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1343 FALMOUTH ROAD/RTE 28
.� _ _ _ I�� 3 ����m� dal: . _ �. �.- ., . . , : , . �., � � _ c - a �, Town of Barnstable - - Building t � Post This Card So That it is.Visible From the Street-Approved Plans Must be Retained on Job and'this Card Must"be KeRAMpt ` Posted Unti Final.Inspection Has Been Made e j ~. LWhere a Certificate of Occupancy1$Required,such Building shall Not be Occupied until a Final Inspection has been made 1 Permit NO. B-19-2507 Applicant Name: Robert Rostocka Approvals Date Issued: 08/02/2019 Current Use: Structure Permit Type: Building- Insulation-Residential Expiration Date: a 02/02/2020 Foundation: Location: 1343 FALMOUTH ROAD/RTE 28, CENTERVILLE Map/Lot: 229-085 Zoning District: RD-1 Sheathing: Owner on Record: FAIR, ROBERT E& PAMELA K Contractor Name:'°",.,ROBERT A ROSTOCKA Framing: 1 Address: 1343 FALMOUTH ROAD/RTE 28 Contractor License: 113,252 2 CENTERVILLE, MA 02632 Est. Project Cost: $7,808.00 Chimney: Description: Insulation &Air Sealing. ) Permit Fee: $89,82 i. Insulation: Project Review Req: Fee Paid:i $89.82 Date. Rt,. 8/2/2019 Final: (( Plumbing/Gas I Rough Plumbing: ;%Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterissuance. All work authorized by this permit shall conform to the approved application and the�approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. f J i Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open fo rpublic inspection for the entire duration of the r work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this;permit. Service: Minimum of Five Call Inspections Required for All Construction Work: " 1.Foundation or Footing Rough: 2.Sheathing Inspection g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: . "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT �? -ISSUED RECIPIENT ` Massachusetts Department of Environmental Protection Bureau of Resource Protection- Waterways Regulation Program X264996 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent,Nonwater-Dependent,Amendment G. Municipal Zoning Certificate._ Robert E. Fair Jr. &Pamela K. Fair t Name of Applicant 1343 Falmouth Road Long Pond Centerville Project street address Waterway City/Town Description of use or change in use: - This project involves the installation of a new"T shape seasonal aluminum residential dock to be located on Long Pond (a Great Pond). f . To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is not in violation of local zoning ordinances and bylaws." Printed Name of unici al Official Date�-41A,- / C � ure of Municipal Official Title City/Town f i CH91App.doc•Rev.08/13 Page 6 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment Important:When filling out forms A. Application Information (Check one) on the computer, use only the tab NOTE: For Chapter 91 Simplified License application form and information see the Self Licensing key to move your Package for BRP WW06. cursor-do not use the return Name(Complete Application Sections) Check One Fee Application# key. WATER-DEPENDENT- General(A-H) ® Residential with <4 units $215.00 BRP WW01 a ❑ Other $330.00 BRP WW01 b For assistance ❑ Extended Term $3,350.00 BRP WW01c incompleting this ...........................-.........................................................................................................---------........-_. application,please Amendment(A-H) ❑ Residential with <4 units $100.00 BRP WW03a see the — "Instructions". ❑ Other $125.00 BRP WW03b NONWATER-DEPEN DENT- Full (A-H) ❑ Residential with <4 units $665.00 BRP WW15a ❑ Other $2,005.00 BRP WW15b ❑ Extended Term $3,350.00 BRP WW15c ------------------------------------.-..-..-..-..-..-.._::-..-..-.._..-..-..-----------------------------------—- - - - - - -------- ------ Partial (A-H) ❑ Residential with <4 units $665.00 BRP WW14a ❑ Other $2,005.00 BRP WW14b ❑ Extended Term $3,350.00 BRP WW14c Municipal Harbor Plan (A-H) ❑ Residential with <4 units $665.00 BRP WW16a ❑ Other $2,005.00 BRP WW16b ❑ Extended Term $3,350.00 BRP WW16c Joint MEPA/EIR(A-H) ❑ Residential with <4 units $665.00 BRP WW17a ❑ Other $2,005.00 BRP WW17b ❑ Extended Term $3,350.00 BRP WW17c Amendment(A-H) ❑ Residential with <4 units $530.00 BRP WW03c ❑ Other $1,000.00 BRP WW03d ❑ Extended Term $1,335.00 BRP WW03e CH91App.doc•Rev.08/13 Page 1 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment B. Applicant Information Proposed Project/Use Information 1. Applicant: Robert E. Fair Jr. &Pamela K. Fair Bob.Fair@Teradata.com. Name E-mail Address 1343 Falmouth Road Mailing Address Note:Please refer Centerville MA 02632 to the"Instructions" Citylrown State Zip Code FM F71 Telephone Number Fax Number 2. Authorized Agent(if any): Michael Pimentel (JC Engineering Inc.) mpimentel@jcengineeringinc.com . Name E-mail Address 2854 Cranberry Highway Mailing Address East Wareham MA 02538 Cityrrown State Zip Code 508-273-0377 508-273-0367 Telephone Number Fax Number C. Proposed Project/Use Information 1. Property Information (all information must be provided): Robert E. Fair Jr. &Pamela K. Fair Owner Name(if different from applicant) Map 229, Parcel 85 41.6565 70.3362 Tax Assessor's Map and Parcel Numbers Latitude Longitude 1343 Falmouth Road, Centerville MA 02632 Street Address and Cityrrown State Zip Code 2. Registered Land ❑Yes ® No 3. Name of the water body where the project site is located: Long Pond 4. Description of the water body in which the project site is located (check all that apply): Type . Nature Designation ❑ Nontidal river/stream ❑ Natural ❑Area of Critical Environmental Concern ❑ Flowed tidelands ❑ Enlarged/dammed ❑ Designated Port Area ❑ Filled tidelands ® Uncertain ❑Ocean Sanctuary ® Great Pond ® Uncertain ❑ Uncertain I , CH91 App.doc•Rev.08/13 Page 2 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment C. Proposed Project/Use Information (cont.) Select use(s)from Project Type Table 5. Proposed Use/Activity description on pg.2of the This project involves the installation of a new"T" sha a seasonal aluminum residential dock to be "Instructions" pions" 1 p located on Long Pond (a Great Pond). 6. What is the estimated total cost of proposed work(including materials&labor)? $15,000 7. List the name&complete mailing address of each abutter(attach additional sheets, if necessary).An abutter is defined as the owner of land that shares a common boundary with the project site, as well as the owner of land that lies within 50'across a waterbody from the project. Emanuel Alves 42 Emerson Road, Millton, MA 02186 Name Address Jose DaSilva 1325 Falmouth Road, Centerville, MA 02632 Name Address Name Address D. Project Plans 1. I have attached plans for my project in accordance with the instructions contained in(check one): ® Appendix A(License plan) ❑ Appendix B(Permit plan) 2. Other State and Local Approvals/Certifications ❑401 Water Quality Certificate Date of Issuance ®Wetlands To be determined File Number ❑ Jurisdictional Determination JD- File Number ❑ MEPA File Number ❑ EOEA Secretary Certificate Date ❑21 E Waste Site Cleanup RTN Number CH91App.doc-Rev.08/13 Page 3 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment E. Certification All applicants, property owners and authorized agents must sign this page.All future application correspondence may be signed by the authorized agent alone. "I hereby make application for a permit or license to authorize the activities I have described herein. Upon my signature, I agree to allow the duly authorized representatives of the Massachusetts Department of Environmental Protection and the Massachusetts Coastal Zone Management Program to enter upon the premises of the project site at reasonable times for the purpose of inspection." "I hereby certify that the information submitted in this application is true and accurate to the best of my knowledge." Applicant's signature Date Property Owner's signature(if different than applicant) Date Agent's signature(if applicable) Date CH91App.doc-Rev.08/13 Page 4 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment F. Waterways Dredging Addendum 1. Provide a description of the dredging,project ❑ Maintenance Dredging(include last dredge date&permit no:) ❑ Improvement Dredging Purpose of Dredging 2. What is the volume (cubic yards)of material to be dredged? 3. What method will be used to dredge? ❑ Hydraulic ❑ Mechanical ❑ Other 4. Describe disposal method and provide disposal location(include separate disposal site location map) 5. Provide copy of grain size analysis. If grain size is compatible for beach nourishment purposes,the Department recommends that the dredged material be used as beach nourishment for public beaches. Note: In the event beach nourishment is proposed for private property, pursuant to 310 CMR 9.40(4)(a)1, public access easements below the existing high water mark shall be secured by applicant and submitted to the Department. CH91App.doc•Rev.08/13 Page 5 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment H. Municipal Planning Board Notification Notice to Robert E. Fair Jr. &Pamela K. Fair Applicant: Name of Applicant Section H should 1343 Falmouth Road Long Pond Centerville be completed and Project street address Waterway City/Town submitted along with the original Description of use or change in use: application material. This project involves the installation of a new"T" shape seasonal aluminum residential dock to be located on Long Pond (a Great Pond). To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans have been submitted by the applicant to the municipal planning board." Printed Name of Municipal Official Date Signature of Municipal Official Title City/Town Note:Any comments, including but not limited to written comments, by the general public, applicant, municipality, and/or an interested party submitted after the close of the public comment period pertaining to this Application shall not be considered, and shall not constitute a basis for standing,in any further appeal pursuant to 310 CMR 9.13(4) and/or 310 CMR 9.17. CH91 App.doc•Rev.08/13 Page 7 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment Appendix A: License Plan Checklist General View ® PE or RLS, as deemed appropriate by the Department, stamped and signed, in ink, each sheet within 8 1/2 inch by 11 inch border . f ® Format and dimensions conform to"Sample Plan"(attached) ® Minimum letter size is 1/8 of an inch if freehand lettering, 1/10 of an inch if letter guides are used ® Sheet number with total number in set on each sheet ® Title sheet contains the following in lower left: Plans accompanying Petition of[Applicant's name, structures and/or fill or change in use,waterway and municipality] ® North arrow ® Scale is suitable to clearly show proposed structures and enough of shoreline, existing structures and roadways to define its exact location ® Scale is stated &shown by graphic bar scale on each sheet ® Initial plans may be printed on bond; final plans due before License issuance must be on 3mil Mylar. Structures and Fill ® All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ® Cross Section Views show MHW*and MLW*and structure finish elevations ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown ® All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ® Cross Section Views show MHW*and MLW*and structure finish elevations > ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown ® Actual dimensions of structures(s) and or fill and the distance which they extend beyond MHW*or OHW* " ❑ Change in Use of any structures on site must be stated *See 310 CMR 9.02,Waterways Regulations definitions of High Water Mark, Historic High Water :Mark, Historic Low Water Mark, and Low Water Mark. Note: DEP may, at its discretion, accept appropriately scaled preliminary plans in lieu of the plans described above. In general, DEP will accept preliminary plans only for non-water dependent projects and projects covered by MEPA to address site design components such as visual access, landscaping &site coverage.Anyone wishing to submit preliminary plans must obtain prior approval of the DEP Waterways Program before submitting them with their application. CH91App.doc•Rev.08/13 Page 8 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program X264996 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent,Nonwater-Dependent,Amendment Appendix A: License Plan Checklist (cont.) Boundaries ® Property lines,full black lines, , along with abutters' names and addresses ® Mean High Water(MHW)*or Ordinary High Water(OHW)*, full black line ❑ Mean Low Water(MLW)*, black dotted line, (.............) ® Historic MHW*or OHWk(----) ❑ Historic MLW*(..._... _...� ❑ State Harbor Lines, black dot-dash line(—.—.—.—)with indication of Chapter&Act establishing them (Ch. ,Acts of) ❑ Reference datum is National Geodetic Vertical Datum (NGVD)or(NAVD). ® Floodplain Boundaries according to most recent FEMA maps ❑ Proposed &Existing Easements described in metes&bounds Water-Dependent Structures ® Distance from adjacent piers, ramps or floats(minimum distance of 25'from property line,where feasible) ❑ Distance from nearest opposite shoreline ❑ Distance from outside edge of any Navigable Channel ❑ Access stairs at MHW for lateral public passage, or 5 feet of clearance under structure at MHW. Non Water-Dependent Structures ❑ Depict extent of"Water-dependent Use Zone". See Waterways Regulations at 310 CMR 9.51-9.53 for additional standards for non water-dependent use projects. Note: Final Mylar project site plans will be required upon notice from the Department, prior to issuance of the'Chapter 91 Waterways License. CH91App.doc•Rev.08/13 Page 9 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X264996 Transmittal No. Chapter 91 Waterways License Application -310 cnnR 9.00 Water-Dependent,Nonwater-Dependent,Amendment Appendix A: License Plan Checklist Cont. w Registry Statement 3 ca 3112 inche 5 inche Fo Locus Map Hist Sheet 0my aD zM a -21/4 inche 1 U Sample Plan 81/2 inches F P.E. 0r R IS SUMP 3 3/4 inch e Plan Accompanying Petition of... D EP Swnp First Sheet Only 39" Border CH91 App.doc•Rev.08/13 Page 10 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x2sa99s Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent,Nonwater-Dependent,Amendment Appendix B: Dredging Permit Plan Checklist For projects applying for dredging permits only, enclose drawings with the General Waterways Application that include the following information: General View ❑ Submit one original of all drawings. Submit the fewest number of sheets necessary to adequately illustrate the project on 8-1/2 inch X 11 inch paper. ❑ A 1-inch margin should be left at the top edge of each drawing for purposes of reproduction and binding.A 1/2 inch margin is required in the three other edges. . , ❑ A complete title block on each drawing submitted should identify the project and contain: the name of the waterway; name of the applicant; number of the sheet and total number of sheets in the set; and the date the drawing was prepared. ❑ Use only dot shading, hatching, and dashed or dotted line to show or indicate particular features of the site on the drawings. ❑ If deemed appropriate by the Department, certification by the Registered Professional Engineer or Land Surveyor is included. Plan View ❑ North Arrow ❑ Locus Map ❑ Standard engineering scale. ❑ Distances from channel lines and structures if appropriate. ❑ Mean high water and mean low water shorelines(see definitions of"High Water Mark"and"Low Water Mark"at 310 CMR 9.02, C. 91 Regulations). ❑ Dimensions of area proposed to be dredged or excavated. ❑ Notation or indication of disposal site. ❑ Volume of proposed dredging or excavation. ❑ Ordinary high water, proposed drawdown level, and natural (historic) high water(for projects lowering waters of Great Ponds). Section Views ❑ Existing bottom and bank profiles. ❑ Vertical and/or horizontal scales. . ❑ Proposed and existing depths relative to an indicated datum. ❑ Elevation and details of control structure(for projects lowering waters of Great Ponds). C1191App.doc•Rev.08/13 Page 11 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist Please answer all questions in the General Waterways Application form. If a question does not apply to your project write"not applicable" (n/a) in that block. Please print or type all information provided on the form. Use black ink(blue ink or pencil are not easily reproducible, therefore, neither will be accepted). If additional space is needed, attach extra 8-1/2"x 11"sheets of paper. ❑ Proper Public Purpose: For nonwater-dependent projects, a statement must be included that explains how the project serves a proper public purpose that provides greater benefit than detriment to public rights in tidelands or great ponds and the manner in which the project meets the applicable standards. If the project is a nonwater-dependent project located in the coastal zone,the statement should explain how the project complies with the standard governing consistency of the policies of the Massachusetts Coastal Zone Management Program, according to 310 CMR 9.54. If the project is located in an area covered by a Municipal Harbor Plan,the statement should describe how the project conforms to any applicable provisions of such plan pursuant to 310 CMR 9.34(2). ® Plans: Prepared in accordance with the applicable instructions contained in Appendix A-B of this application. For initial filing, meet the requirements of 310 CMR 9.11(2)(b)(3). ® Applicant Certification:All applications must be signed by"the landowner if other than the applicant. In lieu of the landowner's signature,the applicant may provide other evidence of legal authority to submit an application for the project site."If the project is entirely on land owned by the Commonwealth(e.g.most areas below the current low water mark in tidelands and below the historic high water mark of Great Ponds),you may simply state this in lieu of the"landowner's signature". ® Municipal Zoning Certification: If required, applicants must submit a completed and signed Section E of this application by the municipal clerk or appropriate municipal official or,for the initial filing, an explanation of why the form is not included with the initial application. If the project is a public service project subject to zoning but will not require any municipal approvals, submit a certification to that effect pursuant to 310 CMR 9.34(1). ® Municipal Planning Board Notification:Applicants must submit a copy of this application to the municipal planning board for the municipality where the project is located. Submittal of the complete application to DEP must include Section H signed by the municipal clerk, or appropriate municipal official for the town where the work is to be performed, except in the case of a proposed bridge, dam, or similar structure across a river, cove, or inlet, in which case it must be certified by every municipality into which the tidewater of said river, cove, or inlet extends. ❑ Final Order of Conditions:A copy of one of the following three documents is required with the filing of a General Waterways Application: (1)the Final Order of Conditions(with accompanying .plan) under the Wetlands Protection Act; (2)a final Determination of Applicability under that Act stating that an Order of Conditions is not required for the project; or(3)the Notice of Intent for the initial filing (if the project does not trigger review under MEPA). ❑ Massachusetts Environmental Protection Act(MEPA): MGL 30, subsections 61-61A and 301 CMR 11.00, submit as appropriate: a copy of the Environmental Notification Form (ENF) and a Certificate of the Secretary of Environmental Affairs thereon, or a copy of the final Environmental Impact Report(EIR) and Certificate of the Secretary stating that it adequately and properly complies with MEPA; and any subsequent Notice of Project change and any determination issued thereon in accordance with MEPA. For the initial filing, only a copy of the ENF and the Certificate of the Secretary thereon must be submitted. Note: If the project is subject to MEPA,the Chapter 91 Public Notice must also be submitted to MEPA for publication in the"Environmental Monitor'. MEPA filing deadlines are the 15th and 30t"of each month. C1191App.doc•Rev.08/13 Page 12 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Waterways Regulation Program x264996 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist (cont.) ❑ Water Quality Certificate: if applicable, pursuant to 310 CMR 9.33, is included. ❑ Other Approvals: as applicable pursuant to 310 CMR 9.33 or,for the initial filing, a list of such approvals which must be obtained. Projects involving dredging: ❑ The term"dredging"means the removal of materials including, but not limited to, rocks, bottom sediments, debris, sand, refuse, plant or animal matter, in any excavating, clearing, deepening,widening or lengthening, either permanently or temporarily, of any flowed tidelands, rivers, streams, ponds or other waters of the Commonwealth. Dredging includes improvement dredging, maintenance dredging, excavating and backfilling or other dredging and subsequent refilling. Included is a completed and signed copy of Part F of the application. Filing your Completed General Waterways Application: ® For all Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application&Payment to the appropriate DEP Boston or regional office(please refer to Pg. 10 of the"Instructions"for the addresses of DEP Regional Offices). ❑ For all Non Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application&Payment to DEP's Boston office. Department of Environmental Protection Waterways Regulation Program One Winter Street Boston, MA 02108 ® Application Fee Payment for ALL Waterways Applications: Send the appropriate Application fee"(please refer to Page 1 of the"Application"), in the form of a check r money order, along with DEP's Transmittal Form for Permit Application&Payment: Department of Environmental Protection P.O. Box 4062 Boston, MA 02211 * Under extreme circumstances, DEP grants extended time periods for payment of license and permit application fees. If you qualify, check the box entities"Hardship Request"on the Transmittal Form for Permit Application&Payment. See 310 CMR 4.04(3)(c)to identify procedures for making a hardship request. Send hardship request and supporting documentation to the above address. NOTE: You may be subject to a double application fee if your application for Chapter 91 authorization results from an enforcement action b the Department or another agency of the Y P 9 Y Commonwealth or its subdivisions, or if your application-seeks authorization for an existing unauthorized structure or use. CHMpp.doc•Rev.08/13 Page 13 of 13 I CERTIFY THAT THIS PLAN WAS MADE IN ACCORDANCE WITH I THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS. , DATE REGISTERED PROFESSIONAL ENGINEER .Z !a LOCUS III F LOCUS MAP SCALE 1" = 2000' 0 1000 2000 4000 APPLICATION FOR CHAPTER 91 WATERWAYS LICENSE (30 YEAR) PROPOSED DOCK LOCATED AT 1343 FALMO UTH ROAD CENTERVILLE, MA 02632 Prepared For: Robert Fair Jr. & Pamela Fair 1343 Falmouth Road Centerville, MA 02632 Prepared—By. JC Engineering, Inc. 2854 Cranberry Highway East Wareham, MA 02538 Plans Accompanying Petition of Mr. Robert Fair Jr. & Mrs. John L. Churchill, Jr., P.E. Pamela Fair to Obtain a Chapter 91 Waterways License for a Proposed Dock on Long Pond, Located in Centerville, Barnstable County, Massachusetts. Sheet 1 of 4 Date: 03106115 I CERTIFY THAT THIS PLAN WAS MADE IN ACCORDANCE WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS. DATE REGISTERED PROFESSIONAL ENGINEER FALMO T WIDE D-ROUTE 28 N86"30'25"E 209.73' I MAP 229 PARCEL 85 69,660 S.F.i a w � ZO � N w A n • N N N 0 o w rn m o MAP 229 PARCEL84 N/F Alves MAP 229 PARCEL 86 N/F DaSllva- Benchmark Top of CBIDH Elev.=50.68' Assumed o.�uwc Y1 NHESP 2008 PRIORITY. I NHESP 20�8 LINE HABITATS OF RARE SPECIES to of 1�..� AND ALSO ESTIMATED O u' .. ••� W HABITATSWILDLIFE(APPROXIMATE LINE)— w N2sP%���UN' _ _ — _H —••— GE OF POND ,. APPROXIMATE FLOOD ZONE ' LINE PER FEMA MAP PANEL A #25001C0562J(DATED 7.16-14)� —••'' SONG p o-Is ND111 ! 3Q ZONE 5p01 , EL,3C6�Rw.PON01 _`000 • PROP.STANDING ALUMINUM DOCK (SEE PROFILE&DETAILS) , NOTE:NEAREST DOCK IS GREATER THAN I 100'AWAY FROM PROPOSED DOCK. 0 25 50 100 SCALE 1" = 50' Sheet 2 of 4 LOCUS PLAN John L. Churchill, Jr., P.E. I CERTIFY THAT THIS PLAN WAS MADE IN ACCORDANCE WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS. DATE REGISTERED PROFESSIONAL ENGINEER FEMA FLOOD ZONE(DOCK): ASSESSOR'S MAP&LOT: ZONE X(<500) MAP 229,PARCEL 85 AS SHOWN ON COMMUNITY PANEL: DEED REFERENCE: #25001 C0562J(DATED 7-16-14) BOOK 22380,PAGE 215 PLAN REFERENCE: PLAN BOOK 91,PAGE 137 EXISTING i MAP 229 \ \ BR.DRIVE GARAGE PARCEL 85 \ 69,660 S.F.t 00 \ /) < EXISTING 1,503 <'] GAL.SEPTIC TANK U RED a BRICK WALK \ Benchmark < N Tap&CB/DH gqb� El—=50.68' m #1343 F A.—d 11 EXISTING fFFFn / DWELLING I WALKOUT / / a bti TEP 4fivi PAT10 El / 4- `s UPPER PATIO ,�,1• yjry giiFJ�„ N•• N / T08EnElaOVED6 .�.. . w � pEp1NGE0 yaM G0.ASS — — �..�. _�._•/ WA N I/ m 54 /� .iHE'P Z�pe LINE�..�••�a '�(�•=—=50_/ GETATED AREA-46 .. WALL 46 �5Y/�..i•.i"// -� LAWN AREA vl / 3,^ -42N s / 4. 44� —38 /42 e �•C.. AVIS EVIOUSLYADE0.�PF�KI /p7 OOD 5p0 �y /361 i EP3P ROVERFD UR 40�L ON,X i-- / ✓AREA •�38'=� EDGE°i 46 G� �36—�pNG PON&111 _ ,44— WALL VEGETATED AREA __/ EL= EPT �42 GF 4'Wx5'LRAMP (A / ^32—/ SET TOP OF DOCK TO EL 38.0(Y --PROP.STANDING / ALUMINUM DOCK. /•sA— (SEE PROFILE&DETAILS) /�� / —26- 29. / i1A_/ / 0 15 30 60 SCALE 1" = 30' Sheet 3 of 4 SITE PLAN John L. Churchill, Jr., P.E. I CERTIFY THAT THIS PLAN WAS MADE IN ACCORDANCE WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS. DATE REGISTERED PROFESSIONAL ENGINEER TOTAL LENGTH=50.8'(includes ramp 44.2' TOP DOCK EL.=38.50' 38.0' 1 FT.(min)FREEBOARD 10:45' NANNUALHIGH (TYP. A WATER EL=37 5'1 EXISTING __uu..... a u._uu._u :.......... ....... •___ STEPS 36.7' 36.3' 35.5' A ` '3 POND EL.=36.7'1 34.0' (10-18-11) 4'WIDE x 5'LONG RAMP 32.2' 30.0' 29.0' SINGLE DOCK SUPPORT FOOT PAD OCK SUPPORT HEIGHTS VARY: EXISTING POND GRADE (5.75"x 15')TO BE PLACED MAINTAIN TOP DECK EL.=38.50' (ELEVATION VARIES) ON EXISTING GRADE OF POND OR 1 FT.MIN.FREEBOARD NOTES: 1.)TOTAL LINEAR FOOTAGE OF DOCK IS 50.8 FEET(INCLUDES RAMP). 22 TOTAL COMBINED AREA OF DOCK SUPPORT FOOT PADS TO BE PLACED ON BOTTOM OF LONG POND IS 103 sf. 3.)TOTAL FOOTPRINT OF DOCK IS 2712 sf.(INCLUDES RAMP). DOCK PROFILE _ N.T.S. DECK PANEL LAYOUT NOT SHOWN FOR CLARITY_ (SEE DECK PANEL LAYOUT DETAIL ON.THIS SHEET) DECK PANEL(TYP.) STRINGER(TYP.) N STRINGER(TYP.) ei I 1" 1.6" —III'— II N vi II I _ _= ____IL_ ___ JL L _ - ----�r-----1 ---- av - -- - p(�38.5"--JIL=39.2" LI I 2.6" II 120.1" II v 1 125.4" 1 1--4.0' L 4.0'J-2.0'—I J (10.45') 125.4" DECK PANEL BRACING LAYOUT(TYP) DECK PANEL LAYOUT(TYP) N.T.S. N.T.S DECK PANELS / 4 ---------------- FULLY WELDED > 2"x2"LEG POCKET SINGLE 5.75"x 15'DOCK SUPPORT FOOT PAD ON ADJUSTABLE LEG(TYP.) SECTION A-A N.T.S. Sheet 4 of 4 John L. Churchill, Jr., P.E. Q Dr- Town of Barnstable *Permit I �4 y�' b Expires 6 months from issue date Regulatory Services Fee 6 BnBxsrnBM MASS. Richard V.Scali,Interim Director i639• Building Division x. P Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA'02601 www.town.barnstable.ma.us Office: 508-862-4038 r Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - •RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address fj FA L-1'K L)IIJ RV C�I�1 L WjtJE t M O Z 6 3 a` Residential �Value of Work$ f � �' Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address / SE91 E PA M EA K, FA I IZ 1343�1 tTH ED., CLKA U R iLt E ►4 4 o R 3 a Contractor's Name' S J A �W A A u„C, Telephone Number 15702 9a0 oaf 6�t►o G Home Improvement Contractor License#(if applicable) 1 OI 16Z.`l •Email: k S ILVIA iPS WAND SUM C',Ol'''I Construction Supervisor's License#(if applicable) C S 'C)I(.9 3 aZ ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner , [� I have Worker's Compensation Insurance - Insurance Company Name HAP_rr D. y?yP j2 W P%-ITEP—S y Workman's Comp.Policy#�(o S600PZVSIO /76AI T 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 710ME DIS L ❑Re-roof(hurricane nailed)(not stripping. Going over '` existing layers of roof) ❑ Re-side - 11 1. . . ❑ 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 El"ectrical'&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. y A copy of the'Home Improvement Contractors License&Construction Supervisors License is required; , SIGNATURE: T:\KEVIN_Dduilding Changes\EXPRESS PERMITAEXPRESS.doc Revised 061313" " , Massachusetts -Department of Public Safety toBoard of Building Regulations and Standards . Construction Supervisor License: CS-016.932 RONALD J SILVV 44 ICE VALLEY RD OSTERVILLE N11'0265 J,•�..�� .n'.14, Expiration G Commissioner 11/18/2015 - c .w ��e tpoayunao�cueaLLli a�C�o�c�elt�lr Office of Consumer Affairs&Business Regulation WME IMPROVEMENT CONTRACTOR gistration: 1.01627 Typepiration t-8/24/2016:. PrivateCorporatio; SILVIA&SILVIA ASSOCIATES INC Ronald Silvia 1284 A MAIN ST �'s OSTERVILLE,MA 02655 _ � Undersecretary , • F ,r The 6mOratvealth of Massachusedds Depard sedt of Industrial A.ceidents . Office of i wO#gaticins 600 kf'ashington Shed _ Bosdvri,M4.02111 ivti ItrasgOP, iQ Workers' Compensation It smrance,Alffi_davit:Bin ders/ omtractorslE.leetricians/Pluffibei^s Applicant Information Please Print L.gl ibly ,. . Name(r min 811iZationtlnaividwo— SILY')A s(LN LL.CI. x City/StatelZip:OS rF-'/I C - WA ..040 ST .-.Phone k SZ28 ` X Q DoZAG Are you an employer?..Cheekthe-appropriate boz. T3Pe of Ppr,oJect(required):q�d) 1.1Iam.a employer with 4. I affia geneaal contractor and I 6. ❑New constr t ion employees(full andfor part-time)-* have hired the sub-conoactois 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_ ❑Demolition Y w employees e and have warlcirig forme in any capaCitg_ 9.. Puddingaddition [No worloers'comp,t� ce:' comp.ins ' I ❑ d-} 5 ❑ tVe are a corporation and its 16.01 Electrical repairs or additions 37❑ I am a homeowner doing all work officers have exercised their 11:❑Plumbing;egatrs or additions myself o warps'. right of exmwtiosi per.MGL insurance s d j c_152,§1(4X and we na 12❑ Of repairs. e o workers . 13.❑Othei� Nza- I F; comp;insurance requiredI a ticsar that diecks box#1 man also fill out the section below slwwin teen mmQkery '�Y pP g r,,ampe>bsarioa Policy inSnenmeaa , Homeowners who submit this af5dm iadic=S they are dniag all wol and dbea hoe o=de contractors amst submit a new affidavit emdicatiag saveb_ SCaatracimrs that chkk this box must attached=sddifional sheet s4owing.the nmbe of the sub-contracmas and state whether ar not those entities have empkweu. if the sab-cnatsaam bare employees,they angst pm made their—kegs'camp:policy n—ber. - I I care art employer thaffs pt avid rt worl4rers'co�grrsalion irasurrmco for aaw eitrgloyees. ,Betoiv is tleepa/icy r�rzd}ab sine. irefortmadon: Imurance Company Name. HA E ADM U/UDEZW IT6KS X S . Fohcy or Sel€ins Inc.4: (a S 6 DUR Sc8 3/0 76 oZ.I F piratioa Date:�� L15' rob Site A 3f,3.FAUVI ' CM M= Ci Y rstatei - I&&. .Od,G� Attach a Dopy of the workers'compe-usation policy decllaration page(showing the policy number and ezpiration date).. Failure to secure coverage as requirt'a1 u Section 25A o€MGL c. 152 can lead to the imposition of criminal penalties of a .. . fine up to$1,500.00 andtor one-year immsoAment,as%y ll as chit penalties in the.form of a STOP WORK ORDER and a fine of up to$250.00 a day against the Violator_ Be,advised that a copy of this statement.mav be forwarded to the Office of Investigations of the DIA for ice coverage verification_ I do hereby certi�p wiI t ras and pweatttes of pej�-,uy at Hie irrfarwaiion protRded cabove.is.trate wid correct: 'Date: 8 d 13 O, .47 use:eanll D6 atot traits iti this ores,t4v be couipf tEad by city or toavat Ociai City or Town v PermMACense#..,;: „. Issuing Authority(tarrle one) 1:Board of Health 2 Building Department 3.City/I`owri Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.'{}#her Contact Pecson.. Phone#c . ACO® DATE(MM/DD/YYY`n CERTIFICATE OF LIABILITY INSURANCE THIS,CERTIFICATE IS;.I,SSUED AS A MATTER OF INFORMATION,ONLY AND CONFERS NO RIGHTS UPON7HE CERTIFICATE HOLDER. THIS CERTIFICATE'DOES NOT AFFIRMATIVELY OR'.NEGATtVELY,AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED.BY THE POLICIES ' BELOW. THIS:,CERTIFICATE DF INSURANCE DOES NOT,•CONSTITUTE A CONTRACT BETWEEN,THE ISSUING.,INSURER($) ,AUTHORIZED REPRESENTATIVE OR.PRODUCER,.AND_THE CERTIFICATE HOLDER. - IMPORTANT:;If the cert(fcate'holder is'an ADDITIONAL INSURED,the policy(ies)must,be:endorsed If.SUBROGATION IS WAIVED,Oubject to the terms and conditions of the policy;certain poilcres may require an endorsement: A statement on'thts certificate does not confer rights to the ceitificate`holder irr lieu of such endorseme , s) ,_ ONT ,PRODUCER l$ f. •.,... NAME.. Kathy. S via The Fair Insurance Agency Inc Y .,r PH°HE (508).775-3131 FAX 619 Main Street' ". ED L ".kathy@tYiefairagency com Suite 7 t INSURER S AFFORDING COVERAGE:. NAIC#' CenteL-villei. 0202 •-- , INsuRFRArt:FIRST:MERCURY INSURANCE :. INSURED iwsuRERla':Haitfor' Uri rwriters'.Ins :-AR Silvia & Silvia :LLC InisuRERc.`. P.O. 'BOX 43O INSURER D c 1284 -Main .Sheet *� �NsuRERe. Osterville_ MA '02655 INSURERF: COVERAGES CERTIFICATE NUMBER:CL148500807 "' " , 'REVISION NUMBER: ; -THIS IS TO CERTIFY THAT THE POLICIES OF,INSURANCE LISTED BELOW HAVE BEEWISSUED 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?OLICIES DESCRIBED HEREIN IS SUBJECT'TO'ALL•THE TERMS, EXCLUSIONS AND CONDITIONS OF POLICIES:LIMITS SHOWN MAY.HAVE.BEEN REDUCED BY PAID CLAIMS TYPE OF INSURANCE. . �., °, .: `POLICY EFF ::'POLICY EXP ••'r:' . ': `.LIMITS .i LTR POLICY (MMIDD - (MMAMOrM GNERALIlABILITY` ' EACH OCCURRENCE $ 1,000,`000 COMMERCIAL GENERAL LUtBILfiY PR MISES Ea occurrence $ 50;000 A CLAI S*4AADE OCCUR GL000004595201 /1/2014 /1/2015 MED`EXP(Anyoneperson) $ 5 000 PERSONAL&ADV,INJURY.. 000 GENERAL AGGREGATE $,• ''2,00,0 `000 LIEN L AGGREGATE LIMITAPPLIES PER s L,i `. PRODUCTS-COMPIOP AOG: $ X POLICY PRO LOC $ AUTOMOBILE LIABILITY' COMBINED nt '.. BODILY'INJURY Per erson ANY AUTO r ( p ) ' � a's r' c.. r' ALL OWNED SCHEDULED q BODILY INJURY(Per actxd%ent) $ AUTOS AUTOSr NON-0WNED' �• 'PROPERTYDAMAGE - - HIRED AUTOS AUTOS Per awident $ ! $ UMBRELIA LIAB ' OCCUR ' kF EACKOCCURRENCE $ EXCESS LIAR CLAIMS MADE t f` , ;:1: AGGREGATE $ DED• RETENTION$. $ WORKERSCOprPENSATION, �... "_ !.."•+ �WC.STATU-` .OTH- AND EMPLOYERS LIABILITY Y!N ANY PROPRIETOR/PARTNER/EXECUTIUE❑ NIA `.' m E L'EACH ACCIDENT u; $ 500 000 OFFICERIMEMBFJt FJ(CLUDED? • g60U85831076214 /1[2014 -/1/2015 (Mandatory In NH) - - EL DISEASE-F1t EMPLOYE $ ,,.. .. SOO"OOO It.Y is,cWW6eunder t,. :. E L•DISEASE=POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS`f LOCATIONS!VEHICUES(Ak"Ii ACORD 101 Addlll nMt.RemaAta Schedule,H more epaee:1i required) r -T' ,.•- -.1, ;. _ Fair residence -:Falmouth Road, Centerville • ,� a i y. � �. e f i 4 �. r r t� , CERTIFICATE HOLDER § . . CANCELLATION ' t_ SHOUL.D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE s` THE EXPIRATION DATE."THEREOF, .NOTICE WILL=BE 'DELNERED ':IN Towin of Barnstable ' f ACCORDANCE WITH THE POLICY PROVISIONS x :Main Street ,.. Hyannl8; MA 02601 re Au rHOR1ZIMREPRESENTATIVE w' S � +, I•` 1[athy Silvia�FPaIR31� ��•o� � �r'�✓.�� ACORD 25(2010/05) '' ,a °" ©1988 2010'ACORD`CORPORATION. All rights reserved INS025(zotaos)o Mfi'' ', The AdORD harner and.logo are registered marks of AC-ORD. J. - 'ARIA a Town of.Barnstable - Regulatory Services Richard V.Scali,Interim Director Building Division : :.. Thomas Perry,CAP t Building Commissioner 200 Main Street,.Iyannis,:MA 02601 www.tovvn.barrnsiiible:ma.us i Office; 508-862-4038, Fax 508 790-6230 ` ' Property Owner Must' Complete and Sign This Section If Using A Builder 14T S a 1 - r IF PAIIZ as Owner of the subject property hereby authorize,_RON" I to act on my behalf,, - in all matters relative to work authorized l y this building'penmt application for:- �',GU^TDvT't UL NAoa� 3a (Address of Job) , Signature of Owner . 4 Datc, r Print Name IQroperty Owner is.hp,O ng for permit,please complete the Homeowners License Exemption Form on'ihe ` reverse side. TAEVIN D&jlding Changes )dPUSS PtkM tk,PRESS doc: t I Revised 061313 . ,k N. Town of Barnstable pert Expires 6 mo 6s from is e d Regulatory Services Fee + sextvsrnBte. • 1� Thomas F.Geiler,Director�►�� Building Division r Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 13 43 at WoT I boa t,) MIMI t!F M Oa6 v a Residential Value of Work A000,OO Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address OBEY I 13 LNQ iT!}j _POk k) CE-Ut-T- l LLE MA C X. 3 Z Contractor's Name BSI LV I d S 1 LV 1 A LLC Telephone Number_,S0&�0 Cj aa6 X O 6 Home Improvement Contractor License#(if applicable) 10 1 WO -1 Construction Supervisor's License#(if applicable) C S I Log'3 a ❑Workman's Compensation Insurance 5 PRESS PERMIT Check one: ❑ I am a sole proprietor ; ❑ I am the Homeowner ® 1 have Worker's Compensation Insurance OF BAi RNSTABLE Insurance Company Name COA ZT1 S i msp u A7cr COMEM) Workman's Comp.Policy# W C '98 70 261 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 r Replacement Windows/doors/sliders.U-Value p,aq (maximum.35)#of windows _ *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNA C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content:0utlook\DDV87AAZ\EXPRESS.doc Revised 072110 Thee Commonwealth of Massadiusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 wMik n►ass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbei-s Applicant Information Please Print Uidbly Name(Businessioiganizationdudividual): Sl LUl Q S t LV IA Ll..C Address: 1 a8`r A MAIM 2-1 CAy/StaWZip:Q=EVtLLE W CILES Phone i 5Q0 - X0 -Gd aLx 10 6 Aree you an employer?Check the appropriate boa: T of project r . 4. I I am a general contractor and I Type P J ( eq��� 1.® I am a employer with 3 ❑ g 6. ❑New construction employees(full and/or part-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 S. E]Demolition working for me in any capacity. employees and have workers'. 9. [_]Building addition [No workers'comp.insurance comp-insurance- required-] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3-❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself o workers' right.of exemption per MGL mY � �- 12.❑Roof repairs insurance required.]1 c.152,§1(4),and we have no employees.[No workers' 13.0 OtherSR�EU7ALL S�) LES comp.insurance required.] 'Any applicant that checks bum 91 must also fill out the section below showing their watiiers'compensetion policy information. i Homeowners who submit this of uhmit indicating they are doing all work and then hue outside contractors tmmst submit a new affidavit indicating such. Contractors that check this bmc must attached an additionsd sheet showing the name of the sub-comtacmrs and state whether or not those entities hsae employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam air employer that is pro►zding workers'compensation insurance for my en►ploy am Below is the policy and job site inforinatiom Insurance Company Name:CttA P-T/S J YJ1&)MkX1: WMF)Ah)Y Policy r#or Self-ins-Lie.M 1P' l_ICi O tU C gcSS701J6-f Expiration Date:-4 I,L)a Job site Address: city/state/zip:cr-UE I lL wrA Cab XZ 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 2.5A 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 tender thepains and penalties of pery'nry that the information prmzded aboi'e is true and correct Si ter �� Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitfUcense## 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#: i , i6 5/17/17/2011 `� CERTIFICATE OF LIABILITY INSURANCE D '°° 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 KathySilvia NAME: The Fair Insurance Agency Inc. PHCN u E (508)775-3131 IC No:(508)790-1677 619 Main Street ADDRESS:fairins@capecod.net P.O. BOX 430 CUSTOMEER R ID D0000208 Centerville MA 02632 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Seneca Insurance Co INSURER B:Safet Insurance Co. 39454 Silvia / Silvia Associates Inc -INSURER C:Granite State Ins. Co.-ARWC 13102 P.O. BOX 430 INSURER D: 1284 Main Street INSURERE: Osterville MA 02655 INSURERF: COVERAGES CERTIFICATE NUMBER:11-12 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM1DD MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 A CLAIMS-MADE ID OCCUR SGL3000362 /1/2010 /1/2011 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED AUTOS 007908 /1/2010 8/1/2011 X BODILY INJURY(Per accident) $ SCHEDULED AUTOS X PROPERTY DAMAGE $ HIRED AUTOS (Per accident) X NON-OWNED AUTOS Underinsured motorist $ 100000 Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB" HCLAIMS4VIADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ C WORKERS COMPENSATION WC STATU- I IQLH- AND EMPLOYERS'LIABILITY Y I N TORY LIMITS E ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) C009870964 /1/2011 4/1/2012 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 5OO OOO DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Robert Fair Jr ACCORDANCE WITH THE POLICY PROVISIONS. 1343 Falmouth Road Centerville, MA 02632 AUTHORIZED REPRESENTATIVE Kathy Silvia/FAIKS1 ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025 poo9os) The ACORD name and logo are registered marks of ACORD ' �1HE Ire, r r " irlIiNBTABLE, *' MASS. ' 16!5 Town of Barnstable Regulatory Services Thomas F.Ceiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,.MA 02601 www.town.ba rnstable.ma.us Office: 508-862-4038 Fax; 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder, as Owner of the subject property: hereby authorize etc— i S` V I to act.on my behalf, in all matters relative to work authorized by this building permit application for: ( 3 � 3 �„�w.�,Tl, �L�• Cz.;,�-�� (tom d �� (Address of Job) Signature of Owner jr, Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAL\EXPRESS.doe Revised 072110 Massachusetts- Department of Public Safety Board of Building;Regulations and Standards Construction Supervisor License - License: CS 16932 Rete .0 1�99t' 'J�% ,RONAL j,f$iiLVIAA PO BOX t3dl 0STERVILL'EPMA-02655 Expiration: 11/18/2011 Conunissioneri Tr#: 9663 ✓1ze -�anvno�euealllz a�✓f/laoaac�ivael�d Office of Consumer Affairs&B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration PkI01627 TYP? FExpirationZ2612�42r PnuatehGorpor:•atia SIL IA&>SILVIA ASSOGIATE�kNE.. on�,. / ald Silvia 1284 A MAIN ST: £ OSTERVILLE,MA Undersecretary Undersecretary J , r a 1 Town of Barnstable *Permit# � CGI Ezp' 6mondisfrom issue date ERMIT OCT 1 2007 Regulatory Services Thomas F.Geiler,Director TOWN OF BARNSTABUL� Building Division.. Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA.02601 www.town.barnstable.ma.us . Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address M UU lo � 7 []/Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addressd l y - k 1M t-Z-)- -t-t o C'.euTt-�ul: (I _IMA- v 2t.o�32. Contractor's Name � `V i A A- 5 i I V I A, Telephone Number e::2:U(S-y Zv-v z.ZCo Home Improvement Contractor License#(if applicable) U 2.7 Construction Supervisor's License#(if applicable)-. 3`Z Dw/orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 0/"I have Worker's Compensation Insurance Insurance Company Nam \M5 Workmen's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers of roof) LB/Re-side . [TReplacement Windows/doors/sliders. U-Value f %`7 (maximum.44) *Where required:Issuance of this permit does not exempt compliance with other town department regulations,i.e.,Historic,Conservation,etc. ***Note: PrevertyDwner must sign Property Owner Letter of Permission. ro th Home Improvement Contractors License is required. SIGNATURE: VZIZ-1% Q:Forins:expmtrg Revise061306 p� 6/ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 101627 Expiration: 6/261/2008 Type: Private Corporation SILVIA&SILVIA ASSOCIATES,INC. Ronald Silvia 1284 A MAIN ST. OSTERVILLE.MA 02655 Denuh Admi;;,ii to; y J1. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR 016932 j ; Number: CS Birthdate: 11/18/1949 I� Expires:11/18/2007 Tr.no: 8527.0 Restricted:'00 RONALD J SILVIA G PO BOX 430. C,4, —J, OSTERVILLE, MA 02655 Commissioner The Commonwealth of Massachusetts Department oflndustrialAccidents = Office of Investigations d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print Leeffily Name(Business/OrganizationAndividual): s.JI M A '�' s.C�l[Vi A Address: IALf A MA 0- , City/State/Zip: d citQ," �2. MA n Phone-#: fig' 4'LO 02Z1Q a b�Q Are ou an employer?Check the appropriate box: -Type of project(required):. 1.7I am a employer with Z0 4. ❑ � I am a general contractor and I 6. New construction . employees (full and/or part,time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- , • listed on the.aitached sheet. 7. ❑Remodeling These sub-contractors have Demolition ship and have no employees 8. ❑De tton workingfor me in an capacity. employees and have workers' Y P tY $ . 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions ' 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' 1340 MO comp.insurance required.] 1'!' S Mb1 ~ *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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is-the policy and job site information. Insurance Company Name: SQQQ. Policy#or Self-ins.Lic.#: wC, Q Expiration Date: �O Job Site Address: 343 . T:A MDtrtff 'IZ701• City/State/Zip: lX1C1 -VI Ile 1''V, 02!132 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DU fbr,'nsuragce coverage verification. I do hereb ertc pains•and penalties of perjury that the information provided above is true and correct Si a e: Date: r!u 7 Phone#• Z —L.9 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): .1.Board of Elealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Insttuctions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver nr trustee-of an individual partnership,associMiem�r other legal entity,employing employees. However the owner of a dwelling.house having not more tha> thiee abat{ments anld Ab`resides therein,or the occupant of the dwelling house of another who emp4oys persgus to'do mairite e,construction pr re�pai� ,prk on such dwelling house or on the grounds or building�a+ppur'teuanf thereto shall not because•o ch 6npl ym�nf be deemed to be an employer. it ,j 6 d ,"r-•. d`:, N,, ;"•t't• '..S.$ �'S.'_i ro'�r`8;„��±. �rj Z f" 7�.�•!;� �..y MGL chapter 152, 25�(6)also slates that every state or local lic2nsing agency slil'witihbl'dhhe 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 •l' enter into any contract for,the performance of public work until-acceptable evidence of compliance with the insurance requirements of this chapter have been presentedto 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-contractor(s)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 tll+s 55 iiji4r iber"sioY pa s,;,are not'irwed to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy isrectujiEe i.al ydvised that this affidavit may be submitted to the Department of Industrial Accidents for confiiiiiation 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 e,DeparfiA n U prot+`id�dh space at the bottom of the affidavd ft ydxi#1"i1l out in the event the Office of Iuvestiga%ms'fias ter r,,bntact you teggrding.the applicant. Please be sure to fill in the'permit/license number which will be used as a reference number. Iu addition, an applicant . 4t"lia#'mtt6t sfibinit�ntltip�>�emit/license applications in any given yea ;?€e ,py�utnite affiat'�ndicating current policy information(if necessary)and under"Job Site Address"the applicant should write `all•locatioiis 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 fo 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 like to thank you in advance for your cooperation and should you have any questi ns,_— please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Cammenwealth of Massachusetts Department of industrial Accidents Office Q.f Invest gadow 6QG Washingtc6 Street Boston,ILIA 02111 Ter.# 617-727-490.0 ext 406 or 1-977-MASSAFE Fax#f 17-727-7749� Revised 11-22-06 www.mass.gov/dia I . Town of Barnstable. Regulatory Services BABNsTABLE' Thomas F.Geiler,Director y Mass. g `6prFo;�.cA`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 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize SI1VIA sklyiA to act on my behalf, in all matters relative to work authorized by this building permit application for: . I3�}3 '��lwtou�4 mod• (Address of Job) `2 c - 9 0-7 Signature of Owner Date Print Name Q:FORMS:O7,NERPERMISSION 05/23/2007 14:08 FAX 508 790 1677 FAIR INS SILVIA &_SILVIA 001 wffm CERTIFICATE OF LIABILITY INSURANCE _ oil/2 PRODWER-�(S08)775-3131 FAX (508)790-1677 THIS CERTIFICATE IS ISSUED AS A Mj!V TER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPCIN THE CERTIFICATE The Fair Insurance Agency, Inc HOLDER.THIS CERTIFICATE DOES N11'r AMEND.EXTEND OR P.O. Fox 430 ALTER THECOVERAGE AFFORDED I3Y THE POLICIES BELOW. 619 Main St. Centerville, MA 02632 INSURERS AFFORDING COVERAGE NAIC 9 INstmo Silvia / Silvia Associates Inc INSURERAt Scottsdale Insurance �1:1 E'TAL 619 Main St Nominee Realty Trust INSURERS: Safety Insurance Co. 39454 PO Box 430 1284 Main street INSURERc,Granite State Ins. CO 13102 Osterville, NIA 02655 INSURERD; - INSURER_QQj e: ' RAGES THE PCLICIES OF INSURANCE-LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOC 114DIGATED.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,EXCLUSICINS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR ADD TYPE OF INSURANCE. -POLICY NUMBER POLICY EPPECnVE POLICY PIRATION I :i LIMBS GENERAL LIABILITY CLS1042443 09/01/2006 08/01/2007 EACH occvmlll:NCE s L ow, COMMERCIAL GENERAL LIABILITY DANWG TO FE'rTED L I' CLAIMSMA4E I X I OCCUR MEDEXP(Ar�o,,oP&sen) S S,OG I A PERSONAL%AC1V INJURY S 1.000,0001 GENERAL AG(MAGATE S 2.000.000[ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-,XIMPIOP AGG $ 2 ON.No 1 POLICY 7 4PWR T LOC AUTOMoen E LJABILITY 3007908 08/01/2006 08 01/2007 COMBINED Sil'44LE LIMIT s . ANY AUTO (Es acddoncl _ t 1,000,00 ALL OWNED AUTOS 80DILTINJIIKY 8 X SCHEDULED AUTOS (Ptr Pemn) B X HIRED AUTOS BODILYINJURY (Poraaldonq S X NON-OWNED AUTOS PROPERTY DJAIAGE $ { ti (Per aaoldeg - GARAGE LJABELflY AUTO ONLY-D,ACCIDENT S ANYAUTO OTHER THAN EA ACC $ AUTO ONLY:, AGO $ occEss/uMBREw►LIABILITY ' 4606410 08/01/2006 08/01/2007 EACH occURRIsNCE != a 3,000,000 IIX OCCUR ❑CLAIM3MADE A60KC-AMR S 3,000,000 A s DEDUCTIBLE RETENTION E I S wORI(ERg(UNIPENSAY,ONAND WC8959263 04/01/2007 04/01/2008 ITORYI wcslA'A, ENIPLOYERS'LJANUTY - E.L.EACHACIX:TENT S. .+.500i�0O C ANY MROPRIETORIPARTNERIEXECUTIVE I , ;- OFFICERIMEMBER EXCLUDED? E.L.DI$FA$f' [A EMI-LO 5 Soo '06 ; IT yea,desaft under 0 $PECIAL PROVISIONS below E.L.DISEASE POLICY LIMIT I S SOO,0 ,i DESC RIPMN OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS ! i CIEEEIEFIC& :I t T HOLDER ANCrELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIE 5 n CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE LSSUING INSURP.F.WILL ENDEAVOR TO MAIL IS DAYS WRITTEN NOTICE TO THE CERTIFIC 41'E HOLDER NAMED TO THE LEFT. Town of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHAI L IMPO,-1:NO OBLIGATION OR LMOUYY South Street OF ANY KIND UPON THE INSURER,ITS AGENTS OP IrEPRIIBENTATM& Hyannis, MA 02601 * AUTHORIZEDREPMENTATNE '9�I�1*4{fDNI�.'�d(�✓!I s ! lKathySilvia/FAI7S1 (_ ACrJRD 25(2001108) C;ACORD CORPORATION 1988 jl TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel a� Permit# Health DivisionJdmz� — Date Issued L 0S Conservation Division Application Fee 00 Tax Collector Permit Fee 44 M 11(Q Treasurer l( V Planning Dept. T EXISTING jSYSTEM Date Definitive Plan Approved by Planning Board LIMITED TO BEDROOMS Historic-OKH Preservation/Hyannis Project Street Address [ L1110 �77&Ala Village Owner n �) 1. Address All c Telephone "' 3 Permit Request ' a �emaakl, cvt Li I. de.tl Y1 L 6m e Wit C°0,b< (Ro are-(_ Qj" Square feet: 1st floor: existing /Vlh proposed 14-- 2nd floor: existing N 6—proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation A.QCO. b' Rim Construction Type w' ` n 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 IiNo On Old King's Highway: ';0 Yes-'- [<o Basement Type: 0-Fu I ❑Crawl �IValkout ❑Other C* rl Basement Finished Area(sq.ft.) i � Basement Unfinished Area(sq.ft) _ Number of Baths: Full: existing new Half:existing 1 new l Number of Bedrooms: existing new Y Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas O'Oill- ❑Electric ❑Other Central Air: ❑Yes° ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:O existing ❑new size Pool: ❑existing ❑new size Barn:❑existing' ❑new size { -Attached garage:0 existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑]Yes IJIN_� If yes,site plan review# Current Use - v { Proposed Use �.) U & - BUILDER INFORMATION rr -Name 61112S Is Telephone Number bV 4A� (llo> Address j[Ca hctto 1; (ir('et l l e- -q License# Home Improvement Contractor# IS1 Nll Worker's Compensation# C .64 1 -AY ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 8UJ 0 0 1(w fill SIGNATURE DATE 1 — 3•-05— FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE r O' HER DATE OF INSPECTION: _ FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL , PLUMBING: ROUGH " FINAL , GAS: ROUGH FINAL. FINAL-BUILDING z _ DATE CLOSED OUT ASSOCIATION PLAN NO. co i • T \ °FAME, Town of Barnstable ti Regulatory Services { 9 SA MA'n LE, Thomas F.Geller,Director A �ATEo ,. "1 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 ' Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete.and Sign This Section If Using A: Builder I, , as Owner of the subject J property hereby authorize PuLto nS bt4 to act on my behalf, in all matters relative to work authorized by this b u E ' g permit application for(address of job) 0064 truilk JO-03 � D Signature of er - Date Print Name - ' 1 The Commonwealth of Massachusetts . — Department of Industrial Accidents _= _= Office offnYestfgatfoos . ,�• 600 Washington Street ...... Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole parietor and have no one workin in any ca achMON MEN m an employer roviding workers',compensation for my employees working on this job. X. <. .. ` � `:; ;`>�•,�;'<>C " > ' is sS % i>S G ? s `3` >?<l;i? 2 i' '23a......``.. ..:.: >::..: .;::;.:;:::.: ;. h aom an.;name.: ;::.. . . .. ....... ..... X. i:::::.:i:::::•::i::i :•:it i::: .. ::::::::::::: :.v... ••::i•:is C•.:::.i::•::::::;1..::. ::•. .� ::. ::: :.:: :•:::::::::: :.�. •:.::::::::.:�•::::::::::::::::.:: :::::::::::::::::::::::::::::::: ::. .. . . .....:.: :: :..: ;c> .:... ......... ...... . ..., .......... ................. .. ....... .J...... ... d.. ..........:.::.:::.�:: :::.�.................. ...... ............:.::...:.:::.::::::::.:::::::::::::::.:�::::::::::::::::::::..:..::: :.� :::::.::.:':.: *, •i. v:::..:i•::J: ;t::?C4iCl): 3iif <%`i iit :i:':` `?i i? :'..Otl z i; i;ii ^i: `...?............. �1SUTan ❑ 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: com}nanv name adre . : :.:.:.....:......:::....; >::::>: >> Antnranee.:co.;:.;:;.:::.:::::.:.:.:..:::::.:::.:,:::::.::.::.:.:.:::....,..::::..... .:::.........:.., ..:. .;.::::::;::>;:::..>r ... .::.:.. .::.. ..::::::::. c an >t m .address,. one:#: oli X. X. X. 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$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Signature `` Date Print name � Pea L(� _ Phone# Rr6—4A l d official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/95 PJA Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 employment be deemed to be an employer. MGL chapter 152 section 25 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 commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out mi the eventthe Office of Investigations has to contact you regarding the applicant.1.Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retiumed in- the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office oI Investloadons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 i Town of Barnstable Regulatory Services '" MASI Thomas F.Geiler,Director mass. � 9`�prE 6 9. p`'� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 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.Type.of Work: sz,t�, - e iLA�`s Estimated Cost 32, 0,0 Address of Work: Owner's Name:_ �^ Lcrn t Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law []Job Under$1,000' ElBuilding not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOMEIMPROVEMENT 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: 1313 Date U Contractor Name Registration No. OR Date Owner's Name RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE i�a'il 0Y'Co. f�0 square feet x$64/sq.foot= , _x 31= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq.f� , >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: x.0031= square feet x$96/sq.foot= STAND ALONE PERMITS Open Porch __x$30.00= (number) Deck _x$30.00= (number) Fireplace/Chimney _x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) permit Fee projcost -2'-10 1/2'` - 3'-9 1/2 5'-11" III. ! I C.0co 1 ILO ce) tj co it LO 2668 Existing Bath i 7'-6 5/8" — i - 12'-710 I 12-7 '-1 1/1®"7/16" I -� 3'-9 1/2" =� 5'-11„ Tile Shower Corian Seat and Jambs Glass Shower Door Steam Unit relocated O j N � fn kj- ED u7 I I N CV ' 1 Remove Shower �- r- Move Toilet C-4 � N j I o 0 CO j(, New Cabinets and Counter??? I °i j f ( CD Ir 2668 Proposed Bath 2'-1 1/16" 10 5 15/16 �- 12'-711 i 1 [I tmb� Lt.76[!9Zf! �M S . � {�' �fi✓�+��BQARD�QF BUILDI(JG REG�ILATIONSF rr Lrlce @"CONSRU�CTION SUPERVISOR` K. s � - �� ,s a x FrSCOTTE�CRO � OSTERVI LE; MA . C - ,,��y,',, .. —�'------^ �--�.�'-- .N`>;^' �, � »v x'ram.r t•r 1,o , ✓. Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: i Board of Building Regulations and Standards, Registr�oo 131378 One Ashburton Place Rm 1301 j — 13/2006 4 Boston,Ma.02108 lug _ " e Corporation a PEACOCK&C - INC. SCOTT CROSS 1112 MAIN STREET N1T �M Not valid without signature OSTERVILLE,MA 0265 Administrator oFTt rpN, Town of Barnstable *Permit# j I + Expires 6 months from issue date BAMST BM : Regulatory Services Fee •� Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner ' 200 Main Street, Hyannis,MA 02601 �' ��. Office: 508-862-4038 D E C 2 2 2004 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDEr %ARNST ABLE Av Not Valid without Red X-Press Imprint Map/parcel Number �Ul� Property Address ❑Residential Value of Work zgsao 00 Owner's Name&Address ✓ v''� re. Ut4fsf o vas 9W5 . _9&43 Contractor's Name s c 'm S, Telephone Number 9 Home Improvement Contractor License#(if applicable) 3 Construction Supervisor's License#(if applicable) ErWorkman's Compensation Insurance 4q Check one: ❑ I am a sole proprietor ❑ I am the Homeowner r ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# L Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Weplacement Windows. U-Value_(maximum.44) *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. Home Improvement Contractors License is required. Signature • i Q:Forms:expmtrg Revise053003 r °FIRE T°,l� Town of Barnstable P Regulatory Services + BAMMBLE, i y MAss. g Thomas F.Geiler,Director i639. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject 1 property hereby authorize Q. 4 to act on ray behalf, in all matters relative to work authorized by this building permit application for: -AI�4�5 0-4 ;�Z (10.1 0.10i e -MA (Address of Job) Signature of Owner Date 2,haayl _ .f Print Name Q:FORMS:OWNEUERMISSION , xk.�k - ,, � feel;�oh�svrno�uyea�;;•o�.�aoaq�ltuge�d ° 113OARD'6F�,d ILDIN(s REGULATIONS J ' -- •� � '� ;�Llc�nsn CQN$TRUCT'IQN SUPE,�VISOR 5008'0' { jScoTfT E cRo r=`a �, n' �r 62 a OSTERVI�I Ey; ' ��/�,,�; - x , s Commissioner C +r c�4..�s+ia 4x«r��,'�s3 �F r t`e• �>` ✓fie {000nmoawrea�c o�./�aa�ac/tuaelld ? Board of Building Regulations and Standards License or registration valid for individul use only date ti i ea the expiration . If found return to: i. HOME IMPROVEMENT CONTRACTOR f before p , �• ( Board of Building Regulations and Standards , Regis 131378 One Ashburton Place Rm 1301 t --— 1312006 ! Boston,Ma.02108 y a Corporation i t PEACOCK&C ,.b INC. SCOTT CROSS 1112 MAIN STRE NE " "`< G'L....,-X-i Hsu✓4'- OSTERVILLE,MA 0265 Administrator Not valid without signature • f 4 :rom.Simone Lima 508"428.3068 To:Peacock&Cros°y Builders Inc. Date:3/16/2004 Time:1:01:54 PM Page 1 0! i A"%,0RD . GATE:(MM1001YY)' 3/18/2004 PRODUCER' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY HOLDER. THIS 'CERTIFICATE DOES NOT AMEND, EXTEND OR 806 MAIN STREET ALTER THE COVERAOE AFFORDED`BY THE POLICIES BELOW. PO BOX 632 COMPANIES AFFORDING COVERAGE OSTERVILLE, MA 02655 . COMPANY A GEMINI INSURED COmPA.`:Y PEACOCK S,CROSBY BUILDERS INC. B AIG P.0 BOX 151 OSTERVILLE, MA 02655 COMPANY C . � CDhW�iNY •. D 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 B Y 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. coI TYPE POLICY EFFECTIVE POLICY EXPIRATION LTR POLICY NUM"R GATE(MWOOM) DATE(MMIDOM) UMITB A GENERAL LIABILITY GENERAL AGGREGATE f 2,000,000 X COMMERCIAL GENERAL LIABILITY ICGL9048672 3.12.04 3.12-05 PRoovcrs•COMP/OP AGO i CLAIMS MADE O OCCUR{ - PERSONAL A ADV INJURY S _ OWNER'S&CONTRACTOR"S PACT rAeHoecugREtdCE It 1 000 000 FIRE DAMAGE (Anyone fire) s MED EXP(Any ono pe",n) AUTOMOBILE LIABILITY I - ANY AUTO c COMBINED SINGLE LIMIT S ALL OWNED AUTOS BPDILr INJURY s SCHEOULEDAUTOS (Peroer6on) HIRED AUTOS ' BODILY INJURY S NON-OWNED AUTOS F ' I - (P9(eCC10en!) ~+ PROPERTY DAMAGE S GARAGE LIABILITY AUTO ONLY.EAACCIOENT $ ANY AUTO. OTHER THAN AUTO 0N11` - �' EACH ACCIDENT 6 AGGREGATE I EXCESS LIABILITY EACH OCCURRENCE $ I UMBRELLA FORM AGGREGATE 6 OTneR THAN UMBRELLA FORM f 'WORKER'S COMPENSATION AND - v+CTO SgV Urn A V•11S' O(M,ER� B.J EMPLOYEAV UAB4.ITY IWC 547.81.26 3.12.04 3.12-05 EL EACRACCrOEM ➢' 100 000 '+E ogOoRIE'OR/ 1!^—( - EL DISEASE•POLICY LIMI7 S rultNE°EVEKECU7r.E `J INCL - 500,000 °"'cE°e.°c L_—lI ExCL EL DISEASE•EA EMPLOYEE f 100,000 OTMEit DESCRIPTION OF OPERATIONSILOCATIONBNEHICLESISPECIAL ITEMS •, X ➢HOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL + 1 Q DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, TOWN OF BARNSTABLE BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY e OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES AUTHOPWV REPRESEINTATTVF#U A ` Y