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Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director TOWN OF BARP11 TA LE
Building Division
639
►�� Tom Perry,Building Commissioner : A1 ` (
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 DIVA S1
Fax: 508-790-6230
PERMIT# c� CJ L l Oc'C Ss FEE: $
SHED REGISTRATION
200 square feet or less
Location of thed(address) Village
1L Me Lao -
Property owners name Telephone number
Size of Shed Map/Parcel#
ignature 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
-zrConservation Commission(iignature is required)---L,
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shedreg
..� .
REV:05201 i
=� MORTGAGE INSPECTION PLAN
(THIS PLAN WAS NOT CREATED FROM AN INSTRUMENT SURVEY AND IS FOR MORTGAGE PURPOSES ONLY,
MACDOUGALL SURVEY WILL NOT ASSUME LIABILITY FOR ANY OTHER USE).
SS.7. C�
36� �V O),,
LOT 29 F Q
A.M. 172
PAR. 149 00
6
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LOT. 30 Al
A.M. 172
PAR. 150
J,�NQh `�\lS�A,q r ,, Q� O
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,F PI_ ��siOyq\ 00�
A.M. 149 77
PAR. 089
A.M. 172
PAR. 079 NOTE: IT APPEARS THAT THE ASPHALT DRIVES
CROSS OVER A PORTION OF LOT 89 "PARK"
1 CERTIFY THAT THIS MORTGAGE INSPECTION PLAN WAS PREPARED IN ACCORDANCE WITH 250 CMR SECTION 6.05 OF THE MASSACHUSETTS RULES & REGULATIONS FOR THE
PRACTICE OF LAND SURVEYING. THE BUILDING SHOWN IS NOT AFFECTED BY A SPECIAL FLOOD HAZARD AREA AND DOES _CONFORM TO THE LOCAL ZONING
BY-LAWS IN EFFECT AT THE TIME OF CONSTRUCTION WITH RESPECT TO SETBACK REQUIREMENTS OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UN ER MASSACHUSETTS
GENERAL LAWS CHAPTER 40A SECTION 7. REFERENCED DEED SUBJECT TO AND WITH THE BENEFIT OF ALL RIGHTS, RIGH WAY, EASEML _ Ott V ONS AND
RESTRICTIONS OF RECORD, IF ANY THERE BE AND INSOFAR AS THE SAME ARE OF LEGAL FORCE AND EFFECT. f/I/� ' �p '
PRUFt
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TOWN: BARNSTABLE (CENTERVILLE)
` a DATE: 11/17/08
APPLICANTS: ELBA & RICHARD T. MERGET
CERTIFY TO: CAPE COD FIVE CENTS SAVINGS BANK SCALE: 1"=30'
�
%� i SSA TITLE REF: 3827/137. ti°Ff�� �� MacDougall Surveying
PLAN REF: 257/094
ED1�t�AFDN . FLOOD ZONE: "C" & Associates
o A. COMMUNITY PANEL: P.O. Box 2428
STONE 250001-0015—C Mashpee, Ma. 02649
N0. 289i3 z DATED: AUG. 19, 1985
�o,1 �° CURRENT ZONING: "RC" ph. (508)419-1086
�� fax. (508)419-1087
�0 �L email: macdougallsurvey
JOB# 10419 ftomcast.net
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Town.of Barnstable *Permit, co14090gS_
OExpires 6 months m�ssue-date
• r
Regulatory Services Fee
w BARNSrABL& «
MA-S& Richard V.Scali,Director
039. �0
Building Division .
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
1 1,510 Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address �¢cn �P� yl
D-fCesidential Value of Work$ �fsu� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �G�- r,••vt L
Contractor's Name L�6�5C.< �G1trL�c P rr Telephone Num r) / ::J//
Home Improvement Contractor License#(if applicable) Jov SD Email:
Construction Supervisor's License#(if applicable) S 27�
orkman's Compensation Insurance
Check one:
❑ I am a sole proprietor PREVU
❑ 1_4virthe Homeowner NOV 7
g-fhave Worker's Compensation Insurance T®W� 1 201�,
Insurance Company Name s U`r o�8,,A4S►r
Workman's Comp.Policy# U W C stm
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
VRe-side
e-roof(hurrican nailed)(not stripping. Going over existing layers of roof)
vin�
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
"Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Im vement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
F
QAWPFILESTORMS\building permit forrns\EXP S
Revised 061313'
Diff CaywnanywaMi ofMassachaEse fs
Deporhnmt afludrutrid-4Ecidents
- (i ce Offivestigaiions
600 Wask- in on&reef
Bostan.,MA 02UI
wfww.xnass�gaaWdia
' orkea-s' CompensatianEasorauce davit:$uifdersi€ ontra:ctors/ElectriciansMumbers
AppEcant T format on Please Print Legibfy
Dame(BusinEs3/OYgaui-allon(hiI dwl)_ ��✓n T/1J "'PAS
CiWS tatdZip= 1 Phone 4:
Are you,an employer?Check the appropriate box; � . of project r
/ 4-_ ❑I am a:general contractor and I (egnared):
a emp loye.r tivi _ ❑New on.e: loyees(falland(orpart-#ime * l�a�el t�esubcouhactois. 6_
2_❑ I:min a sole proprietor or partner- listed on the attached sheet: 7_ deliag
slnp oral aave no employees TIC sub-contractors have S- ❑Demolition
working for me in any capaciijr_ emplo},,and have wwkcers' Buildingaddition
?7Vo Rro± ers' co rn�rance comp-msurante_ _ ❑
5-❑ W,e are a corporation and its It}_❑Electrical repairs or additions
3_❑ r I ofE=hati�exercised thek 1I_. Plumbin aim or additions.
I am a)inmemvn�doing all wow ❑ la� ,
10TY-self [No zvorb!rs'comp_ rig;bt-ofex�u fioa per MGL 12_❑Roof
e_152, s I and we aas`e eta repairs
�ttc�xatlCF.'required]� 3 lTh
employees_[Na wDzIcess' l _.❑O.thr�r
comp_ms-urance segiured-]
'Alay spplic3st thxt checks boa fl meet also fill out the section bOow sl+ wbmgg ineir taodrers�rompenss.`io�poii�eafoa
t Same ,-s trbn sob=A tip a,d%VA MKVC t++rg they are tieing an trade ssxi thLa hire oalsitle co�ixactnrs must sabrnit a�a�dsrit mt�ce�g sncFL
:buu cmrs th_gt rh xk this box sz r �md strip abet e[drnat thee$ mites fisve
empIffyers_ TIt'M1p sub-contr$ctom h-�e empIoy�s,t$ey must pimide t =t rnxk-O comp.policy awube r
I ari ar€empP7yer that is pmidi►rg workers'c-ompgturhun imuraace f`or my ewTLayem Het.Dty is the paLicy artd}ob sits
in fotmatii'o t
lnnimce Compau Name: --tr�ipyl
Policy cr Self ins-I<�� L,4,tr (y 6 "D (�j ExpirafiouDate: f l ,
Job Site Addre-,s: C /� 5 Cif-vistatel.7ip:
Attach 2t copy of the work 'compensation policy dedarstion page(showing-the policy number and expiration date).
Failure to secmc coverage as reguiredunder Sectioa 25A o€MGL tw M can lead to the imposition ofcriminal penalties of a
fine up to$15 t)t OG andlor one-year impris�as well as civil peualfies in the foam of a SWOP WORK ORDER and a fine
of up.to$250-00 a.day against the violator_ Be advised that a copy of this statement maybe forwarded to the Office of
lm,estigutions of the DIA for insurance coverage verification_
Idri{tc�r eiil,C rtFP4rthe pm-ns and that the inforrrzat&n prmided abova" truce. d correct
Sianature: r Bate- 7
Phone ir: 4'II -7 ll "
OjjcjaL use attFy. j)�a scat wl its in this area,tg bs canipleted by di}:or town Dffic aL
City-orTown: _Pt r 3RfIa-seise AE
E-sming Authority(drde one):
1.Board of He--Ith 2.Budding Departmemt I CitiFff,own Clerk 4.Electrical LaslZector S.Plumbing Tnspector.
6.Either
Contact Person: Phone#:
6
Informafion and Instrue ons
Massachusetts General Laws chapter IS2 requires all employers to provide workers'compensation for their employees.
PursuaLt-to`this statute,an ernpIcyee is defined as"._.every person in the service of another under any contract of hire,
express r 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 Iegal representatives of a deceased employer,-or the
receiver or trustee of an individuaE,partnership,association or other legal entity,employing employees_ I-llowever the
owner o f a dwelling house having not more than three apartments and who resides therein,or the occupant of the -
dwellin�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(e7 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 buildiugs in the commonwealth for an.3T
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally, MGL chapter 152, §25C(7)stories"Neither the commonwealth nor any of its political subdivisions shall
enter intc any contract for the perio_rmance of public work until acceptable evidence of compliance with the;nsuZaace
req=em tits of this chapter have been presented to the contracting authority."
Applicants —
Please fillout the workers' compensation affidavit completely,by checiciinc,tape boxes that apply to yrur siltation and,if
necessaryjsupply sub-contractor(s)nane(s), addresses)and phone nsnbe,-.(s)along with u'err of
insurance.!Limited Liability Comp��es(LLC) or Limited Liability Part.elships(T_LP)ve-r&uno e?nployets other tan the
members cjr partners, are not mquize:d to carry workers' compensation hs,rance_ if an LL.0 or LLl'does have
employees; a policy is re4u ed_ fie advised that t}iis affidavit may be s:brrrifted to the Department of Tndu_sa ial
Accidents for confirmation of,i s --ance move age. Also be sure to sign and date the acfi d2v t. '11?e affidmirit show mid
be returnee to the city or town that the application for the permit or license is being r;4nested,not the Departnent of
Industrial ccideats. Should you gave any questions regarding the law. or h:you are requ i-ed i o ob n a workers'
compensation policy,please call 111,-Department at the number listed below. Set;assured companies should enter heir
self-insurance license number on the arppropriate lme.
City or Town OfraciaL
}
Please be stye that the affidavit is c-omplete and p-inted legibly. The DepaYment has pro`idea a space at the bottom
of he afiid�vit for you to fill out'in he event the Office of Investigations has to contact you retarding the applicanL.
Please be sue to fill in the pemit/Ecense number which will be used as a reference number. Ta ad.d ticn,an applicant
that must submit multiple permit/hcense applications in any given year,need only submit one afdavit indicaang current
policy information (ifnecessa-y)and under"Job Site Address"the applicant should v-z-ite"aH locations la __(city or
town)."A copy of the affidavit that has been officially stamped or marked by fthe,city or town may be pro,,Zaed to -die
applicant as proof that a valid afE i avit is on file for future permit or Lcenses_ A new affidavit iil3.ed out each
year_Where',a home owner or citizen is obtaining a license or permit not related to any business or com-mercial venture
(i_e.a dog license or permit to burn leaves etc.)said person is NOT reaquirr-ed to complete this a fidw"at
The Office of Investigations wouId like to thank you in advance for your cooperation and shouldyou have any questions,
Please do nova hesitate to give us a call_
The Department's address,te:1_ephone and tax number_
T.��CommQrl�k altlt ozl��assacl�us tts
D42paj meat of Iadustdal AQm enfs
€ffice of favesti tiaras '
I Goo Wash ngto-n St��
Revised 4-24'--07' Fax : 6I7-727-T 74 a-
� Ili
Client#:33723 CAREF
ACORD. CERTIFICATE OF LIABILITY INSURANCE o9il�20114
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES.
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms.and condltlons of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsoment(s).
PRODUCER NTACT
NAME:
Herlihy Insurance Group Mc.` PHONE 508 756-5159 5
511, Street ruc No Eld: ac wa: 08-T51�5747
ADDRESS:
Worcester,MA 01606,
508 756-5159 CUSTOMER ID 6:
INSURER(S)AFFORDING COVERAGE NAIC 0
INRURED- INSURER A:Liberty Mutual Insurance Co.
Care Free Homes Inc( 239 Huttleston Avenue INSURER e:EastGuard Insurance Company
y
INSURER c;Safety Indemnity Insurance Comp 1'
Fairhaven,MA 02719
- INSURER 0
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: - REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY EFF POLICY EXP - LIMITS
POL.CYNUMBER MMIDD MM22
A GENERAL LIABILITY BKS56134197 9/01/2014 09/01/2015 EACH OCCURRENCE $1 000 000
X COMMERCIAL GENERAL LIABILITY PREMISES Ee occurrence $100 000
CLAIMS-MADE Fx OCCUR - - - - MED EXP(Any one person) $15 000
X BI/PD Ded:250 PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG s2,000000
POLICY PRO LOC $
C AUTOMOBILE LIABILITY 6213850 7/01/2014 07/Di/2015 COMBINED SINGLE LIMIT
(Ea accident) $1000000
- ANY AUTO - BODILY INJURY(Per Person) S
ALL OWNED AUTOS
BODILY INJURY(Per accident) S
X SCHEDULED AUTOS
PROPERTY DAMAGE $
X HIRED AUTOS - (Per aceldenO - - -
X NON-OWNED AUTOS.
$
UMBRELLA LIAB OCCUR - - .. _ EACH OCCURRENCE - $ -
EXCESS LIAB CLAIMS-MADE - AGGREGATE $
DEDUCTIBLE - - $.
RETENTION , $
B WORKERS COMPENSATION CAWC587199 0910112014 09101/201 1,we sTAru• oTH.
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIYEY/N NIA E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? N - -
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yea,desedbe under
DESCRIPTION OF OPERATIONS below - - E.L.DISEASE-POLICY LIMIT $1 00O 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attaeh ACORD 101'AddlHonal Remarks Schedule,If more apace Is required) .
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN-
Town of Barnstable, Bldg Dept ACCORDANCE WITH THE POLICY PROVISIONS.
367 Main Street
Barnstable,MA 02601. AUTHORIZED REPRESENTATIVE
® 98®-2009 A ORD CORPORATION.All rights reservad.
ACORD 25_(2009109) 1 of 1 The ACORD name and logo are registered marks of ACORD
NST3454IM73450 JXC
C07-Ye
Mee of Consumer Affairs''&Business Regulation rL cett or';registration valid for irldividul use only
ME.IMPROVEMENT CONTRACTOR before the expiration date. If found return to:.
Office of Consumer Affairs and Business Regulation
egistraUon 1`00503 TYPe 110 Park Plaza-Suite 5170
Expiration 6/19/201.6 Supplement'',ird Boston,MA 02116
x ,.
CARE FREE HOMES INC
DANA PICKUP JR
239.,,Huttleston ave
Fairhaven, MA'0271�9 Undersecretary I Not vatid.wi hou sign we -
U '
yic SafeMassachusetts -Department of Pub t
ardsI Boardof Buildi:ngRegulatio.hs'ard 5f hj Construction Supervisor
License: CS-095228 r
DANA J PICKUP
239 Huttleston Avg '.
Fairhaven-MA 02719 I —
Expiration
03122/2016.
Commissioner
Vo
RE FREE
111eS Inc.
239 Huttleston Avenue Fairhaven,Mass 02719
Telephone 508-997-1111 Fax 508-997-1297
Website: www.carefreehomescompan3Lcom
To the Town of:
Job Address: / bR, A-O,b3-,
own of home owner o the o e
Customer Name
at the above location, authorize Care Free Homes, Inc. as my agent to obtain all necessary
permits and to perform all home improvements to my home as stated in the accompanying
contract and application:
L �
C9510 r$1-g"A u Date
SE"TIC SYSTEM MUST BE model:�jyster Harbor.
/ —O 1t ;ALLE'D 11 �0PIPLIANCE
P.`TP E 11 STATE >
".-.°ITARY CODE AND TO
oft F.,/< 4P- 73
TMEt��y TOWN OF BARNSTABLE
HBHBSTdBL$ i .. �
O 39-" �� BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ..... Liild ;One...Family. Dwelling. . ........................................
...... .......... ................. .. ....... ..............
TYPE OF CONSTRUCTION ............. ood Frame
.............�. .................................................... .................................
JUar. 'Y
,•1.9.7.3............19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: -
Location .........................................................t #30. CTLi3ldfor'd Koad............... ....................................................
ProposedUse .....Residential................................. .....................................................................................................
Zoning District RD-1 ...Fire District Centerville-Osterville
..................................................................... ...............................::.............................................
Name of Owner ....Normest Homes Inc, Address Ashley Dr! Centerville
Name of Builder ,.Norme'St.,,HomeS ?nC,...................Address Same
..... . ....................................................................................
Name of Architect .......none Address
..................................... .........................................................., ....................
Number of Rooms 6 Foundation .........Poured Concrete
.....................................................................
Exterior ....Si4R9...............................................................Roofing Asphalt
...................................................................................
Floors .......Carpet...............................................................Interior ...Drywall.........................................:....................
Heating ..A3PID-Air ......................................................Plumbing ...Jj..P! tYhS
ZlD tOOO•
Fireplace ................ye ..........................................................Approximate Cost ........................ ...............................
Definitive Plan Approved by Planning Board ---------------_--_-----------19--------.
Diagram of Lot and Building with Dimensions
SUBJECT TO APPROVAL OF BOARD OF HEALTH
----------------
3),
•
100 �
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name /_0.........................
Normest Homes, Inc.
No ....16?24. Permit for .......one............t ...... I
single family dwelling
Location... .o? .. ....U!.�...1........
......................... enteryille '
.............................. I
Owner NQrmest„domes, Inc.
1 -
Type of Construction .................. uame............
............................................................................... I ;
ti
Plot ............................ Lot .........#30................
i
Permit Granted .....,,,,November 12 . 19 73
..........
Date of Inspection ... ..........
r
Date Completed ......................................19
PERMIT REFUSED '
................................................................ 19
loo70
P:....... � ..............
........................................... . ................ ....... a.
Approved�.............................................79
...............................................................................