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Home My WebLink About0033 DUNCAN LANE x a d/3h7 Cape OEPT• ape Save Inc. 7-D Huntington Avenue JAN 02 2a16 South Yarmouth, MA 02664 �OLE Tel: 508-398-0398 Fax: 508-398-0399 fo\NN®F.gABNST 12/13/18 Brian Florence CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit B-18-3531 Dear Mr. Florence: This affidavit is to certify that all work completed for,33 Duncan Lane,Centerville has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. ( Sincerely, William McCluskey .moo Town of Barnstable Bui Iding, PostThis Card So"That rt is Visible From;the Street-Approved"PlansWust be aRetained on Job and this Card Must be;Kept HAMSMSM Posted Until Final yInspection Has Been Made 4 �� ,.;, �` r i s Permit Earu� Where a Certificate of Occupancys Required,su�ch Building's hall Not be Occupied until a Finallnspect on`has been made 4 Permit NO. B-18-3531 Applicant Name: William M"cCluskey Approvals Date Issued: 10/24/2018 Current Use: Structure Permit Type: Building-Insulation Residential Expiration Date: ,04/24/2019 Foundation: Location: 33.DUNCAN LANE,CENTERVILLE Map/Lot: 147-019 Zoning District: RC Sheathing: Owner on Record: SKEARY,JOHN 1&MARY M Contractor Name: WILLIAM J MCCLUSKEY Framing: 1 Address: 33 DUNCAN LN Contractor License:. CSSL-102776 2 CENTERVILLE, MA 02632 Est. Project Cost: $5,000.00 Chimney: Description: Add 180 sq ft of R-13 fiberglass,and 570 sq ft of R-30 cellulose to Permit Fee: $85.00 the attic.Add MO sq ft of R-19 fiberglass,and 180 sq ft of R-10 rigid Insulation: Fee Paid: insulation to the basement.Air seal the attic plane and basement $85.00 with expanding foam. General weatherization. Date:. 10/24/2018 Final J Plumbing/Gas Gas Project Review Req: g/ C i/d Rough Plumbing: Building Official Final Plumbing: Rough Gas: ,5 Final Gas: 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 the approved construction documents for which this permit has been granted. Electrical' All construction,alterations and changes of use of any building and structures shall be in compliance with the,local zoning by-laws and 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 Service: work until the completion of the same. Rough: The Certificate of Occupancy will not be issued until all applicable signatures b the Buildin land Fire Officials are rovided on this permit. P Y PP g Y g P Minimum of Five Call Inspections Required for All Construction Work: Final: " 1.Foundation or Footing Low Voltage Rough: 2.Sheathing Inspection g g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Final: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Health ' 7.Final Inspection before Occupancy Final' Where applicable separate permits are required for Electrical Plumbing,and Mechanical Installations. Fire Department 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 MG C.142A). t Town o *Permit#f Barnstable orb � ati IT Expires 6 months from issue date Regulatory Services Fee n' • STABLE. 65. Thomas F.Geiler,Director �F Bxos-f PBLE Building Division O\N 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 0 (9 Property Address �3 L �e C JAI 00 [Residential Value of Work � '_ Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address . �1�Y1Y1 1Ca V%A Contractor's Name 3Q I(�C' ��GIQ S �Y1['_ Telephone Number 50g--�)(Q- a` 4S Home Improvement Contractor License#(if applicable) 1(9GLCo0Q Construction Supervisor's License#(if applicable) �9Q„ kxWorkman's Compensation Insurance + Check one: ❑ I am a sole proprietor VI am the Homeowner I have Worker's Compensation Insurance Insurance Company Name R C Workman's Comp. Policy# wea b®a a4S11 ` (}®CA 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) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.44)#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 ed. SIGNATURE: C:\Users\decollik\AppData\Local\Microso indo�vs\Temporary Internet Files\Content'.Outlook\4STGUSQO\EXPRESS.doc Revised 090809 Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement.Cpntractor Registration Registration: 162600 ^t? Type: Private Corporation Expiration: 3/26/2011 Tr# 282115 BAKER & ASSOCIATES INC. MARK BAKER r s P.O. BOX 923 - CENTERVILLE, MA 02632 43, f� ti fir,. Update.Address and return card. Mark reason for change. DPS•CA1 �, soM-oaioa-Gioizis - ( ; Address �_� Renewal T; Employment Lost Card t Massachusetts Depaaa`tment of Public Saafet% �! Br►atrd of Building Re(w aations aand Statndaai-dl% Construction Supervisor License License: CS 74477 Restricted to. 00 . BRETT J BOSSIER ' yxi X 111 WAREHAM LAKE SHORE D EAST WAREHAM, MA 02538 ` �--�— --=�'---' Expiration: 1/6/2011 f T'r : 871-5 Board of Building Regula ions and Standards t One Ashburton Place - Room 1301 " Boston. Massachusetts 02108 Home Improvement Contractor Registration ' 1 Registration: 162600 Type: Supplement Card a A . Expiration: 3/26/2011 BAKER & ASSOCIATES INC. BRETT BUSSIERE 521 SHOOTFLYING HILL RD CENTERVILLE, MA 02632 Update Address and return card. Mark reason for change. DPS—CAI 0 50M-04/04-G101216 l Address _ Renewal F-1 Employment I ' Lost Card j `� .I YLC V/61lvl�tlYltUJC�GI/L ['[CJ.J��I4P.� -- Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ation: .162600 Board of Building Regulations and Standards Reg!st 1.r �x iratton One Ashburton Place Rm 1301 P . , 3/26/2011 Tr# 282115 Boston,Ma.02108 ;Type Private Corporation BAKER&ASSOCIATES INC MARK BAKER 521 SHOOTFLYING HILL:RD __-- __--- _- CENTERVILLE,MA 02632 Administrator Not valid without signature ,�fte �om�maruov,� o�✓�aaoac�ucaell`a _ — Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: - Board of Building Regulations and Standards Registration. 162600 One Ashburton Place Rm 1301 Expiration: 3/26/2011 Boston,Ma.02108 Type. Supplement Card BAKER&ASSOCIATES-INC BRETT BUSSIERE 521 SHOOTFLYING HILL`RD CENTERVILLE,MA 02632 Administrator Not vali ithout signature 4 f The Commonwealth of Massatusetts William Francis Galvin -Publ;10owse and Search Page 1 of 2 r The Commonwealth of Massachusetts William Francis Galvin r: .� Secretary of the Commonwealth,Corporations Division One Ashburton Place, 17th floor Boston,MA 02108-1512 Telephone: (617)727-9640 S S�' BAKER & ASSOCIATES, INC. Summary Screen Help"Vah'Ns form Request a Certificate The exact name of the Domestic Profit Corporation: BAKER&ASSOCIATES,INC. The name was changed from: BAKER CUSTOM ALUMINUM&VINYL COMPANY,INC. on 1/8/2004 Entity Type: Domestic Profit Corporation Identification Number: 000522085 Old Federal Employer Identification Number(Old FEIN): 000000000 Date of Organization In Massachusetts: 01/01/1996 Current Fiscal Month I Day: 12/31 Previous Fiscal Month/Day:00 100 The location of its principal office: No. and Street: 521 SHOOTFLYING HILL RD. City or Town: CENTERVILLE State: MA Zip: 02632 Country: USA If the business entity is organized wholly to do business outside Massachusetts,the location of that office: No. and Street: City or Town: State: Zip: Country: Name and address of the Registered Agent: Name: No. and Street: City or Town: State: Zip: Country: The officers and all of the directors of the corporation: Title Individual Name Address (no PO Box) Expiration First,Middle,Last,Suffix Address,City or Town,State,Zip Code Of Term PRESIDENT MARK BAKER 521 SHOOT FLYING HILL CENTERVILLE,MA 02632 US TREASURER CAROL BAKER MRS. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 02632 US SECRETARY BRETT BUSSIERE MR. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 026323 US DIRECTOR MARK BAKER MR. 521 SHOOTFLYINGHILL ROAD CENTERVILLE,MA 02632 US http-Hcorp.sec.state.ma.us/corp/corpsearch/CorpSearchSummary.asp?ReadFromDB=True... 3/25/2009 The Commonwealth of Massachusetts _ Department of Industrial ustrial Accidents Office of Investigations ; 600 Washington Street Boston,MA 02111 ",tmw.rnass.gov/dia NNorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Le ibhr Name gau zit tlt�al) Y�C� C'ICJ.�7OC t ew `fox qa3 City/state/zip: Phone-9- (c - A AVaumana employer?Check the appropriate bog: T of ro ect r d -4. I anta eral contractor and I }Toe e 7 ( ion }1. employer with� ❑ � 6_ ❑New construction employees(full anchor part-time)-* have lured the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ?. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition ' working .forme in any capacity_ employees and have s 9. ❑Building addition (No workers'comp.insurance comp-insurance.l required-] 5-❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all iWor; officers have exercised their 1.1.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12,❑ of repairs insurance required_]p c" 152,§1(4),and tire,have no 1 •` employees-[No workers' 13. o}ther W W40-.OS comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below slinwing the€r waters'compensation policy mformatioa. 7 Honeowners who submit this affidasit indicating they are doing all wok and there hire ouw&contractors must submit a new affidavit indicating such. tCaatractors 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 salt contractors have employees,they must provide fir workers'comp.policy number. I ain an employer that is prosi ng workem',compensativn insurance for rrty employees. Below,is the poticf and job site informatiam Insurance Company Name: A�;iSoc 1 C3-�--(A L n p\-G sA yl� Policy#or Self-ins.Lic.#: UZ)CC 560 a45A 0 t al O 0 a Expiration Date. Job Site Address: 33*bUncav) �, 1. CityfStateiZip:ce1ninmAIC C@X,3"a :attach a ropy 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 an&or one-year imprisonment,as arell 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 ad-vised that a copy of this statement may be forwarded to the Office of Iirt-estigati of theDIA-foQusur ce overage verification- I do herek penQ try thrat the inforntotion protdded abm a is true and correct Phone#- --2fo�p.' aq 5 Official use ont6. Do not write in fh s area,to be evnipLeted ky city or torten esfciaL City or Town: PermitUcense Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Cityfl`o,%m Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:: Phone#: 6 Date: 6/26/2009 Times 1:17 PM TO: @ 9,15083626115 Pages 002 Clie*9742 BAKERAS ACORD,. CERTIFICATE OF LIABILITY INSURANCE 6/26/0�°`Y"Y"' PRODUCER THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR y ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyannough Rd., PO Box,1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER& National Grange Mutual Insuranc Baker&Associates,inc. INSURERB: Associated Employers Insurance P O Box 923 INSURER C: Centerville,MA 02632-0071 INSURER D: 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. tDI POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DATADM TE�°D� LIMITS A GENERAL LIABILITY MPJ7223M 04/19/09 04/19/10 EACH OCCURRENCE $1 000 000 NCOM MERCIAL GENERAL LIABILITY - - DAMAGE TTo Ra NT D occtjrrenc $500,000 ES tE CLAIMS MADE N OCCUR MED EXP(Any one person) $1 O 000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG s2,000,000 POLICY F1 PER LOC AUTOMOBILE LIABILITY . COMBINED SINGLE LIMIT $ ANY AUTO , (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS _ (Per person) $ HIREDAUTOS - BODILY INJURY $ NON-OWNED AUTOS (Par accident). PROPERTY DAMAGE $ (Per accident) GARAGELIABIITY - AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUI O ONLY: AGG $ EXCESSNMBRELLALWBfllTY EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ r $ B WORKERS COMPENSATION AND WCCSW2454012009 04/23/09 04/23/10 X we ", . OTH- EMPLOYERS'LIABNITY ANY PROPRIETORIPARTHERIEXECUTIVE - E.L.EACH ACCIDENT $1 O0,000 OFFICERIMEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEE $100 000 If es,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500 000 OTHER DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Officers are included under the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable - DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL lQ_ DAYS WRITTEN Thomas Perry _ NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Hyannis,MA 02601 REPRESENTATIVES. - AUTHORIZED PRESENTATIVE C. ACORD 25(2001108)1 of 2 #S59110/M58469 LS1 ACORD CORPORATION 1988 o HE * s,►xxsrrABLK �A,O� Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 s Property Owner Must Complete and Sign This Section If Using A Builder I, , as Owner of the subject property hereby authorize t" P�C1 to act on my behalf, in all matters relative to work authorized by this building permit application for: 33�u�nccvl L.n. Ce�n�ecy,��e (Address of Job) Si re of2er Date 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 Intemet Files\Content.Outlook\4STGU5QO\EXPRESS.doc Revised 090809 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map�' Parcel (✓ Permit# 2 Health Division G; 4 srI t � T `r ,t?Date•Issued e;EiCF�'"' ' Conservation Division 0� �'-�9 � � Application Fee Tax Collector Permit Fee Treasurer S Planning Dept. PTIC SYSTEM MUST gE INSTALLED IN COMPLIANCE Date Definitive Plan Approved by Planning Board VWTH TITLE 5 Historic-OKH Preservation/Hyannis ENVIRONMENTAL CODE ANDTOWN REGULATIONS Project Street Address 1 J y ,,j C-A A�) 1,A Aj — Village le—A..) Owner Address N Telephone ,S Permit Request do u s tv o r AA) C_J__�A t/4 t--d o rv-, Square feet: 1st floor: existing 7 4 7 proposed O 2nd floor: existing 74 Y proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 000, Construction Type Lot Size_/S , 1-7 .S i Grandfathered: ❑Yes VNo 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: VIFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) �V Basement Unfinished Area(sq.ft) `74 Y Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new a Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: IC1 Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes `i No Fireplaces: Existing A-)6 New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool: ❑existing 0 new size Barn:0 existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded 0 Commercial ❑Yes *tAo If yes,site plan review# Current Use 1 �S Proposed Use BUILDER INFORMATION Name _ e o'� �C\\ la�M u aJ Telephone Number 4_a '76 D— Z/ 5/6 Addres License# 0 7 A D ks m A Home Improvement Contractor# l 71,E Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO f A- MP SIGN DATE -D S G 1 7r FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ADDRESS- VILLAGE OWNER l DATE OF INSPECTION: FOUNDATION '+ FRAME INSULATION C) w FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL n f GAS: ROUGH M }- FINA - � Z5 FINAL BUILDING t Na � SRt - S ca C-) < 5 ' DATE CLOSED OUT h _ � J 5 ASSOCIATION PLAN NO. S cC co R'nn v r: .> L ^' fJ t Permit Number REScheck Compliance Certificate Checked By/Date Massachusetts Energy Code REScheckSoftware Version 3.5 Release la Data filename:Untitled.rck CITY: Centerville(Barnstable County) STATE:Massachusetts HDD: 6137 CONSTRUCTION TYPE: 1 or 2 Family,Detached HEATING SYSTEM TYPE: Other(Non-Electric Resistance) DATE:02/08/05 DATE OF PLANS: 2/8/05 ` PROJECT INFORMATION: Mr. John Skeary 33 Duncan Lane Centerville,MA COMPANY INFORMATION: I D.L.Dadmun Custom Builders 51 Pond Street West Dennis MA COMPLIANCE:Passes Maximum UA= 15 Your Home UA= 11 26.7%Better Than Code(UA) Gross Glazing Area or Cavity Cont. or Door Perimeter R-Value R-Value U-Factor UA Ceiling 1:Flat Ceiling or Scissor Truss 32 30.0 3.0 1 Wall l:Wood Frame, 16"o.c. 112 13.0 3.0 8 Window 1: Vinyl Frame:Double Pane with Low-E 6 0.340 2 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in REScheckVersion 3.5 Release la (formerly MECchecl and to comply with the mandatory requirements listed in the REScheckInspection Checklist. The heating load for this building,and the cooling load if appropriate,has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125%of the design load as in Sect OCMR 1310 and J4.4. Builder/Designe Date. r 1 , oFe rod Town of Barnstable °-� Regulatory Services saxxsrnsr�, Thomas F.Geiler,Director MASS& 4p zbg9 a`�� Building Division TED MP'� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 P emit no Date AFFIDAVIT HOME Ei RROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work Estimated Cost 7t &)y' Address of Work: �U A a.J Owner's Name: j 1� oo �Ar� Date of Application: 09 7 6S I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THMIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRA A OR GUARANTY FUND UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby appl for a permit as the agent of the owner: Date Contractor Name Registration No. OR D Owner's e Q:forms:homeaffidav The Commonwealth of Massachusetts -- Department of Industrial Accidents — 600'Washington Street sh Boston,Mass. .02111 Workers'. Com ensation.•Insurance Affidavit-General Businesses r�a`wua; i address' P� //O city �S' C N -� S state: zi'M O �byhone# 7 b ��6. work site location(fall address): ❑ I am.a sole proprietor and have no one Business Type: El Retail❑Restaurant/BaiJEating Establi$hment ' working many capacity. ❑Office❑ Sales(mcluding Real Estate,Antos etc.)' I am an em to with D-'em•lo a �fihfflart time.).. ❑Other //// %%/ ��i. �l/%/% //% %%///%%%///%/%%%/�/GO% M V1117111711, I am an e�uiplo er providing work ' compensation for my employees working on this job. coin"sri�•names. �:.•� �'�r�• eddre3s'' • ' '�.,�'°-Cs•�' ''',,:•'." •,.-� ,' tom'N.. .�-�� ,:�'• .Atone._#:•�',"�y..�:!•�� "��. •�:/:�/ s citV� . . .irisiirariee.co'' L:�.�.�.` ../«�:�...,!� •,; �-.,:..:x:•:.. oh •#� ,:C.••fi,. .�. .�'. the independent contractors listed below who have the followin workers, I am a sole proprietor and have hued ep g • compensation polices: •i company name• - -- - address:. nlione# . ter. ;:i:�`` 'r"i.•::: •' :t�":�;.. •• .,'•; 1F.t.:• .fir. _ •r'. �;ti insurance co. :_:= - a e•_ coinn v' "an n a� •h n #:. •U t1" insurencecb, Do lay, Faflure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that g copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do h e y certi nder pain penalties of perjury that the information provided above is true an car ct. . Signature Date Print name 1 �vyt u�B Phone# � official use only do not write in this area to be completed by city or town official L permit'license# ❑Building Department ❑Licensing Board mediate response is required ❑Selectmen's OMce ❑Health Departmentn• phone#; ❑Other ) Information and Instructions Massachusetts General Laws,chapter 152 section 25•requires all e#19yers.to provide workers'-compensationi for'their.. f� from the law', an employee' is.defined as every person in the service'of another under any contract employees: As quoted lie oral or written. express or d, f hire' a implied;o � xP An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in ajoint enferprise, and including the legal.representatives of a deceased:employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. ,However the owner of a dwelling house having'not'more than three apartments and who resides therein, or the.occupant of the,dwelling house of another who,employs.persons to do.maintenance, construction or repair work on such dwelling house or on the grounds or building$ppurtenant thereto shall not_because of such employment.be deemed to be an employer. MGL chapter 152 section 25 also's-fates that every state'or local licensing agency.shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who has not produced acceptable evidence-of compliance with the insurance coverage required. Additionally, neither the - commonwealth nor.any.of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this.chapter have been presented to the contracting . authority. Applicants Please fill in .the workers compensation affidavit completely,by checking the box that applies to your situation.,Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alsobe 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.worlcers'compensation policy,please call the Department at the number listed,below. City or Towns . Please be sure that the affidavit is complete and printed legibly. The 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 a be sure to fill;in the permit/lieeris.e number which will be a reference number. The.affidavits m e used as , . . . .Y.be.returned to it or FAX unless other�arr ements have been made. the Dep artment by.ma 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 ca1L The Department's address,telephone and fax number: . The Commonwealth Of Massachusetts Department.of Industrial Accidents no of Imsf gawns 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 7274900 ext:406 I � - 1�1 Town of Barnstable Regulatory Services s8 .$ Thomas F.Geiler,Director 161 ,m Building Division TomPerry, Building Commissioner 200 Main Street, Ijyamis,MA 02601 Wyyy.town.barnstable;ma.us office: 508-862-4038 ' Fax: 508-790-6230 Property Owner Must Complete and Sign This Section if Using ABuilder I J ,v -C r ,as Owner of the subject property' authorize:� �- '� to act on my behalf; :here by in all riiatters relative to work authorized by this building permit application for: (Address of Job) � n S' afore of D e Print Name RESIDENTIAL BUIL]DAIITG PERAUT FEES . APPLICATION FEE , New Buildings $100.00 Residential Addition $50.00 � ( Alterations/Renovations $50.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIONSMENOVATIONS OF EXISTING SPACE 3 square feet x$641sq.foot=_ D L�� _x.0041= plus from below(if applicable) - GARAGES(attached&detached) square feet x$321sq.1= x.0041= ACCESSORY STRUCTURE>120.sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf-1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) FirepIace/Chlmney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00. Relocation/Moving S150.00 (plus above if applicable) Permit Fee �•� Projcost Rev:063004 �fze Par�ea .acs{ivaell $OARD 9F 4'UILDIt REC�ULA-T OWNS L10010: C®NSTRUGTI:O:N SUPERWs-OR Fluff` ¢ 074-05 956 I 6 Tr.no: 7157.0 i DAV L DA0, 51O� D VYEST'DE�NNfS, MA Commissioner r $aatid:ar$add>ilit Hp ggufatians ME 1 �0►/ S�ndard Re h= EMENT CON7 . gj �dt(on RACTpR.. RllaRn 128718 Pg/200S 6AVID, pAp N CSOIE1 Bjl I'� MON 51 POND ST \, y i•% --------------- ,e � . LJ 4 A+j4 os � t:, r1 ', th l 1 t .r P s �� I.', .( +1 § .'°,I t s44 a i' r'.r r 1 t ! w,. p r 7 \V ! t. -1\ q\f r' > i,t ry , k 11 r I I t ( I ql I 1 { I 1 I 1 1 a (} d I s P H i I , r \ tl t, y. p. a rr - ia. 7 \t.. 11 v ,r ::i I t rt(( tz: fr `t lybyt t H j,i1. . r. It. r+{I,.1.P\ 1t'I I r+� r C. :ry S -ai; ! ?1. Ft , rfyl. al -il S F �, 1 .,,. it.i r+..i"T y{ 'l1. I f 1 14 +-1 3l; , s .:.. \4 { r-, r 'E.;,.: + .t --x 5r 'I\r,e b i. .: 1 +.;r t+t Y l., 7 -!,i¢ Att, l,j C, �,Y i f .., f, .*. 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