........� . ....................... APPLICATION Section 1 — Owner's Information and Project Location Project Address CPtMQ n ege.- .e_2 coc,el Villages Owners Name, ,Owners L6gdlAddress_f g i-( Cry n�,p 0&e-C,w v-e— ''City a nk :i�t.�,�._ -State r—Zip Cj -c,3 az. 1; Owners Cell# 50b-'aio - I�t,, c( (E-mail �'vS' " a • ten 4 �z ,n^ Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet El i Commercial Structure under 35,000 cubic feet R Single/Two Family.Dwelling- _# ,J* �= t Section 3 —Type of Permit �� ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Ch'ange of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ F'I e Alarnjq Rebuild [��Deck Apartment © S rinkler ste 0 Addition ❑ Retaining wall ❑ . Solar ,x ❑ Renovation 0 Pool ❑ Insulation F _ Other—Specify, 4 S tice on 4 -Work Description? V 1, 2nf a l..l �Z.Lfy 41 -k) & t K Ai NLc�1 ..� 4J-e 7�L. j L.I��LI A(J��yrY �tl ��cw.�rAc�tC�. ��nit�lnn l g� o/a h'TC� —dA 161 I Application Number........................................I............ I Section 5—Detail Cost of Proposed Construction__ j� Square Footage of Project 2 Z0 a 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 i 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 T act—A.t-4- i I n cnm 2 Application Number........................................... Section 9- Construction Supervisor Name ; Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# 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.Attach a copy of your license. Signature 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 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section-ll=-Rome_Own License Exemption - Home Owners Name:-3 sfi �P�2S Teleph&6 Number 5 8-ZSo ya t-1 Cell or Work Number rI understand my.respo 'bilities 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 require y 780 CMR an a Town of Barnstable. Signature` Date- APPLICANT SIGNATURE Signature. (—Date?(I (Cl fPi�int-Name= 1i5-�;� �iAS� `Ulephone Number�-; �S--zF o E-mail permit to: ��,c-�iA . M.?� Y AV?.c!z 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 approval Section 13 — Owner's Authorization i 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 job) Signature of Owner date Print Name - - � i _ x _ .�. I � � � i x I � e i - I i � � � � The Commonwealth of Massachusefft Department of Industrial Accidents Office of Invadgadons 600 Washington Street Boston,MA 02111 www massgov/dia. Workers' Compensation Insurance Affidavit: Buiaders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: (y C 8,N. C'1 r, � C� 1. City/State/Zip: l v Phone#:. `7)0F) ZW -'c -k R cA Are you an employer?Check the appropriate box: project 4. general contractor and I �a of1ectr p (required): �uir� 1.El I am a employer with 0 I am a g 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 8. ❑Demolition working for mein an capacity. employees and have workers' t Y aP tY• # 9. ❑Building addition [No workers'comp.insurance comp.insurance. ,roquired] 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 right of exemption per MGL myself[No workers comp. 12.❑Roof repairs insurance wed,]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 subcontractors 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.Lie.#: Expiration Date: Job Site Address: City/Statelzip: 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. - 1'do hereby certl under thepa ks penalties ofperjury that the informationprovided above is true and correct Phone#: Oj,jscial 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.EIectrical Inspector 5.Plumbing Inspector " 6.Other Contact Person: Phone M 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 contract 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 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 issuuance. 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 lime. City or Town Ofcials 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 Investiga" 600 Washington Street - Boston,MA 02111 - Tel.#617-727-4400 exit 406 or 1-977-MA.SSAFF. Revised 4-24-07 Fax#617-727-7749 wwwxam.gov/dia 1803)2-3 UNREGISTERED LAND CAPE COD TITLE & ESCROW Deed Book 24163 Pale 72 CAPE COD COOPERATIVE BANK Plan Book Poe Lots ELISABETH A. H HELWIG REGISTERED LAND Reg. Book Sheet Lot(s): 311612018 Certi icaie of Title p 210 Blk: Lot 151 Censzrs Tract MORTGAGE INSPECTION PLAN Scale: 1"=50' 64 CAMP OPECHEE ROAD, CENTER YULE, MA a 60, A.P. 210-148 � O h A A.P. 210-148 1 O ^� V Cv �• t.� R 65' GAR.. }.: ;o A.P. 210-151 © :m 0 22,460 S.F. h 0 0 P 4 # 64 120' CAMP OPECHEE ROAD C'F.RTTFIC'A TfON i File number: 180312-3 UNREGISTERED LAND Attorney: CAPE COD TITLE&ESCROW Deed Book 24163 Pa e 72 Lender: CAPE COD COOPERATIVE BANK Plan Book Pa a offs) Owner: ELISABETH A. H HELWIG REGISTERED LAND Reg.Book Sheet Lot(s): Date: 3/16/2018 Certificate of Title Assessor's Map 210 Blk: Lot 151 Census Tract MORTGAGE INSPECTION PLAN Scale: 1"=50' 64 CAMP OPECHEE ROAD, CENTERVILLE, MA . 60, A.P. 210-148 0 w w A.P. 210-148 0 o C\? C\t g 65' CAR A.P. 210-151 0 22,460 S.F. b I o b P 4 120' CAMP OPECHEE ROAD P,. CERTIFICATION I CERTIFY TO THE ABOVE ATTORNEY,BANK,AND THEIR TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR DWELLING WAS IN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS.GENERAL LAW TITLE VII,CHAPTER 40A,SECTION 7. FLOOD DETERMINATION BY SCALE,THE DWELLING SHOWN HERE DOES NOT FALL WITHIN A SPECIAL.FLOOD HAZARD ZONE AS DELINEATED ON A MAP OF COMMUNITY #25001CO56IJ AS ZONE X DATED 7/16/14 BY THE NATIONAL FLOOD INSURANCE PROGRAM. 31f� fey \jH OF ftggss9 cry Olde Stone Plot Plan Service, LLC `So GARY S. P.O. Box 1166 0 LAB3F Ii No. 40,,Y�i Lakeville, MA 02347- Tel: (800) 993-3302 Fax: (800) 993-3304 qno su,` PLEASE NOTE: This inspection is not the result of an instrument survey.The structures as shown are approximate only. An instrument survey would be required for an accurate determination of building locations,encroachments;property line dimensions,fences.and lot configuration and may reflect different information than shown here. The land as shown is based on client furnished information only or assessor's map& occupation and may be subject to further out-sales,takings,easements and rights of way. No responsibility is extended to the landowner or surveyor,or occupant. This is merely a mortgage inspection and is not be be recorded. Town of BarnstableBuilding". � x, ; t- ';�ti ?.YP;�:, "` � �`r ;� ,'4sx x�, ? a ,.� �%',� ,�r ,,v ..� �.; „�, �ti 3 ;�:. '`, y -This GarduSo Thait is Visible From th Streeq roved P,Ians;MusI Rei; ned,on Job a'nd this Card Must":be Ke t BAaxa3rweLEPS x pp. y P Permit - s Posted Untll Finalnspection HasBeen Made :f �.; i id. � 11 ;s Where a�Cert�ficate of Occupancy s uired,such Building=shall Not be Occupiedxunt>1 a Final Inspection has been made �, w Permit No. B-19-2045 Applicant Name: BEARSE,JUSTIN M Approvals Date Issued: 06/28/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 12/28/2019 Foundation: Location: 64 CAMP OPECHEE ROAD,CENTERVILLE Map/Lot: 210-151 Zoning District: RC Sheathing: s : - Contractor Name., Framing: 1 Owner on Record: BEARSE,JUSTIN M g Address: 64 CAMP OPECHEE ROAD —on ctor Lcense" `' 2 CENTERVILLE, MA 02632 Est Project Cost: $200.00 t �k_ Chimney: Description: ADDING A 6'SLIDING PATIO DOOR IN LIVING ROOM.ALL MATERIAL Permit Fee: $85.00 AND FRAMING TO BE DONE/USED TO MEET B,UILDIG,' .' Insulation: Fee Paid $85.00 REQUIREMENTS {' C Date 6/28/2019 Final: Project Review Req: HEADER TO BE PROPER SIZE TO SUPPORT 117 AD CARRIED ' _ z •� ��r --:` Plumbing/Gas 1 ,, Rough Plumbing: " _ Building Official g Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized bythis permit is commenced within sixmonths after;issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoningby laws and codes. This permit shall be displayed in a location clearly visible from access street ot road and shall be maintained open for pub it inspection for the entire duration of the Final Gas: work until the completion of the same. <: ' n Electrical The Certificate of Occupancy will not be issued until all applicable signatures bq the Building and Fire#Officials are provided on this permit. . Minimum of Five Call Inspections Required for All Construction Work Service: 1.Foundation or Footing 2.Sheathing Inspection A `, r Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is'instaIled 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage 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. 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: S ......... Z40Z Application Number—Je.......... ... ......Y............. . ........ OeA MASS. �?, Permit Fee........................................Merfee,....................... 0 7A TotalFee Paid............................................................... ...... TOWN OF BARNSTABLE Permit Approval by...... ............ .......on.... 2-1 hq .................. . BUILDING PERMIT .......................Parcel..............�.1. ................... APPLICATION bb Section 1 — Owner's Information-and Project Location Project Address.... G4 tAnnq (?.R)C Village 00 A!0 L L Owners Name Owners Legal Address— 0 S?aCA&ze, City . State zip 02-&1&7 Owners Cell# I L4-D%Lk E-mail -S 4 M- Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet 2--single,/Two Family Dwelling Section 3 —.Type of Permit ❑' New Construction Move Relocate ❑ Accessory Structure EJ Change of use El Demo/(entire structure) ❑ Finish Basement El Family/Amnesty ❑ Fire Alarm Rebuild- El Deck- Apartment Sprinkler System ❑ Addition ❑ Retaining wall E] Solar ❑ Renovation ❑ Pool El Insulation Other—Spec Section 4 - Work Description J,Q_ rk-io dtx)r t w to rykg F41, Last undated: 11/15/2018 s Application Number..:::..... t.::..................................... ~ Section 5—Detail Cost of Proposed Construction 200 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 r El Wiring"' ' ' ` Oil Tank Storage EJ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑`Add/relocate bedroom i 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: 11/15MI8 Application Number..................................... . ... Section 9- Construction Supervisor } Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # 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:Attach a copy of your license. 'F Signature Date Section 10-Home Improvement Contractor Name - Telephone Number k 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 CMR and the Town of Barnstable.Attach a copy of your H.I.C... . Signature Date Section 11 =Home Owners License Exemption Home Owners Name: ?�;.r� �� i Telephone Number 666�2,bb L 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 req ' d by 780 CMR and the Town of Barnstable. Signature Date f. APPLICANT SIGNATURE Signature ' Date 67 Z. x �o2�Sti Telephone Number 5 - k Print Name .\ us ; a E-mail permit to: ,s4�-„ o 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 approval 1 Section 13— Owner's Authorization L , as Owner of the subject property hereby I 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 t - j r f Last updated:11/15/2018 fi ji OpeLV ` ez r i 1 s rt . i I ' , , , � E ✓� ��DFpl To N 21:2 p19 GliN o"CS 9NSTge`� i The Commonwealth of Massachusetts Department of IndustrialAccidents . Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians&lumbers Applicant Information Please Print Legibly Name(Business/OrganinWon/Individual): oJS n %eAaS Address: (oLf n pg.&V �v City/State/Zip: CZA�-E2 6 L(A-- Phone#: La (Lt cm Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with- 4. []'I am a general contractor and I 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 S. ❑Demolition I workingfor me in an capacity. employees and have workers' t Y aP ty. # 9. Building addition ur � [No workers'comp.insurance comp.insurance.: El • �] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.21,am a homeowner doing all work officers have exercised their 11.0 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 infnmmation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors 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 ant 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.Lie.#: 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 under th p ' d penalties of pedwy that the information provided above is true and correct 7 Si c ature: Date: 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): 4 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 iri 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 bwldings m 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 nurnber(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 conformation 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 Wa*kgton.Street Boston,MA 02111 _ Tel.#617 727-4900 ext 406 or 1-877 MASSAM Revised 4-24-07 Fax#617-727-7749 www.maw.gov/dia C Dj� /12r/1 y INSULATION 15 ' 14 PI4S40L{94 Stp Mt(Sf IN4ATfOAM fY$N(Ntl(G 4.J,{V, S_f IATif OYLTS4f INLUtaIION CfINNOf AA$ �� Sk'!� . 1-800-696-6611 Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601 Date: `/ Dear Building Inspector f Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All worlc has been inspected by a certified Building Performance Institute (BRI) inspector. All work preformed meets or exceeds Federal & State Requirements. Propertx Owner Property Address Village , c t ee Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( } ( ) ( ) ( } ( ) Slopes Moors ( ) ( ) ( • ) ( ) ( ) Walls OK6 ( ) °( f�l ) o<) ( ) Sincerely He y E Cas y Jr, President C e Cod I elation,Inc, ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma ParcelFPP_I911J � 9 (oP Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Dlc 1? Historic - OKH _ Preservation / Hyannis Project Stre Address Village 9 Owner I�JCU L i Address c` Telephone Permit Request WV wuylt C& lvq f..0 r+`1 u�h :7C7 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total n Zoning District Flood Plain Groundwater Overlay Project Valuation �` Construction Type ���/ r_� 00 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement 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 Auu•horization ❑ Appeal # Recorded ❑ Commercial ❑Yes 2c, If �es site plan review # Y Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) z Named/ oe Telephone Number .L_ � 7�✓�%Z l Address License # Home Improvement Contractor# Worker's Compensation #k a de�vrr�5 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L5 t SIGNATURE 7AO DATE ` FOR OFFICIAL USE ONLY APPLICATION# 1 DATE ISSUED MAP/PARCEL NO. ti ADDRESS VILLAGE OWNER r DATE OF INSPECTION: d,FO.UNDATIO.N; 0-1 4,--J%W Ir,„s UlN JJw; Y>, " FRAME ,8 k v}INSULATION,.., , FIREPLACE i' h ELECTRICAL: ROUGH FINAL w .... ._ PLUMBING: ROUGH FINAL 9 GAS: ROUGH FINAL FINAL BUILDING' p DATE CLOSED OUT ASSOCIATION PLAN NO. E' T .ice Massachusetts —Department of Public Safety \ i` Board of Building.Regulations and Standards Construction Supervisor License: CS-100988 HENRY E CASSH) r .. 8 SHED ROW WEST YARMOUTH Expiration Commissioner 11/11/2015 a I C � _ C.)Lt'1c <�i`�,i>rlstarner Allairs �1nd Business R�.gt.11�lti'c�l) �! 10 Park Plan - Suite 5170 Boston, Massachusetts 02116 1-lome Improvement Contractor Registrati011 Registration: 15M67 : 1'ype; Private C.Orl.xlrcitiun Expiration: 1 2l15/ '1114• irlF M631 :APE-- (.',OD IN SUI.....ATION, INC 1I1I.-ARY CASSIDY -_ Id R' AF=FDON CIRCLE YARMOUTH, MA 02664.. . Up(hitc Mklress and returti card. Mark reason fui dwilgl- A(ldi ( I Renewal I I!;ntl.11uyntonl I I Lulll:;ud li', ariir,nnrr'r�rr��fG c`-c..r!lr.l.unrrirrl-C(� - - un Allitiu & liuslncss licgulatiol, L.iccnse or registnntiun vAitl for iudivitlul use on,l), IMPNOVEMkN t CUty"hRAC fQl: hefu,c the expiration that(:. If found reLtu•n to; I �yi�tr,�Uu,i: 1, ;13b67 Type: Office of Consumer Attalrs and.Business Regidotiou 1'/15/2014 Private Corporaiic•it 10 1'avk Naza-Suitc 5170 " liustuo,MA 02116 N. t.;iK1:Ll lu(li,r�crrclar)' Ot V,, I alto t Il;ll 're The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 - www.massgov/dia Workers' Compensation Insurance Affidavit: Buiilders/Contractors/Electricians/I"l tunbers tkp >at Information (Please ]Print Legibly Name (Busin,.-ssiorganizabon/ladividual): Address: City/State/Zip: , 4, Phone #: Z / 4/— Are you an employ rY Check the appropriate box: ❑ Type of project(required):l.�.l am a employer with. 4. I am a general contractor and I—��_ employees (full an4d'e part-time).'' have hired the sub-contractors 6. [I New construction ' listed on the attached sheet. 7. ❑ Remodeling 2.❑ 1.am a sole proprietor or partner- ° ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' (No workers' comp. insurance comp. insurance.t 9; ❑ Building addition required:) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions .❑ I am a homeowner doingall work officers have exercised their ;1 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 . � , „ / ; 3a.❑ I am a homeowner acting as a employees. [No workers' 13.�Other � i /�/ 46 general contractor(refer to#4) comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'com}xnsuttioitpolicy information. t Efomcowncrs who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit anew affidavit indicating such. 'CUntrutom that check this box must attached an additional sheet showing the nameof the sub-coatractorx and state whether or not Wore entities have. . entployccs. if the rub-coatractGn have employees,they must provide their workm'comp.policy number. J am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: T'/.f/ G Policy#or Self-ins. Lic. #:'`yG Expiration Date: n , Job Site Address: W 44t City/StatelZi : i 'p Attack a copy of the workers' compensation policy declaration page(showing the policy nuimber,and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 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 statern.ent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify nder the ga nd penalties of perjury that the information provided above is true and correcx i Z Date, Phone#, 'Official use only. Do not write in this area, to be completed by city or town ofciaX " ,City or Town: Permit/LIcense# Issuing Authority(circle one): L Board of health 2. Building Department 3. City/Town Clerk 4.EIectrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: •�~ f� }t�e ��r--� CAPECOD 27 _ MYOUNG DATE IMMfODIYYYY) �,... _ CERTIFICATE OF LIABILITY INSURANCE . _ _ 7_lsl2_DIY fHIS C013 ERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO _A E � -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 holderis an ADDITIONAL INSURED,the policy(ies)must en endorsed, If SUBROG fhu ATION IS WAIVED,subject to terms and conditions of the policy,certain policies may require an endorsement. A statement an this certificate does not confer rights to the certiticate holder in lieu of such endorsement s PrlunuLFR LlceII e# PC-514062 coNrAUI -- Rugors&Gray Insurance Agency,Inc. NAME: Margaret Young PHONE 434 Rte 134 Al No Extl' FAIL No South Dennis,N EMAIL IA 02660 - — -- --- --. f-L._.. L.,.._-.. - ADDRESS:myOun cr rogersgray.coIn INSURERSS AFFORDING INSURER A:PEERLESS INSURANCE COMPANY INSURER B:COMMERCE INSURANCE CORAPANY— CaPe Cod Insulation, Inc. INSURER C:Evanston Insurance Company . I 18 Reardon Circle — 1 INsuRERo:ATLANTIC CHARTER R INSURANCE GROUP_ South Yarmouth, MA 02664 wsuRERE: _ �- -- I INSURERF: - COVERAG, ES CERTIFICATE_ _NUMBER:_ _ REVISION NUMBER II'tuS IS 10 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOV[FOR THE POLICY PERIOD INDICAIFD. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTI0 WHICH THIS OLHIIFICAIE MAY BE ISrUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, FACLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSft . . AUT9 ST3BR— -- I fR TYPE OF INSURANCE PMIDD EFF POLICY YY �-=--- - -- ---- ..-- POLICY NUMBER MMIDDIYYYY MMIODlYYYY LIMITS i GENkitALLIAtNUTY EACH OCCURhCNCET-- __-1,000,000 �A X COMMERCALGENERALLIABILITY wCBP8263063 4/1/2013 4/1h2d14 `DAMAGETORCNTEO — ` --'— PREMISES tEa ocaurenco)_, b 100,000 CLAIMS-MADE L_x, OCCUR G VIED EXP(Anyona porson) $ — 5,000 __..____ PERSONAL x ADV INJURY $ 1,000,000 GENERAL.AGGREGATE - $ - 2,000,000 GFN l A('3hRECA1 E UMIT APPLIES PER: PRO- PRODUCTS-COMP/OP Ali(a $� 2,000,000 I -I _ _._ J I OLICY�- .LLOG AUIOMUbILE LIABILITY C�A'181NEC1—SI N�(aLE LIMIT Ea acddanl) _. 1,000,000 B AN.OALIWNED _ 13MMBCKVMK 411/2013 _4/1/2014 BODILYINJURY(Perprarson) $ - - ALL.OWNED SCHEDULED - - ------- AUTOS X AUTOS" BODILY INJURY(Per acddent) X hnRED AU'f05 X NON-OWNEO AUTOS PRbPRT4 DAG $ ' PER ACCIDENT ^_ $ X UMBKELLA I.IAB G C xt E]$LiAF1 X 04C UF2 EACH OCCURRENCE __$._ 1,000,000 CLAIMS-MADE XONJ453512 4/112013 4/1/2014 AGGREGATE $ 1,000,000 Utlr X REIEN'fION$ 1U�D00 $ U: �� _ WORKERSCOMPENSATION - - —T' T V41r STATU• rOTI-I- I AND EMPLOYERS'LIABILITY D ANYPKOPRIkTORIPARINER/EXECUTIVEY y. WCA005259.04, 6/30/2013 6130/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICtiWMEMBER EXCLUDED? (�, NIA —_. _ _ ) (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 tr Yos,dnxdbn under - . ....-__. 1 I OESCRIPI'ION OF OI'_ERAI'IOIVS Uelaw_ E.L.DISEASE-.POLICY LIMIT $ 1,000,000 UcSCRIP PION OF OPERA11ONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,.if more space Is required) - _^ - Workers Compensation includes Officers or Proprietors. j Adddonal Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder. 1! , 4 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 13EFORE Cape Cod I Insulation, Inc THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. -- -- --- --......... AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 10/23/2013 10:40AN FAX 5083250390 WINGWORKS LANDSCAPE (0711/0002 Too )O '✓W OWNER AUTHORIZATION FORM 5E I, I 4h (Owner's Name) ! owner of the property located at I (Prope Address) (Property Add ) ! hereby authorize l) �iLV , (Subco ctor) i an authorized subcontractor RISE RISE Engineering,to act on my behalf to obtainia building permit and to perform work on MY property. Owner's Signature Date r , i i y, Assessoc's Office:(lst floor) Map U Lot ' '.: Permit# «� / Conservation Office(4th floor) = Date Issued Board of Health(3rd floor)(8:30-9:30/1:00-2:00) ' Fee Engineering Dept. (3rd floor) House# Planning Dept.(1st floor/School Admin. Bldg.) d `' f : BARNSTABLE, . Defi ' Pla pproved by Planning Board 1 19 �, 1659. • rED M/y� TOWN OF BARNSTABLE Building Permit Application roject treet Ad ess Villa ,.Owner Address .:Telephone � . `Permit Request - cc a- ct n f Yl NY L -Total 1 Story Area(include 1 story_:garages&decks) square feet / st bi u C Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ T 3a•pb Zoning District Flood Plain Water Protection Lot Size Grandfathered? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type , Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure q Basement Type: Finished /1f Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds Other ,dew,,� Builder Information Name ` Telephone Number � -R 1� Address lP 5� License# ff 2 / Home Improvement Contractor# l2 o"7 Q Worker's Compensation# _f zzg j 18Y GJ NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWINGREASON(S) - - FOR OFFICIAL USE ONLY r, PERMIT NO. #6916 DATE ISSUED June 22, 1995 MAP/PARCEL NO. 210. 151 r r4 ADDRESS- 64 Camp Opechee Road '� VILLAGE Centerville, "MA 02632 OWNER William & E. Hautaneri a k DATE OF INSPECTION: FOUNDATION r FRAME INSULATION t FIREPLACE t - ' ELECTRICAL: ROUGH FINAL ! h { PLUMBING: ROUGH FINAL GAS: ROUGH FINAL17 }: 1 FINAL BUILDING DATE CLOSED OUT e r • ASSOCIATION PLAN NO. ; 4 11%02'9a 17:02 '$817 7 27 7122 DEPT IND ACCID fa 00. . -y Coitu"iuUeaftlt o f 11Ja,1Jac1iuJetb ' aUaParfrrtenl o�.�nduafria,��ccic�enEe . 600 !/ .4,-y&-Shn l James J.Campbell &ton, Vaaaad ssrFta 02f f f Commissioner Workers' Compensation Insurance Affidavit Z A/— ( /pee) with a principal place of businessat: �—``— (�tyisesrvzio) do hereby certify under the pains and penalties of perjury, that: () I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Company Policy Number () I am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number () I am a homeowner performing all the work myself. I c .de:scand t`at Z copy of&his stzternent will be fomarded to the Office of invesd7ptions of the DIA for coverage verification and that failure to secure coverage s rec_,i;ed under Section 25A of MGL 152 can lead to the imposition of criminal penalties eonsistine of a fine of up to s 1,500.00 and/or cn-= years' imprisonment as well as civil penalties in the for:of a STOP WORK ORDER and a fine of S 100.00 a day against me. Signed this 2()- day of 19 J Licen e ermltt���/G��g�-� Building Department 75 /Y Licensing Board Selectmen Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375 _ TnT,j-,T nT RARNSTART.F RTTTT TITM(_ PFRMTT # . .. °: The Town of Barnstable � si►tuvsrnsrE. - �eE Department of Health Safety and Environmental Services 116 Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 mph Can Fax: 508-775-3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement, removal, demolition, or construction of an addition to any pre-eldsting owner occupied building containing at least one but not more than four dwelling units or to strictures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. Type of Work: Est. Cost Address of Work: y Owner.Name: Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S 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: Da a Contract r name Registration No. OR Date Owner's name I � �lze �oom�wouupallf o��,/�a�livael�a ; _ HOME IMPROVEMENT CONTRACTORS REGISTRATION I 4 oard of Building Regulations and Standards I One Ashburton Place — Room 1301 I' Boston, Massachusetts 021.08 I I . HOME IMPROVEMENT CONTRACTOR -Registration 100740 Expiration 06/23/96 r Type — PRIVATE CORPORATION I S I HOME IMPROVEMENT CONTRACTOR. -, I az"istratiam 400140 Capizzi Home •Improvement, Inc. I Type -..PRIVATE CORPORATION.- . Thomas Capizzi , Sr . I 'ENPirstion 06/23/96 1645 Newton Rd. Cotuit MA 02635 I Cspi>o<i Nose Isproveseet, Inc I Thous CAP1111, Sr. I -9 ffLM Newton -Rd. I IADMMTPJAM •Cotuit NA 02635 i� �i s �o�n�wo�uosalGE c�.��aeaacr�iraeQs ' ' Restricted Is: 10 1EPARINENI IF PUBLIC SAFETI CONSTRUCTION SUPERVISOR LICENSE I 10 — lose lug Issber• . . Expires: lirlldrle: IA - luosry Aolr CS 146111 10/21/1119 W2111118 16 - 1 12 F11111 Noses Restricted Is: 10 0AVI1 N 1181 COMMISSOHM 110 PLUM NOTION RD i t E FALNOUTB, NA 12536 ti