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.. -. ,�, - � �, y': 4: ` � � � �._ _ Town of Barnstable *Permit# PERMIT R lator Services ua� �"``��ep Y ?/,d I tom, NAM pd 20�4 Richard V.Scab,Interim Director 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 Lnprint Map/parcel Number Z 3�I!Z 3 Property Address 1 CLL/O 7— 8 Pg—Residential Value of Work$ Minimum fee of$35.00 for work upder$6000.00 Owner's Name&Address A1_)1Ne4'k15-Z)&- J ' t ( ,CLLI C> S% ery N p Contractor's Nam I GJ elephone Ntunber'fD�-ZL Home Improvement Contractor License#(if pplicable) Email: Construction Supervisor's License#(if applicable) ©i570 / Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name MS lG w Workman's Comp.Policy# ;�l le, !Z 7 O l k35.23 f Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders-U-Value 3 (maximum.35)#of window(2) #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspectiom 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 cop f the Home Improvement Contractors License&Construction Supervisors License is equJ SIGNATURE: TAEVIN,Muilding ChangesEXPRESS PERN=XPRESS.doc Revised 061313 , _ - WOO 1J.a•' ZAL' 'L'lY' _ 6Car,$5TA>y 67 FibiilDl3 .i"aw i;ieraiiariwc". 25Ai6ltzh.Ro,nd * Lieft:H,AT,Q0 • Ga�elrm�Iisdr ' = , .�a ,������ .������. • Pa�Mitt VIVATOM VvMbs It pO*.jL A'mouri"aWSrAM:MOVE ►jim.•ryrs4arred�n 4.sAe P nay t J. i " .12 - $ rw f its JBCAdyy and as+ esn�yt aoen q+� ldaaae the mOuca zu4lgr verA D of southurn MOW radaind V&NIG-wa.=3 d/w's.RRMKw by A,nd dataww an Ike� ai'Spa+ i 9rn e�P.w - afI�,!ia�.�� ioui"u1:r ftw+3r<@Wdoinia mai t� gft 4f _ e .t'RBre, ens as$�oeli ' `2Maas; .r[I1MA1• _ - - +iae esdiiiad _. aysn�f�+- ri?; ��^4' ' �Chalk O yeti a � I itdtM�tAl(l 4EIp - zuy CM-fit COO nm- w alchwi r 813 of the 6ert .mod eAadaiw_„W I ems+04OWMOOP OUt Ta 91114114010 ft SW9 GI and Oft � "fly , � etfie +ate�� �sf �a�i�a� •�•a�fe� �;vi1nPlu�6n•oIa'o�,l,�lt4;r aural arse 6iii�C+66 ri�ide'k}'€tea!elr6.�t .e9esel&ar e�ly: �u�reir(ay esie 1,aiafrMma» 6 i�i�4fa�fr cos� dt amiss tre� o par [e�ay �l��•�i�E m+4Arm idol Vim&4 wndmir.oftoduW111t tht ltmffm it tuw e � � �a� 7�e+ sti■ o si i}JtFORS io 4hs*W,)WS,Of a7d� "61agal, bare; itiw n, � o� 1>a �alsd,a�!!�a a�iil: okE vri t dR '� , .- AMA a �a�it� i_ 6_71v Irmo l ems ent Jj eel►of t� go" A f9k�'�a y (2 ��iiiaditliGad ta a�;W �kii a€es�io Limb, -t�if� - _ 'iivacL we ,b�e +' �� _ olri> t i G g#tic ±� dA fi.■a Esc th4aj,� s as east1� e d o s i> i ee t�Y$m la Er• iwat+�: �cc, &C,iiftfYty}�rso '1e o > z ftaft ors i�f>s a91�cr■train it • -- fk air .o� � r'r ee�id>fili a�iF] rit •! 41 k o %be,t7hri�L tsef�d�s�w�dfksr Hwy oi®ii y° �r(,I"*,tb� nl�sai�esalu, deg� $ati��i9a.ve�i1=$ e e . 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I '� at if FnItt►aw�hr+eofnq/�riih Ow Initruo44� � If19�F f3i weilww�� rar� �twnre,aR+efre dP�of tfTw �IId _ In_ b, r+ubgp rw+sntF tiew d,ti t1m e 'l�' nel Tlr itEr'•da.. a pate3 � ftir ir» awsai :rp■� a..gfa.l;ji,. --- ,+►am +�� a t`hv n � k 4flow- +�h� r� f . 1 p k tF it _ f 'Iff f Il stPha _j al y 17 th i� ear �lisno�,b t band . flows tIR y;au f d 1�wp . 3t wngi i�,T+i<h,trR gfilt-- off,It you r f a b .ft ifw � a isnal.ff d v inu to f5°ig'eliis r +df~ rss l�ler "0 001pon Iryou if,�rao to rim f �b tb f I Q'Iblh to tkon u •to fttupo the wods to tfie®ri�P•afld tlfirlf� ,off �W iirn nere ,fi"�fa o for p°s�Rs�r,� ficw+a�i ell �abils-surani,u,A -. I 11�9n it klF do r e rrwi e�ate ag 0r"�iun untl10101 a +�9bt "16 aonipyf th* pol9y oll;wr d�lliniiw + 1 e i d t o tr ndh a 4"itww Cuff of this taftralk do iwtaiib dW jk T �hi�r t"WLTO +I t111a A tf®If1i�r1�I�F d@IIq+Cr oL Ll O.t Old 91 1f. _ _ w�- irylA tlEi_ to kWAkndin Ilrrltte�ffu� r fhllC-T bfij Tf'1_' �i 1 � i (Mid fTn i � ;d�Itg XSN a + i OWN IAA, VI, IN-poi'Cam now ," Dulro"Coop Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen Nor License: CS-095707 r-� BRIAN D DENM."N 1 r 7 LAMBS POND CIRCiI:E Chariton MA 01507 !72.,v Expiration Commissioner 09/08/2014 ��ie �paa�u�7roo��oefz t '�/��aQ�aiu�el1• Office of Consumer Affairs n Business egulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplernenl Card - SOUTHERN NEW ENGLAND WINDOWS LL Egsiration: 9/1912014 DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 Update Address and return card.Mark reason for change. - sn r o zounyi i ❑Address ❑Renewal i�Employment ❑Lost Card Mre arCoasoour Affairs&Bad—8eaolat oa Lkense or registration valid for lndivldul are only OMEtMpROVEMENT CONTRACTOR before the expiration date.Iffoandreturn to: ORice orconsumer Attain and Business Regulation RoWstrntion: 1-M45 Type: IOPark Plain-Sane$170 1 Expiration:0lWO14 Supplement::ard Boston,MA 02116 - SOUTHERN NEW ENGLAND WINDOWS LLC, RENEWAL BY ANDERSON DEN. 1137 ISONPARK BRIAN . ; 1137 PARK EAST DRIVE WOONSOCKET.RI 02895 - f _ i Uodrrs rotary - Not valid wilbout signature f Client#:30124 SOUTNEW ACORD.. CERTIFICATE OF LIABILITY INSURANCE r DATE(MM/DDIYYYY) 8/06/2013 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 policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions 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 endorsement(s). PRODUCER ONTACT Anita Little NAME: Willis of New Jersey,Inc. AICC E. Et):856 914-4660 AIC,No): 856-914-1881 1015 Briggs Road,PO Box 5005 ARE anita.liftle@willis.com Box 5005 INSURER(S)AFFORDING COVERAGE NAIC# Mount Laurel,NJ 08054 INSURER A:Selective Insurance Co of the S 39926 INSURED INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen 26 Albion Road INSURER D: Lincoln,RI 02865 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 CONTRACTOR 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. LT RR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSR WVD POLICY NUMBER MM/DDNYM (MMIDDNYM LIMITS A GENERAL LIABILITY S202945900 8/10/2013 08110/2014 EACH OCCURRENCE $1 000 000 X MERCIAL GENERAL LIABILITY pAMAGE 7 RENTED PREMISES Ea occurrence) ccurrence $1 OO 000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $1 O 000 COM PERSONAL&ADV INJURY $1.,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $3,000,000 POLICY ECOT LOC $ A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/201 COMBINED SINGLE LIMIT Ea accident 1 r000r000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident A X UMBRELLA LIAB OCCUR S202945900 8/10/2013 08/10/2014 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS-MADE AGGREGATE s5,000,000 DED I I RETENTION$ $ C WORKERS COMPENSATION 0000068028-RI 8/21/2013 08/21/201 X wC STATU- OTH- AND EMPLOYERS'LIABILITY YIN B ANY PROPRIETOR/PARTNER/EXECUTIVE AIC927818352394 8/21/2013 08121/2014 E.L.EACH ACCIDENT - $1 000000 OFFICER/MEMBER EXCLUDED? N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1 00O 000 If yes,describe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER ' CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE ©19884010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL r The Commonwealth ofMassachuseas Department of Industrial Accidents Office of Investiqations •. ' 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print LeQibl Name (Business/Organizadon/Individual). LLL' Address: City/State/Zip: L/A/CD& , Z,r, 1j.-xBbS Phone#: 5/0 -YD0 Are you an employer?Check the appropriate box: Type of project(required): 1.[d I am a employer with A O 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/orpart-time).$ have hired the sub-contractors' 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [l Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp,insurance.t 9• [1 Building addition required.] S. 0 We are a corporation and its ID.O Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c.152,§1(4),and we have no l employees.[No workers' Other Iti/ comp.insurance required.] *Any applicant that checks box#i must also 5U out the section below showing their workers'compensation policy infilmation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubmit a new affidavit indicating such. tCoi tractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is provi nig workers'compensation insurance for my employees Below is the policy and job site information. /Y Insurance Company Name:—AVA2-&WatU Policy#or Self-ins.Lic.#:A'/�.7�1.f 3 A--7 Expiration Date: c� Job Site Address: c)/ ST City/State/Zip: e/�(p Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the form ofa STOP 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 Investigations of the DIA for insurance coverage verification I do hereby certi under the pains and pendlties ofpedury that the information provided above is true nd correct c Sianature: Date: 2 Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.'Plumbing Inspector 6.Other Contact Person: Phone#' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION S � Map Parcel l ZZ- Application# c` Health Division Conservation Division ��f�'IO�f f Permit# Tax Collector Date Issued O�Z Treasurer Application Fee Planning Dept. Permit Fee30 Date Definitive Plan Approved by Planning Board a ` Historic-OKH Preservation/Hyannis I Project Street Address Village t LL r� Owner E-44,t o7E At>e 2 S o/q Address l( 1::_: ,4J tvTl <--r 0_.514 TE0,V 11_(_E Telephone S—o - 7"7 Permit Request_ 14- r�y is 1 IN 6- 0 E C K ✓4 N 0 ? OZ /K(6- r A (P s� Square feet: 1st floor:existing !©s 6 proposed 2nd floor:existing proposed Total new Zoning District Flood Plain o Groundwater Overlay Project Valuation 1 D. ©ova Construction Type $ Lot Size 3 9 77 So r 7 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation: E Dwelling Type: Single Family Ur--' Two Family ❑ Multi-Family(#units) _ f Age of Existing Structure 3 3 Yku Historic House: ❑Yes ®� On Old King' Highway:. ❑Yes Basement Type: ull ❑Crawl ❑Walkout ❑Other ` Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing 1 new — Half:existing ( new Number of Bedrooms: existing_ new Total Room Count(not including baths):existing (o new First Floor Room Count (� Heat Type and Fuel: 4as ❑Oil ❑ Electric ❑Other Central Air: ❑Yes G-Igo Fireplaces: Existing 0 New Existing wood/coal stove: ❑Yes CtiYtq_0__ Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage: existing ❑new size 5 76 Shed:❑existing ❑new, size — Other: Zoning Board of Appeals Authorization ❑--Appeal#-- Recorded O Commercial ❑Yes U<O If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name Ec�_i...t__4:e7 164—!J 0 C A So N Telephone Number 5 c9 '7 ( `!3 Address I c. r o7T S i . License# bJT-C AV11-LE . H14 0 ,7 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Y SIGNATURE DATE t -7 �I FOR OFFICIAL USE ONLY PE�MIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE r' OWNER DATE OF INSPECTION: FOUNDATION 61S)Sprra"3 6A Z01 6�,q FRAME C �!�" 0 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL } r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING j DATE CLOSED OUT ASSOCIATION PLAN NO. 1, The Commonwealth o,f Massachusetts Department of Industrial Accidents Office of Investigations Y 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunoibers Applicant Information Please Print Legibly Name (Business/organization/Individual): IJ-i o7l- 2r&g o N Address: I( CL L t o7t ST City/State/Zip: CC/4 T ER.y[u,C R4 Phone #: o S1 Z -71 - 1 3 Are you an employer? Check the appropriate box: 'Type of project(required): 1.❑ I am a employer with 1 4. ❑ I am a general contractor and I 6 employees (fall and/or part-time).* have hired the sub-contractors El New construction 2.El am a sole proprietor or partner- listed on the attached sheet $ El Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its reed,] officers have exercised their 10.❑ Electrical repairs or additions 3.LId I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof r "Ifo__ insurance required.] t employees. [No workers' ,-,/ K(STIMCw ck: 13.i�Other �� C r Z* . 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 lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and,pob site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500..00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and panalties of perjury that the information provided above is true and correct. signafore: >f zz Date: O Phone#: 5 t9 7Y Official use only. Do not write in this area,to be completed by city or town official. j City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plummibia0 inspector 6.tither i Contact Person: Phone r: 1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees, Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract ofahire, t express or implied,oral or written." An employer is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or . renewal of a license or permit to operate a business or to construct buildings`in'the`corfimonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es) and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the " members orpartners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a.policy is,required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the.permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom. of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address; telephone and fax number: The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 617-727-4900 ent 406 or 1-o77-MA Fax +; 617-727-7749 Revised 5-2b-©5 W-W—W.mass.gov/dia °FTME1°� Town of Barnstable Regulatory Services BARN9 SS. Thomas F.Geller,Director F 6 . 0. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. k610,4IR EX IS-r iNCr 7rC_K 04'K6 Type of Work l "a D 97— &V1411y GL.JE Estimated Cos* OOc> Slv� cJ�4t,5 Address of Work: It AE*L L►a7T' S'T e E/J?E k.VI G.LAE I l d DEG 1Z Owner's Name: 1'L L.IOT( ff N D CAS o N Date of Application:_7e/L'-t 1"I 2 00 I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑B g not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Signature Registration No. OR ate Owner's Signa e Q:wpfiles.forms:homeaffi d av Rev: 060606 'All � M h ait" s 12 t , , � Y 3 h ` I , +.. 1 s # r sr i7 OL 44 ��/+��y ` t5 # r... ..;...- ,y, ,.,ri,,.,,„,,.. «...,:.w.,........_n,.r.,..w ,- ,-�..w.+.._.µ o-:,;.. r...,n:,.��./,�P'.f`:µ':,: •w � -rrl ^�...�w. 4�1 � i j d Y q/ A4 Qi� lfP _f.,ff'yrh vv kc 41�0✓Z ;�.r .�T6►F°gvl +'$O 4 . + e r v Town of Barnstable �P�pU THE Tp��o� • Regulatory Services II Thomas F.Geller,Director aniws'rnsr.E, 9 NAM � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-79076230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: J ULY 1 -7, 1 D JOB LOCATION: II J-.,1OZr 57 0,0111TE2V/ —t1£ number / street L/ village "HOMEOWNER": L4 1 O IT 411 DER.50 N � 0� 7-7 I'16�7 � SII�M E .name home phone# work phone# CURRENT MA1L1NG ADDRESS: ll F L_L-t OTr SET, city/town state zip code .The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family-dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109,1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,.rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. ature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section.127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions .� of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack'of awareness often results in serious problems,particularly o when the homeowner hires unlicensed persons.-In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns, You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt t p ptAE Is p}r►1�1� H.B: �� # K .'po5 39 R "sg zZi i s, sz 2.65 q,f .19 M 4, . E1' w ^a. ELLI,CLT�-_D_--and J0 _ANNr o may® �h� k ..AN DE b' .� WILLIAM E.. AN EI S 10 0to ' 1 Q106 2� f ^� ► OF jR 1 Q N viC1, ALC ED C9�� AND.ERSON ltl E4341, a` ��ti: 065 t [� fir'/ %03T g 29/72 PLAN OF LAND OF a z {s EL.00Tt: b end J� ANiV- E 6UDE 5®6V =• �. �yLOCATED: IN CENTERVI LLE,:.MASS ..SCALE: 1 " o 40� - SEE DEED RECORDED 9/29/72 _IM ®ARNSUBLE REGISTRY OF DEEQ,S d Asses ap and lot .number ... ...........:........................ dF ` /=dcory Sewa a Permit number LE �.... y�FTHET��y TOWN OF BARNSTABLE C Z BARESTeIIiE" 9�0�16 ytr\e�0 DUI.L.DING INSPECTOR YP i." Ca APPLICATION"FOR PERMIT TO .... 1Pdr� a....�1 l!'�.e;Ir��`k'{...../.�!y ....... ............................ t TYPE OF CONSTRUCTION ........ .... . Amrf ........................................................ .................... ................................................19........ �.r v ,. TO THE INSPECTOR, OF, BU;LDINGS: • The undersigned hereby applies for 'a permit according to the following information: Location ....LI.:....46_.kk..1 .TT.......5- ................0k- !. _? V.d�°sr'. �-..........14, A.V 5 ........................................................ ProposedUse .......Gd:. f J4>`a............................................................................................................................................ ...............Fire District Y.T".� l�iAJ,.9..� Zoning District ......................................................... .....&`/ .. .. .. ... c,=............ .:. .. >�nme of Owners ..J..4......... 1 �✓;��(,''if�l k. Nameof Builder .......... :p�y3fd/..�'�l+�.ZG.......................................Address .... ........... :.................................................................... ..:..Name of Architect ...... .....P.Y.eoc.......................................Address .................................................................................... Number of Rooms .........../.....................................................Foundation ....CO..aivickeTrS...... ......................... Exterior ... ...... .:`.!'.�..............................:......Roofing ... ........- .. y..................... Floors /�1 c .kq.y.c'?).e-E..f..l .................................:............Interior........ ... ................................................................:................... Heating Is ................Plumbing Fireplace .........J42.N.6........................................................Approximate Cost ........... ./ S .. � ...... ' Definitive Plan Approved by Planning Board _______________________________19________. `� Area .....�.. �.�...�t ...Y-77—. .wInge-E Diagram of Lot and Building with Dimensions Fee �— SUBJECT TO APPROVAL OF BOARD OF.HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . ............ i X ElliottD. &. J�J��x � ° .. � � � ^ +, . ' garage & deck � Permit for .................................... - ` � . ' ' « . / ~0�--------------'' a�' . ��/�;����� _ . ' 11 Elliott Street Location ................................................................. Centerville . .--....---------------------- � Elliott D. .� JmAxnn E. Anderson ~ ' ` Owner ................................................................... frame � Type of Construction .......................................... --------------------------. ^ \ � Plot ............................ Lot ................................ ' ^ � � .. , ~ ' Penn� ��nonte6 .....December...l3..........1p 76 L Date of Inspection --------..---.lV ' u» 916,' Date Con�o|e,e6 .. .���---�—���V r '� � PERMIT REFUSED , ----------.—.-------.—�—. lA � ----.---...-------------'^--... �--'---^^^----------^------`` t - \ ''--~-----------'—'---z'------' ' . r ' .,..------.----------.-------.. ~ ' ' ~ ^ � , . Approved ................................................ lQ ^ ' ---------.----------------- . -------------------------.— � ( � . Cam"" Assessor's map and lot number "r 4"fF t.-�_f T Se(niagewPermit number ....................................'F�r`rrK . .U.�- �, .... _ ypi tN E TOWN OF BARNSTABLE li 8AWSTAIM, i "6 9 BUILDING. INSPECTOR ° 0 MPY a' y APPLICATION FOR PERMIT TO .... '.A5C:7...... ► .g.2� .....fal.N. D...... ���.�..................................... ^ TYPE OF CONSTRUCTION ........ !!,AOZ 21)...... Y M F................................................................................ ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / � t 10 T� �T, � F ri ti 11.1 Location ..............:....r...........................................................:,.......:............................................................................................... ProposedUse ..:....�1�a� ' .�............................................................................................................................................ Zoning District ........................................................................Fire District .....�+1.;.��, It{'Name of Owner lr,....Y !�... Address ...le.... .�t:.!0 .......C�N Nameof Builder ............._:........::...::........................................Address .................................................................................... Nameof Architect ......... .. .......................................Address ...."`.:.. ................................................................... 4 Number of Rooms ........... .....................................................Foundation .... ....`n t.C.R. E. fS � r. ... ..................................................... Exterior �G—x7"v�2 fI Roofing ...��!St�;ff�;..�.....5 :{/tll;l=C'...................... ............................................................... Floors 6��/'a/ �? .......................Interior ............ .................. ........................ .................................................................................... Heating .........�n N .........................................................Plumbing ......... !. ...........:............................................. ............... Fireplace pp � (?fV .........................................................A Approximate Cost ......... .......................................................3,9 im c v Definitive Plan Approved by Planning Board --------------------------------19--------. ��'` Area ...... . 2. '...�`�Q...1"7.-r-t1er?,fE Diagram of Lot and Building with Dimensions Fee .................:............................. 'SUBJECT TO APPROVAL OF BOARD OF HEALTH s , t I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name :Kct:.+`f�.. :. �:c.�it t..+Q�a�-................... Anderson, 4116Aott D. & JIVAn E., A=230-123� 1$$71 A gage & deck No ... .......... . Permit for .................................. ........................... ................................................. Location ... 11 Elliott Street Centerville ............................................................................... Owner Elliott D. & JoAnn E. Anderson .................................................................. Type of Construction frame ........................................ ....................................... Plot ..................... Lot ................................ Permit Granted December 13 1976 ..... .......................... Date of Inspection ........... .......................19 Date Completed ...... ..............................19 PERMIT REFUSED .. ....... ..... .. .... .. . ... ..... ..... ......... 19 Approved ................................................ 19 ...............................................................................