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HomeMy WebLinkAbout0031 CAPTAIN LUMBERT LANE a ZZ3• r -4 Town of Barnstable MAi l� Regulatory Services i Richard V.Scali,Interim Director B" MASS. ' Building Division _ � 634' Tom Perry,Building Commissioner c Ep MA'S 200 Main Street, Hyannis,MA 02601 - M www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# ,�-lIv-,��Z S S FEE: $ 3 S- , SHED REGISTRATION ��,yt ex RESIDENTIAL ONLY 200 square feet or less he- Location of she (address) Village Property owner's name Telephone number /y7-61/ /1�/7 5� Size of Shed Map/Parcel# zo Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:304:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:110413 . ,. Town of Barnstable BL111Cllilg Post This Card d That it is'V�sible From the Street Approved Plans Must be`Reta�ned on lob andthis Laid Must be Kept ". i Posted Until,Fina1 Inspection Has Been Made -fF . A`,� " _ n f . '' '� s»'*:,,.;, .:•.:�.r.... �'�""�"'`t�„��'_' ^�` •s+�ma, ;ram F `,¢,ee. ,_� r« '�zx„� a �.,�„dra+.�'r'�m�ra, w << '+ `a��.Y � Permit . Where aCertificateof Occu anc istRe wired;such.Buildin `shallNot be Occu ied untilaFinal Ins `ectin has been me P Y, 9 g° P Permit No. B-16-2955 Applicant Name: ANDERSON,GLEN A& KAREN M TRS Approvals Date Issued: 10/12/2016 Current Use: Structure Permit Type. Building-Shed-Residential-200.sf and under Expiration Date: 04/12/2017 Foundation% - Location: 31 CAPTAIN LUMBERT LANE,CENTERVILLE Map/Lot: 147-011-005 Zoning District: RC Sheathing: Owner on Record: ANDERSON,GLEN A&KAREN M TRS jContractor Name: - Framing: 1 Address: 31 CAPTAIN LUMBERT LANE ,„Contractor License 2 z CENTERVILLE, MA 02632 „ ¥ Est Project Cost: $0.00 Chimne y: . Descri tion: 10 x12 shed jPe�mit Fee: P $35.00 Insulation: Project Review Req: 10 x12 shed Fee Paid $35.00 �W; � 'Date � 10/12/2016 Final: Plumbing/Gas ' r Rough Plumbing: Building Official ,. Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced.within siz months 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 zoning by laws`and codes. a .. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. f �. Electrical The Certificate of Occupancy will not be issued until all applicable signares liy the Building and Fire Officials are provided on thi5:permit•tu Service: Minimum of Five Call Inspections Required for All Construction Work: � b 1.Foundation or Footing * 2.Sheathing Inspection � Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed - Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 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). Fire Department Building plans are to be available on site Final: ,, All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ti sa° z v 7,7-3 CIO a� NJ z 3 ry T,© o a !/ �� •0F 29874 QI8TrOl 15, 000 5• F w . 100 wIr_)rN 2a' Fac>-jT C�. Z�I "� �h�1 I� 13 G(e7. qo s CERTIFIED PLOT PLAN f7l.-07 PR Cl -N � NEW CONSTRUCTION ONLY � • � IN TOP OF FOUNDATION IS_S FEET. - ABOVE LOW POINT OF ADJACZNT 17 ROAD. SCALE: / = 9�7 DATE: '-44> I CERTIFY THAT THE �", Al!D 1 717`A Q/ EE 0 CrL1RT . .. SHOWN ON THIS PLAN 18 LOCATED t3R0UND AS INDICATED AND K oFsHE r Town of Barnstable *Permit Expires 6 mont&s from issue date Regulatory Services Fee * 4t * RARN UBLESS. , 9� 1639. `��' Thomas F.Geiler,Director Q!/12-01y? ATFD Mp`t A / Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number lq_� I Pro erty Address CA /' J!/ Lv4e-� Liz 09y,r( w _ Minimum fee of$25.00 for work under$6000.00 Residential Value of Work� Owner's Name&Address e fi4etr, ,ij #11/V LIJetj t N CeA14_V r1l1f A. (��0- Contractor's Name ` /}/J1 -� (f('/ __ Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) . YNY0 ❑Workman's Compensation Insurance PERMIT Check ne: - PRESS❑ a sole proprietor ❑ am the Homeowner NOV 16 2009 I have Worker's Compensation Insurance A TOUVN OF BARhISTA�I�� Insurance Company Name {�� ��/lCON �/V S Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. 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) VReplacement e #of doors Windows/doors/sliders.U-Value 0, (maximum.44)#of windows - *Where required: Issuanceof this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is r required. SIGNATURE: QAWPFILES\FORMS\building permit forms\EXPRESS.doc . Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600=Washington-Street _ Boston,ALL 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly N2rne(Business/Organization/Individual): MOON •Tk,�O(i: L', a Address: f% 'S % �✓i ��� ��' i City/St to/Zip: �U00N) d c Itp 4 N,9? Phone #: Are u an employer?Check the appropriate box: Type of pr ject(required): 1. I am a employer with C) 4. ❑ lam a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6• V�Rewodeling construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y p n'• y 9. ❑Building addition [No workers'comp. insurance comp. insurance.$ .,❑ We area corporation and its 10.❑Electrical repairs or additions required.] 5 3.❑ I am a homeowner doing all work T officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL I2.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have -employees.->f�he sub-contractors have employye ,tlsey-rrmsrprovido-theeh-w-orkemi ortip­.policynnmber- - -' - - - - -- - - - - I am an employer that is providing workers'compensation insurance for my employees:-Below is the policy and job site information. �`�' Insurance Company Name: . , � (`j (} INS Expiration Date: / f✓ Policy#or Self-ins.Lic.#: � � �F p � � „ Job Site Address: o/V U tN City/State/Zip: C > vn a 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 a 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 herebycertify under the ains and enalties of perjury that the information provided above is true and orr'ect. .f P ., P Si.nature: Date: Phone 4: ( / / �00 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#. From:Shaunna Robinson,Hunter Insurance At:Hunter Insurance,Inc. FaAd. To:Denise Glode Date:923/09 09:45 AM Page:2 of ACQRD CERTIFICATE OF LIABILITY INSURANCE OP ID s DATE(MM1DD/YYYY) MOONA-1 09/23/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC# INSURED Moon Associates Inc. INSURER A: Rational czange Irisuzance Co 14788 DBA Gutter Helmet DBA Renewal by Andersen of RI , INSURER8: Beacon Mutual Insuzaace co, DBA Gutter Helmet Roofing INSURERC: DBA Moon Works 1137 Park East Drive INSURERD: Woonsocket RI 02895 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MMF";; ) DATE(MMIDDM') LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A X COMMERCIAL GENERAL LIABILITY 14PS26619 09/16/09 09/16/10 PREMISE(Eaoocccuence) $500000 CLAIMS MADE X❑OCCUR MED EXP(Any one person) $ 10 0 0 0 PERSONAL&ADV INJURY $ 10 0 0 0 0 0 GENERAL AGGREGATE $2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $2000000 POLICY jEa LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1000000 A X ANY AUTO BIS26619 09/16/09 09/16/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $E OTHER THAN AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1000000 A X OCCUR cLAIMs MADE CUS 2 6 619 09116109 09116110 AGGREGATE $ $ RDEDUCTIBLE $ X RETENTION $10 0 0 0 $ WORKERS COMPENSATION AND X TORY LIMITS ER - B EMPLOYERS'LIABILITY 28586 10/01/09 10/01/10 EL EACHACCIDENT. $500000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $560000 It yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $50 00 0 0 OTHER DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL.PROVISIONS CERTIFICATE HOLDER CANCELLATION BUILDIN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Building Cont. Reg. Board NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Dept., of Administration IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR One Capitol Hill REPRESENTATIVES. Providence RI 02908 AU Typ D REPRESENTATIVE ACORD 25(2001/08) 0 ACORD CORPORATION 1988 I 1. I { 1zl�+�y�y y�Y �}, `,Y t .�y.}i'� Oft e#y'j�ng�y��{�f%�,j�� . D L'i h"J .4 � .KNfFl76i11/t`i Y1.ffah- 4F 31A � Y.�Q Vfi f' a tr } at- a Y p i�� lx 7 2t��1 fir# �285438 ibm on ,.. : JANGES out . . •1 r �i �r r U1rtI�YSeCr�xa�-y -. y ,c^�j jjrA 11}t �}kkg{ gt1+r.. }g d• �Y�o, i'6 ,'"i$t �r Lo «-.•- {'' :s x}'a."?'v `� 133o a+ be' fT;i:,tdj ., '. .. _ RF Am pwmm 'T n 4XtS PAf tote' At wit r� non ���ate::" off � ." . f ;•3i33xiakn�}.tti�i ': ��v.:, ��',� �' ,: ` 1 S , # 4 N • �4Ai CC C ' Renewal Sales Agmement c auorsru _y j/�-�@_y..�?/.?�Z !�/S�4/�_�y x."V► er .. _... Aciac at by Ank.m o RFa&C"nj 4t E.dS iiwwC.j,._:...r.`_�..Ls�. .......�d.�,...•._'�.7(.i11R'0AS71Cf f�. `. ,. byAndersemEm ,,iiy 5c�r.Ca�P �3��.������ 42(Jhaeskr?ViersrSer ... ,1 N+�r fsse�bs.c ars�r k:rxv�.aen�ar �,.a.:iPo.,St.,as..'•r10 - —L j r licrw ON• :s*,to VW9 MA Utg1S "` CRUIS lot Its _. }......... ......f k Cot;. _ f+14 �+ s .. ........... —_ .... .. tg,"v SMA--r., ........; ._..._. v rU ar rim.�/\sn�ar,afaaa�i4Ai�r-rMao..al aPtwrws RamiiMa Nw .'9ha � ,-. .. -' .. _..L Iawra;�µ -,� "t�M�+al�mrmq+yht'h;,s 9Si Mwza +e...;manxsuramW4'domma'Pawls+aawl+DY��puypa.a � p. zvJ �� f 'Tcro.tlo'W4Fa^uPa9a+?ef xm!am ..d+wrcAaimddwsampPuaf �agBtxc'iEo .... ... dGd ....., ! p�„' .,apgmwaw�Ga+r+liEfA� gRmx+ma ymfiMvaoao.A.PmwNistl.a�m.n '�PsAu�re�PMmnW.' !K_ �' YQ�tlA'y3 LkNC �d11PW6PS9Egene P�p�'y�p7R i . r 1@"'�O�t -..T...,,.......,...._.......... j► -... �. maltla uysiStOr i �...�_ _�9��.�✓?� i_.:i " PYIrR �1Mf" ^�t�e•WiYdMKlaOcr#taC`i�+w�lolHWefTatean ' wftm :...ZCY.�... .............._.... 1d�BOGt�ISSD I..,� .... ..., 4aP+Toar Gni�a.aa�w'_aap�A'�IbR�tms a4tRM+tx CC. ' 'CL2t 1 Mf1111FIJ'aeY�I�UaUI♦}MI in"`AW4mm�tAS�rimw o��4k�0ar almwntl�geMwt �a�wwuMatMt�Mn ':apgr'*oss e..r.aWMkSaregnapgl4t� r� y ¢ i=a1 "'a�R�Abw .�..-.- w.k�e.#eNaiv kabaxwmbbo `y =emmar. aOmt.,nr. <dsa..e. `ce:e.arr..Pa...rrs.uw .q "amawwl+pmeaewca*am.•ammouaw Feral�awrro.a.r ewaui4.%slrkcyawraaaf'pn�xt,ror - SJ au:eClSa. L � N(tWJ; ,1 Wmw!pw,rN.,oa'.rl,o•.Mt.Nws.w��.,..�.�..r..w..,a'�.��vr.w.....+waw.M1SR�.,...e asv r+�.awPww . E l i ��ypf THE Tp�ye� S TOWN OF BARNSTABLE i DMAH3W=9T6HL i 'gyp 6 q. MASSACHUSETTS O r� 00< Solid Fuel Stove Permit .l./ �I DATE OF APPLICATION � a .IFS........................... &PT.. ISSUING PERMIT ............................................................ NAME (owner) ........ ... .....yl��.:../- 1. ........................................... NAME (Installer) ..........HkSAC&................................................. I �, 1 r - / �7 uJ'C iG n ADDRESS ....t �......�~ t. 1..............................................................G�.. ADDRESS ............... ..'............ ..................................................................... STOVE TYPE /26A).........aa.J19 -f.0 5: . CHIMNEY: NEW ........................ EXISTING Manufacturer ..Isc ......��u. 5. ................................................................ CHIMNEY: asonry . .......................................................................................... Mass. Approval U.L......1. 1 f CHIMNEY: Metal This is to certify that the above installer has permission to install a solid fuel burning applia ce at the listed address in accordance with an application on file with the ...................................................................................................-11ite Department, and subject to the provisions of the Commonwealth of Massachusetts State Building Code and regulations made under the authority thereof. Issued By: .................... . Title �. �7 7 �l1q.� Date �.. ....... .r........."'I".".. ............................. �..... Permit to install expires 60 days after issue date Stove ..................../Ve.'..1.....Q. :S.jL.r............................................................................................................................................................................................................................... Stove Clearance t t-`�' ~-`J. Floor ......................k. �..........................................:.................................................................................................................................................................................................... Smoke Pipe ............ .'vS L .... .A LL ........................................................................................................................................................................................................................... SmokePipe Clearance .................................................... d...t............................................................................................................................................................................................... Chimney ...............................IV K. ELY.................................................................................................................................................................................................................................. SmokeDetector yiff�5.................................................................................................................................................................................................................................................................................................................................................................................................................... The undersigned hereby certifies that the installation of solid fuel burning stove and equipment made under au- thority of permit dated ...,14,/...� ✓.... JL...... has been made in accordance with provisions of the Commonwealth of Massachusetts State Building Code now currently in effect and pertaining thereto ......................................................................... ' Installer INSTALLATION APPROVED .............l. (P..g ..`��............... By: . ................................................... Title: •S�•• date WHITE: FIRE DEPARTMENT — CANARY: BUILDING INSPECTOR — PINK: APPLICANT TOWN,OF BARNSTABLE BUILDING PERMIT APPLICATION Map, Parcel Permit# &7R 7 7 ,I Health Division Y Date Issued Conservation Division r` Fee �4o�S od i Tax Collector a a AL Treasurer• AM�� Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH ' Preservation/Hy nnis t _ q , Project Street Address, Village Cc A04V c E'Owner �-�1.�.✓! ��lC''�''a�"� - Address � >� Telephone ` x ` Permit Request 1a� e 1, p% 'e"07'v- ,;7 tejPla 44e- 15 _ S Square feet: 1 st floor: isting proposed 2nd floor: existing proposed Total new Estimated Project C 0W Zoning District Flood Plain Groundwater Overlay 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 /tom r�Historic House: ❑Yes ;o , On Old King's Highway: ❑Yes U04T-- Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 1 4 Basement�Unfinished Area(sq.ft) s Number of Baths: Full: existing ew Half: existing new Xtr Number of Bedrooms: existing n Total Room Count(not including baths):existing ne FFi to Room ount H pe and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other C ntral Ai . ❑Yes ❑No Fireplaces: Existing, New, Existing wood/coal stove: .❑Yes O No Detached gar ge:❑existin ❑n size Poo: ne size Barn:❑existing ❑new size Att ched gara e: exi ing new size - Sh existi g ne size Ot or., Zo in and of peals uth tion ❑ Appea # Recor ed❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use e- BUILDER INFORMATION ' Name `(�� Telephone Number Address t- License#-- `7""! 4 15 1Y : Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO .��•� �ca yy j�.57 ®+� SIGNATURE DATE l� r 'FOR OFFICIAL USE ONLY PERMIT.NO. - DATE ISSUED .. - `, f _ ; ' ' 3; ,P•s# ...,...i _ i t `J - -f.. ! ;• ��J ' # MAP/PARCEUNO. :' + I • 1 ;- ADDRESS; ,- VILLAGE ' r 4' ,•� + OWNER,, 4 , --� r jj - •// EE #.2 f .sue i _ t.• / y r �+•'• � f . r #, T. �) DATE OF INSPEC-FIO ! t , F '• ` - r ,, ` i w;l FOUNDATION r �� s?a%` `+ ' ." v r FRAME INSULATION , FIREPLACE Tz ELECTRICAL: ROUGH FINAL '! • r` PLUMBING: ROUGH FINALI GAS: ROUGH - FINAL FINAL BUILDING `. �, ` .�'" ' ' , ,• '-. $ f ` .. _ • -� , -- � i � _i r t DATE CLOSED OUT •� ; ': s ASSOCIATION PLAN NO. sl 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 registere7contra ,with certain exceptions,along with ther requirements.Type,of Work: Estimated'Cost Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law 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 here y apply.or a permit as the ent of the owner. 15 l>QoZ D e Con r N a Registration No. OR Date Owner's Name q:forms:Affidav Department of Industrial Accidents � •_ �•::-� Offices nllnyestfgarlons y'`• NO 600 Washington Street Boston,Mass OZlll ` Workers' Compensation Insurance Affidavit NO name: V 6 J6% a-q location: 2Ll city a Z 6 hone I am a homeowner performing all work myself. I am a sole arovrietor and have no one worldrig in any capacity ❑ I am an employer providing workers' compensation for my employees working on this job. comnnnv name: address: city: phone#� insurance co. 201icv# M/m///%///////////////////%////////////.�!/,��/////.%//.11G/"/////a'%lG!///////////,C%/%:l%G%//%//%(/.11l/.l%/!!%/// ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloning Nvorkers' compensation polices: comaanv name: address- phone insurnnce ca. 201fim ';•, .... .: :• :c::,:,::. .... ..;.:..max;•>aww::,.:,;:.>..:.... camnanv name- address- ciri- phone#� ............:........ .:.. .. .. insurance co. Faflure to secure coverage as required under Section 25A of MCL 152 can lead to the imposition of criminal pennitin of a One up to S1300.00 and/or one vean'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the ORlce of Investigations of the DIA for coverage veeidcatiom 1 do hereby certify under the pains oral p allies of perjury that the information provided above iss&w. Co C�q Sigtanire Date l v� Print name ` i ' Phone official use only do not write in this area to be completed by city or town of cid city or town: petmitNcense 0 Building Department ❑Lkensing Board ❑ check if in�ediate response is requited ❑Selectmen's Office ❑Health Department contact person: phone t!; Other_ �mvea 993 P1A1 I Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' comperisatim for thy',, ernplovees. As quoted from the "law", an employee is defined as every person in the service of another under any cam of hire, express or implied, oral or written. An employer is defined as an individual partnership, association, corporation or other legal entity, or any two or more the foregoing engaged in a joint enterprise, and including the Iegal representatives of,a deceased employer, or the roc:S•e: trustee of an individual, partnership, association or other legal entity, employing employees. However the owner or 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 an such dwelling house or on the grounds c. building appurtenant thereto shall not because of such employment be deemed to be an employer. J , MGL chapter 152 section 25 also states that every state or Iocal licensing agency shall withhold the issuance or renew: 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 um l acceptable evidence of compliance with the irmirance requirements ofthis chapter have been presented to the contracting authority. Applicants PIease 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 ,:d:ate 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 caul the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed Iegibly. 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 applic= Please be sure to fill in the permittlicease number which will.be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangement 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. The Department's address,telephone dad fax number. ,. _ ' _ . The Commonwealth Of Massachusetts ;- Department of Industrial Accidents ` amce of Invesduadoin 600 Washington street Boston'Ma. 02111 • fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 ,-2 ._ DEPARTMENT OF PUBLIC SAFETY CONSTRUGHON=SUPERVISOR LICENSE Nua6er Expires: — - -- -- Rest��te44Tu, 16. m, 6RE60RY �'"TiAR1I'AN 98 MOCKIM&BIRD LN MARSTONS MILLS, MA 62648 HOME IMPROVEMENT�COMTRACTOR J,"`Registrati0n 110023 240 fZa XPlTation =-W 0 MOW L �GREGOR C`VARJIAN BUILDER. , 6REGORY (.NARJIAN 3 r OCKINGBIRD ALN C„. -�gpMINISTAnTOR �.-nARSTONS MILLS MA 02648 4".1 1 24436 ,�� f • TOWN OF BARNSTABLE . Permit No. ------ 1 Building Inspector Cash �s»nor rar OCCUPANCY PERMIT, Bond X "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 aj. certificate of occupancy has been issued by the Building Inspector."}( G - % 041 Issued to BaySide BU.ildirlA G4; InC. Address Wiring Inspector, Inspection date Plumbing Inspector x � e ' Inspection date Gas Inspector ) ^17 ..�,..� Inspection date 7'g ff, A 2 `Engineering Departmentit�i:2' Inspection date,/-,/4_,1,j ' 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. r , Building Inspector s A/ r 3- ;. 41 Wjz, ``- J � �,�.'�` �. Q.. �r v Y• ^gym H.OF 2874 w h� SUR�� 15, 000 100 wIb-r� i ��f 1 j• j �,L) 10, F2.�-jT �. Zv. �s �3 E 2 Ao 1rJ' �L CERTIFIED PLOT PLAN GAT EW CONSTRUCTION LYIt _ 'TOP OF FOUNDATION IS_ FEET. IN ABOVE LOW POINT OF ADJACZNT`' ROAD. SCALE, / "_-17 v DATE, /car` ;//, ,BA r v°� ® LM J OE ENR 1 I CERTIFY THAT THE Al �L4 �T E.®ISTEREO RE®1$TER�D SHOWN AN THIS PLAN IS LOCATED CIVIL LAN® aa-3. ON THE GROUND AS INDICATED AND ct CONFORMS TO THE ZONING LAWS ENGINEER I3URVE �iR aX� DF BARNS LE , 1�1SS. JR • 7i2 MAIM S'.TREET `+ ..,. ;oa, s�2 - _ H YA N RI.S, M:AS St.., . f 0HE9T.4:�'�'':,.L. ®ATE CEO. LAND SURVEYOR IAssessor's ma and lot°:number 0 9/ate/�Z 2 G p �STMEr� p - Y Sewage Permit number .....:..�?••2."..5$�.�.....................:. � INST�LLE� �C�ANCE , Q / ^^qq �' ' WITH�� ��TITLE Z BAR33TABLE House number ............ .1.......................... .4�F91r. .....'.........Y � � o! +r�P NJ!) 9°°,,�039 Ot�l6i ENT'AL CODE .� TOWN , OF `.BARNSTABL ° BUILDING t'-NSP-,,.ECT0R APPLICATION FOR PERMIT TO C ....::.. ......�r.4........).or b........ TYPE OF CONSTRUCTION ...:4 . .. ......................................................... ............................... .. .... . .t....../,/....... 19..:1�Z TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .. ..�i ................ .1 .. ..........................: ...... � .. .� .......� ���� ProposedUse ...�J �lrl�........ ,�. .y. ..................................................... .................................... Zoning District .......1 . .... . .l�.:C�P...........................Fire District ......L. .......................................................... Name of Owner ..... .. �... . �:......�Q..Address .... ......1 r�........ j.�....... Name of Builder' ...........5 .:................. ..... .....Address /1'1.... .......... ............................................. i Name of Architect ...�. U� .....�? GGddress .....� t!. .. !� / .......:.tip.... . Number of Rooms ........... .. .......... ..... ..............................Foundation ... ................................... Exterior ..W,.. ............... ........ .................................Roofing ....:...... .. .... ........ ... ......... . ...... . .... Floors ............. ....r'.� �.. ..............:..........................Interior ................ ...��................ f� ` U........ Heating ' ' .....,.... —?.................... Plumbing s�...���. ........ . . e! .e. .... . Fireplace .. ................� .. .....'..�k?--.�.f r . ... Approximate Cost .. .C. .. .......... Definitive Plan Approved by Planning Board ----J=---�----------19 2 . Area ..l.N.. ..................... Diagram of Lot and Building with Dimensions Fee .... 5a./.... ..... SUBJECT TO APPROVAL OF BOARD OF -HEALTH �1 )- 2 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of tVT.own ns a reg ng the above construction. Name .e ................. ........................ - -,i, BAYSIDE BUILDING CO, INC. 24436 a ... Permit for ......................One Stor.y............. f �.iii$.rle Fdmi.ly Dwelling ..... ................................................................ Location Lot #.2.4, 31 C� tumbertIn. ... .. .. .. ..Centerville ............ .................................................................... Owner ...Baysid,e Building Co. .................................................:............ Type of Co6struction .....Frame.......................... .. ....... ................................................................................ Plot ............................ Lot. ................................ Permit Granted ..0c;to-bak...6.,1....... ...19 82 Date of Inspect! ........ ........... 0�! 9^9 . . Date Croeted ..... ....... eeI r z / Assessor's map and lot number .�!x ..;l' /. , c� r�r QQ . .., THE y _ y — f..C<!......A .y �. Sewage F�'mit number ........... ..�.....�-'�..y �:...... d� �+► BAUSTAU House number ...............3..1..................... . :..............:. s� M6 9 �OYPya` TOWN - OF BARNSTAB;LE BUILDING INSPECTOR APPLICATION FOR PERMIT TO I l?� ( �`C ......... 1 . .f !�1�!v?� �........!���r: . r . . .... .. .�'.. ............. ` ......... TYPE OF CONSTRUCTION .... ....... �r,!w'2 .......................................................................................... .......� ......19... Z TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .l .... ..0 .................../7 .....? `.............................(,., ProposedUse .... 4/z........ 4..........., ?z. ............................................................................................... Zoning District ........,,41-r.....`..., ..........................Fire District ...... ! .......................................................... Name of Owner ... rj� .1;4... .Ys 1:......1..4.... :.Address ....:5 ....!? .....f..5.........(.. ".4� ........ Nameof Builder. ............;iQl l� ............................................Address ..., wit!tQ............................................................... Name of Architect .......... ...... -.-?f��rl�.�.G+Address .....6,11�6......1...:w...........,.::............................ �2Number of Rooms ................ .............................Foundation ..... ............................... Exterior ..f�[/ ..........��i / .............................Roofing ... .. .�t !r?'� Floors 1....' ... 1....":.r... l�f ..............................Interior ..... ...........;1,r G�-eh,- Heating !�d....r.;?.: .. ..... ... .....Plumbing ..... jr✓. ...........,.r..................... . �- 1 Fireplace ..1....''.:. ... ...Ga"!'. .:f!:. `1..iJ.!... .Approximate Cost ... t ...... Definitive Plan Approved by Planning'Board -- /_"! ---------19�2.. Area ..................... Diagram of Lot and Building with Dimensions Fee �•�. 1............................ SUBJECT TO APPROVAL OF BOARD OCHEALTH !" _ = I 26 f } s { s OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations'of the Town of Barns,able regarding the above construction. _ / Name ....... .. ................................... !...................... k, /Ay 7 / BAYSIDE BUIL ING . INC, A=147-11 No ..?4 4 36 Permit for ..One Story . Single1 . Family Dwelling.._•..•. , Location ,Lot #24.r. ._ 31._Capt.,,.; uA grt.* Ln. Centerville ...:........................................................................... Owner Bayside Building ............. ..... Type of Construction ..Frame ............................................................................... Plot ............................ Lot ................................ Permit Granted .... ..........19 82 Date of Inspection ....................................19 Date Completed ......................................19 / o ��o _Centerville Linda .6:.. Mutascior . ., i 00 _ . . . � T.A . tletonsing to am stable lstr icy. ... "" •, Registry •• e-Y,gicate No. ...9P � ... in Book ..D 5........ Page ...a 1981 No. 67785 ••December• 15..•,,,,,,,,,,,,;, rt Plan 37432E with Certificate .... Date of Plan ;d Plan . Land.•Cou. .. 65, ......::.............................. District in 547 No, ... Filed Plan No. 'Barnstable Registry .................. Boo$c..... .. ....... TIVE E INSPECTION PLAN NORTH CAMBRIDGE aO OPERARichardADKWaIsh, Esquire 1fQAG Rudolph and Lucy GI �o. 2/D. G✓/DF L`ASE�Y1 ENT O ABoYE RoLNI G 8 Pow Lor 59 'vE STORY O I t Al., Ily� ti 0 kA SEE REMARKS ecember 7, .:1985 Ps 46144 ClY I CERTIFY THAT THIS PLAN WAS PREPARED IN ACCORDANCE WITH THE COMMONWEALTH OF MASSACHUSETTS PROCEDURAL AND TECHNICAL STANDARDS FOR THE PRACTICE - EASE"w1FN7" O . GRouAip Pool, 1 E s 0'ry, 0 u` oe EE REMARK ecember 7, , 1985 46144 � r le 1"= 4-0. I CERTIFY THAT THIS PLAN WAS PREPARED IN ACCORDANCE WITH THE COMMONWEALTH 1y OF MASSACHUSETTS PROCEDURAL AND TECHNICAL STANDARDS fOR THE PRACTICE OF LAND SURVEYING 250 CMR 6:05`AND WITH 1 H...• , a HE SPECIFICATION{ - i.. LLi' _ -_- ON SHEET ATTACHED HERETO - iM„M OF 999999 K/ ENNETH y�,r a B. - ANDERSOti 0 k No. 31298�o �fC15TER�S L LA�O kr ' .v • � s �• l �AUST BE . Assessors offioe,(1st floor): _ SYSTEM o r - Assesstror's map.and lot number l l. �lr::.Q dIC COMPL►AN F THE T� STALLED IN Board,of Health (3rd floor): ' �— ' [I ► TITLE T WITH 5 Sewage Permit number .....................................................•.:. , AL ® 2 BIHdST/1DLE, Engineering' Department (3rd floor): L' I�®_ "� �QT".P �-''; �o�, rb3 •� ,, W � N a House number . .. �2! .... �P� �dFlA �� -4 APPLICATIONS PROCESSED .8:30-9:30 A.M. and. 1:00-2:00�P.M. only}i TOWN. �OF BARNSTABLE BUItDIH-G IHS�PECTOR r ��' � APPLICATION.;FOR PERMIT TO ..! 0.6.(...l1 TYPE OF; CONSTRUCTION. ..........:... . ,.. •,. ........................... ......... Q& .-23r...19 TO THE INSPECTOR OF BUILDINGS: ' The undersigned hereby applies for a permit according to the following infor tion: ALLocation ................!'tJ ... ...:...... 1 ef - °llL� ... ..... .................. ProposedUse .................W!.!.� X.J.0.0m...........................:...............,.......................... .:............`.................. :.:.....Fire District ........... Zoning District .............:LC .d�' ' 1. ................................................... Name of Owner .... .�1.[ ....:......A.A .,!l b.:..E'r;,....Address '.. .�.. •............... . -•-'jam' /'�,�� , fj�/� Name of Builder .. 1...! Q....I.UJ.L�s .�.. .............Address .....L.C4!�... .X.. ��•J�...........!!.1. ....... Name of Architect ... ...........Address .... .r....k.L3.X....� ���......... l.l.!Wt,.!P�' .. Number of Rooms ...........�.....:................................................Foundation ....��(�� ....t,.C�!/C&. e................................. . Exterior .....1>� ��(�tJ! '. ..... 1(1 �QSA. -A00.............Roofing ...:.... Floors . ....................I...............................................:.................Interior. ........... ............................................ ... reatin .............. m .. .� . . i, f 60fU Fireplace &..... U ....... Approximate Cost 10 600 p ............................ ..... Definitive Plan Approved by Planning Board -------- -- - �9 -----.- ..... :Diagram of Lot and Building with Dimensions'•— Fee pit 0.............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH • r - • .' a �• •.{. � ! - - e OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules•ancl .Regulations of the Town of Barnstable regarding the above • construction, Name ..... . .. .S. ... Construction Supervisor's License .09 3$5 MUTASCIO, LINDA D. JR. - No�� 30131 :permit for Cosmetic Alterations ' e . Sin le Famil Dwellin ` ................. #59 31 Ca tarn umbert Lane 1 ��Location :...Lot....... .r.... L ............P.. ...... _ Centerville - - - e _. I...... ............... .................. Owner Linda D. Niutascio Jr ......... . r° Type of Construction ..... rame K ...}........... Plot .............................. �LotL ........7................... r November 3 - . -�''` 86 .r Permit, Granted ;...... ... r......... .l 9 ,y A Date of-,Inspection.... �.. 19 n+ Date Completed .. .. 19 N• . I��..� -�} .- w. - .x a .r r • .� 33 t - r r' t• r �` � '� Rix as 3£+,t � ± C y "` •• 1 �.r"• ,.r' _ � �-. f � .. ; - ' � a� ... _ - "''ti: r•� ram. �agv y+�y�w¢ day=4T k serf 4 �y� � - !' •- l- - _. � - ,•- .. x - J `• f Assessor's offioe.(1st floor): Assesgr's map and lot number ...................•.................. ...... Q�e off Board of Health (3rd floor): Sewage Permit number � ^ . ..1,z? Z BaHa9fADLE . Engineering Department (3rd floor): °o kt L e� House number ................................ ....' ............. a` 0 VpY APPLICATIONS PROCESSED 8:30•9:30 A.M, and- 1000-2:00 P.M. only TOWN OF 1BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......� a1 �YUC_i l .................... n......................................................... ......... .. TYPE OF CONSTRUCTION ............. n..../......... (�� .7t...:��. .................................................... ............. .r. ,-..19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following informatiori: Gc �. C.�� ��. rib er+ La pa 6 'e r t/ � Location ...................................... ................................ .. .........................................�... .......1....:......... foffl. fProposed Use ( rom....................................................................../'....................................:. y.............. ................. Zoning District `. ........................Fire District 0/CJ .........�...fp ..............` .................... Name of Owner ...� f-t..,...........IJ..1.ofaa(D.....if......Address .A....��II�R.�t�. f.1.a t 1-9-J4 Q._ Name of Builder AM.............Address .....PO Px�.�.... /QS�..Q�• A [J + _rz.R.,, ............................... P................. Name of Architect ...!•! - .. ...!�s... �.Q II.!...........Address ....P.D.-....h.i_? ....�c�,J7.......... p/���......... I Number of Rooms ...........{.....................:...:.............................Foundation .... �� ......� 1 � A ��........! `......... . ....................... Exterior ......1_. ...� ...hrm.� ...... .......ifgd.0,5.......................Roofing .........cry I.&.. ......................'.................................. i Floors ..................................................................Interior ....................... t Heating. .:.... f,,,Q/,k.... ..� ............................. ...Plumbing �!' '�`.. .... . AveFireplace Approximate Cost ........ ..........`................................................. Definitive Plan Approved by Planning Board ------------------------_-------19________ . Area Diagram of Lot and Building with Dimensions -- ,q� p Fee .!......0 SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �. ! >...�}r1 . .... ................... Name .. v Construction Supervisor's License .................................... T MUTASCIO, LINDA D. JR. A=147-011-0®5 > 005 30131 Permit for ..AJ terations Single Familx..DW�1.a i ng................... Location ... .......U.-Ca-Atain...Lumbar.t# Lane Centerville Owner ..Linda D.. Mutascip.3...Jr. ............... Type of Construction ..FraMe............................ ............................................................................... Plot ............................ Lot ................................ Permit Granted ...j°TUveTub.e.r-3. .............19 86 4 Date of Inspection ....................................19 Date Completed ......................................19 es `� o I L 9, oFtKME r Town of Barnstable *Permit# 1' F-Vires 6 months fiom�iss+erdtTte I Regulatory Services Fee snluvsrn M vMAMThomas F. Geiler,Director _ Building Division 1 QWN OF BARNSTABLF Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 141 011 `aC . Property Address 31 CAPTA�� ✓�f3�T L Residential Value of Work tUja" Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 14o_&,A' ,a z� A#1.,9 Contractor's Name 0Ae(_wibe t71Tf�.P��S�� I LLB-- Telephone Number s0&'�� � �Z:74 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Sc/2� 3 Kworkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance y�,, Insurance Company Name U A Workman's Comp.Policy# 006"'-t 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof), XRe-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is r red. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 Fy, 7be Corrtrrrrrrm-ealth of f 3-14wr cim.seas Di.Tarnnent n,f g udristrial Aeciifents• > t' OfflCe o,f 17?VeS1igrra'rorrs 00 ffwshingmt Strt::et 'd Bastvra,. 14 02111 �';:;`�,xIF->-�^`V• 41'FF'1{:.�rlt'ISS+g171:%tr�t•t`# Workers'Compensat on insurance. ffitlasit::Bind..P>«{`C°n>�ti:etas ec>€a e.i ustPl rn er s Applicant Infarmation Please hintL+���� Name NPgW,106 5��LP(21)64&- Addirew I<3 yt`ecq- I,41. ST C'it��state;'Zip: fV ASwe I�� OZ A j l o:s �'c7Fs • y' •�� Are.you an eraploger?Check the iapprop-na:te:box- Tr pr.of project(retluilecl): 1.,1 ain a mplow wish 4. ❑.1 am a general contractor and I have hired-die sub-contracecr, 7 ❑ltiesr construction en�r€cyees(ftz€€3nd`or lxait.-Z9ra�).' •� 2.El gm g sole prop4�ietat or g~srEuer- lived on f12e attached skeet. _. ❑Reui�deling. ship and lucre no employees Thei a.stab-contractor`,lw.,e S. ❑ Demolition wol inn fbn-mee ill any capacity- errtployees=d have workers + 9. ❑$ui dtng'-additi n [No w olkels'comp itnutatisre courp.M IM-ance..+ r u red.� `. ❑ We..are:a corporation and its 1.0-❑Electrical regains of addit nits e,cl - officers av-e exercised se their 11. piumbrtse.ve- aims or additions, 3.❑ 1 un�1?emeav�irefd.in�Lill work h la . my—wif.:,'1 o workers'c. tight of exetriptiori per MGL 12.❑l aauf repairs j imurance rer{uired.j c. 152,§1:(4),and w-e have no ernplo ee . [-c warlcers° 1z� tlieS S I®)A cov%i.inawance.r•equsfed,]i 'clay sppIkamr "I amasi ahc MI.-wr,the sect oabetow&bo-wica sbeirwwkers'c*mper5aaetz,palicy infonmii on, :w orseo:tneu w1w Saba st sbis-affl&w N iDzU-:atk g they a.e Mar ail ived,sa-d;:ieo bire uu-ni le ccmrfacturi mu<t sdbmit a uEtT 3dLik'it rndicatiag sud. =� r trar nzs chat%ize s d zs box nit xtt�rLe3 RL addvsaa:s useet siLzwwiug the metre of-Le zdc--cDwzmaon and sts a is L••effigr as not those ew.is s havr- ez p�oyee. IF.the sub-,ccuuwoz:k.,ze ei tmyees <bet nml gm;7detae wo:liers':emp.polio,nimber., l a nt Bit I.tTsuranc efor l3ty ejfiph7 ees, Below is the padiet:'an-.d jah sill In wance Company-.Name: Polic_r;«or.Self-ins.Ur. :: 00:-437 xpxttosD; 14 12- 1 LdQ L�w� iis Site ,zde_,: Z - ca11 1� 61 A Attachpoky. 02632 a c-apy of the workers'compensadon poliq declaration (shotving the ps ky.ni brier amyl exp ration date):. Failure f z seewe coverage as required under Section''5 A•-of MGL c, 152 can lead to the itsymitim of cri mi l penayties of a. fine 41 to$1.500M and..'ar one-year imprisonment;.a.well as civil penal'm in the:fbim of a.STOP WORK ORDER.and a fine of rag to.$?-50.00 a day agaimt:the-tiolator., Be advised fh at a copy of t1:iF=;at€raient may be forwarded tc the Office of Inve_sisgations o€the DI for ifr_,urance cc-cerage.verilica,tinii- 7ifs!tea i�t c rEtf$rttrtder tft$drrrr'sts real y rtotFi$s a`jrerjtsr,rdtoi tdr��.tfcfarrrcerttgli;vaxaMfederl b .dF is true and correct. i ttiue: C Q. I S ryciral use only. ➢o root Fwriie in tlds annar to be reerupf$tetd by city ar try+rat o rial City or Town: 1'ermitUcemse# Issuing Andiwity(circle oste): h 1.134ard of)'lealth. 2,Puildhig Department 3.Cityf' own Clerk 4.Electrical.InTector 5.Plumbing Inspector CA serhs\�to��\ ryIntemetFiles\Content.Dutlook\DDV87AAZ\EXPRESS.doc Re isl;ZO£l IW-rsan: — phime#;-- — 6 Client!:61439 CAP9PNT onT> t+�ieDrrv'rn A G?RDTM CERTIF1 ATE OF LIABILITY-INSURANCE o411SJ2041 TWCEf2TIFICATE IS ISSUED AS A ii6kiltk OF If1F0RfM170N Of•IL,Y AND CONFERS NO RIGHTS UPON THE CERTIFiCAffi'HOLOER: :15 �CERT'IFiCATE DOES.NOT AFFIRMATIVELY OR NEGATIVELY AMEND,:ExTENO OR ALTER THE COVERAGE 4FF012DEq.BY.T'NA POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTnVM A CONTRACT BETWEEN THE ISSUING INSURER(S),At1T ORIZED REPRESENTATIVE OR PRODUCER,AND THE.CERTIFICAATE BOLDER. --mom"mwaaw MPORTAPIT:Ii : Ice itiCate: Idar.is:an ADDITIO.t+IA NSURED;: POUcy(ks).must boandarseq If St7,BR0 'TTC1N I8 W .NED subjOcctn ti%i. rma and totldltlbni of:the:'pclf ;vOiUlti: 6iWea iAro an."dorsernerit A:ataun-wnt.an this c6M-tate:do"not confer tights:to-the �' P. �X rd:4. cerklncate holder to t1ou;of:ku_>h endorsemd_ls!(s'.. . ....... Pseavueex' Rogers.&Gray.Ins. .P:tymouth $Q8-740431 I.. . lc Not 341 Court Street P O:Eton 3700 ' Fly. >n6:.. .,..M..A 023613700 _... tt+suBrxtsiaA FFQO;P _O ovEkAoE b& treoA:Ar ' Capew.ide.Ente.rpfises..a,LC ttsvRfxa. ' J.P.Maeoni,�T&3:ons _..._ . RO Box 763 vieuRgn s,•. .Centervi ft MA 02632 ' o ,Wpm..... E1It3lRN.N.U.MAER,.. 'fWS.IS b.CERTIFY THAT THE.POLICIES-OF INSURANCE LISTCO P=W HAVE BEEN=.UED TO THE INSURED NAMED ASQVC FOR*7r1E PCL!CY PERIOD INDICATED.NOT'�A"STANDING ANY REQ.VIRCMENT;TERM OR CONDITM Of ANY CONTRACT OR OVER DOCUMENT WITH RESp.EC7 TO WFOCH THIS CERTIRCATE MAY BE ISSUED OR MAY.PCR A)N.TmC W3URANCEAFFORbM BY THE POLICIES DESCRIBEU.+tERGEIN IS SV&MCT'I'O:ALL:THE TERMS, EXCLUSIONS AND.CONWIONS OP SWH POLICES.LIM173 0OWN MAY HAVE BEEN REDUCED OY PA1O Ckiv(. ... 'rxreoel�tataltt?•exce .. ::. gtuar - - - .A. CpP8500:05t)813 'I OdCl1 .1 # _ iaRL:e . 1fi , Qt CL4MSIMMDE OCCUR - PI 1tsOtlAk 4' pt+ltlf °QitO 0 , f tom' -- — rot , < - ,� _A?+AVM T'ALL OWNED AV03 -. aoOtY;}:�vRtrPei�ocaaxl:;3'' CMCOLR;GQAi7TtM . .. )0gr0:AUT05 ` fl I'M-O YNED AW0.1 T z At X.: �±6Qt84A 3#lQ t1 df1t11: tt1ft` . W. 'A aa,Y YIN ODi;48'1 4ttf11 _... O AMCPtiOPkIETOJVDARTNERlE3c�r F�:i:EACf1 � '��• � • OGF R/MEMD6R OCCLUDED7 l l 1trA': (Ma�Rwf!In HM 1t1.f. itS$s.•� .: �tps�0 • AA �4��!!#d�T►Q!iI4ILACAT1ANs:nf>:FfIGtJE;S.Ha�A:i►4GRotokAaaad�elRaan�ixe.;,sl�lavl•.:Irm>ea.+r4doh:wavk�4}: pop -orsmartnerslEko4fAi4e:i fff e,o/Mernbom:Exdu&d: #2i�ti;3rr Capon S"Aftached 0escrijstions) tr z 0AUANY ci Tzf , ov : scars :t : aresra t W�wra� T11f i E7Wf12ATIONCX7} F,3tiY ,Rft"-$EOEttVERE>�IN A ANCE WITH n= PROvxStOriB: 09988-WOVACORD All rlghti..I*proed. ACOR0.26 f 2009109) 1 of 2 The AGORD name and logo Is:ro mgietetod marks of-ACORD #866874/MM71 LAT' i L is .��,,. .t 71il �I.iriii.i` .!• rcFr.sN CS 89273 �esuu:itr, tu: 00 RICHARD M CAPEN 122 WHITMAR RD COTUIT, MA 02635 11/271201 1 nnim..,.nr,r 9638 a Office of(oncumcr \fl;+ir•x& Rusioe.< Rr_-utafino HOME IMPROVEMENT CONTRACTOR Registration: 143358 Ty pe: Expiration: 7/8/2012 Ltd Liability Corpo CAPEWIDE ENTERPRISES L.L.C. RICHARD CAPEN 4507 R RTE 28 _sue COTUIT, MA 02635 ( ndcrsccrctar� Restricted to: t30 — -- 00- Unrestricted 1G- 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause.for revocation of this license. Refer to: WWW.Mass.Gov/DPS License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation r 10 Park Plaza-Suite 5170 Boston,MA 02116 td wtth t signature OFIKE A gn BARNSPABLE. ABLE. ibgq. Town of Barnstable �Q' QED MA't a 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 ,as Owner of the subject property hereby authorize ' ^' �R'l �L�-� to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) ignature of Owner ate area M . Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary IntemetFiles\Content.Outlook\DDV87AAZ\EXPRESS.doe Revised 072110