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0018 FIVE CORNERS ROAD
,. .. ;� �. G � •,, K — y �. . 'w .e �� y �.. .,.. .. � r�y +` �. .. �'. o� o � �. Si + � " c o ^�r� �I i o � .. o � a ¢� k - , a R ,. .. - � - � � 4 i � � � � .. ., $ .. .. - Q - o ' p � _ _ � � o _ 0 ._ _ o G .. o, .i _ k oxTME , 3SA88. Permit Fee........... .. .................Other Fee........................ Imo¢ ti TotalFee Paid.............:.r)... �.............................................. TOWN OF BARNSTABLE Permit Approval by.. .. .......................... o�... ............� BUIE DING PERMIT MV........��( ....................Parx1. C ......... ................. APPLICATION fir►,�.z� sE'• " Section 1 —Owner's Information and Project Location Project Address � Czy u iS Village Owners Namey'1 Owners Legal Address City State Zip — owners Cell# �� 8S s e-mail Section 2—Use of Structure Use Group~, ❑ Commercial Structure over 35,000 cubic feet ,-- ❑ Comm'ei;ial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit , ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ~❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alamo Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ?® Renovation ❑ Pool ❑ Insulation Other—SpecifyS Section 4 -Work Description J TsRct :2/9201S Application Number.................................................... Section 5—Detail Cost of Proposed Construction Square Footage of Project Age of Structure: - �' -',, Dig Safe Number # Of Bedrooms Existing ,Total#Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas 0 Fire Suppression ❑ Heating System ❑. Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal "❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway � �+ (I f Debris Disposal Facility: d V �'�' I am using a crane ElYes No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Ye ❑ 2 s No Section 8—Zoning Information Zoning District Proposed Use - Lot Area Sq.Ft. r •- Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required k Proposed Side Yard Required " Proposed ` Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Lag=(iwfed 2/9/2019 '- � � z low � F a fide a:r x• rrre '� '' r�x £, v "'" t+� uMe x omm Pir P���33 33 3 di �'�S�•.� "'��� �l1 y s%awOWN h y'. 5 77 RE r �3' yQ( .r ��* 7 a4�• � �: _ v �� 3 d�°� ,"a rye �:5�. a�r 3 � 3 e., '�� f ,a• R S nE. „ 3�Sy'c" s'3�'� a,�,p 3 �`, E -�. k .°- �:• �`, , Y d..£: # t > *::c ,: a"s :�•� � �Ek �.. ��'"`"` •� � h�a�� � ��', �s a ��\��� � atr��, `'� ay,s 4 wmWI � yy`. 5 3 'Ng � .:, a ��� UA�R�' £ a1C$ y Ju �` `' E, � ,3 § ,x�M� � . ia, d ,`r £Iff' � § Y v ' � ;• „$�E �^ra` ��}7£N 9ia.a ar � .�.� s F ���4 rie - zd � `✓e ><7� q;� ', (3 3 q`���� rP t 4 �.��� a' r ,�eHS'i g" _ 93K3yi 4f� MON�� v r 4,` The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPReant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: /'e��- �� ��Tone#: 1111� /l Are yo employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I * have hired the sub-contractors 6. ❑Ne nstruction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ emodeling ship and have no employees These sub-contractors have g, ❑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 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF1 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' 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self ins.Lic.#: . - / J Expiration Date: Job Site Address: ri FJ UL C1 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. 1 do hereby certify and r the pa' penalties of perjury that the information provided above is true and correct: Signafore: Date: / `V Phone Official use only. o n 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#: r 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 employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the 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 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 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4400 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia CEDARWORKS, INC. EXTERIOR CONTRACTING POB 1229, Brewster, MA 02631 508 648 6117 chrisyerkes l gyahoo.com www.cedarworksonline.com 8/15/18 Bernie and Mary Hall 18 Five Corners Rd. Centerville,MA M cell: 508 367 7812 B cell: 519 8515055 Cape: 508 420 0869 Behall2kgmail.com " Dear Bernie and Mary, Thank you for considering Cedarworks, Inc. for your siding renovation project. We have many years experience in exterior remodeling. You'll be pleased to know the job will be supervised by the company president, and we never use subcontractors. Cedarworks, Inc. is a Cedar Shake and Shingle Bureau(CSSB)and Maibec shingle approved cedar installer, a licensed HIC& CSL in MA, and fully insured. Please visit www.cedarworksonline.com for references and to view recent examples of our work. SCOPE OF WORK: Install new siding on main house and various small jobs. Job includes permit, labor,equipment,materials and all cleanup and disposal. SHINGLE SIDING: Remove and replace natural white cedar shingles on house (see below for options). Install shingles with 1 1/4"galvanized staple fasteners over typar weatherproofing paper. Maintain approx. 5"course exposure to the weather. Match to windowsills/headers where possible. Does not include newly shingled area between rear shower and rear door area. THREE SIDES of HOUSE,NOT including FRONT SIDE,A EXTRAS: $8,200 PRICING NOTE: Price has been reduced to $8,000,because of the discount issued in tandem with the Goulets.NEW PRICE: $8,000 (not$8,200).No cornerboards included at this time. NOTE: All extra work in addition to this contract, such as rot repair, or any other work not listed in this contract, shall be billed at our standard rate of$75/hr/man,plus materials (+20% on mats). TERMS: I require a signed contract copy and a deposit for one-third of the job total. Additional 1/3 progress payment required at job halfway point. Final total payment is due at the completion of the job. Any balance remaining 30 days past job completion date will be subject to 5%interest fee. Thanks again for your consideration; I hope we can work with you on this project. Thank you, Chris Yerkes, President Cedarworks, Inc. CONTRACT AGREEMENT: We agree to t job desc pti an to s as set forth by Cedarworks, Inc. o /27/18. SIGNED _DATE , SIGNED DATE *Note that all invoicing is done via email. Please let us know if you prefer paper. Application Number........................................... Section 9—.Construction Supervisor Name Telephone Number s� (9 Address City r4Ww� State Zip License Number C P License Type Expiration Date ' Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation r y 780 CvlR Town of Barnstable.Attach a copy of your license. Signat<re Date • I� S do -10 —Home Improvement Contractor Name ►'7{ v� 10 ZIP Telephone Number .S Address 3� m< /City State Registration Number I 76 75 I Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the MM Code. I understand the construction inspection procedures,specific inspections and documentah and the TownofBarnstable.Attach a copy ofy our H.I.C.. �, Signature Date C � ction 11-Home Owners License Exeinption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT SIGNATURE /--AP Signature Date (� Print Name rrk)S "Telephone Number E-mail permit to: 04-YiS#1 celclalrl 'kS 94 l i r)- . COY► T.,..f..., a_a.nmMAI0 Section 12—Department Sign-Offs Y Health Department © Zoning Board Cif required) Historic District 0 Site Plan Review(if required 0 Fire Department t <<� y> a p` °. x".�.fi , Conservation : 0 . . For commercial world please take yonri plans directly id the fire department for appiavaL`• 1 Section 13—Owner's Authorization I, as Owner of the-subject property hereby authorize •'' , to act on my behalf in all matters relative to work authorized by this building permit application for: (Address of j ob) Signature of Owner v 4 date Print Name f Last iwdat:&2/92018 Town of Barnstable *Permit Ez�ires 6 months from issue date Regulatory Services Fee s, — • AN a' Mnas � Richard V.Scali,Director `'; _ ® , se 3g6 ♦ .. Building Division Paul Roma,Building Commissioner MAY 2 6 2017 200 Main Street,Hyannis,MA 02601 TOWN lA��� �� �H�f���_� 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 /! esidential Value of Work$ Minimum fee of$35.00 for work under-$6000.00 Owner's Name&Address 1yt G Contractor's Name `S Telephone Number Home Improvement Contractor License#(if applicable) Email: LAN-�1� ❑' 706rkLman's ' G+ Con Supervisor's License#(if applicable) Compensation Insurance r j Check one: ❑ I am a sole proprietor . ❑ I am the Homeowner , n—T' ave Worker's Compensation Insurance Insurance Company Name "lik Z-na&&4 Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accomp ny 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.32)#of windows #of doors: *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 y of.the a Improvement Contractors License&Construction Supervisors License is` r ired. SIGNATURE: „ Q:\WPFILES\FORMS\building perms ormAEXPRESS.doc `. - 01/25/17 t 3 e�rasken er, �'rtdr�striat�ccire -- Owe afhow-iftgatEorrs { ' 600 WashhWon r�treet Bltston,MA 0211I 4 i-twiu mmigtrpldia .. cwI,e& Campensafian Insurance Affidavit EmldersiContrackws/Elechi imL- hers AppHcant. n Please Print Le 1'la=s.nCETIR �M Address: Poi. M4 OU3" ��07 W Are . an employer?Ch-eckthe appropriate b= ' Type of project(required):I �I aM a emp1oYr wffi 4 ❑I am a general conhmetor.and I 6. ❑N an employees(fall an�dfor part-#xm * bane lurecl�e sub contract= _. Z.0I am a sale propuetcw orpartur " listed on. the.attached rheet. 7. odeing These sub-contractors have ship and have noemployees' � -� • 8_,❑Demalifioa .. �vadang form'in any capacity: employees xgos rs' 9. ❑Building addition jirTa�arl�ers' comp.Mm a„ce F comp_ naaml re tired 5. ❑ We are a cmporafim and its lO.O d Eleoxic repairs or ads 3-❑ lama homeowner doing au work officers have Wised their 1L❑Ph=biagrepaim ar addafioms of eaempfibn per MM 7 mysel€[No W0kkers'oomp_ 110 Rnofrepairs � �*+ zice required-]E c.13Z §1(4k and we have no employees.[No wodss' 13:❑OtFter comp.msmumc a required.] �$riyappFcmt�iiatcbedubos#1�talsofiIlort tl�esectFoab�Taw�nsdag3ie¢�s+o�Cee compeasalinupe�epiafnamsr�ua ffauievwagrsw3so s¢f=t ff3is d E&ry i kffCxdm.9 ds,ey zm doin6v s1F sro¢iE axdtbea hat outside cOn 2dum t.submit a aewal�dseyt iociicatiao snrTi ` fComuctu6i tehecY3�zbox mostattarsaaddi6unslsireds&vingthmm=eoffesub-co sandstftvdmtherornotftseenti6esbwe -gooyns.Ifthesa5-tartraoaeshaveemP10Yee%they mustpmuI&tiW s udmm'camp.palicymmnbes lain art errrp r tfrat is pru�Rdir .yvori€ers'con rrsrdiort iumzran wfbr uzy anT& zes $etoov is the poficy andigh siti informatbiL InsuranceConaganyi&me: Job Site Addre= r'G CifyfStaa: c�i�-, ��G ' _ ►Y Affach a copy afthe workers'compensation.polkydeciara6im page(showing the poficy mrxuber and expiration Sate). FaAme to secure coverage as requirednudes Section 25A of MM a 152 can lead to the imrposihm of criminal penalties of a tine up to$1,34a OU m&or one yw imprisonment,as w611 as cif penalties in the for of a STOP WORK ORDER and a fine of up to$250-OO a day a aint the violator. Be adcdsed that a copy of this statement maybe f xvnded to the Office of Iztesdgatioas of1he DIA for imsnrnncj,- ge s�ifrcatign Ida hereby a res >prmmkd abmw h trot$mid c arrest Svisaature Date Phone� . O aL am rally. Dv not tlds area,ter be corup&dd by tafp or town noaciaE City or Town- PernIIt Micerrse# Issming U&0r€t3*(drde trarej: L Board of Real& 1 BuilTing Pepar[ment S.Cityt£osa Clerk 4.Electrical Iuspector,S.Plumbing Inspector 6.Other Contact Pierson: Phone P. laformation aild 11astruefious y. Massachasetis G-C - Laws chapter M regoaes all employe$s'fn provide wark='coupensat=far their employees. p to this stye,as�Ioyre is detmed as.¢.M=Ypersan in$ie serPiee of another nude$any contact Of'& t, express or hmpliA*oral or wrifti.." An m plvyer is deff 0ed as`�aa in�iffiA parfn�,asmabfivn,cmparafion or a ie�r legal�9, any two or more . of the=foregoing=gRgCd m a3oint eMtM13d=,andinclndmg the legal jeF= da&=of a deceased employer,or the receiver or trastee of an mffividaaI,parbamsUip,asociafim or ofberlegal entity,emPlOy'ng employees- However the owner of a dwelling honsa baying not more than tI=apm nets audwho resides Ihmcia.,or the occupant of the- house of another who employs p=cins to do maw ce,rrn,¢tT ac t;on or repair wail-oa such dwelling house dweIImg thereto shaRnotbecanse ofsaoli employmentbe deemed to be an employ=n7 or on the grounds or bur7d'mg apjsnrtenanf . MGL chapter 152,§25g6)also states thA'every state or local firers agency shall wifhhold fhe i=ance or renewal of a Ticense or permit to operate a l}mskess or to construct buRdings is the commonwealth for any applicantwho bas not prodnmd acceptable evidence of cdmpr=m with the iasvrance_coverage required_" Ad itionallY,MCrZ chapter 152,§25CM states fiNmithm fhe--uW eal$i nor'ny offs political sobdiv%sians slzaIl enter into any contrast for the perfb=anoo ofpubho Wmk u3tl acceptable evidence of compliancewilh$ie fi=mce. re�rane ofthis chapter have lieenpresenicdto•hie co tarlov.mffiozity." AppIiczal� Please flI oizt the workea�'comperesaiion affidavit completely,by chug boxes aPPIY to,YoTm sifnaiion and,if necessaq,Supply ems)�e(s), address(es)andphon.D mber(s)alongwdiilic r c�r�e(s)of „stz ce. L r itedLiabOy Companies(LLC)or L�itEdLiabiTitp Par�eiahips(LLP)' n°.�PIOY�otter tban Ilia members or pazfnexs,are not rimed to cm xy worke&comPmsafian.ins -anm If m LLC or LL P does have empIoyees,a.policy is rmjm terL B e advise-d fad this affidavit maybe snhmz`h--�d to the Department of Industrial Accident mr confmmafion of insmaace coverage Alm Be sore to sign and date the affidavit: The affidavit should beret=ed to$e city or town brat the application for the permit or license is being regnesbA not the Department of Trdzrstrial A�-.cidemfs- T ouldyou have any gaes i s g the Iaw cr ifyou are rcgmrrd to obtain awolic=p compensation pofiey,pleasa call iiie Departmext at Ilia nu bez listed below. Self-iasared companies should enter their self-insm-,cmce licensenrnber on the aPproguaf5line. City ar Town-Officials Please be sate that the:affidavit is complete and pxited Iegffily..The Department has provided a space at the bottom of the affidavit for you fn fill out m.iha event the Office oflnyestjg ans has to coxdact you g th a applicant: Please:be sure is frII in the pe lIicense number which will be used as a reference n ambet In addifion,an applicant ear need o sabmrt one a$davit mdlcating cnn�t Ie ermit�Iiceinse Lions in a�gtven Y �S' - thst mt<st sohnzit mules p �P - - d under">ob e Res"tie licant sh.ouJA write-aU locations k (CY or policymfoxxnaiion.(ifnems-ary)an aPP town):"A copy of the aff davittiiat has ben officiany sfmaped or marred by the city ar towi may be provided to t3ie agpIican#as groofthat a valid affidavit is on file for f�nre'permits or licenses_ Anew affidavitmorst be filled out each year. here a home owner or citizen is obtaining a license or permit not re•I dad in any bTiCTT1ese or commea�ial v�rH "W a dog license or permit in bum leaves efe.)said person is I\TOT rmTi=d to complete this affidavit The Office of lnyestig Jions wouldl�a to thank you m advanca for your coaperafian and shouldyon have any questions. please do not hesiate to give is a call The I?eparfine�t's a.d&tss,telephone and AX number: y ' t1�of It�1as�'ach�.�s Depadmemt of hibstdA Aoadanta f��af�e�g�tio� 6wwa*b�:= BasWu..MA 0�11I T6.4 617-727-49GO*xt 4-06 ar 1-9 MA SSAF Fax#617 727 7M Revised4-24-07 Town of Barnstable Regulatory Services of Richard V.,Scali,Director 4 Building Division Paul Roma,Building Commissioner KAM 6s� ��� 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: cit3#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. DEFIIVITION 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 r 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,tbat 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 when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFIL.ES\FORMS\building permit foims\E3IPRESS.doc 06/20/16 �VE Town of Barnstable ` Regulatory Services ` IUM Richard V. Scab,Director. 65 Building Division. Panl Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.towmbarnstable.ma.us Office: 509-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r11`e `r'1 subject bj as Owner of the su property. T, l P Pay ` hereby authorize to act on my behA in all matters relative to work authorized by this building permit application for. y`c C,LIYn&'S (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. tune of Owner Signature of pli t l�1 �77C�1�� Gv�ilil S Print Name Print Name Date Q:F0RMs:0VRgMPEPIV0SI0NP00IS ., DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE F11/22/2016 S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS , TIFICATE 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 1 IMPORTANT: If�thficate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to. the terms and co 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 NAME W.Scott Kerry - KERRY INSURANCE AGENCY P"c°NIv Ext: 508)255 8000 FA/'47Cc No: EMAIL scoff ker insurance.com ADDRESS: P O BOX 1945 INSURERS AFFORDING COVERAGE NAIC# N.EASTHAM MA 02651 INSURERA: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B• CEDARWORKS INC INSURERC: INSURER D: P O BOX 1229 INSURER E: BREWSTER MA 02631 INSURERF: COVERAGES CERTIFICATE NUMBER: 105427 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $. - 5y: CLAIMS-MADE OCCUR •°'+.�... - DAMAGE TO RENTED PREMISES Ea occurrence $ - MED EXP Any one person) $ 1 N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO-- LOC - PRODUCTS-COMP/OP AGG $ JECT AUTOMOBILE LIABILITY r COMBINED SINGLE LIMIT $ Ili Ea accident ANYAUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EEXCESS LIAR CLAIMS-MADE NIA AGGREGATE $ DED RETENTION$ $ _ WORKERS COMPENSATION X ST TUTE ER" AND EMPLOYERS'LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE Y/" E.L EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? MIA -NIA NIA 6S60UBSD82888516 11/22/2016 11/22/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St AUTHORIZED REPRESENTATIVE Hyannis MA 02601 �Daniel C Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD Ced®rworks, Inc Exterior Coatruti., POO t w���. + tt MA EC631 K ii1.I7 aa,i.;tit 1I 3 "t3 1s Five Rd C M$420 at" � J . Aw --Of . , ` .. . ?. {.W s�� i 1 J lwi6tii�1 "m ilA 1W e a �'ll be vpmv P , tom WWI jobL Job xl�l dig .. � go how(see tc.Iovs-ffm Afl s t r grr XdA F x �6 9 rn•;x z- �� . '' � `�. -. a �,r! e ,' r.. s Office of consU mer Affairs& / &�a �l OME IMp usinessRegulation;Registrat n- ., NTCONTRACTOR Fon:- rr. Expiration:___. ? 6751 Type: r CEDARwORKS INLt Corporation HRIS YE "' 32 SEEC IF DRI SREWSTER MA s_ 02631 •ice Undersecretary License or registration valid for individul use only.,, before the expiration date. If found return to: Office of Consumer Y.> 10 Park Plaza- Affairs and Business Regulation Boston Suite 5170 ,MA 02116 {t , is Tr Not valid it out sigDaturi 1 ------- _--- of any use group which Unrestricted-Buildings nreSn less than 35,000 cubic feet(991rn )of Massachusetts 1---a �___ Department of Public Safety . Board of Buitdin 2uGlv'c`i sYacc g., u)aiions and Standards ' .,. l.11llltl Ullll)ll Ji7UCI Y/)Ill License: CS_104167 -- �ISTOPHER PO BOX 1229 7 possess a current edition of the Massachusetts e• Failure top Br+ewsterAM 02401. R c Code is cause for revocation of this 1:� State Building `^'Mass•Gov/DPS• For DPS licensing information visit: =� r. b. Commissioner Expiration 07/06/2017 j 1 _ Yr r Town of Barnstable *Permit# Expires 6 months om issue ate Regulatory Services Fee • EARNSfgB� �Q M" Thomas F.Geiler,Director �3O i639' 0� rFDMAYs� Building n Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us - Fax: 508-790-6230 Office: 508-862-4038 _. RESIDENTIAL ONLY EXPRESS PERMT APPLICATION Not Valid without Red X-Press Imprint Map/parcel Number ( v Property Address I�Residential Value of Work �L Minimum fee of$35.00 for work under$6000.00 Owner's Name& Address �L Telephone Number q4 l Contractor's Name Home Im roveme licable L WRIT p rit Contractor License#(if app ) , Construction Sue p rvisor s License#{if applicable) s ❑Workman's Compensation Insurance AUG 3 0 2012 . Check orie; ❑ I am a sole proprietor ❑ I am the Homeowner 0I have worker's Compensation Insurance o f BAR��TABLF- �O Insurance Comparjy Names Workman'sComp- Policy# J Copy of Insurance Compliance Certifi to must accompany�eachermit. Permit Request(check box). J�'/Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-ro Going over existing layers of roof) of(hurricane nailed)(not stripping. g ❑ Re-side #of doors ❑ Repjacement Windows/doors/sliders.U-Value (maximum.35)#of windows giiired: Issuance of this permit does not ezem t compliance with other town department regulations,i.e.Historic,Conservation,etc. *Where re P P _ ***Note- property Owner must sign Property Owner Letter of Permission. provement Contractors License&Construction Supervisors License is A copy of the Home Im re fired. SIGNATURE: Q:\WPFILES\FORM�-building permit f0nns\E7<PRESS.doC Revised 051811 f Tlee COM7H a+aavWAM of Mamameas Dqw&nmt efludkoid Act Off"of'.dirt VSd8aa dOM 60 W g*w Street on,MA 02III wwmmasLgoWAa ir Workers'Cm rasa aim airs AME&—Rst Maze Print 'blv Nam Address= g: ® Are u ancheek the appropriate box: Type of project(required):I.( 1�m employer wa—,3 4. ❑ I sat a Smerel contractcr and 1 6. ❑New conskoction aanployt:es(M a ffgatt-time).: bavc hind the moors �,/ 2.❑ I a n a wle�proms ar ga lzw Pissed an ttae aah�. 7- flL3 abp and lhasne no emplay a These have 8. ❑Demolition wadriag far me in any capacity- �� wozloersp 9 ❑$m"lfag addition RD tarn 'cam.insurance "=P- ❑ .l 5. ❑ We are a I aca nd its 10"❑Electrical repairs or ' 3. I am a homsovmw doing all wo& officers have amacised flag 11.0 Ping repairs or edditior e a>tYWIL[No vim' rigla of emempkan Per MGL 12-❑Roof repairs taquire&]p c_15Z$1(4),and we have no 13-0 Odaer eaoployees.[NO worms' caamp:imp MT-lived-1 �� duos ebad�a bet#1 aatmtt alma fll oat t'�s�baJaav xbosaio�gttsaaar�ais' pol6ey fi�oatameiaa Y HOMMWOM Vft VAu*d&a iood8eaafaag tl"too 40h*2B VM&cart&m bm omi&con=O==M smbaoit a ww affidavk n dkn&g stuff ZC=naxa wAwt che&*1s tress aamct whucbed an add sbM dwwbg tbM tie of the a aced state wbw&w arrant ft"Mies nave ampby"L rfrbeaab`caMest bMOVIWYW%&yxooestpaovldadMdrWG caa C=P.PCftjWMLbQL I aan eat earap8aryaar °ae�t�a�ars'eooas iaasar�atca ferr arty stet. i3eFirtr ass tharpobicy andioPe srtar informta dom h mra m Cc ampa ny riaate: Policy#or Semins.Vc.#: Ci'� won D-.: Job Site AAefi=. 1 �i7/LT/; i1�i3 1 , CitylStatalZip: �l�!/TZ 7�17_�,i� ARGt&a amopy of the workers!compenzatkm policy declumthm Page(shouting the pa"number and e"p anon date). Failure to mean comage as Axpaired under Sew 25A of'MGL c� 152 can,lead to the iruposifim of criaml penalties of a fine up to$1,500.00 aandlor one-yaw iaprhmalext,as well as civil pendfies iat the fay of at STOP WORT d2RD ER.aw a ime of°ap to$250.00 a day aagaicat the violdw. Be advimd that a copy of this datemad nzy be Bxww&d to the Office of Inveedgadm of t6o DIA for inumance coverep boa. Ida Ieersb3'eat°a t7tarpow am � e' g'that dhe on t prov�rl aboveis&X*card e»rratcat a Qj9tetatl xse aanty, Do not wd&ht thtb Ot be completed by city or&way oudaf City or Town: Permftli.,icense# Uming Aatbw*y(drde one): 1.Board of Haft 2.RdUbg Dqmlment 5.CIWT*m Oa* 4.Electrical Imrspeeter 5.Plumbing lnsfreet r. 6.Odw (Contact Peso: one 9: 6 } O KM . ' Town ®f Barnstable Regulatory Services Thomas F.Geiler,Director Building-Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using .A Builder I r f.rliA.ram' \ �. _,as Owner of the p pro subject property rty hereby authorize a�P �- to act on my behalf, in all maattxs relative to work authorized by this building permit application for. ZLZCIF� 6r&,4�Z< L2 (Address of,job) Signature of Owner Date - Print Name If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the reverse side. Q:IWPFILESWORMS\building permit knusWXRESS.doc Revised 051811 �/!ze a''"�n°°Z"`ec�l °l✓Gl"°°curz��°eta License or registration valid for individul use only Office of Consumer Affairs&Business Regulation g HOME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to: Registration::=1:00497 Type: Office of Consumer Affairs and Business Regulation TDDA 1. Expiration: 3/25f2014 Private Corporatio' 10 Park Plaza-Suite 5170Boston,MA 02116OX INC` ,11 David Cox 19 LAVENDER LN W.YARMOUTH, MA'02673 Undersecretary I Not valid without signatur Massachusetts-- Department of Puhlic Safct�- Board or Building Rc.aulations and Standards ' Construction Supervisor License j License: CS 63537 r"`-. t i. DAVID R COX. I PO BOX 401 S YARMOUTH, MA 02664 I . Expiration: 10/15/2013 ('ununissioncr Tr#: 4314 l --f—Ai,i)••✓aU%.na ra:v. Page 2 of? Da*?�l9rO12 11-43 AM?3;0:2 of 2 DAVID-2 OP ID:KG CERTIFICATE OF LIABILITY INSURANCE °�'��"°°""VI 07ti 911Z 7143 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE GOES NOT AFFIR14ATIVELY OR NEGA111VELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY 7W POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWSEN THE ISSUING; INSURER(4 AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT! If the 00411Flt 2ts holder is an ADDITIONAL INSURED, the policy(les)roust be endorsed. It SUSROGAT-10 13 WAIVED,subject to the tense and conditions of the policy,certain poiloles!ray require an endorsernent. A statement an this cortiflcats does not confer rights to the aerNAotte holdor to 11su of such endorsement s. ftao :A 509-771-I632 NMOE: Northwood Ins,Aeoncr,Inc. gO$�93-a9E3 340 Main g1Ce�,Sitlte 8 c.N a�ree NyRntrslt:,NIA 02�601 - — _ '— INSUMA AFFORDING cDYatAOE NpIC INQtrWRA:Travelers Insurance Company - nr, David Cox Ina INsuaeR®:Progressive Casualty ins.Co �Ylsr>mouth,MA 026" INSURE F• :OVERACES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE DEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOICATED, NOTWIT4STANOING ANY REQUIREMENT,TERM OR CONDITION OF A,NY CONTRACT OR OTHER DOCL►MENT WrrH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDS) BY THE POLICIES DESCRIBED HEREIN 19 SUBJECT TO ALL THE TERMS, .EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIN)CLAIMS, TYPE OF iNeLP NOR ?OLICY HiiftlSER ' 9Rt FQ �i-ryy ►4EFF �I-�-W"— ''Yy UP L I L NMt OZ tA!lIAML1TY I i i EACH t7CG iP7Ev2_� �5 1,000,OQ A COMMERC:PLGENCRALLIASR..IT'( ! r3014S1iVt791$ 0114112 � .01M4N3 1?-PEIL�I74SIEd]C'-r4ACa 900,00 _CLAIMSMADE ITOCCUP ) I I�EO@xF,t�ny�'9pascnj Tg 101 X 8uflrtee!Owners ,PERSONAL E AW IM1 PY S 1,000,00 GENERAL AGSREGA7E 5 2,000,00 GENLAGGk�GA E.IxI'APPuca`PEF: I ) _ r PF.COIiCTS•Ct1M'l0P AGv IS 2,000,00 AUrOMMLS LKGUTY { ( o t'a...L e �,c:art f sa ImIT ANY AU'0 - IOB717739.5 04119M 2 -04MS/13 BOG Y Ird,L.'fiY(Psi perlCtU Is 250,Q0 ALL OWNED I 1 -� $QO, AUTOS X SCMEDULEC AUTOS I I ROD-YIN AJRY(Par emaimt) HIRED AUTOS xNON CYUNED I """UP v MAGE Pe S — AUTOS ; ,ac.Went — 100,00 S� _ UMMMJ.A L" OCCUR ; i I Fs.CH OCCJPt[-V[� 5 &itCESaLIA6 t,AM15NIP.D i I f IACGREP?ATE ---I - rQED I Z—USCION 6 I S M RKR{RS t ItKWATION _ I MO11111MAYERS'LioiLt Y Y f N j Y —+= A ANY PROPR2r0kPAF1NE:L _-Jnv_ � ivy A e.i EAc►ACCIDENT EXCLU7kP s 900100 UP=u rn�}�EF tNrtedMllY>n rLVI Y OKU1091OX742 6/1 212 OM 2 04M 8/13 E I.G.SEn�E•eA E nPLOtEc s 100, IrYe�6t+ccrC)r indec -- DES �'!oN OFO R4rI0u5 iwv I E L.DISEASE.POLi_'Y LMI' s $001 I D@TION OF OI"@RA710NOI L9CA710H61VfliOLL�a(Atlt�t+A�CORD tt75,AddlEoo>U Rvmntka SohcQt;la,ilrnory saacelangWryaq vid Cox is not covered by the Workers' .Comp. pollr.y CERTIRCATE a L ER CANCELLATWN TOWNSAR SHOULD ANY OF THE AiIOVH ORWAt6ED POLICUM 89 CANCELLED BEFORE. Town Of BarnstableTHE- EXPIRATION DATE THOREOF, NOTICE WILL BE D&W RED IN 290 Maim§troat ACCORDANCE WITH IN E POLICY PR01 SWNS. Hyalrfnll;z,MA 02509 AUDIONZRE0 RYe?R UWAMVH (D 1988.2010 ACORD CORI'0RATION.-All rig hts reserved. ACORD 25(2010/DS) The ACORD name and logo are registered mark*of ACORD f u TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map .° Parcel_ 5� 4 ¢! Permit# ' 4 133 2 , ��N O AR STABLE � Health Division �� 3 Date Issued - / .- n 5 Conservation Divisions 1 � 20P j"' _Y 3 Est; 9: Of$ Application Fee o . Tax Collector Permit Fee Treasurer - 13IVISIo Planning Dept. EXISTING SEPTIC SYST M_�4 Date Definitive Plan Approved by Planning Board U MffoTo 2, S OF BpRpOMS Historic-OKH Preservation/Hyannis Project Street Address e �oR��iP DZ 6S-S— Village Owner 6t C�to Art Address -F!tre lemek_9 R15 Telephone CIS, q2q— 1��y Permit Request 9 X i 6 r.Anm6gs fol?w. `U / Hi?- ' ROOF Lc S evert ��, o2x8 rRA#rIyA y Xy'S �ooru S� f r �Ieu��g(L Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation q, 000 Construction Type PT FnAmE COMPOSIT malty(,, Lot Size Grandfathered: ❑Yes A No If yes, attach supporting documentation. Dwelling Type: Single Family A Two family 0 Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes fd No On Old King's Highway: ❑Yes . AF.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 0 Other Central Air: O Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage: 0 existing 0 new size Pool:0 existing 0 new size Barn:❑existing ❑new size Attached garage:❑existing ❑new 'size Shed:0 existing ❑new size Other: _-Zoning_Board.of AppealsAuthorization Cl Appeal# Recorded❑ Commercial ❑Yes 'A No, If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name 1 O5 U- I���� Telephone"Number Address ILI &A/ � � License# �,e*fen i c Home Improvement Contractor# �26 3 Worker's Compensation# ALL CONSTRUCTION DEBRIS.RESULTING FROM THIS PROJECT WILL BE TAKEN TO LJVJ6:_ SIGNATURE -!/t/ DATE J . 5 FOR OFFICIAL USE ONLY F PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME f INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL A GAS: ROUGH FINAL s - FINAL BUILDING Q'� n C DATE CLOSED OUT N , ASSOCIATION PLAN NO. �? - .i N • f f}aE r Town of Barnstable Regulatory Services ainara # Thomas F:Geiler,Director 0 .�h`��' Building D"' Ion TomPerry, Building Commissioner 200 Main Street,Ijyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-862-4038 Fax; 508-790-6230 Property Owner Must complete and and Sign This Section If Using A Builder I C ewe, i/i'l.l 4/ ,as Owner of the sub)ect property :hereby authorize to aet on mybehalf, in all matters relative to work authorized by this building permit application for; VII5 Its 1*4 D�6 Address of Job) 4Sign e o Owner Date ��C vn��� r • Print Name The Commonwealth of Massachusetts .. -- Department of Industrial Accidents 600 Washington Street Boston,Mass. .02111 Workers'; Comiensation.Insurance Affidavit-General Businesses �s�o`�•'�+w,- 'J:.,Y+ 'ctz,YID( .y�..cr+�F,1�,r 'S.y. .. ..'., �.�: � ..''�,w'81 name' t Cy address: lo• c;t 51 �,' 11`Q state. b 111� zip: aN���• nhane# 77 t— 7e L q work site location(full address): Five_ W,,,prtej IZA OSTeR <.tit /� d (� I am.a sole proprietor and have no one Business'I)'pe: 0 Retail❑RestaurantBar/Eating Establishment working in any capacity. ❑Of [l Safes(including Real Estate,Autos etc.)` ❑I/m an toes jull& a�r%t%t/im/e/.: ❑00%t%her%/ /%�///////JG//i%O�//%///I am an,employer providing workers, compeasation'for my employees working on this job.. ' panV•II>iIItet. 77 tid�ress�` '•� "� t • 4. city' •�UV� �����.,'' Ahone#.: ��'e) '�Z t ���'�`� '.:. r•Y O .insurarice.cIffIo' s� - - . •• I am a sole proprietor andhave hired the independent contractors listed below who have the following workers' ; compensation polices: company'ns'riie= - f f?Y t ddress8. city ` tilione#... '•.t .Sri -:id: '.i:•. ''i::• -].• lliSur9nCe'CO. ��l/%/�/%�d i t. �'• '.'•e: c` en n uI oinp y - insuranc_•cb:." •. :..:•:.. •. -•.:.'+.:;:::;•:.�.:.. o icy:#-::,•::•,.-':�`•:,�:.�;.:... 1:0 ME EMMOMEMEMEN MWEEMMEMMEEZZ Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a flue 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 It copy of this statement may be forwarded to the Office of Investigations of the DlAfor coverage verification. ; I do hereby cerfi and r the pains and enal ' s of perjury that the information provided above is 7/i d coneSignatured Date Tl 0 f Print name Phone# (LJz5)1 1— I .. 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 Sept 2003) r Information and Instructions Massachusetts General I,aws.chfapter�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 m 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, ' any two or more of the foregoing engaged in a�joint enferprise, and including the legal representatives of a deceased,employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. 'However the owner of a dwelling house h"g-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.conunonwealth 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 . Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation..Please supply company name, address.and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department-of Industrial Accidents for confirnnation 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 regard4ffie"law"or if you are required to obtain a.workers.' compensation policy,please call the Department at the number liste4below. City or Towns . Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill.;in the permit/licens.e number.which will be used as a reference number. The.affidavits maybe returned to 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. wom The Department's address,telephone and fax number: The Commonwealth Of Massachusetts- Department of Industrial Accidents fie of 088098dens 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext.406 o�TMe roe Town of Barnstable Regulatory Services : y sAaxsTAsr�, Thomas F.Geiler,Director 9 MA99. 4A 26119 A.� Building Division rfD MA'( Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 Permitno 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 strictures which are adjacent to ° such residence or building be done by registered contractors,with certain exceptions,along with other . requirements. q Type of Work: �A �� -� 0�� Estimated Cost // Address of Work: Owner's Name: (z�✓✓� //y1/'" i Date of Application: G I hereby certify that: Registration is not required for the following reason(s): []work excluded by law ❑Job Under$1,000 Building not owner-occupied []owner pulling own Permit Notice is hereby given that: _ OWNERS PUt,LING THEIR OWN PERMIITIDOR DEALING�ROVEME�f WORK DO NOT HAVE CONTRACT ORS FOR APPLICABLE ACCESS TO THE ARBITRATION PROGW4 OR GUARANTY FUND UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: err✓ attor Name Registration No.r ate OR Date Owner's Name Q:fomis:homeafPidav u 80Aft OF B'lJ►LUi /` Q° uael License, C REGI-1LATION•S ONST RUCTION SUPERVISO Num.bcccs R Og a.- 2213 �ctat� ,Fts3 976 �tQ/06 ' Tr.no: 82213 . ✓OSHUA D WR���`�� ���•'i I_ 306 WEST BAY R � 0STERV6LLE. Administrator ku ir y OME/4fp Re h,Q��e - 9 s �n FNT CONT �- , ' 14288, j' —' fJOSH A 34 MAIN i` CENTFRVjLC�FE MAY r �;.• �nisrrator - r iLORTGAGE 1NSP=TMN PLAN APPLICANT. CIMINI/MCLACHLAN TO WY CENTERVILLE LOT 30 130.DO' DECK LOT 28 � , 411 LOT 29 164.50' BUMPS RIVER ROAD a ♦ SiEPHEE_"J ►J _ ► - " DOYLE A �c V ' • � ram= - FLOOD PANEL: 250001 0015 C FLOOD ZONE _C DATED.- 8119185 Y I hereby certify that this mortgage inspection plan was prepared fora Plan is For AMERICA S WHOLESALE LENDER° Bank Use Only The location of the building shown does _MT_ fall Within'a special flood hazard zone. PLAN REF. = 31043A Per taped inspection it appears the location of dwelling does ------ conform to the local by—laws in effect at the time of construction with respect to horizontal dimensional setback requirements Scale 1" _ __4�1.'__ FT. or is exempt from violation enforcement action under Mass. General Laws Ch. 40A —Sec. 7 Date: �22104_ PLEASE NOTE The structures on this inspection were located by tape not instrument and are approximate only. An actual survey is necessary for a precise determination of the building location and encroachments if any exist, either way across property lines. This inspection must not be used for recording purposes or for use in preparing deed descriptions and must not be used for"variance or building plan purposes. This inspection must not be used to locate property lines. Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. This inspection is not to be used for any purposes other than mortgage. Yankee Survey accepts no responsibility for damages resulting from said reliance. PHONE: 508-428-0055 YANK E1 SURVEY CONSUT TANTS . FAX 508-420-5553 UNIT 1, 40 INDUSTRY RD, MARSTONS MILLS, MA 02648 36705 RJB , r 4 a j ,�� I f �• � t��F p 4 r �-,� � 4 �. y f • ram' � � t 1 t i a - j i t t I + i i rf" i f i to �s i • 14 it ri I f r i , � � I � ' ' i I �I � � I I4 � I f � i I it � ili �i i 'ij ) .I. II. I� � . ill. I � � � I . . � � . . .I it iil � I � � � � � I . 4 . Iliii � i I ii ` ill i � � � j I I _ i 1 � i I ' i ,. � � I � j � i � �� I I I I 1 � � ' � , ! i i i � � � � Ili � � � f � � I � � � i i i __ � � .� ._;4._.-..-•.,may .f �' ._.T.z -,�._. � .-�.•-_�' B--T-_��d. •.•.-�? _ .,• a .. V, G _ ' Ll ki ' ���il\ � � ,. i --T^•!�.—`—jam � y "��: �'. {'�..�-��. •r.lr/"1'"'t'�-.r 4 j,-- :J-tv�U_ - t } ( �ZA inNIB 19 , rr t x , Chop D iA p 4.� i i ► j ! � � � + + � � � � � � � � � { � + � � � _ _ _ T � - - - 1i i - - - - - - - - -- _ _ _. _. _ _ - - - - -- - - - - - - - - - - i I , � f - - - - - - - - - - - - - '� + I t i - - - - - -I f - - - - - - - - - -� �- - -- - -- -- - - - - - - .. - - - - - - - - it 1 t - - - - - -- - � -- - - - - - - - -- - - - -- -- - �_ I_ � + � The Town -of. Barnstable .. _ . BARNSTABLE. Department of Health Safety and Environmental Services. MASS w Building Division 367 Main Street,Hyannis,MA 02601 Dffice: 508-8624038 - Fax: 508-790-6230 PLAN REVIEW Owner: n) Map/Parcel: pp _ Project�Address: / l�) -e Y S Builder: The following items were noted on reviewing: Reviewed by: Date:_ '�D Town of Barnstable Approved 'Regulatory Services pp � Reg Fee Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Horne Occupation Registration . Date: Zee Name: �fc-,A) L Phone#: C)s - +a1 53!!I� Address: AB 1r C*r_g� -Village: l�yitt Name of Business: v Q0-IF Type of Business: Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation . within 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 the 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. After registration with 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 customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • 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 the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation, other than one van or one pick-up truck not to exceed one ton capacity, 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 shall be 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 dwelling unit. - I,the undersigned a a n agree with the above restrictions for my home occupation I am registering. 4"te: 22 b� • Applicant: Da - Homeoc.doc