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0010 FAIR OAKS ROAD
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CA _Ari rS'. ix.', J+ rr,y _r„tt7 'y: 5'Y1 /P _ ,X: ,:y.:y a __[l. ,� ft r.: + ,. ,,,,/ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V Parcel XQ1 Application® Health Division Date Issued 0 Conservation Division Application Fee Planning Dept. Permit Feb 'W Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis 1 Project Street Address T-74((4- Z5 Village `� h Owner 0 -Le0vr_Qv_%G� Address Telephone S6&_ "CZ-(�_ IS-7 KO Permit Request r) Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation'�� 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 Historic House: ❑Yes Flo On Old King's Highway: ❑Yes �lo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) C?' -3 Number of Baths: Full: existing new Half: existing Jr-gw - Number of Bedrooms: existing _new . rD Total Room Count (not including baths): existing new First Floor Ro m Count' Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo/coal stogy:. Lf-Yes ❑<No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) .. Name Cr A L�— Telephone Number &J�5-� _ 5: a Address � � O License # �A kaeVim' Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TA E TO 4 75 SIGNAT DATE —�` FOR OFFICIAL USE ONLY .t APPLICATION# ISATE ISSUED MAP/PARCEL NO. e ADDRESS - VILLAGE OWNER DATE OF INSPECTION: f UNDA*TION4UJA-1 L s-� i_: I • - _ _ FRAME -- - - + INSULATION,!'..� FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL _ f GAS: ROUGH FINAL E FINAL BUILDING • '- ' DATE CLOSED OUT ASSOCIATION PLAN NO. The Commarn€-u of Massachusefts Defiarrm ent aft uhurrid Accidents -- OffWe v,f'lmr fftigations 600 Wias-Irington,S`reef Rastan,,MA 02111 wmit ariass.gmldut Workers' Compen-sationInsum-ace Affidavit:Builders/Contractors/EiectriciansfPlumbers Appl'cant Iufarmai on / --------!�5 `Pllease P�r/iint(Legibly _ 1�13II]I:r,a�L PR nip OL> DdI.Vit�II3n_ v v ✓-mac v City/Stat&Zi.p:�� ` V LYE L phone 47 Are you an employer?Cha the appropriate box: 4. lama contractor and i 1_El I am a employer with t 6. 0 New cx strut oa ayees{fu11 andrarpa�rt time}* have hired the sub-contractors. 2_ a sole proprietor or partner listed on the attached sheet Y- ❑Remodeling and haze no employees These sub-contractors have S. ❑I7enmlition wod=g for me in anycapacity_ employees and have workers' _ rR� 9- ❑Building addition [1tiTo wOrl�ErS' comp.p:insmanee comp_,nsuran req°zred-] 5_ We are a corporation and its 10.0 Electrical repairs or additions 3_❑ 1 am a homeowner doing all work officers have exercised their I I_0 Plumbing repA7rg or additions myself [No workers'comp_ right of e--mmption per MGL 12-0 Roof repass insurance required]I c-152, §1(4),and wehmmno employees-[No worloers' 13_.0 Other comp-insurance required-J.. *Any*tray applibmt that checks boot C armst also 51l oia the section below showing polity axiffirniion_ Homeowners ethic submit this si$dsvif it rrrr rr�a y are doing s1I trvrlc anal then hug offside coatracmrs must submit a aeR at-adxw mdirat n sorh 0mtmcmrs dW check this bar,most sttached an sdditinnsi sheet shamhg the nee of tie so - amd state whether ocnot these Ov(ities have ampIayees- Ifthe sub-conttaetmshxm employees,ffiey must piuvide their worlars'camp_policy aumber_ lam an employer that is prrr i&:ag it orkers'conil ?Loa ion ircrrtrarme for my emp&ryees. Helots is thep hT cy artd job site in,fotmatioti_ Insurance Company Name: Policy:ff cr Self-ins_Lit 4k Expiration Bate_ Job Site Address- Citv/stat zip: Attach a copy of the-workers'comp MISRCon palicg declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pemdfies of a fine up to$I,500.00 and/or one-year imprisonment,as well as civil penalties in flee form of a STOP WORK ORDER and a fine of up to$250.0fl a day against the violator_ Be advised that a copy of this statement may be forwarded to the Office-of InveufS Lions of the DIA far invtrkrtre,coverage vierification- I da hEfre y c,�rf2fy ruder gal rI penalties ofpedary that the in ormatiion protidsd a&nre is hxz and carrect Bate: r- Phone#: Off ciat use only. Da not write in thfs area,to be completed by d(p or town official City or Town: Perm itUcense# Issuing Authority(drde one): 1.Board of Health 2.Buffil ng Department 3.Citylrown Clerk 4.EIec-trical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuautto this statute,an employee is defined as".-.every person in the service of another under any contract of hire, express or implied, oral or written_" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,-or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not b:causejof such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every,state or I5cal licensing agency shalI.witbIioldacne issuance or renewal of a license or permit to operate a business or to constract buildings in'the commonwealth for any applicaat,who has not produced acceptable evidence of compliance with the insurance.cover-a-ge required. M Additionally, GL chapter 152, §25C(7)states"Neither the commonwealth not=anyo`f its political subdivisions shall enter into any contract for the per5ormance of public work until acceptable evidence of compliance,,krith 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 ceri:zicatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(L LP)with no employees other than the members or partners, are not required to carry workers' com-Densation insurance_ If an LLC or LLP does have employees, a policy is required. Be-advised that this affidavit may be submitted to the DeparbDaent of Industrial Accidents for confirmation of i lsurance coverage. Also be sure to sign and date the a,$d2vit '11e a.idawyit 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 requl-ed to obtaia a workers' compensation policy,please call the Department at the.number listed below. Self-insured companies should enter their self-incitrance 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 BE 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 pern.itlIicense 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 Iced out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or co;nm7ercial 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 like to thank you in advance for your cooperation and should you have any questions, please do not hesitate,to give us a call. The Department's address,telephone and fax number: r t t ne Commonwealth of Maassachus6tts-- > . ��Degartm�t f1f l'nd�zstz�al i44ockdE:IItS's 01jace Of layestigatimi 600 WaShUlgtau Sb:tt �c�sTan,1€A 02111 Tel.4 f 17-727-49-0 W 406 or 1-977 MASSAFE Revised 4-24-07 Fax 9 f 1 `27-7-749 Www.mass-gav/dia Propertyn er Must Convkte and Sign This Section if us firm A Builder r 1, ANA-k,)v y y9-:,� S a Ckmer of 6e suYjmt propeny Mittel Binnall by or 25 Geneva Rowed W 2Ct Oa My bebA in A n3amrs rektive to work auffiorimd apP, n fors '. s0 , Sium o C� \ XFINITY Connect Page 3 of 4 J _ 't 1 1 •* / , r �f .., �e�om�n�uvruaecrl�o�Caa�uaeC� �. Office of Consumer Affairs&Business Regulation Licepse or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: 05530 Type: Office of Consumer Affairs and Business Regulation Wxe piration 7/17/2016 DBA 10 Park Plaza Suite 5170 Boston,MA 02116 MICHAEL A. BINNARADDITIONSREMOLD N :t"Michael Binnall25 Geneva RoadSouth Yarmouth, MA 0266`4YUndersecretaryNot vali ithout ignature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 1 &2 FamilyLicense: CSFA-045408MICHAEL.A BINPt`ALL 25 GENEVA RDS YARMOUTH MA 02Expiration Commissioner 04/22/2015 5 Town of Barnstable ;P hermit# Expires 6 months from Usr date ° Regulatory Services Fee • s�tvsresrs, • MASS' Thomas F.Geffer,Director I UZ Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6.230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY rr __ \ Not Valid without Red X-Press Imprint Map/parcel Number 1, (0 O � �C��Z Property Address �Q (#,z- PGss A > CE&n E j( L, Residential to Value of Work$ (� Minimum fee of$35.00 for work under$6000.00 e Owner's Name&Address ,N �, Z. isV m ts Contractor's Name CAJP&L, F>(9,Sr-AAL,_L_ Telephone Number`j&-7 6 0-41 U Home Improvement Contractor License#(if applicable)]O<5 ® Email: &JK'A:Y-tt,. Construction Supervisor's License#(if applicable) - ❑Workman's Compensation Insurance e: Iraa sole proprietor AU G 3 20�3 the Homeowner ❑ Lhave Worker's Compensation Insurance TOWN OF BARNS7ABLE Insurance Company Name Workman's Comp.Policy# 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 ❑ oof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ 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 Home Improvement Contractors License&Construction Supervisors License is 'red. SIGNA Q:\WPFILES\FORMS\building permit fo \EXPRES .doc Revised 060513 The Commonwealth of Massachusetts VDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A Please Print Legibly Name(Business/Organization/Individual): L, �,.1._. Address: \ bh1r�%Acn- ( �w,,CJ lam. City/State/Zip: Ca"#> �1- Phone#: g'e" -L4- 20 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I mployees(full and/or part-time).* . have hired the sub-contractors 6. ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑Building addition [No workers comp.comp. insurance P• required.] 5. We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a--' _ fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. .Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby.certi nd the pa' and penalties of perjury that the information provided above is true and correct Si a Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having.not more than three apartments and.who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or.repair work on such dwelling house or on the grounds,or building appurtenant thereto*shall not because of such,empl6yment be deemed to be an employer." MGL chapter 152,t§25C(6)'also'states"that"every state or local licensing agency shaU*itfihold.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,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 or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: t s The Coriimonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 vvww.mass.govfdia Owner Must and Sign This Section if Us` r A Builder as Ow=of the sWyxt propel Michael Binnall by Naha 25 Geneva Road to act on nVbehaIL in A zs r&five to work aurhorimd by dds bugd4 pemkappl t`on fol- (Addwss of 6b) S of __ me r�Af airs& ifi/ss Re gaa tiom Cli License or.re istration valid for individul use only Office of Consumer Affairs&Business Regulation•• g _ OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �(, registration: ;,ib5.530 Type:. Office of Consumer Affairs and Business Regulation > x iration: _7G;1:Z/209.4:; DBA 10 Park Plaza-Suite 5170 P _ j Boston,MA 02116 MICHAEL A. BINNALLv.-AD,DITIONS REMOLD Michael Binnall j 25 Geneva Road C' C South Yarmouth, MA 02664'== Und r e secretar with ut signature y Not va�d w� g I z I Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construction Supervisor 1 & 2 Family License: CSFA-045408 MICHAEL A BINP>`AL 25 GENEVA RD S YARMOUTH MA 02 I I c J J.•G.� ��.n its Expiration Commissioner 04/22/2015 Regulatory Services P Thomas F. Geiler,Director s�xws�.z, t Building Division r+zAss Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 TOE © TA www.town.barnstable.ma.ns 4 , 7013 11,012.2 2 f;� 12 Office: 509-862-4038 Fax: 508-790-6230 Approved: Fee: Qi �'� - Permt#: o c r 3 HOME OCCUPATION REGISTRATION Date: Name: Phone Address; [D 1 acc ba 5kVillage: l �17t tte Name of Business: pay=W!(Le Type of Business: -_:�Jw6N;yjj / nh(,c�w f(1 T" Map/Lotd I F(' c) j� INTENT': It is the intent of this section to allow die residents of the Town of Barnstable to operate a-home occupation vvithin single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity, shall not be discernible from outside the dwelling. there shall be no increase in noise or odor;no visual alteration to dne premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater.pollution re gistration gistration«ith the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried_on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. . Such use occupies no more than 400.square feet of space. • There are no external alterations to the dwelling which are not custom in residential boil • and there is ems, no outside evidence of such use: ' • No traffic will be generated in excess of normal residentialvolumes. • The use does not involve the production of offensive noise,'vibration smoke,dust or other particular matter, odors, electrical disturbance;heat,glare,humidity or other objectionable effects: • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities.. • Any need for parking generated by such use shall be met on die same lot containing die Customary Home Occupation,and not within the required front yard: :. - "There is no exterior storage or:display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,odier than one van or oue pick-up truck not to exceed one ton rapacity,and one;trailer not to exceed 20 feet in length and not to• exceed 4 tires,parked on:the.same lot containing the Customary Home Occupation. No sign shallbe.displayed indicating the Customary Home Occupation— ' •: .If the Customary Home Occupation is listed or advertised as,a business,the street address shall not be . included: • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the, d-welling unit. I', the enders' e have read and. e ith die above restrictions for my.home occupation I am registering: Applicant: Date: —�J V Honieoc.doc Rev.01/3/08_ YOU WISH TO OPEN A BUSINESS? For Your Information: 'Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this format 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office,:1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in lease: APPLICANT'S YOUR NAME/S: c Z� r � BUSINESS YOUR HOME ADDRESS: � t{'�a J c l a W-M. TELEPHONE # Home Telephone Number g' - NAME;pF CORPORATION ". NAME OF NEW BUSINESS a e t - E OF:BLISINESS IS THISA HOME OCCUR!>TI,.ON? YES �nS4l{zew_t ADRRESS OF;BUSIIyESS �MAP%PARCEL NUMBER [Assessing); .;•;' When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200"Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSIO ER'S OFFICE This individ al .. en i an per it a uire ants that pertain to this type of businesUST COMPLY WITH HOME OCCUPATION A h eP ** IRULES AND REGULATIONS. FAILURE TO COMMENT : _ COMPLY MAY RESULT IN FINES. 2. BOARD OF HEALTH This individual ha a infor f the ermit re uirements that pertain to this type of business. Authorized gnature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: olao77� Town of Barnstable *Permit# O r _ om issue date Regulatory Services r * JW'7- + 1ARNSTABLE, v M^S& Thomas F.Geiler,Director ' 139. DECe 12 2012 Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 �o�N OF SARNSTAg www.town.barnstable.ma.us LE Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number /(OY-0 i t 0 PropertyAddress /V'S �J �eNT eiz vl, L- "'A, © � 3 ❑Residential Value of Work /7 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address p R ki/S Contractor's Name .e4d)T G C Telephone Number /D/' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation,Insurance Check one: ❑ I am a sole proprietor ❑.I am the Homeowner I have Worker's Compensation Insurance } do Insurance Company Name A fil z 1(f I A) 7U2 IC y A)C Workman's Comp.Policy# 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) Re-side #of doors ❑ placement Windows/doors/sliders.U-Value (maximum.35)#of windows 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. e Home Im ve ent Contractors License&Construction Supervisors License is required. ' SIGNAT' Q:\WPFILE ORMS\building permit rms\EYF .doc Revised 053012 ik 77ee Caalar manwealth a,f Massadiusetfs Deparhnentaflndusoiat Accidents 0 Ce�rrInvest gt;Gtions 600 T3'ashington 'Street .Boston,AM 0111 rnww jnassgov1dia Workers' Compensation Insurance-Affidavit: Builders/C-ontractnrs/Ele.ctricians/Phinbers, Applicant Information Please Print Leldbly Name(B,LsJuew/Orgmiizationlludividual): A d Ad&ess: yW) OA)i ✓C /7`V A/co City/Stat&zip: Phone#_ 7�I—A Are you an employer?Check the appropriate box: Type of project(required). 1.❑ I am a employer with 2-5'-' 4. ❑ 1 am a general contractor and employees{full and/or perk-#i=)— * .have hired the sub-cont�ctois .6. .Q Neeu�construction 2.❑ I am a sole proprietor or partner- lasted on.the attached sheet_ 7. ❑Remodelling ship and have no employees These sub-contractors have g_ ❑Demolition. w,,,l�.^Q for me in an c employees and have wtrdcers' �' b y capa' ity. }.-`❑Building addthDu [NO workers' comp.;,mura ce comp-irtsurauce 1t}. Electncal or additions required.] 5. ❑ We are.a corporation.and its _ ❑ repairs 3.❑ I am a homeowner doing all wank officer's have exercised dick 11.0 Plumbing,repaiis or additions' . myself [No workers,comp right of exemption per 1v1GL 12.❑ of repairs insurance required.]g C. 152,§I(4),and we have no employ-(No workers' 13. Oilier comp.insurance required.j *Any applicsut that checks box#1 must also fillow ilie section belm showing their wo&ere compensat an policy inforinstiaa ; I Homeowners who submit this af�dsvit indicating they are doing sawa t and then hire outside contractors must submit a new afdacit indicating such. IContracmrs that check this boat must attached oat additional sheet showing the tisme of the sub-concracbm and state whether or nut those entities have employees. If the sub-c ntraaors have employees,theymust pmuide their works'comp.policy number. I am art employer that is pmvi&ng"Trkers'cotirpertsadon insurartcs far.iffy smploy'eM Below is theponcy andjob site informadon. Insurance Company Marne: ���/(�IQ � �L9{.I r- !-! by<— eo Policy#or.Se1f-ins.Uc.#: 0 J-0% ��Yz Expiration Mte: /© Job site as : aD9 fr t �� Gity/state/4. �z NTEiQ l//�L ,IVY 0Q6 3 Z 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 225A of MGL c. 152 can lead to the imposition of criminal penalties of a. fine up to$1,500,00 andlor 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 sta#ement may be forwarded to the Office of Im-estigations of the DIPS for insurance coverage verification . I db hemby ce#ounder the pains n :ury that the informatkit provided above is bate and correct Z- Si Phone'#_ O,pial we only. Der.not write in this area,to be coutpleted by cite or tetewwt of ficiaL ' City or Town: PerasidLieense ff Issuing Authority(circle one): 1.Board.of Health 2.Building Department 3.Cityffown Clerk #.:Electrical Inspector 5.Plumbing Inspector 6:Other Contact Person: Phone#: 6 Cr The Commonwealth ojfMiwackusetts Deparhnent of 1rnA Estriat A cidm& Offwe o,f Irr tiger ions 600 Washington Street .Boston,MA 02111 n v.mi sxgoi►/dia Workers' Campensatian Insurance Affidavrit Budders/ ntract n-.sfE ectririanslPhunbers Applicant Infarm;ation Please Print Lewby Na : City/State/ : vo G S1 woo rv\A• p a-o 4 o Phone-g- 7 1 3 5 S 'S y�9 Are you an'employer?C herkthee appropriate box: Type of (required): ra' 4. am a, contractor an project Ted)- L p I am a employer with I❑ d I 6- ❑New tiou employees(fall aodlor pert-time).* have hired the sub-contractors 2-❑ I am a sole prepiie3or or parterres listed to the attached street. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition woddng for me in any capacity employees and have wormers' 9. ❑Building addition [No wog'comp-iTanna=e comp_msam+nnP l required_] 5. ❑ We are a rraporaticn.and its 1�-❑IIec�t�1 repaus or °� 3_❑ I ama homemmer doing allwodr officers have used their 11_0 Phlmbmgrepairs oradrlttnms myself.[No wodmrs'camp. right of emw4ykon per MGL 110 Roof repairs insurance regnite&]t c_152, §1(41 and we have no employees.[No wcsd=s' 13�ilther �l �R yw comp-insurance required-] Tiny applicant @iat checks boa#€1 must also sit out the sectim bekw sha inigtheu a there ccm4mns8foa.p0Lcy inform&n- $Mmevwaets who submit this affi&w ibcating they are doing sli wak and then hue outside contactors amen submit a new afds"indicating such_ ZCon=ctm that check tLus6moc most sttwlwd su additional sheet shakemg the nmme of tine sutrcamRtacmrs.aDd:statPwhy crnotthose entities hark employees..If the sabtnm i=rs;lace mooyees,they moil Fmvide*ek wvr km'comp.policg numbff I am an employer that isproviding warken"compamaden iamrance f or my onWht wee. Be' w is tho panic--y and jab situ informahom Insurance Company Name: 1M t-1 Policy#or Self-ins-Iic.: : W G ' o g 5 Q 9 f 0IR Expiation Date: Ic;J f _ ] Job Site Address- �G1 li,' g TI tX• . . Ctty/Statelip:.. ►�/l —�'cL01 -- Att2ch a copy of the workere comapensationp ration page(showing th7e-policy mom er ancl.eqnFaSoN dale). Failure to secure coverage as required under Section 25A of Dt GL c 152 can lead to the imposition ofmatinal penalties of a fine up to$1,500-00 and/or one-year imprisonnimt as well as civil penalties in the form of s STOP WORK ORDER and a ofup to$250.00 a day agaiirst,the dolator_ Be advised that a copy of this stag may be forwarded to the Office of Investigations of the DIAL for insurance coverage veritio I do h eraby grhj}r srtd�r the ads ofpedaq that the informateom.prm idrd sbaw is true and ewect Si.at.iw- / Date: i't3 I Phone#- of j%cial itse&nly. Do not write in this,area,to be completed by cat} or town of c&L City or Town: Permit/Liceuse# Issuing Authority(circle one)-; 1.Board of Health 2.Biding Department 3.ftTown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9- 6 Ca; T ® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY 1NSUR�INCE ,D/D,2D,2 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 CONTACT Marsh USA,Inc. NAME: PHON FAX 1166 Avenue of the Americas A/C-No Ext: A/C No): New York,NY 10036 E-MAIL ADDRESS: INSURE S AFFORDING COVERAGE NAIC# 58880-ADT-MAIN-12-13 INSURER A:Zurich American Insurance Company 16535 INSURED ADT LLC -INSURER BAmerican Zurich Insurance Company 40142 410 University Avenue INSURER C: Westwood,MA 02090 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: NY0006480370-06 REVISION NUMBER:3 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. INSR TYPE OF INSURANCE IADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDDIYYYY A GENERAL LIABILITY GLO 5095899-00 09/28/2012 10/01/2013 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL UABIUTY PREM SESOEa ocanenoe I$ 1,000,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 - GENERAL AGGREGATE $ 4,000,ODO G XEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,0070 JECT POLICY ElPRO- n LOC $ A AUTOMOBILE LIABILITY AL 5095900-00 09/28/2012 10/0112013 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - BODILY INJURY(Per accident) $ AUTOS AUTOS X X O WNED PROPERTY $HIREDAUTOS AO (Per accident) UMBRELLA UAB OCCUR I EACH OCCURRENCE $ EXCESS UAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$. $ B WORKERS COMPENSATION WC5095897-00(Deductible) 09/2B2012 10/012013 X I WC STATLL OTH- AND EMPLOYERS'LIABILITY - A "ANYPROPRIETORIPARTNEWEXECUTIVE YIN WC5D9S89&00(Retro) _ 09292012 10/D12013 2,D00,000 OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory in NH) EL.DISEASE-EA EMPLOYEd$ 2,000,000 If yyes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY.LIMIT $ - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES Attach ACORD 101 dditional Remarks Schedule if mores ace is - uiFed - CERTIFICATE HOLDER -CANCELLATION ADT LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN:TOM LEE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 410 UNIVERSITY AVENUE ACCORDANCE WITH THE POLICY PROVISIONS: WESTWOOD,MA 02090 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Cynthia Y.Kim ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD r cf • C0M + MVYEALTH 0F.MASS#tf#�1ETLS ;=- ' :`;A`;f:E �S6RED_SYStM Cot T £T._ ABOVE 11G04SE Fff � _:-.-A�)�:�`L��C;=D�A::'A��'-�:.5•E C.t1•�.3;;3-Y-`j �-•:.`:-"==:._. _ i• •::T-FJ�1�J�1AS.=:J tEE,_::: r:,:: - __ _ = _ . 10 C3311RSiFX1.AUE c. G 07131/13 .._• — Fold,Then Detnh A{rg A€PeAcri ons ._— —-.J•- 4 Commonvdeaith of Massachusetts � Department of Public Safety kcurih'S<<lemx-S Lirrnsc r License:SS-001779 Yam- Thomas J Lee = � 410 IIniversitv,41ve e. Westwood IN6�02(fl0 c`L Expiration: Commissioner 05/1 6120 1 4 ` 0 I li WE Town of Barnstable Regulatory g 13' Services + saxivsrasr.E � Mass. � Thomas F.Geiler,Director' i659- �0 �Ec1uu►l" Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403.8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Bu ilder as Owner of the subject roe . l P p �y hereby authorize U / to act on my behalf, in all matters relative to work authorized by this building permit: (Address of Job) *Pool fences and alarms are the responsibility,of the applicant. Pools are not to be filled or utilized before fence is:installed and all final inspections are performed and accepted. Signature of Owner" Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS 6/2012 �'THMETay Town of Barnstable Regulatory Services 3ARNSTABr.E. : Thomas F.Geiler,Director y MASS. 1659. �.• Building Division ED MA't - Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print - DATE: JOB LOCATION: number street. village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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. Signature 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 4; 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 pemiit 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:fomrs:homeexempt 62021 �9A 1+2-D- 5-lib iM76wer Ohm I10 - . Q LI I � - - Qf t 1 hA, 1 03 i Ou r • - - 4 r l jmw -_ _ . . : -- - ----- -- -. _ Pt t a&3 _.. So 42.o-5�7D ; � t ZZ z 4Z , { _ a, yy � # CSC. l 31 � 1�. \J 626321 C9A L'w 5-1 b b _ - - -- - t3 _ r ZLii--- - C 1 Uz- eAkAvUE) - �s tq3 5-1 0 E _ no 2 s /1 ij -'Cuv)r-AaA T at�",�> ,^.., s•'r £ —ti. a'"'t t`;i Esc N +, rYr r. s 5 ib t y, Fiji ,y ,j PvP-4 �J'�6&3z ISO 4Z FE r - _ 1/y) i ( Arnica Mutual Insurance Company SOUTHEASTERN MASSACHUSETTS OFFICE QTJ Z Arnica Life Insurance Company 596 Paramount Drive Arnica General Agency,Inc. Raynham,Massachusetts 02767-5172 Mail: PO Box 529,East Taunton,MA 02718-0529 0 AUTO HOME LIFE May 14, 2002 Town of Barnstable Attn: Building Inspector 367 Main Street Barnstable, MA _026012 File Number "F12200203494D Date of Loss: May -13., 2002 Owner/Insured: Joan_R. Rook Street:r10 •Fair Oaks Road Town Type of Loss:--Fire To Whom It May Concern: Please be advised that we insure the above named individual(s) . A claim has been made for Damage to .Real Property and as the insurer, we are presently in the process of adjusting the'. loss. We are mandated to comply,,w,i,th:;Ma,s.sachusetts General Laws, Chapter 139 and as such, if ;there are any present liens on the above property, please notify us within 10 days of receipt of this letter. If we do not hear;:from you, ' we will be under no obligation to pay you any portion of this claim. Very truly yours, William N. Lamb Jr Claims Department Amica Mutual'`Insurance Company wlamb@amica ,com 3 *AR . TY r r ) Toll Free:i-800-59-AMICA(1-800-592-6422),Web Site:www.amica.com Claims Fax: (5o8)824-5927;Production Fax: (5o8)821-5525 .ram•. ., .,. _• JTOWN OF BARNSTABLE BUILDING PERMIT APPLICATION i Map Parcel ' Permit# Health Division Date Issued Conservation Division 4 Feed S �� Tax Collector a ad-3�o�oop w Treasurer - d 1 . Planning Dept. , Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Now;A-pndsS 113 voj,� Project Street Address J L-o a - Village L,4�IC Owner C20 Address Telephone �' ' �- Permit Request U RXIS1 * oS�J,Cr_/ ',�s // .f o OYJ�i AiS' JXJaA,- Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost 0 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 Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zo\g Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION r Name :' k. 61 Telephone Number Address License# Home Improvement Contractor# m W Worker's Compensation# iZC° ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ON SIGNATURE DATE 1 FOR OFFICIAL USE ONLY — PERMIT NO. DATE ISSUED , MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTI ' FOUNDATION - FRAME INSULATION i K �-' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: s ROUGH FINAL K . k c FINAL BUILDING ` DATE'CLOSED OUT ASSOCIATION PLAN NO. t EVEw The Town of Barnstable 2"9- De artment 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 registered contractors,with certain exceptions,along with other requirements. � � � f���o "'"Es `L � -f 6 0 Type of Works �� sated Cost Address of Work: Z(� t Ajk OA AS Owner's Name: -, YJ d)P f J Date of Application: ) 3 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law f—IJob 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 hereby apply for a permit the agent of the owner. Date Co ctor Name Registration No. OR Date Owner's Name g1orms:Affidav r fI tic C1-4ML!1LU/LI✓eUiLi4 UJ �11LL.JJ4Lf�LLJL�aJ 1- = Department of Industrial Accidents Office otfnresffgagfoos 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location: city �LC UI!f i� phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole netor and have no one worki>l in any capacity %%r I am an employer providing workers' compensation for my employees working on this job (` /�S address. - city' r1�/�� f ll phone#. k r iL � insurance co. -1�� olicv# t ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company:name: -: address. ... rite phone#. .........:::. .: ; ....:::: ....... ... .......... . ... ........ :.;:::.... ..... . .... .... ........... ...........:::..: nsnrantie ca. ..: .........,: ,. o tcv ;: a� canrpanv name address. dtV phone# ..:....... nsurance cm.::. olicv#:.. ... ..,. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'Imprisonment as well as dvfi penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is truo,and coned Signature f� Date Print name L. L_ Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# • ❑Building Department ❑check if immediate response is required ❑Selenme Board ❑Selectmen's s Ounce _ ❑Health Department contact person: phone q; ❑Other Ormed 9195 P1/U AF. I HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standards One Ashburton Place — Room 1301 Boston , Massachusetts 02108 - ------------------- ,OME IMPROVEMENT CONTRACTOR ©gistration 103714 Expiration 07/09/00 -- HOME IMPROVEMENT CONTRACTOR y p e — PARTNERSHIP I Registration 103714 I I — Type - PARTNERSHIP PAUL J . CAZEAULT & SONS ROOFING I Expiration 07/09/00 Paul J . Cazeault 2 G i d d i a l t R d . P •O - Box 2781 I PAUL J. CAZEAULT 5 SONS ROOF! 2 I Paul J. CazeaulL Orleans MA 02653 I � I � 42�iddialt Rd. P.O. Box 278 i 5w^To'1 Orleans MA 02653 cow g Board of Building Regulations e Rm 1301 �l Ashburton Place,One Ashb 8 n Ma 02108-161 ,.,.- Bosto , B i rth d ate: 10/20/19 59 License: CONSTRUCTION SUPERVISOR LICENSE Restricted To: 00 Number: CS 026325 Expires: 10/20/2001 PAULJ CAZEAULT 1585 MAIN ST OSTERVILLE, MA 02655 7665 Tr:no: d change of address notification. Keep top for receipt an .. CERTIFICATE OF LIABILITY INSURANCE 08/11/9 PAODUC.EA THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Ma Mors br Servant, Ltd. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5700 Post Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1158 Cast Greenwich, RI 02818 INSURERS AFFORDING COVERAGE INSURED INSURERA:TransCOnt_lne . Paul J. Cazeault & Sons Roofing _..._..._.__.. __......-- . INSURER 9: _- INGURF-R C: 1NSIIHFH D: IN3UA EH F: COVERAGES TI IC POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PEIUOO INDICATCD. 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 CVUMS. Im ii POLIGYFFFFC7(VF POU7VF.YPIRATI(1N LIMITS _ Lin TYPE OF INSURANCE POLICYNUMBEA ATE MM DD DATE MM DD A GENLRALLIABILITY C180024822 04/30/99 04/30/00 EACHOCCUMMENCE 000 000 X COMMEHCIAL(;FNEHAL LIAHILIIY FIHE OA MA( E(Anyu.elrel s100 OOO ---I CL AIMS 7 MADE Ixj OCGUFi MFD FXP(Any(ne Verson) %5�000 --_ x PD Dell: 1 r 000 PFRSONAI AAOVINJURY SI 1 0001 000 -- (:ENEHAL A06HE(;ALE Q,.000,000 f:FN'I A(;(iHFGAIF11M11AVVIIFSVFH: VHODIIC COMP/OPA(iR--- VOI ICY X PHO 1 OC Ai—("] AUTOMOBILE LIABILITY GOMHINFDSIN0I.E LIMIT S (Fa arxidenl) ANY AU TO All OWNFD At)103 BOUILYIN.JUHY. S (Per pe(son) SG H F I)U 1.1.-D AU OS IIIHF.UAUIOS RODIIYIN.IIIRY S — NON•OWNEDAUT03 (Pereccldenl) -- PHOPFHIYIIAMA(;F. .. .. ........._...._._......_.__ .. (Perncudenl) GARAGL-LIABILITY AL110UNIY FAAGGIDFNT S ANY A010 OTI IEH TI IAN FA ACC; S ALITOONLY. AGG S EXCESS LIABILITY EACHOCOLIHHENCE S 6GC.UR GI.AIMS MADE AGGRFGATF S i S OFOl1G7IF(t F A WORKERS COMPENSATION AND WC199413744 08/09/99 08/09/00 X 1 HY D.• -H WC STAIU.IM111- EMPLOYEFIS'LIABILITY F.1..FACHACC.IDFNf S1OO,OOO F.L.DrEASE EA EMPLOYEE $LOG 000 J.. F.L.CIISFASE PCII.ICYLIMIT 6001000 OTHCH DESCRIPTION OF OPEIIATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BYENOORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION SHOU LDANYOF THE ABOVE DESCRIBEDPOLICIES BECANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR 10 MAID DAYSWRITTEN NOTICE107HE CERTIFICATE HOLDERNAMEOTOTHE LEFT.BUTFAILURE TOOOSOSHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANYKIND UPON THEINSURERAS AGENTS Oil REPRESENTATIVES. AUTHORIZED REPRESENTAjIVE ACORD 25-S(7J97) 9 S8 2 8 9 4/M8 2 8 9 3 ( B M 0 ACORD CORPORATION 1908 _ � � , � � .. ,. � `:;1��` ��✓/JL- .. Jj����. ;to ,t�, ...F.,..,,.,,.�_ Assessor's office (1st floor)- fir 0 CF?NE TO Assessor's map and lot number 0).CAX?.... k Cfa 2- Board of Health (3rd floor): Sewage Permit number i BABBSTABLE, .................. ...... ................... .r � MADa EWgineering Department (3rd floor): b House. number ............................................. ........ o wAI \0� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR w APPLICATION FOR PERMIT TO ...........1 .1 ..!.. ............................................. .................................................... TYPE OF CONSTRUCTION ................51,x).r.7...C...... �.................. VV �/ ...........................r... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: -�--19 K Location ............... -!-r; •-...-. `.!-: -!�.. .............. .f. ............................................. r Proposed Use ..... t.e.:?fir �or�,. �.. ... C..jF.....r'?� .5.!. �.G._!1.f...C�.....................................:........................... C/i ZoningDistrict ........... R ... ..,.,..:.A.............................................Fire District 1.0........................................................ Name of Owner ........to J.:`...� .1.(.,:...........Address ,... �.�^....�.....�CJ...0...... .............�,�,�......r�..�.........r.1 e-q,11 f a �............................Address .r r Name of Builder�a?`...r.,7.....�1...,....�...�..,:s:_.�.... .................................................................................... Name of Architect J ?'V.t:�.. r dfY..1.n/1 .!.5....,��,ta.7 .............Address tl.r.'.us'a�.i. )C� .G.? ... ,d•s ,�S yr��^^'' c.,...:....^:.....,...... I r� �) Number of Rooms .....!J......J..../ ,... .....,..�............................Foundation .....�. �c a,..e'. 4 . ... ..................................... J l � �'aCrrJ� c� ...Roofin J�` .Y,.. .F.......... Exterior ....J:...,.�'?.r.b:'1 '�..�,�..�......�,��;tt..�......:...:.....:. g Floors .........� / ....A...........................Interior ....�. ,�. .. , . ,� ... . . .. . .. .................. Heating ............. ...; .........................................................Plumbing ............�? �.'..f............:................:. I Fireplace .............. R.........................................................Approximate Cost ........ L Z L� w. �Cld...a.... ( ............ Definitive Plan Approved by Planning Board __________!2// ________19_< l Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. 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. ' Name ..t r2 �y . .......................... + Construction Su ervisor's License 4� !� A. J. IJUE, CO. INC. A=1!68-9.1-2 -,No .... Permit for .....U.A�uy... .......... ....... ............ 5-t-0..Y . . ..Single„family ........ ....... Location ....L.Q.t.. .......................C.Wa t e X.V.i Ile............ .... ............... Owner ........ Type of Construction .......Frame......................... ................................................................................ Plot ............................ Lot ................................ Permit Granted .......July 1JA...............19 86 Date of Inspection ....................................19 Date Completed ......................................19 C3- AsIssor's office`(1st floor): ' � CF TN E TO Assessor's map,and lot number !. ...16.8.... a reel qa L o� 2— Board W o of Health (3rd floor): `O Sewage Permit number .......:.. SEP i BASB9TADLE. : TIC SYSTEM MUST SE MIA& Engineering Department (3rd floor);: INSTALL 1639 \ems •--- House number ...........................................' O• J;S. D IN C®MPLIANC YPY d' WITI♦ TITLES APPLICATIONS PROCESSED 8:30 9:30 A.M. ands 1:00-2:00 P.M. ENVIRONMENTAL CODE AND TOWN' OF BARV9T% �® BUILDING INSPECTOR � APPLICATION FOR PERMIT TO ..:........ ......................................... ..... ............ ............... i. .. • c , TYPE OF CONSTRUCTION ...............4? !lC�.. ... .. ............................. . .... ........................ ........19.;, TO THE INSPECTOR OF BUILDINGS: The undersigned hereb h f�a , arm' ccarding to the following information: eft ttTti Location . ..... ... ... K � : 11k.............A-.0 t � .�........................................... ProposedUse ... 1.! 19..�.... 4AA,..... . ........................................................................................ Zoning District ........... ..•—:.:4.........................................Fire District ........ - �+ Name of Owner .t-t...�........IVY'�.....1.�1.•.}..,��1G.............Address Name of Builder ....�..w� ..�... . . . . _,.............................Address .................................................................................... Name of Architect ..... ... 1... .... ��...'..l.AUYl .... Y?. ,.........Address . lh.�'? !�.''1� ... IS. /✓1 Number of Rooms .....G...Q ......... ...................Foundation .......�1 NC ...................................... �hJ.1'1.9 ... b ...............Roofing ........As Exterior .......... ..................................................... Floors .......L ! � CG� -/!?�� ....................Interior ..:.c !' � ..... . . Heating p ............ .. . C�(.........................................................Plumbirig ........... .y. ... .. .....+..................... \ Fireplace .....:....... .. ................................Approximate Cost �..d�!�.. ...�LLS ` y Definitive Plan Approved by Planning Board ___________ ________19 ____: Area ... . �... Diagram of Lot and Building with Dimensions Fee .. ........ I SUBJECT TO APPROVAL OF BOARD OF HEALTH et t7 ��® - j - r 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. Name ..e%��......'��C. :��?���J'�.. ...................... Construction Supervisor's License 0.),0.1.31............ A. J. LANE, .CO. , INC. r�o,•e. .. .. a1 ..2�.6.44..:. Permit for ...1.j..S.Gazy....:........... ' .... Single-family...Awellin • Location ..:.Lo t..�i`2.,......I.Q..Fal.?...Q xs...Fo d.. .. .......................CPntprville................................. - Owner ..........E1,...J:...La?��..GQ..... .0................ - - Type of Construction Frame,,,,,,,,,,,,,,,,,,,,,, Plot ............... ........ Lot ................................ Permit Granted July. 11,... ..'� --- ...19 86 Date of Inspection :.........../........................19 s Date Completed ........... .L- .......... ....19990 t -- ,,; { r t Ait ♦ r - ar ' l - }�...:�,t-,.ae._.,"� �.^f ..t r;' ; ►�:Zir,,,,,ti ,{,,:, .. -;-F;T,.. a §e.,,: _• `'-r. ��r e.o,-„z�t?'�.-:�kv`_:. ._._.�:« '�'�_'{"'�. .. "t '� t +� i . by piTNr�`e TOWN OF BARNSTABLE Permit No. . 96,44E ? BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash ($1.:.0.0 f—0.0) 3/Il HYANNIS,MASS.02601 Bond ................ CERTIFICATE OF USE AND OCCUPANCY Issued to A. J. Lane, Co. , Inc. Address Lot #2, 10 Fair Oaks Road Centerville, Mass. � USE GROUP FIRE GRADING OCCUPANCY LOAD je.-0THIS PERMIT WILL,NOT BE' VALID, AND,THE BUILDING SHALL NOT.-BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR..UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE ` BUILDING CODE. J ... Februarv..23 r 88 `....... / ..� -?-� Building Inspector t •.:' '. :' ". + .:J �Q F ; , r 8y Y4. \ !'��'ty 1t * ••11 ''`'F.I'!,c c •PINK DEPT.:.FILE COPY/tWHITE FIELD COP1f l YELLOW APPLICANT COPY \TOWN OF BARNST�hBI�, M::CHUSETTS 1 ,tip { ARz6a 9z 2 PERMIT + VALIDATI614 , - Crl t t 11 t r , ; � � i t• I i t Jul �• �Fi.! alas y v f , DATE, y �rr 19.' 86 P..ERM4T N0 APPLICANT A. J. Lane ADq(ESS A500 'Worcester Rd kramingha�c I.: 020T�8. ' r:': (NO ) d57REET)+ 1 pCONTR 5 VICENSEV• PERMIT+TD Bind 1)Glellin>; ( ) STORY Single-Family7�- fig: DWEBLRNG UnITS (TYPE OF�IMPROV'EMENT) .NO,. }(PROPO'SED USE)4 .. ' ` qT (LdCATIONj LOt`, ��2, 10 Fair Oaks Road, IC tervi}le. zoNING (STREET) :DISTRICT �L BE7WER Y AND (CROSS:STREET):' b ,(CROSS STREET) > SUBpIVISION LOT r J LOT BLOCK SIZE r BUILDING�IS TO 8E' F..T WIDE'BY � FT. LONG.BY `"�FT IN' HEIGHT AND SHALG'.CONFORM IN.CONSTRUC7`IOh a ,, .. T'O TYPE USE GROUP: El FOUNDAT LON ASEMENT WALLS OR (TYPE) 4 REMARKS sewage ��86777 65 y WestBay Realty Trust Os arvii�e ARE°d2700 $ ' ' s ` VOLUME` 4• '' �• ESTIMATED $Q 00Q 00', PERMIT (C.UB.IC/.SOUARIt FEET),.. - i FEE 7,62 OO BUILDING DE T ! J AooR�ss 1500 Worcester Road: Framinizham i i r Y I l MINIMUM OF THREE CALL 'IN$P.ECTOR . IONSREQUIREDFOR AP_PyROVED F�L74rv5wr-v' rcrc-it$•I+�IivcJ'iON,JOB AND THIS WHERE APPLICABLE:SEPAR'ATE I .'ALL-CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR ".{ ELECTRICAL,' PLUMBING- AND I:..FOUNDATIONS.OR FOOTINGS. MADE. WHERE A CERTIFICATE OF. OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. j 2:'PRIOR TO COVERING STRUCTURAL .QUIRED,SUCH BUILDING.'SHALL NOT BE OCCUPIED- UNTIL MEMBFINAL INSPECTION TO LATHE, FINAL INSPECTION HAS BEEN MADE. 3 .FINAAL INSPECTION BEFORE, OCCUPANCY. tE POST THIS CARE SO-IT IS,::VISIBLE�� FROM STREET. BUILDING INSPECTION:APPROVALS PLUMBING INSPECTION APPROVALS '''j ELECTRICAL INSPECTION APPROVALS •'I .2 - - Z 2 . .3 - HEATING INSPECTING APPROVALS - REFRIO RA i[ON INSPECTION APPROVAL ! OTHER. 2. .. 2 _ HEALTH , � t + + WORK SHALL.NOT PROCEED UNTIL,THE PERMIT WICI:BECOME NOLL-AND.VOLD IF CONSTRUCTION. INSPECTIGNS INq ..'INSPECTOR HAS APPROVED THE J'ARIoU$ WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CATED:;ON THIS'C ( STAGES`OF,CONSTRUCTION CAN BE ARRANGED-FOR BY TEL.EPH�^ I_ PERMIT 15 ISSUED AS NOTED ABOVE._ OR WRITTEN N.OTIFICA'TION-., _.. II / y3 , �y 29p 00 . n, Go 1-+C. 11a1.a{ i Q • p D \' O 0 (n. ,n 1 4�,sot sPt v x` Lu ct1 V; 10 0 Ot.p. aa52.50 P Pe'� pd75.31 63.00' q�5.23 . 0.00 joe # 85-492 CERTIFIED PLOT PLAN LOCATION: L-2 FIVE CORNERS RD . BARN . PREPARED FOR: SCALE: 1=50 DATE: 1/8/86 .REFERENCE: RB 410 RG 10 A J LANE CONSTRUCTION I HEREBY CERTIFY THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE _ G'P.OUND AS SHOWN HEREON OF ARNE you down cape engineering H. OJAU1 1•+ 'O CI 6348 CIVIL ENGINEERS N2 �o,, .�� S " \f. R LAND SURVEYORS C l.1E 1` _ ROUTE 6A YARMOUTH MA 5AT LAte SURVEYOR