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0240 FIVE CORNERS ROAD
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'it�.0 1,s.axa.d.dYtL2" .ed.3..As a, .,)i,'Xbnrrr Y4 Lr,.,.a *v 1, ..1 .rN. „Yl 11.a. .P ...ar,,.,v.,.' ,,i5,.,::�...,1. _ _ _ - Town of BarnstableBuilding `= PostTh16 Permit �s Gar=;d So�That�it�sUisible Fromihe Street A' `roved Plans Mu5b'eRetamed on Job andah�s"Card Must<be-Kept Posted Until"Final irispectwn Haas t3eenMade. o ° W`herea Cerf�ficate°of;Occu anc�, s Re, aired,such Baildrn shall NARNWA ot beUccu red until�a Finat Ins ect�on has been made g P Permit No. B-18-961 Applicant Name: CAPE& ISLAND CONSTRUCTION•CO INC. Approvals Date Issued: 04/04/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 10/04/2018 Foundation: Location: 240 FIVE CORNERS ROAD,CENTERVILLE Map/Lot: 168-006 Zoning,District: RC Sheathing: 24 Owner on Record: VIOLA,JOHN T&ALLISON&VIOLA,JASON F T ;': ' iContrac or Name: CAPE& ISLAND CONSTRUCTION Framing: 1 CO INC. Address: 240 FIVE CORNERS ROAD 2A r - ... _ Contractor License: 165936 CENTERVILLE, MA 02632 Chimney: Description: re-roof stripping old shingles Est Protect Cost: $6,000.00 k ; Permit Fee: $35.00 Insulation: Project Review Req: . I FeePaid: $35.00 Final: Date: 4/4/2018 r � Plumbing/Gas r Rough Plumbing: Final Plumbing: Building Official • Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by-this permit is commenced within six months aftd issuance. Final Gas: All work authorized by this permit shall conform to the approved application and th?e;approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road"and shall be�rnai ntained open or public mspectf on for the entire duration of the Electrical . work until the completion of the same. a Service: The Certificate of Occupancy will not be issued until all applicable signatures bythe Building andjFi,re Officialsare provided on this permit. Rough: Minimum of Five Call Inspections Required for All Construction Work: ' 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:' 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. _ Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Town of Barnstable *Permit# -1 X- oF � ryes 6 months f rom issue date°* Building Department Fee s- sn�vsr�s Brian Florence,C1Q,RAM �' Building Commissioner �r i63y. ♦ I iOrEo 200 Main Street,Hyannis,MA 02601APR 0 3 .201 a Il www.town.barnstable.ma.us Office: 508-862-4038 SOWN OF BARNSTAB 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number n / J Property Address %l �O { tX residential Value of Work$ 0 U' 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address S 0/,-' Vic&/ti Contractor's Name 64 (_ e_ Telephone Number z M- 7`7(o e;-30 � Home Improvement Contractor License#(if applicable) g� (a Email: V fi4! CAC-411 J S/Qhtls Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [ I have Worker's Compensation Insurance Insurance Company Name k Workman's Comp.Policy , 7-7 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request check box) e-roof(hurricane nailed)(stripping old shingles) All construction.debris will be taken to (a✓ice ❑Re-roof(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 copy of the Home Improvement Contractors License&Construction Supervisors License is r quire , SIGNATURE: QAWPFILESTORMSTY PRESS2017 I 1 OFTNE r Town of.Barnstable ti Building Department v �` Brian Florence,CB0 -1�a`� 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 to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections.are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name , Date Q:FORMS:OWNERPERM 3SIONPOOLS Rev: 10/17 Town of Barnstable F'THE, � Building Department c� Brian Florence CBO Building Commissioner v MAM 200 Main Street, Hyannis,MA 02601 iOrEo�µp`l a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": - name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINMON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection.procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. 1 The Commomveafth ofMassead jusetff Department of&' =&ialAccidien& Office of Lwem6gafians 600 Washinglon Street Boston,AfA 02111 nvsnv mas&gov1dia ""te}rkers' Campensation Insurance Affidavit:Buflders/ContractarsM ians/Phumbers p�FCaIIt Infm-matiou �7 (� Please Print �T l�alfl8( IIStII2SIIffifl (/ jL �iy' I �L� A drt CitgfStabef �} Phone �, --7 S- ( Are yoope an employer?Checkthe appropriate box: ' Type of project(required): I.LU�i a�a eoapls�yezrtb 4 ❑I am a general contractor and I G_ [-]New construction employees(fall anNor part-ime * Nave hiredthe snb-cam�hrat ss 2.❑ I am a sole pmpdetor or partner- listed on the attached sheet~ 7 ❑Remodeling ship and have no.etmplayees These;mb-contractars have g.,❑Demolition 1 amdhavewo�s' wat�mg for me in any capacity- �°�� $ 9_ ❑Building addition [NO updoam'comp_insurance camp.snc�ran�r required.] 5. [-]'We we a cmporatim and its 10❑Electrical repairs or a,ddifiGns officers have exercised t3u<ir . 3.❑ I am a homeovraer doing.all wow 1 L❑Plumzbingrepairs or additions o loess' of a on per MGL €in=andrequired-]j c.152,§1(4h and we have no 12.❑Roof repairs employees-[No workers' 1-3-El Other camp.insurance regmrea-] allay W icmtfttcbecmbaa LFl mast also fill o=the sectionbeTowshumiug thei vmleW cemppnMdQ0pericyinf=Xti a Samwwaem Who snbm-tt this d&12 a mffr=g they me thing all Want and&en bite oa=&coattactois—st submit a new affidaeat indicating sadL fCaaitsctots this check this brae mast attsched za additional sleeps sbosemg the name of&e sub-contzctam and sta#e Whegm ar not moose en itinhwe employees.Mthe sob<==tms have employee-,ft-TMMtstpMnQ&dudr worker'tamp.policy mm bm lam an e))rplor Pleat is prQuidii)g workers'cattpeaesattcnt insziratres for aryl*carptay�ees Betoty is flea psrticy aced jabs i14lormalZom Insurance company Alame: l 'Policy�or Self-ins.I.ic" I,•g 7r— 3� — 3-7 7�i" t9' l9�7 nvimtionDate: 7 l Job Sate Address_ 2 Y O //G(1, city/StawZip.,�e L Attach a copy of the workers'compensatioupolicy declaration page(showing the policy number and expiration date). Failum to secure coverage as regtureduuder Section 25A of MGL c-152 can lead to the imposition of criminal penalties of a fine up to$00a Oa andfor one-yearimprismunmd,as well as civil penalties in the fora of a STOP WORK ORDERand a fame of up to$250-00 a day against lator_ Be advised drat a copy of this statement maybe forwarded to the Office of Im mstigatinms ofthe DIA.�T c ge yerifimca on- Itlo hereby csro as ' s alffes of pa jk)y'thatthe im,forma€un provided �s" tare alai correct Date: L Phone 027cid use anty. Do)eat wrtta in tlds area,to be cvmp&ed by city artown official City or Town: PermitUceose� Lmaing Authority(cn cle one): 1.Board of$ealth 2.13utTding Department 3.Qtyfrown Clerk .4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - 6 Information and Instructions s Ell 1r) da workers'c ensation for then =- M�s���-ce#s GeheraI Lames cbapfm 152 regoaes en�Iloyers pray omP �Pla3' p t[)this sty,an.e2npIoyw is defined as",..every person in the service of anof er under airy contract oflhire, express or hnp]ied,oral or wrifteu." An Vnp&yer is defined as"air indiv�parfnersbip,associafioM,cOrpord ion or other legal entity,or any two or more of the foregoing engaged is a joint enterprise,and including the legal aepresen aiives of a deceased employer,or the receiver or t mstee of an individual,pmtamship,association or other legal entity,employing employees. However the owner of a dweHing house having not more thaw thrto apartments and who resides therein,or the occupant of the - dweHing house of another who employs peisoms to do malice,construction or repair work an such dwelEmg house or on the grounds or building thereto,shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(t7 also sfafes that¢every sfafn or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct bindings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insuxance coverage required- Additionally.MGL chapter 152, §25CC7)states'Neither the nor my ofits:political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the i„sn-ance. rPq=rMents of this chapter have been p=erted to the Conti aoihcaty." Applicants r Please fill oirt the workers'compensation affidavit completely,by cheakng ffif-.boxes That apply to your situation and,if necessary,supply sob-contr a s)name(s), addresses)and Phone number(s)along with their certiamt*) of iinsuxanca. LirrtedLieh-Uy Compnes(LL()or Limited Liability-Partneshigs(LLP with no employ=other.than.the members or partner are not rega rred to cagy workers' compensation ins room If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe sahmitt--d to the Department of Industrial Accidents mr confiirmation of ice coverage: Also be sure to_sign and date'th e affidavit The affidavit should be-retumed to the city or town that the application for the permit or license is being requested,not the Deparmmeat of . Ln-dash-ial.A r_• dcnts_ Should you have aay questions regardmg the late or ifyou are required to obtain a workers' compensation policy,please can the Departmeat at the number listed below. Self-instaed companies shouId em`�s their self-j sur ace license number on the apprapriefe line. City or Town Officials Please be sure that&D affidavit is complete and primed legibly. The Department has provided a space at the:bottom of the affidavit for you to fill out in the event the Office of Iuvestig ations has to contact you regarding the applicant P lease be sure to fill in the peunitflicerse number which will be used as a reference number. In addition,an applicant that must submit nluliple pennitJUCen se BPP in any given year,need only submit one affidavit indicating cma ent policy iafb ation(if necessary)and under"lob Site Address"the applicant should write"all locatL-ns in (cifY or town)-"A copy of the-affidavit that has been officially stamped or marked by the city or town may be provided to tare applicant as proof that a valid affidavit is on file for futm:E peunits or licenses_ A new affidavit must be filled out each year.'Where a home owner or citizen is obtaiaing a license or permit:not related to any business or commercial vast= (ie. a dug license orpemmit to burn leaves etc.)said person is NOT regm¢r .to complete this affidavit The Office of Investigations would like to thank you in.adv-amce 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 mm�bea: -The -V�th of h chus:� tls ' Degailment of Tn al Aocidenta f ice of JAVMukatio= FQ4� Qn , 2`(,-L 4 617 -4900=t 4-06 Qr I-M-MASSAFE Fax 617`27 7M Revised 4-24-07 m � �� �,►,r:„ Town of Barnstable Building Department Services BMWSrAABU& Brian Florence,CBO MASS 1639. Building Commissioner ED MA'1� 200 Main Street,Hyatmis,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 a� i/ ] b LAl A —�- ,as Owner of the subject property hereby authorize- �►'� �C�w�'i to act on my behalf, hi all matters relative to work authorized by this building permit application for: 2g0 5" 60-P, S �6 /�--j) (.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 perfomed and accepted. tgnature of Owner Signature of Applicant dA 5 1)AJ t,4 Print Name Print Naine - Dad Q:FORMS:OwNERPEItNUSSIONPOOI.S Rev:08/16/17 • ,��� .E�f e rconusea��i a���aaaacjivaeCiis Office of Consumer Affairs&Rosiness Regulation HOME IMPROVEMENT CONTRACTOR ? Registration:665936 Type: .Private Cor oration ` = Expiratio.— p CAPE&ISLAND COwJAY I90 INC. JOSHUA,-KOURI i 55 ELM AVE. '' HYANNIS,MA 02601 Undersecretary ]License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116" of al' without signature T Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-074660 Construction Supervisor k JOSHUA X KOURI PO BOX 210 y CENTERVILLE MA 02632 ;•. 'Commissioner Expiration: 02/12/2019 Construction Supervisor - Restricted to. — Unrestricted-Buildings of an less than 35,000 cubic feet(991 cu Use ic group enclosed s which contain • . pace. meters)of Failure to possess a current edition of the State Building Code is cause for revocation of this centts DPS Licensing information visit: WWw.MASS.GOV/DPS fI►c`�o� CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD"YYY) 5/14/2017 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 have ADDITIONAL INSURED provisions or 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 FRANK L HORGAN INSURANCE AGENCY INC NAME: ' 44 BARNSTABLE ROAD PHONE FAx PO BOX 250 LAIC No Ertl: aC No: HYANNIS, MA 02601 ADDRIESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURERA: LM Insurance Corporation 33600 INSURED -INSURERS: CAPE &ISLANDS CONSTRUCTION COMPANY INC PO BOX 210 INSURERC: CENTERVILLE MA 02632 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 35624081 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 SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD MMIDO COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED - PREMISES a occurrence $ MED EXP(Any one person) S PERSONAL 6 ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY jE O- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY Per accident S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS JAB HCLAIMS-MADE AGGREGATE S DED I I RETENTION S S A WORKERS COMPENSATION WC5-31 S-377540-017 5/7/2017 5/7/2018 STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE YIN - E.L EACH ACCIDENT s 100000 OFFICERIMEMBEREXCLUDED7 �N NIA (Mandatory in NH) - - E-L DISEASE-EA EMPLOYEE S .100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-.POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously Issued certificates,only as they relate to workers compensation coverage. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN ST ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD 35624081.1 1-377540 1 11-10 WC 1 n0270258 1 5j19/2017 11:09:46 PH (PDT) I Page 1 of 1 vo w wwe� M 4 Ml Restrictions 1st Floor 250 This Certificate of inspection is hereby issued by the undersigned to certify tha inspected for general fire and life safety features. This certificate shall be fram within the space as directed by the undersigned; Failure to post or tampering Name of Municipal Building Commissioner Thomas Perry Signature of Municipal Building «; Commissioner / . ' S N 7 NIh 1� - Y v PROJE NAME�T� a LL;B)GT i v•l t't` ` ADDRESS: \l E� C -c'oE'Y-SZC� PERMIT# Ct a . PERMIT DATE: M/P: LARGE ROLLED.PLANS ARE IN: BOX, Cep SLOT ) Data entered in MAPS program,on:. BY: q/wpfiles/forms/archive t y C�b r � L i { Enginer&ring Dept.(3rd floor) Map 16' Parcel �U F'�S Permit# :21910 i House# Z D Date Issued 73 L`:jV Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) NO Conservation Office(4th floor)(8:30-9:30/1:00-2:00) ..q� L Planning Dept.(1st floor/School Admin. Bldg.) / IMF Definitive Plan Approved by Planning Board 19 _ - • BARNSTABLE. TOWN OF BARNSTABLE Building Permit Applic tion Project Street Address duo Fk e Lh� ? . Lam-- 72 Village 6-4— �)112, Owner d1' gas E2�& UQ Address Telephone - Permit R uest ( /'' CtiGC- �Yc.t� First Floor square feet Second Floor square feet Construction Type S IM] 0 i�>,l a 10 Ln Estimated Project Cost $ � , j(p 1p , DM Zoning District Flood Plain Water Protection Lot Size 4. Z aw.g Grandfathered ❑Yes ❑No Dwelli pe: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing ture Historic House ❑Yes ❑No On Old King's Highway ❑Yes o Basement Type: ❑Full awl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Are t Number of Baths: Full: Existing Ha isting New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ectric ❑Other Ventral Air ❑Yes ❑No eplaces: Existing New Existing d/coal stove ❑Yes ❑No - Garage: ❑Detached Other Detached Structures: ❑Pool(size) ❑At ed(size) ❑Barn(size) None ❑Shed(size) ❑Other(size) Zoning Board:;es p eals Authorization ❑ Appeal# Recorded❑ Commercial ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number—, Address License# Home Improvement Contractor# _ Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEB IS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR ~`7 DA ' BUILDING PERMIT DENIED FOR THE FOLLOW G REASON(S) I C.� � Q 1 5 - :f is FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED. t MAP/PARCEL NO. ' ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ' ROUGH FINAL PLUMBING: ROUGH FINAL -- GAS: ROUGH FINAL f-FINAL r BUILDING L_rf cz f / DATE CLOSED OUT 1 ASSOCIATION PLAN NO. j V� w , .�. n erannyunin-caftlr of:)tassachusctts Departine"I of Industriul.4ccidcnts Offi-ceal/arestlgativns •�1�=;j� __�:�+ 6110 Strew 4; �•:'`'` +' BtaW11.91ws. 03111 1 �•' Workers' Compensation Insurance Atfid.av it •tn inf rtn i6n• - natnc .location. nhone tin.G- I am a homeowner performing all wort: myself. I am a sole proprietor and have no one working in any capacity �__„__•„�___ r I am an employer providing workers' compensation for my empiovees working on this job. enliumov n tmt• •tddrets• CON- nhnnc nniicv it I am a sole proprietor general contract r, or homeowner'( cle oue) and have hired the contractors listed beio�� whc the following workers"compensation p • es: i3 - 8YUY comnam• narnc, / nhnnc a• S ';)Z5 - 2-71 h r-� ►c niic� t: c as o(� �' in-mr-inc rn. - ---...•—....�._. cnm :In.• nhnnc' address. sin nhnnc a• insurance c olic•0 _ •,_..• _.Ji"':v.•.s -.. .. •...�. _...,..r. 'r••'.'",�-r+�+:►r..N�........_v: 'w.ar—.�ilYP..•_�...Y►�a Attach additional sheet if neer,,�:.rsi...v— Failure to secure ci»erase as required under Section 3A of;1IGI 152 can lead to the imposition of criminal penalties of a line up to SI.500.UO ant une%cars'imprisonment as%well:ts civii penalties in the form of a STOP WORK ORDER and a riine of SI00.00 a day against me. I understand the copy'of this,tatement may he funvarded to the OlTice of investigations of the DIA for coverage verification. I do Iterchr cc,rr 11 ua Cr the p Init'rs o rrjurr that the information provided above is true and COMM Sianatu' Date SS Print n 6Z2 -4 Phone# 7 �ofticial use univ do not%write in this area to be completed by city or town ofGciai permit/license it 1«Itluiiding Department sin or town: C3Liccnsing Iluard check-if immediate respunse is required [:Selectmen's oriicc(:ticalth Department _ r^rlthrr ,lassacausetts General Laws chapter 152 section _'5 requires all employers to provide workers' compensation sor their mpirn-ecs. As quoted from the "la��". an etirpl(tree is defined as every person in the service of another under an\• ontract of dire, e�presc or implied. oral or written. .n i'llrpi rcr is defined as an individual. partnership. association. corporation or other legal entity. or anv two or more . ►c forcaoinu enuaged in a Joint enterprise. and including, the legal representatives of a deceased emplover. or the :cciver or trustee of an individual , partnership. association or other lecal entity, employing, employees. Ho%vever the xner of a d%%-ellinu house having not more than three apartments and who resides therein. or the occupant of tite xcllin�,. house of another who employs persons to do maintenance , construction or repair wort: on such dweliin�, hour out the __rounds or building, appurtenant thereto shall not because of such employment be deemed to be an empioyer. GL chatitcr f 5? section 25 also states that every state or local licensing,abency sliall withhold the issuance or nelval of a license or permit to operate a business or to construct buildings in the communivealth for ani- )plicant who has not produced acceptable evidence of compliance with the in coverage required. 7ditionall,.. neither the commonwealth nor am• of its political subdivisions shall enter into any contract for the ."formmnce of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha _n presented to the contracting, authority. plicants 2se fill in tite workers' compensation affidavit completely, by checking the box that applies to your situation and pivin_ company names. address and phone numbers as all affidavits may be submitted to the Department of sstrial Accidents fot confirmation of insurance coverage. Also be sure to sign and date the of idaviL The :aV it should be returiied to the cityor town that tite application for tite permit or license is being, requested. :he Department of Industrial Accidents. Should you have anv questions regarding the "law" or if you are required c:ain a \vorkers' compensation; policy. please call the Department at the number listed below. v or Towns .se be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of .ftidavit for you to fill out in the event the Office of Investigations has to contact you regarding, the applicant. Pleas ire to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to Department by mail or FAX unless other arrangements have been made. Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. se do not hesitate to :Live us a c211. Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents office of Investigations , r= 600 Wasliinbton Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (6I7) 7274900 ext. 406, 409 or 375 (.omrnonweahk of filla�eackwetb 1JaparEnsanE o�J�ndu��ria[�ctE�anf! 600 VL/u4illon Street James J.Campbell osEon, Ma jac4watis 021 / / Commissioner Workers' Compensation Insurance Affidavit - f Morton Buildings, Inc. r (ticeases/penaisu.) . with a principal place of business at: P 0 Box 399, Morton, IL 61550-0399 (Citylsute/tip) do hereby certify under the pains «nd penalties of perjury, that: {� I am an employer providing workers' compensation coverage for my employees working on this job. Insurance Co. of No. America (CIGNA) RSCC42506473 Insurance Company Policy Number O I am a sole proprietor and have no one working for me in any Capacity. () I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors fisted below who have the following workers' compensation policies: Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O 1 am a homeowner performing all the work myself. 1 understand that a copy of this sratement will be forwarded to the Office of Investigations of the D1A for coverage verifleadon and that failure to secure coverage as required under Section 25A of MGL 152 case lead to the imposition of criminal penaldes consisting of a fine of 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. Signed this T� ._day of ��� 19 censee/Permittee - building Department Licensing Board Selectmens Office Health Department TO VERIFY COVERAGE INFORMATION CALL: 617.727-4900 X403, 404, 405, 409, 375 Ca Rey _ o c Fioo5e �TrV& e6P AJ rS Xo - - "N�M'�]4�rvrLLf bra sS •i Za:vilk E R� •fir Assessor's map and lot number ... Sewage Permit number ... �v-s.T.....h�.... .E �� /��ccaiz�q u�E GuiT�- • ��w�� ....... Ae G�v z-vT1o, S yoFTNEr,�y TOWN OF BAR.NSTABLE ti BAHBSTODLE. i "6 �on U]LDI C IOSPECUR o'FO YPY a' APPLICATION FOR PERMIY TO .....././l f.:. ...... ..........w...:! ...... ..... . .............................................. r q ` �i G !+�c� rf �. TYPE OF CONSTRUCTION ........../....?�....�r Y..L+ z...............1..ff-e.... ........ ..Y.pv:::...//r..: ar�............ .........G/....... ..�1�..-.............19...L TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......... ......L�G�.t �? .°. ......11.................... �'?a. .li ��..... fYe✓..�: ....................................... ProposedUse ....... Gf! l '.. ....... l, ,e!.. ............................................................................................................ ZoningDistrict ..........fi.k�...................................................Fire District ................................................................................. Name of Owner .®. �G........../.:/�.3!. X1.G Jc..........Address �`.�� ..L��roz!Q�' ... �;F-7zec frki .. .Ald, C Name of Builder ...... . ..........:.....Address .... `(......�7.� 1 ?F��Sy. Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exierior .....................................................................................Roofing .................................................................................... Floors ...................... ...............................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace Approximate Cost ....2,..... Definitive Plan Approved by Planning Board ______________________ ______19________. Area Diagram of Lot and Building with Dimensions I&LO d � ���n� < Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH �2•a Y S V ou7� I hereby agree,to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. NameG......... -'`�`�e........................ ' . ' ' � . , . ~ ' . ^ . . ' ` . � . ~ ' � } � ' v ' | � . ~ . | ^ _ . . | � � ` - ^ . .� Varmon, John Location ........Five Corners Road Type of Construction ...gri ate ID001 Date Completed PERMIT REFUSED ' ^ . . ^ Approved ^ ' . _----------- ........ � ~ ' � ----------------^------^' ------------'--^--'---^'~^'' ' � Assessor's map and lot number ..........:. ' Sewage Permlit number .T... � c ...................... Vla TV Y BARSSTAnLE,MASIL i RFD dPY a• BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......��lf: /..�:....... ......J rn�i �7.... '�� !� ...: .......................................0 A .......... ( `. ..../ ....F ......YYPE OF CONSTRUCTION . ........ .........G. ....... .. ..........:..19...%- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the, following information: ......�.f`.l..r.�..:..L0. ?�.�. ..r�.:.... ................... �'t! Pr.>r�.✓.1..� ..... 1`!�c✓.�.,�...................... Location •••••.••••••••••- ProposedUse ;...... f .1 '.'n '' ....... �Lf.r..�.......... ..:..................: : ...... .................... ......... ......... ............... Zoning District ..........�j..G......................................................Fire District ................................................. Name of Owner .d. �41�..:....../.`l�.Y..'�? .G.:?f.:..........Address n.6%!. d/:...C:P;Y7.FUGi Name of Builder . .Q �.. ,l' fj� 4 I �dvsf Yrr �- /7 �... .. .1..?� - .�iA......... ..c7...............Address ..�'/.......... .. . ....�........ ............�Y........ Nameof Architect .............. ....................................... .........Address ..................: . ................................. Number' ...............Foundation .. .................... ................................................. Exterior ........ . ....................'.......... ............ . .... Roofeng .........`.......:.:.....:.. .......................... Floors ... ..........................................:............................. .Interior ............... .................................... Heating ..................................................................................Plumbing .................:..................................... Fireplace ..Approximate Cost ..��4! v ................................................... Definitive Plan Approved by Planning Board ---------------_------ 19_______. Area ............. Diagram of Lot and Building with Dimensions S' U•.:....•..•.•••••......•... c' 4/ cf `'S �;c:7�. . Fee O' SUBJECT :TQ!APPROVAL' O'F BOARD OF HEALTH- "c y .:. . .. ....... . . . `. {:i t:, :.iC:.e. t 'r,Jj'�(ti.-ti,.,Gj .\c-L` Pfgl.ii' ji hereby agree to conform to all; tFie+`ule -,,and Regullgtions:,of the Town;of arnstaole x gafctftig the above _ construction. Name.':.�lL L� ............�c-:.'. � o Harmon, John Permit17�176 21-10 FI-V Q• ,f June 25, 1974 C(/Y17 rcS�C% Swimming Pad Cen 4tv; t Five Corners Road Centerville i Town of Barnstable *Permit#� �SHB 1p►._ , p on Ex Tres 6 m the flan issue date • :: p,gil atory. SeY`�'ICe3 Fee ,Thomas 7.Geiler,Director Builchng Division -'Tom Perry, Building Commissioner MAR ;, O Z005 . ...200 MainStreet,•Hyannis,MA 02601--.-... TOW Office: 508-862-4038 -_._. ......_.... .. ... . . .. , . . ... . . . . • .. it .. Fax: 508-790-6230 _•_ _ -EXP SS: ERTVI['Y' I�Y;YCA'Y'�ON RES]DENTTAL ONLY. Not Valid without Red X Press Imprint � Map/parcelNumbei / � ®® o Property Address ©®. Minimum fee of$25.00 for work under$6000.00 Residential Value of Work Owner's Name&Address Telephone Number Contractor's Name , Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑WOrlanan'S Compensation Insurance Check one: . ❑ I am a sole proprietor,. ,the Homeowner . ❑ Ihave Worker's Compensation-Inswrance fiance Company Name 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 be taken to ❑Re-roof, (not stripping. Going over existing layers of roof) m�ximnm.44 (] Replacement Windows. U-Value ) *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 Q:Forms:ex�g Revise063004 ... 4� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,'7`h Floor --- , Boston,Mass. 02111 Workers' Compensation Insurance Affidavit:Buildin /Plumbin /Electrical Contractors e - ame: C _ Q � • address• i City state• zip• phone 9 . work site location(full address): I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel" ❑ am a sole ro rietor and have no one workin in an ca aci Buildin Addition ❑ I am an employer providin workers'compensation for my employees working on this job. v :yc4•.a..r. n ,L Q+ut'nS ".. L, v ',±'• f�:;..Pt•'�•f i' ,.t. L r''e'`v "�y:, _iv.�, l f � .^t N zr '•7 .7. '•S ,v'G #fL 11a41 ro �v I rain � TT 4 '+� dF T <4 �• S�•PSr, A) L '3-, �'" L 1,,9 L 4 1 ,sue. 'fr �t• c�F,)4^. C +tt' .'S�E�'f'.�t,�.. Y� t f�+'R'S -s. .J `� ' ^ P t .�'��'R!.A�" c ,y�,;fi a�.�; sL •`�:r^,F' +f�+ ,'�4 v� ; r Fv.. + ,�',r_. ,� ."r' h :3.. 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'hS q'r.A'IICe'+C��^: '.d`^..£' .,� ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have " the followmgF workers compensation polices: _ '••,..r.v::4+. „p•. ,.^r,,. .Y y; 3duy;K�.'L4Y.'i, et�.r x.?l:e;• 'Ft,E..r '•+r r a. 4 ::ti,•':':d'= - J. ,r4. i•1•.�;r;;�r i •aSa +A- } 7A 1 r <� elh� 1!'f`� i I f J f`r " tT,'ti.•L yf r. ,L r. i 1';' ,.Y t ,ts R fit.r ;C;L y J ,4-£9 r ..0 £';_.7 '..;.r..'_,yt:l •y;5-... rW'. .k.JT .•G.•:x}d s: tt. ry"e +yo- L ,ea. vra.:r•.. ..r.. �";L x..0 i .> •.. , r• 1 y rf � Y � J .. F,. .. F i yd�t: :a j r - 4 8'f}ate�S::,�3..:,:...v,•t:J.A:.rnk:a.x:e...n..;r..:.a:.!.Ir_ _ta...�.... ;4. ..k-w.v..; N„+..,:1 ..L.:{...;-. 1 :K': .. •A r a .. rit r L i Jt :L 1 { .,.y 4 R � �' 2 -. !K'I'+a y J t, .A� •i5 .Y+_ �r - S Qll�,.#�. utsur8'rreea'h�:•.._... a..._c. .:.,a.t ...,. .r.:.z.... f . ...,.. . 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 farm of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby under t e p ' and penal'es of perjury that the information provided above is true and correct + Signature Date `s, ` �s Print naive Phone#, official use only ° do not write in this area to be completed by city or town official s city or town: permit/license# ❑Building Department' OLicensing Board ❑check if immediate response is required A ❑Selectmen's Office []Health Department contact person: phone#; ❑Other (£evised Sept 2003) _ _ t 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 urtenant 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 to a business or to construct buildings renewal of a license or permit to opera s in the commonwealth for any g 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. !'!I Way 1111MINIM, MINIMUM Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance.coverage. 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 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. The affidavits may be 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. The Department's address,telephone and fax number:. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 v Engineering Dept.(3rd floor) Map �; Q0 Parcel Permit# I'7 House# L(Q FJ5. Date Issued ,Board of Health(3rd floor)(8:15-9:30/1:00-4:30) '�- �7� 'ee 64—r d� conservation Office(4th floor)(8:30- 9:30/1:00-2:00) rf 4 SEPTIC.SYSTEM MUST BE Planning Dept.(1st floor/School Admin. Bldg.) C �N ' Defin ,ilive7zRIan Approved by Planning Board 19 ENV 110 7'®w�3 0 TOWN OF BARNSTABLE Buildi g Permit Application ' rr Pro tre Address �fil.�e� c.PJLQ� rsV L�1 '�02 Village ' Owner Address :t Telephone — f Permit Re est First Floor fT_ square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: -Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) 'Zoning Board of Ap Authorization ❑ Appeal# Recorded❑ Commercial es ❑ es, Y No If site plan review# Current Use Proposed Use Builder Information Name / f Telephone Number Address License# 6,5 S 0 Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DE IS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY c> - J PERMIT NO. l DATE ISSUED MAP/PARCEL NO. + I ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION i FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: .yw ROUGH FINAL FINAL BUII DII�7Crr`. Q s<:, 3`e DATE CLOSED`OUT ASSOCIATION PLAN NO. The Commonwealth oftltassachusetty •�:i __.-�•�� Department of Industrial Accidents y _1 vt-Nl( 6110 {i•ashinrton Street ;+W _�-. Bosun.Mass. (12111. Workers' Compensation Insurance Affidavit loci ion-, city n nnc �L 1 am a homeowner performing all work myself. Lama a sole proprietor and have no one working in any capacity .... -.-....r•--- I am an employer providing workers' compensation for my employees working on this job. camnanv name: address: city phone#� insurnnce co nolicv# I am a sole proprietor. general contractor, or homeowtur(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comn•ttv name: address: city phone#• insurance co nolicv# �• •p� .. ... - _... +.r:str:. :�' .-75wrt:-=-Y•s•;:�"R',e�c�*b'F'�=� ".-uae•+�s�-•;�-T1':f7,.w..,6`,:.,�.::^t?+�.:'=+�R'4z:x..r�a�.�•,'R!h+R.:��e:�a.r..s comi2inv name: nddress- city 11hone#� incur•tnce co policy# Attach addi_tionai sheet if necessary ,W ."'s•-`i ^�CKisfte .- a.c.a..�a fir.••1-=2.11�••34 r.r:i�r� �ritiiain .••,.. ice_-"`�•.y. .Iwsc;.�i�a: Failure iu secure ctn crage as required under Section 25A of 51GL 152 can lead to the imposition of criminal penalties of a fine up to SI.500.00 andiur une •cars'imprisonment as well as civil penalties in the form of a STOP NvORK ORDER and a fine of S100.00 a day against me. I understand that n cop)'of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. ' l do terebr certii• ider tit nd to of petjun•that the information provided above is true and correct. Q Si_na rc Date l L Print name Phone# a official use only do not write in this area to be completed by city or town official city or town: permi0license# rnBuilding Department Licensing Board check if immediate response is required Oselectmen's Office C311calth Department contact person: phone*; r10ther , (rinsed 9M5 PJAI L Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' cnntjnnsation for the employees. As quoted from the "law", an emplitme is defined as every person in the service of another under anv contract of hire, express or implied, oral or written. An emplorer is defined as an individual, partnership, association. corporation or other legal entity. or all-,,two or mor the foregoing enuaged 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. Ho%%,ever th 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, he or on the `_rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe MGL chapter 152 section 25 also states that even,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 anv contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter 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 as all affidavits may be submitted to the Department of industrial Accidents for• confirmation of insurance coverage. Also be sure to si25 gn 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 tite Department of Industrial Accidents. Should ydtt have any questions regarding the "law" or if you are require: 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 o the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple: be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t 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 question please do not hesitate to give us a call. The Department's address. telephone and fax number. _. UP-R, The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 nhnnn i�- (A17) 777-4900 i.t_ 406— 409 or 37 Uf11 h 0 8 F RO N6 ASSESSORS LOT s (JONN .S & BETSY ANN 1-1ARMON) VV rn �s� o3p 6ti ASIZOT 134, CRANBERRY BOG z O O . v AS/LOB' 107 BOG Nr.4 PER RESAW MOIR , AS/LOT, :8-6 207 06 sail;n N69.4.3 3 ! J A,S%LOT 8-8 CB AS/LOT RES ZONE.- 'RC" This MORTGAGE INSPECTION Plan is For FLOOD ZONE.' 'B'= TC>tiM1' : _7 .' _ _ _ _ _ _ REGISTRY f. OWNER: GAIAC_MORTCAGE CORPORATION _ t}F p REF 50 -:.. -... -_{� IJ AhRR( f�9TR�C 4P j1 !?0Y3' , _ SC'AI,E: 1 — I HEREBY CERTIFY IV) 1L)__7j 77-77777___ _ r."OM,PAN3 ---_--_-----_--THAT THE BUILDING ;%� OFs, YANItEE S tJRVEY" SHOWN ON THIS PLAN `IS LOCATED ON THE-GROUND AS PAUL _�cyG CONSULTANTS.,�_5 SHOWN AND THAT ITS POSITION DOES CONFORM a TO THE ZONING LAW SETBACK REQUIREMENTS OE' THE,, o MLrrVTMrW N 40B (SUITE 1} TOWN OF BAF;N _T4RLE_ _ AND THAT -, rya �� � INDUSTRY ROAD I T DOES_ !V(?T L-FE, �4"I'1 F{11! THE SE'ECIAI.,—FLOOD HAZARD p ,tea° MARSTONS MILLS, MA. ,02648 AREA A5 SHOv�T ONTI;C II.U.D MAP DAT�;Ci f�__' TE 1.:)'l�'r�___-- J,<> CtEa� ��� L: 2'?�I-G051 O,y , 6 ai Na, FAX: 420 � >3� � THIS PLAN NOT MADE FROM AN STRUMENT I r�: 4ilRVr} NOT TODEilS> f) FOR FENCES, ETC'. 1908.5 DCR �•" 1"Q�oF 9X4" KAFT ERS a4" 04 fJOT�: AI-L wouo )5 m FvLL L)jM9 r5io(J)*t- ?IN6_, - AG•L - 6r���E NtrT- !T ffoYvN Co2tq.1CR 1 I 2X4 PUQLIIJS. . " PLywou _ 2xFJ So��ts i(,�O.G vJ SLOC�ING �! 4W even r �� t WEAL TN •t o�EPM=�IE/NT OF PUBLIC SAFETY O ONE AiTWp�TM PLACE s w �• is i:� - - ... BOSTON.MA GM01 LICENSE CAUTION EVIRKTION _ rr fiONSTR. :SUPERVISOR .J4 ' FOR PROTECTION AGAINST 0 2!2 3/1996, EFFECTIVE DATE. uc-No. AFT,PUT RIGHT THUMB pH£ 66/30/1993 lG44R6 a PRINT IN APPROPRIATE 6 BOO(ON LICENSE. T04A45 3 POWERS 1 POWERS LA BLASTING OPERATORS �. $y 4 026-34-4327 W YAR-4-JUT" PA (12673 1 MUST INCLUDE PHOTO. j9MMOLAS MOMONO) .. . :+E7..; MarMr,n smwwwruCEtl6Ei m00FFxvALv HEfGHT: Uoom smmTurg 006: I794 ? TMw vocuwoff GOAT a _ « 9CiNMINE�riiaUlBOnE90NRTUfElf1E cJYfvwONTWVERS0M0iWE HOLMR WHEN EN- i 1 I �y. Look Up Print Page 1 of 3 . Owner Information-Map/Block/Lot: 168/006/-Use Code: 1010 Owner Owner Name FIELD,TRACY A Co-Owner Name Property Address Owner Mailing Address 240 FIVE CORNERS ROAD 240 FIVE CORNERS ROAD CENTERVILLE,MA. 02632 Map/Block/Lot 168/006/ . Assessed Values 2011 -Map/Block/Lot: 168/006/-Use Code: 1010 2011 Appraised Value 2011 Assessed Value Past Comparisons Building $ 186,900 $ 186,900 Year Total Assessed Value: Value Extra $ 3,400 $ 3,400 2010 - $428,700 Features: Outbuildings: $ 33,400 $33,400 2009 -$449,000 Land Value: $ 182,000 $ 182,000 2008 - $473,500 2007 -$484,600 2011 Totals $405,700 $405,700 _ 2006 -$455,900 Residential Exemption Received=$90,000 . Tax Information 2011 -Map/Block/Lot: 168/006/-Use Code: 1010 Taxes Fire District Rates Town Residential C.O.M.M.FD Tag $0., (Commercial) Barn FD-All Classes $2.3'1- $8.05 C.O.M.M.FD Tax . C.O.M.M-All Classes $1.33 Town Commercial (Residential) $539.58 Cotuit FD-All Classes $1.68 Community Preservation Act Hyannis-Residential $2.04 Tax _ $ 76.24 $7.28 Hyannis-Commercial $3.24 Town Tax(Commercial) $0 W Barnstable- $ Residential $2.65 Town Tax(Residential) 2,541.39 W Barnstable- $2.34 $ Commercial 3,157.21 . Sales History-Map/Block/Lot: 168/006/-Use Code: 1010 History: Owner: Sale Date Book/Page: Sale Price: FIELD, TRACY A Dec 29 2008 12:OOAM 23339/ 165 $ 1 FIELD, BRETT R&TRACY A Jan 9 2004 12:OOAM 18112/ 148 $615,000 http://town.bamstable.ma.us/Assessing/print.asp?searchparcel=168006 8/12/2011 Lodp Up Print Page 2 of 3 POWERS,PATRICIA A&THOMAS B Mar 8 2001 12:OOAM 13621/045 $ 100 POWERS,PATRICIA A Jun 15 1996 12:00AM 10257/ 101 $ 135,000 BANKERS TRUST CO OF CAL Mar 15 1996 12:OOAM 10111/ 1.01 $ 135,100 RICHARD, WILLIAM A Apr 15 1979 12:OOAM 2894/059 $ 1 . Sketches-Map/Block/Lot: 168/006/-Use Code: 1010 OP 14 74, TUS BAS 4 UNIT 2424 2424, 6AR 2 14 22= FOP= 35 AsBuilt Card N/A . Constructions Details-Map/Block/Lot: 168/006/-Use Code: 1010 g Building Details Land Building value $ 186,900 Bedrooms 4 Bedrooms USE CODE I01C Total Improvements Value $225,193 Bathrooms 2 Full Lot Size(Acres) 4.04 Model Residential Total Rooms 8 Rooms Appraised Value $ 182 Style Colonial Heat Fuel Gas Assessed Value $ 18'. Grade Average Heat Type Hot Water Year Built 1964 AC Type Central Effective depreciation 17 Interior Floors Hardwood Stories 1 3/4 Stories Interior Walls Drywall Living Area sq/ft 1,932 Exterior Walls Wood Shingle Gross Area sq/ft 3,916 Roof Structure Gable/Hip Roof Cover Asph/F GIs/Cmp . Outbuildings&Extra Features-Map/Block/Lot: 168/006/-Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value FPL2 Fireplace 1.5 stories 1 $ 3,400 $3,400 http://town.barnstable.ma.us/Assessing/print.asp?searchparcel=168006 8/12/2011 Lodp Up Print Page 3 of 3 SPL1 Pool-Concrete 480 $ 11,000 $ 11,000 SHED Shed 80 $400 $400 SHED Shed 144 $ 1,800 $ 1,800 UTIL UTIL,BLDG 1560 $20,200 $20,200 . Sketch Legend Property Sketch Legend AOF Office, (Average) FTS Third Story Living Area SFB Base, Semi-Finished (Finished)' BAs First Floor, Living Area FUS Second Story Living Area TQS Three Quarters Story (Finished) (Finished) BMT Basement Area GAR Garage UAT Attic Area (Unfinished) (Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story (Unfinished, CAN Canopy MZl Mezzanine,Unfinished UST Utility Area (Unfinishec FAT Attic Area (Finished) MZ2 Mezzanine, Semi-finished UTQ Three Quarters Story (Unfinished) FBM Finished Basement MZ3 Mezzanine, finished UUA Unfinished Utility Attic FCP Carport PAT Patio Outbuilding Listed UUS Full Upper 2nd Story (Unfinished) FEP Enclosed Porch PTO Patio WOK Wood Deck . FHS Half Story (Finished) REF Reference Only VVKO Wood Deck Outbuilding Listed FOP Open or Screened in SDA Store Display Area Porch http://town.bamstable.ma.us/Assessing/print.asp?searchparcel,=168006 8/12/2011 MLS Client Detail Report(294) Page 1 of 3 Client Detail with Addl Pics Report Listings as of 08/26/11 at 12:06pm Active 08/23/11 Listing#21107593 240 Five Corners Rd Centerville,MA 02632 Listing Price:$475,000 County:Barnstable Prop Type Single Family Prop Subtype(s) Single Family ",. Town Barnstable Beds 4 Approx Square Feet 1932 Assessors Records Baths(FH) 3(2 1) Year Built 1964 Lot Sq Ft(approx) 175982((Assessors Records)) ` Tax ID 168-6-0-0-BARN Lot Acres(approx) 4.040 lit ilgg Wf 4E T i http://ccimis.rapmis.com/scripts/mgrqispi.dll 8/26/2011 MLS Client Detail Report(294) Page 2 of 3 Oi: .r r,f T, (i i Directions Rte 28 to Five Corners Road to#240 Sign Public/Internet Remarks A wonderful,totally renovated farmhouse on four acres of level land including an income producing cranberry bog.The recently updated home has been designed with style and quality for comfort.The large kitchen,with cherry cabinentry and top of the line appliances,center island opening to dining area with fireplace make this a charming family gathering spot.there are 3 bedrooms and 3 baths.The spacious living room and large screened in porch make up the first floor.Two bedroom and one bath up.This is a wonderful oportunity to create your own lifestyle.An inground pool,2 car garage and a 30x50 out building provide space for landscapers,builders, horses,and farming.Come see this unique property. Location Description South of Route 28 Street Description Paved,Public Listing Page Special List Cond. None. General Page Zoning residential Year Built Desc. Actual,Renovated Total Rooms 7 Total Levels 1.8 Level 1 Baths 1.5 Level 2 Baths 1.0 Basement Yes Basement Description Bulkhead Access, Interior Access . Foundation Concrete Foundation Width 38 Foundation Depth 24 Fndation Wing Width 22 Fndation Wing Depth 24 Irregular No Topography/Lot Desc. Cleared,Corner;Level Association No Garage Yes #of Cars #2 Garage Description Attached Parking Description Off-Street, Unpaved Driveway Year Round Yes Separate Living Qtrs No Waterfront No Water View No Miles to Beach .1 -.3 Water Access Ocean, Public Beach Description Ocean Beach Ownership Public Interior Page Fireplace Yes Number of Fireplaces #1 Master Bedroom 12x12 Level: First Floor Mstr Bdrm Features Closet,Private Master Bath,Wall to Wall Carpet Bedroom#2 16x16 Level:Second Floor Bedroom#2 Features Closet,Wall to Wall Carpet Bedroom#3 16x15 Level:Second Floor Bedroom#3 Features Closet,Wall to Wall Carpet Laundry Room OxO Level:Second Floor Living Room 22x17 Level:First Floor Living Room Features Fireplace Kitchen/Dining Combo Yes Kitchen OxO Level:First Floor Kitchen Features Gas Fireplace,Granite Countertops, Kitchen Island,Upgraded Cabinets, Upgraded Countertops Floors Laminated Veneer,Tile,Wall to Wall Carpet,Wood Exterior Style Cape Pool Yes http://ccimis.rapmis.com/scripts/mgrgispi.dll 8/26/2011 MLS Client Detail Report(294) Page 3 of 3 , Pool Description Heated,In Ground,Vinyl Dock No Energy Saving Feat Storm Windows,Storm Doors Exterior Features Patio,Fenced Yard,Garden,Other-see remarks,Yard Roof Description Asphalt,Pitched Siding Description Shingle Mechanical Heating/Cooling 2 Zone Heat,Natural Gas,Gas Fireplace Water/Sewer/Utility Septic,Gas,Town Water Hot Water/Water Heat Natural Gas Warranty Available No Advertising Publish to Internet Yes LegaUTax Annual Tax $3265 Tax Year 2011 Improvement Asmt $186900 Total Assessments $186900 To Be Assessed Unknown Mass Use Code 101-Single Family Title Reference-Book 23339 Title Reference-Page 165 Land Court Cert# 00000 Underground Fuel Tnk Unknown Lead Paint Unknown Flood Zone Unknown Presented By: Sheila Bearse Kinlin Grover Real Estate Primary:508-362-5505 3221 Route 6A Secondary:774-994-1723 Barnstable,MA 02630 Other:508-362-2201 508-362-2120 Fax: 508-362-9001 E-mail:sheilabearse@aol.com See our listings online: August 2011 Web Page:http://www.kinlingrover.com/sbearse www.kinlingrover.com Information has not been verified,is not guaranteed,and is subject to change.Copyright 2011 Cape Cod&Islands Multiple Listing Service, Inc.All rights reserved '^ Copyright @ 2011 Rapattoni Corporation.All rights reserved. , U.S.Patent 6,910,045 The listing contract has not yet been validated by MLS Staff. http://ccimis.rapmis.com/scripts/mgrqispi.dll 8/26/2011 I T G� A 1 /g Syr 1 CA CERTIFIED PLOT PLAN FOR FIVE CORNERS RD. & ROUTE 28 CENTERVILLE, MA. ASSESSORS MAP 168 PARCEL 6 PREPARED FORtM w� THOMAS POWERSNASAH SCALE: 1" = 80' FEBRUARY 25, 1998 Z-Z�-98 Weller & Associates 1645 Falmouth Rd.—Suite 4C Centerville, Ma. 02632 .(508) 775-0735 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 0 t Permit# Health Division till Date Issued Conservation Division T DO -� P � �S Fee (� Tax Collector ��Boa Treasurer -.TJ7 1C SYSTEM MUST BE Planning Dept. H5,'STALLED IN COMPLIANCE WITH TMEB Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND . Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address Zq1D FVt �p F-ft Village oQARM l Owner _1 1DYlrla f/1� Address %a-fyk-- Telephone -242)(0 4, zµ Permit Request 4 1 Square feet: 1st floor:existing 1-77� proposed 2nd floor: existing 1) proposed Total new Estimated Project Cost �b�' Zoning District R C, Flood Plain Groundwater Overlay Construction Type 1 o Size "�� }CAA Grandfathered: ❑Yes ;Xlloo' If yes,attach supporting documentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(#units) Age of Existing Structure 2 Historic House: ❑Yes O40 On Old King's Highway: ❑Yes 2<0 Basement Type: UrFull ❑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: Ud Gas ❑Oil 0 Electric ❑Other Central Air: ❑Yes &6 Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:U4xisting ❑new size Barn: existing ❑new size Attached garage:Ualexisting ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ ACommercial O Yes to If yes, site plan review# Current Use Proposed Use - -- �� AA Q BUILDER INFORMATION Name )Y1�lY?Q,!� �J• L �] Telephone Number Address ! bu 7, --� License# CS ®Dq g to Z r V��- • Home Improvement Contractor# I $3Q4 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO k J SIGNAT RE DATE FOR OFFICIAL USE ONLY - s PERMIT NO. DATE ISSUED 721 MAP/PARCEL NO. '^ ,° • r g ADDRESS VILLAGE OWNER I a. �� •'� � .�l4 5"` `ww a •, 1 DATE OF INSPECTIGOJ,;N: FOUNDATION FRAME ��c� w. otc,�� INSULATION FIREPLACE ..; ELECTRICAL: -ROUGH _ FINAL PLUMBING: ROUGH FINAL 4'^ GAS: ROUGH, � "" FINAL - + I: m µ FINAL BUILDING f3 DATE CLOSED OUT �� + ASSOCIATION PLAN NO. ' T 41��Ay G� OF A • J . 1 ' I 1 _ 1 /; 1 CERTIFIED PLOT PLAN FOR FIVE CORNERS RD. & ROUTE 28 CENTERVII.LE,MA. ASSESSORS MAP 168 PARCEL 6 PREPARED FOR ry►t� ��t THOMAS POWERS ,"„ "' N 1 SCALE: V = 80' FEBRUARY 25, 1998 �46. _ •' Z-2�-98 Weller & Associates 1645 Falmouth Rd. —Suite 4C Centerville, Ma. 02632 (508) 775-0735 • TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE •� . JOB, LOCATION G t-e-P ����c«e�.t/ ���c..� ' • Number Meet address Section of town "HOMEOWNER" � Z;V �� Name Home phone Work phone PRESENT MAILING ADDRESS ��- =.• ity town State Zip ccc The current exemption for "homeowners" was extended to include owner-ccc-= dwellings of six units or less and to allow such homeowners to engage ar. J. dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to side, on which there is , or is intended to be, a one or two family dwelli attached or detached structures accessory to such .use and/or farm st�Tuct•:.r: A person who constructs more than one home in a two-year period shall not considered a homeowner. Such "homeowner" shall submit to the Building Off:. on a form acceptable to 'the Building Official, that he/she shall be res=c::L. for all such work performed under the building permit. (Section 109. 1. 1) The undersigned "homeowner" assumes responsibility for compliance with the Building Code and other applicable codes, by-laws , rules and regulations. The unders_?ned Ohomeowner" certifies that he/she understands the Town of Barnstable Building Departament LTt= ins ection procedures and requiremen and that he/she will comply w' oc and requirements. :HOMEOWNER'S SIGNATU =ROVAL OF BUILDING OFFICIAL Tote: Three family dwellings._.35., 000 cubic feet, or larger, will be require: :o comply with State Building Code Section 127. 0 , Construction Control. HOME OWNER'S EXEMPTION The code state that: "Any Home Owner performing work for which,xa:-lbuildin c permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that i Home Owner engages a person (s) for hire to do such work, that such Home Ow. shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuminc the responsibilities of a supervisor (see Appendix Q, Rules and Regulat'_o::: for . licensing) Construction Supervisors, ' Section 2. 15) . This lack of aware: often results in serious problems, particularly when the Some Owner hires unlicensed persons. In this case our Board cannot proceed against the ?nlicensed person as it would with licensed Supervisor., The Home "Owner ace as supervisor is ultimately kesponsible. � , _o ensure that the Home Owner is fully, aware of -his/her responsibilities, m ommunities require, as part of, the permit application, that the Home Owner ertify that he/she understands the responsibilities of a supervisor. On t: ast page of this issue is a form- -currently used by-'several ,towns,. You ma"," are to ame_^.d and adopt such a form/certification for use in your community ' 6V�T.WI.LDo1J �xryT Wluo°W Eicr�T wr�now �%�JT-8'S�r�2 �]tr SS O - __ D�TM i 41n .... )� s AL-..) n P" K 1-re-H ed ASEA r r '3 Alifl IIJNJ n)M It ABOVE NtiW STN A)Ew i496 IA) pIACE a YrIx.$"ob 'l l..e-Ir, pc0t� . towDoWy ADD w,Qb4W 4 _ DELETE bAt' It ,FLDO Per,rJ ff 9 IERt -�10D£L .. �, 514AAo.J MAC o0e-JDN.JfOA) '1 j).667Y _ r x .w t &ate F r r -, FRAM/NGcrroa d[¢M • L 2.P)56g.FJLL 4.LT._DAo,'t s a - `.:....«.,-. a 2. ,:.r 'cc. r >. -.a's ._,e•c+a<. 1.: - y"x' P - , .,ti• t - •t .e'a....-. ,i .....• ,. �-! i t �A. ,. ,... Jk .}..Y o_. �.., L� ..2=y,.F -i L ��lu y 1 •.' • Y i .. rt aX Sry.r log ^_^`M. .Y'�Y' ti - .1'.:. b. T ,sz 5 , y '"i r `k �, �-.', 4 ds'-r^ 4 _ "s` ..sf .r r"�.: ,..f, " w' -3 ..1, ra ,p, -r` WON F ,..a f Xi' =�1 ,.+a C ". � r^.- ux r t x f•- -' s.:�� ''" '�2 y ':r.' • r � � - a, .x• s . . 'G �` �.t _� !�t �nJt � e *Ya � a �s �',� � tp ., e'r�+. .. Toe v - -- p r - -- - e 11 'G �5 lb 0 - - MATCM EX"J-/ & 1 _ Tim%A...jk, t j Y, _ The Town of Barnstable InxNsTA133 �. g Department of Health Safety and Environmental Services �pTE1659. a e Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition-to-any pre-existing owner-occupied building containing at least one but not more than four dwelling units or-to-structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: )f►4F �� Ld1:���L�Y IG(Ql��s C Estimated Cost Address of Work: 2,4 b RIl OP YXA t`-�c s r 4Ak O NO Owner's Name: I �YVYX/J l� Date of Application: I I"l�CM I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS"PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. Date ne ' Name q:forms:Affidav -z =--_ The Commonwealth of Massachusetts n = �— Department of Industrial Accidents = - aI/ice 011HY809atioos - � 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location citV nhone# -7 I am.a homeowner performing all work myself. ❑ I am a sole pr rietor and have no onewkz capacity %% � I am an employer providing workers' compensation for my employees working on this job. com anv name. address shone# insurance ❑ 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 anv name.: :: 'address.:' .:......... .:.... _... ...::. :... .. :. .:.::.... .:::: .: ..... .... ...:..::.:::..:......::: :::... ............ ' :':',: > '':::..:...,:.:: ::>::::::.;::: "::::>:.: one#: ,city' °h ...... msnrance.ca. ca anv name.; ,. address: ty� phone ct a -. is ..::;:::;;i insurance ce. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one vears'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 DIA for coverage verification I do herby ceqify under the pains pod t of perjury that the information provided above is truce and correct Date T t7 GD Signature — Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required 'OSelectmen's Office ❑Health Department ' contact person: phone#; ❑Other (revised 9/95 NA). 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 Irenewal 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 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. The affidavits may be rehued t'o 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 of imlestlgatlons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 BOARD OF BUILDING REGULATIONS } , w License:.CONSTRUCTlO 86 SUPERVISOR r.,. Number: CS 0094 ` # Birthtlat®:,0212311948 Tr.no: 17590 py2312002 Expires: Restricted To 0,0 AS THOMASB POWERS PO BOX 727 Administrator ` f W YARMOUTH, MA 02673 y. - f. ar _ BuildingI - - d •o f� .Regulations and Standa 1�-d One Ashburton Place - Room 1301 �- Boston, Massachusetts 02108 I f Homey Improvement Contractor Re . gistration' - ------- Registration: 118304 Expiration: 2/26/01 -- -- ------- Type: Private. Corporation �i6e�omvaeon�avalAi o�../�aoeac%uaelCa � . HOME IMPROVEMENT CONTRACTOR CHANNEL PONT REALTY INC " ' `~ I: : Registration 118304 G - THOMAS POWER - v' ' i Expiration: 2/26/01 PO BOX 277/ OFF SOUTH SEA AVE j Type: Private 1 rporatio. z W, YARMOUTH MA 02673 a CHANNEL PONT REALTY INC' ..� . - . THOMAS POWER G� o ' % 211/ OFF S00TH SEA- , f a i ADMINISTRATOR W. YARMOOTH � 02673 - v �k i ESTIMATED PROJECT COST WORKSHEET Value LIVING SPACE square feet X$55/sq. foot= GARAGE (UNFINISHED) square feet X$25/sq. foot PORCH t square feet X$20/sq. foot= DECK square feet X$15/sq. foot= OTHER 3 �Q[4 3 to 1 An AI D� square feet X M/sq. foot= coo SAC Ir,A�u Total Estimated Project Cost .:99091'b i Centerville home has growing appeal I CapeCodOnline,com Page 1 of 1 v Centerville home has growing appeal By Kathy Sharp Frisbee March 28,2010 2:00 AM Edible landscaping comes with Five Corners Bog Farm in Centerville-, a'century-old, income-producing cranberry_, bog homestead. j t Adjacent to the two-acre bog,which grows East Coast native Early Black cranberries, is a freshened Dutch Gambrel home, heated swimming pool, 50-by 30-foot barn and a pond. Extensive stonework alternates with landscape plantings of perennial gardens,Japanese maple and linden trees, plus over 30 cedar shrubs for privacy. "You can farm the bog yourself or lease it to local growers,"said owner Tracy Field,who grew up on the Cape and noticed the home when she was a child. New cedar shingles cloak the home,which has a front brick path bordered by fragrant boxwood shrubs leading to a portico entry. Branching from the foyer of bluestone flooring and cream walls is a first-floor master suite with bog views. Pine French doors open from a second foyer door to a kitchen and dining room with red oak laminate flooring, pewter gray walls, a fireplace and a bronze candlelight chandelier with Toile print shades. New granite lines the kitchen's main counters and a 10-by 4-foot island counter,complementing pine flat-panel cabinets, a tumbled stone the backsplash and a soapstone sink. Sliding glass doors open from the dining room and family room to a screened porch, providing expanded entertainment space and bog views.The family room has a Vermont Castings gas fireplace,with a west-facing half -circle window above the pine mantel and a muntined south door opening to the enclosed pool courtyard. A Good Morning staircase rises to two second-floor bedrooms and a bathroom. 240 Five Corners Road, Centerville ROOMS:3 bedrooms,2.5 bathrooms ` „ l BUILT: 1964 SQUARE FEET: 1,932 ACRES:4.04 UTILITIES:Gas heat,air conditioning,town water ANNUAL TAX:$3,235 PRICE:$499,000 w a. CONTACT: Ronnie Mulligan,Century 21 Cobb Real Estate,508-775-2121 z 13 ; Copyright©Cape Cod Media Group,a division of Ottaway Newspapers,IncAll Rights Reserved. http://www capecodonline.com/apps/pbcs.dll/afticle?AID=/20100328BIZ/328030l/-1/BI... 3/29/2010 it T T) 60&mj0005 Hem>L-rz A-Tvf) P.-r. qAt PT, PDjT (t)aA 0 0)PIA)-e /T I x, bo q'I &tj 71(-11 ---—------- 4yT- ------- QUA k D),, P V/AJ 10jL-A D (AT H L6. 41 ALum , bo-T-7+- Qvy IXI, �OTF/T-f - V.N 4 L 8CA D/ �007)NCUS ]l- L- 31 Dl� V— qxq RT, posit j f-I td1 P/A-)C- jf�APE(Z Tf:, TZ)P X /,0 1 Df-- Q. AT tc 7 cxi ix MAHO&A) - - TI- -d X 9 P T--, P-"I./%-"I' 17- '1 0" 51'-L p 0,x,9 PO 7', ------- iQ" 5oA)A -w �IIIIGH00 aXvyv tOTT, E&A)7- -.---C-- L-�-VA770A) A,ow-L-e SCALE-Ay APPROVED BY: DRAWN BY R VIS DATE: REVISED /H A C&&)4- - --RD f c)A) 77J 667Al DRAWING NUMBER