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0047 GOOSE POINT ROAD
M' t a 'Duct Leaka 8 Twt Form c�e:mo � 7 Name.- � ,l�,�� � ✓JC'P�W Date: C� Ate: Time: a:od 6'NI-- bdow Ta4cmtm( Y swwzip: OuWOOr Tmp (F): lhe: i Mor Am(ft�: n ry ClEms.: Syaen Alrtlow(OW m cooling sin(tins): n,WM (3 f above] Heats (�): city/StIft Frkmy Location Of o co RgtomDuctwork: t �/ -------------- Tq Deeresa Press Ted Pmm-e: Baseffm Drat (Pa l I?=pm Flow Press. e Pon Madel/.9N-.Fan Teak 2t1i11FLf NSO Acushilet Fzwgy solutions Total Loaf' (of): q.:,.. Lao pachem$Pi#5059315 C MAllowed: � Phone(774)320-0360 Totd%Floor Maas ' Town of Barnstable Building , Post Th�s,Cardici That rt isYUisible From;the Street Ap,proved:Pla'ns.Must lie Retained on 1.ob and'tthis Card Must be Kept, Posted Until Final Inspection HasBeen IVlatle •' '`' Permit Where aCertifca to of Occupancyis Required such Building shall,Nye Occupied until a Final Inspection hasbeen mRade� Permit No. B-20-16 Applicant Name: MOHHMED RAHMAN All Cape Builders Approvals Date Issued: 01/23/2020 Current use: SCANNED Structure Permit Type: Building-Smoke Detector-Fire Alarm Dection Expiration Date: 07/23/2020 JAN 2 9 2020 Foundation: System Map/Lot: 252-082 Zoning District: RD-1 Sheathing: Location: 47 GOOSE POINT ROAD,CENTERVILLE Contractor Name:''- MOHHMED RAHMAN All Cape, Framing: 1 Owner on Record: UHLMAN, MELISSA MORRIS Builders 2 Address: 25 RACHEL CARSON LANE �- Cont"ractor License 173492 t � Chimney: CENTERVILLE, MA.02632 Est:.Project Cost: $0.00 Description: adding 6 more smoke detectors Permit Fee: $35.00 Insulation: r Fee Paid_` $35.00. Final: Project Review Req: E Date: 1/23/2020 . . Plumbing/Gas b Ruh Plumbing:Rough Final Plumbing: Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application',and the'approved construction documents for which this permit has been granted. _ Final Gas: All construction,alterations and changes of use of any building and structures.shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the ,` work until the completion of the same. � --`� � �, Electrical . 11 : Service: The Certificate of Occupancy will not be issued until all applicable signatures by the.Building and Fire Officials are°provided on this permit. Minimum of Five Call Inspections'Required for All Construction Work: ` Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 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. _ "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 5 office ofiC-onsum@.>�Mts&+EkiWness R ulation H©fE IMPRO' ENT CONTRA FOR THY Mdual 1 i 1oro MOHHMED DB/A ALL CAPE r' MOHHMED RAHM 700, PHIN.NEYSL'` BARNSTABLE,MA U26 Undersea ey ' I Registration valid for individual use only before the;expiration date.1f found return to',ulation ,Office of Consumer Affairs and Business Reg 1000 Washington Street=Suite 710 gcston,°MA 0211-8 s � i .1{ i-0-t valld without signature X Construction Supervisor s of any use group which contain .0westficted Building t any cubic meters)of enclosed less than 35,000 cubic feespace• a current edition of the Massachusetts Failure to possesse is cause for revocation of this license: State Building Cod tion about this license govldpl For i 27-32 Call(61T)727-3200 or visit wwN►• • Commonwealth ofMagsachusetts 'Division of Professional Licensure Board of Building Regulations and Standards Con sl�r 4a rvisor CS-105918 �ires: 09115/2020 &, ig, MOHHMED AA ' • . �a 70 OLD PINN O BARNSTABLE IV�O?a :• r2g`�f Sx Commissioner CL The Commonwealth of Massachusetts Department of IndustrialAccidents, Office of Investigations;. ° 600 Washington Street Boston,MA 02111 www.massgov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers` Applicant Information Please Print Lezibly Name(Business/Organizaiimvbdividual):" `� �� •� Address: .® Q, P ti 2r13���-J� Z 3 0 r, City/State/Zip: r n � �� Yh G Phone#: boo LA Are you an employer?Check the appropriate box: . Type of project(required): 1.El am a employer with- 4. I am a general contractor and I � 7. [ 2emodelingployees(full and/or part-time).* have hired the sub-contractors 6..�New construction 2.L`'l I am a sole proprietor or partner- wed on the attached sheet. ship and have no employees These sub-contractors have g• E Demolition working for mein any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.ir=ance comp.incnranCe 2 reqWred.] 5. We are a corporation and its 10-[ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their, 11.E]Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.E]Roof repairs insurance regui el]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 hue 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. y I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site, information. Insurance Company Name: - Policy#or Self-ins.Lic:#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine; of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insin-ance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date: 1 Phone#• y` `0 E� "t l� �� Official use only. Do not write in this area,to be completed by city or town official z City or Town:. Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and'including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who,employs persons to do maintenance,construction or repair work on such dwelling house or on the grormds or building appmtenant 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 permiUlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should writs"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents, s Office of Investigations 600 Washington Street Bastoa,AMA 02111 - Tel.#617-727-4900 ext 406 or 1-877-MASSAM Revised 4-24-07 Fax#617-727-7749 wwwMaw.gov/dia ' 4 Carter, Jeff From: Carter,Jeff Sent: Monday, January 13, 2020 9:56 AM To: 1suza2000@yahoo.com' Subject: Permit/Application:TB-20-16 at 47 GOOSE POINT ROAD, CENTERVILLE for Building - Smoke Detector - Fire Alarm Dection System. Good morning, Please be advised.that we are currently reviewing your permit request for 47 Goose Point Rd.,Centerville. At this time we have to deny your permit request until additional information is provide. Please provide the following: 1) Construction documents—provide a full and labelled floor plan of the basement and resubmit through the health department for sign-off. And, if aggrieved by this notice and order;to show cause as to why you should not be required abate the violation in this notice,you may file a Notice of Appeal specifying the grounds thereof with the State Building Code Appeals Board within forty-five (45) days of this notice in accordance with MGL 143 c. 100 and 780 CMR. Feel free to contact me with any questions regarding the above request. Respectfully, Jeff Carter Local Inspector Building Department Town of Barnstable 200 Main Street Hyannis, MA 02601 508 862-4035 F 1 Application Number. ........ lC.................... KAS& Permit Fee........... ................Other Fee:....................... a639. TotalFee Paid............. ................................................. ...... TOWN OF BARNSTABLE Permit Approval by................ ................On........................... BUILDING PERMIT Map...C-.).2 P=el.............................. ...... ........ ................... APPLICATION Section I — Owner's Information and Project Location Project Address C-pos f' per,*%r-- Village SCANNED Owners Name- b*mers Legal Address `2� JAN 2 9 2020 G City.�— State Zip Owners Cell# E-mail Section 2 —Use of Structure Use Group_ ❑ Commercial Structure over 35,000 cubic feet Commercial Structure under 35,060 cubic feet Two Family Dwelling Section 3 —Type of Permit F] New Construction ❑ Move/Relocate E] Accessory Structure ❑ Change of use ❑ Demo/(entire structure) 0 Finish Basement El Family/Amnesty (��;�-Fire-Alarm Rebuild El Deck ApartmentSprinkler System ❑ d 't*'on E] Retaining wall E] Solar '--Renovation ❑ Pool El Insulation Other—Specify Section 4 - Work Description YV' T.s;qt iindAteei- 11 ninni R 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 Wong ❑ Oil Tank Storage Smoke Detectors ❑ Plumbing _ ❑ Gas ❑ Fire Suppression t,« ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public _ _❑,,Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 Application Number............................................ Section 9- Construction Supervisor r� Name TV), G Telephone Number Address-70 ��� h� n»,?S 1"City 13r ri) > fZ 1 RrState Yvn P' Zip G2- C 3 0 License Number 0�� Q� License Type Vn rf S4wtPExpiration Date 9 2 I 11 1,14 ?10 Contractors Email_7y � Zoo o P 0 Cell # 5-d S ^ `J — 61 � 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.Attach a copy of your license. Signature Date I/� 2� Section 10—Home Improvement Contractor Name Yv ( Telephone Number Address 70 oW P�`Y'\(�L- City. .,-�5'h 11 State "� Zip G2 j G Registration Number 3 �1 Expiration Date 0 0 a l 22 Za I understand my responsibilities under the rules and regulations for Home Improvement Contractors 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.Attach a copy of your H.I.C... j Signature Date Section 11 -Home Owners License Exemption Home Owners Name: yTelephone 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 APPLICANT SIGNATURE Signature Datej Print Name Telephone Number -S 0 9 3 E-mail permit to: S`'� G �00 Yr. \06' Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ , Conservation ❑ f For commercial work,please take your plans directly to the fire department for approval 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 job) Signature of Owner, date Print Name Last updated: 11/15/2018 Town of Barnstable BuildinW, g P;os#:This Card So Tat it is Visible:-From the Street„Approved Plans Must IezRetained on Job and this Cartl Must be KBAMSTept ' Pos#ed Untih'F�nal Inspection Has Been Made - ' .�� , � ', a Permit Where�a Certificateof Occu anc pis Required;such Building shal!.,Not'be Occupied until a Fnallnpectionhas�been mailed Permit No. B-20-226 Applicant Name: TIMOTHY OBRIEN ffN2 Approvals Date Issued: 01/24/2020 Current Use: Structure Permit Type: Building-Sheet Metal'-Residential Expiration Date: 07/24/2020 Foundation: Location: 47 GOOSE POINT ROAD,CENTERVILLE Map/Lot: 252-082 Zoning District: RD-1 Sheathing: .� Owner on Record: UHLMAN, MELISSA MORRIS =; Contractor NameTIMOTHY,J OBRIEN� Framing: 1 Address: 25 RACHEL CARSON LANE Contractor License: 7451 2 CENTERVILLE, MA .02632 Est. Project Cost: $7,500.00 j e Chimney: Description: install a 3 tom heating/ac system in attic with 10 supplies and 2 Permit Fee: $85.00 j' Insulation: returns Fee Paid:' $85.00 (' Final: Project Review Req: Date. 1/24/2020 Plumbing/Gas Rough Plumbing: = � "" � Official This permit shall be deemed abandoned and invalid unless the work authorized by this'permit is commenced within six months afte�Mle. Final Plumbing: All work authorized by this permit shall conform to the approved application and the 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-lawsrand codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Final Gas. z � The Certificate of Occupancy will not be issued until all applicable signatures�by the Building and,Fire Officials are;provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Service: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lirnng is installedt Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Final: 6.Insulation 7.Final Inspection before Occupancy t Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "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 Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Commonwealth of Massachusetts t- �-�- Sheet Metal Permit leolrt Map Parcel Date: a2. ,Zc� Permit# a Estimated Job Cost: $ i�ur�® • 0.0 Permit Fee: $ SCANNED Plans Submitted: YES, NO Plans Reviewed: YES NO JAN 2 9 2020 Business License# Applicant License# 7 y'5 i Business Infomoation: Property Owner/Job Location Information: ,,p r / ct Name: �v�o fydy O�f� _ Name: ���01 �✓� So-AL Street: 14(D6ck Ale-61 M Street: q2 �ua�e �orhr l�p r City/Town: d:516<19.1U s City/Town: Cohn t--/1/L I�¢ Telephone: �d i�Z"//7(, Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES ✓ NO sfaff Initial J-1/M-1-unrestricted license J-2/.M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept.Approval Institutional Other Square Footage: under 1.0,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing _ ,.:Kitchen Exhaust System Metal Chimney/Vents. Air Balancing . Provide detailed description of work to be done: AC " At�c 4-, U r-vt s i I I-e rt ►-r,j)�S .1•NSURANCE COVERAGE: 1:have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes ,No ❑ If you have checked 1,(gl, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity Q Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waiyes this requirement. Check One Only Owner o Agent ❑ Signature of Owner or Owner's Agent ' By checking this boxo, I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and'Chapter 112 of the General Laws. Duct inspection required prior to insulation installation:YES NO Progress Inspections Date Comments Final Ins-pection. Date Co--=ents Type of License:.. By AMaster Tide ❑Master-Restricted Cityrrown �]Joumeyperson Sig ature of Licensee Permit ❑Joumeyperson-Restricted License Number: Fee$ ❑ Check at yywvd.mass:govTl w Email: ` oily. ob rtc"A 5Q)Lobl" 1.CVyj Inspector S ignature of Permit Approval ■■■■■..■�■■■.. 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Q New cros Mplos�(fan andkr part-time * Dave lviiedtTie lair-caa a s 2,�I ata a sale gropaetrnr argartues- wed m1he attar r1 shy 7- El�1° avd�,e na Fmplss�s Giese sots cnufc-actas have g,.El De=lfEion � er�Ioyees�ha�*e warkPss waddug for many C32acity. CCMP_ # 9. ❑Euilditag aA 1ft, [NO updm&gyp- e $ Wear a wspara aau�l s 10-[]Eledical repairs ar ad� reVked-I cfficsrsb=CXEcisedtms 1LF]Flumbmgrepaisarad&ims 3.❑ lama tic�erdoivg au w of Per MC�L myself LNa�ratlr to rip_ � 1-0 Roof'repaas , i aace re siie3j Y c. 1 aadwe fi$�e s-El Obier [No WuAce& cog sns rcguaed.j guy Bppfr,�fast cher�-s'Goz claut�sLsa f�Ilu�t3ce setGoabeTacrs��rwo3ce�®easa5gapa�pi�a�x�i ' nsaeour csw�Su7s�tTtnst�d2�:`cID YL. m�asg��MidUMhffinaasidec0MhjCkM3=St5tanemsfad. and iuc;-,_�.chrr3c`[Lss 6ozraust m sdditi®sl S�eeC s'Sac�gthen-xae cf tI7E SIIlNc �d 513f2' ®rautffinse �SRE . �,,,,x�I€tbzsufi-taafi��9F�,�Y���zdeY�=a u�'•�p-pa�3�bP?• • I'am au etnpZa}sr f7in#;i�praizrlirrg iv�r�sers'rordizrn i�sriraurs,�or m}'emPr°}�ees $eTD��isf7is palsy ar,�3�ab s�a InsuMce camp=YNa=_- 'Pafic�¢orf-iIio_ a Job Site httacb a OFF of zsarl ss'cu�prusxhoa poEw-d�ra�Fdle(�ov��P°Tcy n=ber as l espsAton&a#e). Fat7.nre ti secare coverage as rEq,uizednuder Sec km 25A of MM a 15 caa lead fa the iagpositim of tArn"A permltses of a .. fine up to I U Of}Eadler auo-yearimpfis as rail as rivl peuatties is•he f��e STOP WORK gyp$tkmid-a fi b of ulrfa $1"so a o against uiolaf He.z3rised fat a copy of this sta maybe forwgrded.f0he Office of Jest ptam offe DIAL fnr fnsuzance covemg .Iota TisMIy cad i., d psrragmy a.rYM; uY fhat-Big�arrizQ#�rx�raii�3 abm�a is bars as d errrrrect Sim Dater I Ph v g, (° Frss trr y Da ua#wAg in t ds=a,to Fie cvMpTeted by city arta,vu a Eity or Tam: pP, Tc eFise I - .A4nA�ttrrrity(d rc 0 ): iBoara.•�l�tk 12.E �P��3.Ci oymC1 4 MrstrizalT�p�r �.p gEmpector 6.Other CCabd P'er= Phone 7- 6 u_�. -ua..�•w .ter_ .!■:u t� �.NNo.. _1 .+uu ■•�.. 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(Address of Job) **pool fences and alatms ate;the,responsibility of the applicant Pools ate not to be filled or utilized before fence is installed and'all final inspections are petfotm.ed and acceptecL Sigriatute of Owner Signature of ant hr 1 M U Print I�Iatne _ Print Name 4 Da Q.F0RM3:0WNaPERMISSI0NP00LS Rev 09/16/17 Town of Barnstable Building Department-Services Brian Florence, CBO 'o Building Commissioner 200 Main Street, Hyannis,MA 02601 s n�a�nsr�Frs i - ' Mesa. �, www.town.barnstable-ma.us s639. � Office: 508-862-4038 Fax: 508-790-6230 - HOMEOWNER LICENSE EXEMMON Please Print DATE: , JQB LOCATION: . m nber shut. vmnc "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: CityRnwn' state zip code The caaent exemption for"homeowners"was extended to include owner-occupied dwellings of six traits 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. DEFDMON OF HOMEOWNER person(s)who owns a parcel of land on which he/she resides or fi tends to reside,on which there is,or is intended to be,a one or two- fan 1y dwelling,attached or detached stractm'es'accessory to such use and/or fans stractares. 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. accepmble to lhe B ilr l the building_perurt. (Section 109.1.1) The undersigned`homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,roles and regulations- , The undersigned`homeowner"certifies that he/she underst mi s the Town of Bamstable Binding Department mmuntm inspection procedures and-regnire=*s and that he/she will comply with said procedures and requirements. Signature ofHomeowner Approval of Building Official Dote: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Bolding Code Section 127.0 Construction Control HOMEOWNER'S EREM[MON• The Code states that: "Any homeowner performing work for which a building permit is required shaIl be exempt from the provisions of this section(Section 109.L1-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.-" &Sany 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\wPFRM\FOAMS\buUdingpemritb=\E DRESS.doe 0$n6/17 J CAMlAA:O�I�IVALT .OFMASS0.�HUSE.77Ss.. .: ` o 0 0 *'ice yE �� SUES�TH��FOL�OWINGIC�iSE��:J f' "'a MAS#ER-iJNRESl RIC� Dr ^ .. ¢ . IViQTHY�J O'BRIEN r! 41 EC t AOWM ON. PT 07J28/2021� � 616579 �'� �/ZZ�ZO " euuefR9"3aejorlwaas - x r 7 - r Z16/Z � s x: Ol1ZZ� � - d : s t s Ft ri i "Y= i CERTIFICATE OF LIABILITY INSURANCE 712/12/19 TE(MM/DDIYYYY) �' 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 CONTACT - NAME: Schlegel&Schlegel Ins Brokers,Inc. HONK Ext: 508-771-8381 ac No: 508-771-0663 34 Main Street AD�RI�ss: schlegelinsurance@gmail.com West Yarmouth,MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: NGM INSURED INSURER B: TIMOTHY J OBRIEN INSURER C: 15 OAK NECK ROAD APT 32 INSURER D: HYANNIS,MA 02601 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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 ADUWBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD IWVD POLICY NUMBER MM/DD MM/DD LIMITS x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAMAGE PREMISES fEa occurrence $ 500,000 MED EXP(Any oneperson) $ 10,000 A MPP8416Q 12/07/19 12/07/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 RPOLICY❑ PRO. LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO z' BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? ❑ N/A $ (Mandatory In NH)If yes,describe under E.L.DISEASE-EA EMPLOYE $ DESCRIPTION OF OPERATIONS below L L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF BREWSTER ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARMTNET BREWSTER MA AUTHORIZED REP TI IN HAND, @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Project Name:Tim barn. O+' 91 Vj MI System (�/� iC 1347 Goose Point Rd,Centerville,MA 02632,USA Manual J BARNSTABLE :.. HARBOR -Summer Outdoor F:1 '.rye Summer Indoor F: Design Grains Daily Range:„ ---- - Winter Outdoor F Winter Indoor IF,- r „ Cooling RH Elevation(Ft) L r Cooling Loads j ;Name ^Area, Sensible�-s .Latent 7 o -� .Windows&Glass Doors 0 0 0 P _ „ Skylights 0 _ 0 0.. Doors. 0 0 --- — 0- _ a Infiltration ,w � _..-_.... _.... Above Gratle Walls 0 0 0 40.6% Floors# 0 0 0 f y � ; � r0 0 0i Duct , Uentllation 0 0 .......-._. ._ 59.4?% -��" Infiltration 0 580 2,091 _ - - Internal, 0 0 0. _......-.:. xDuct 0 126 3,783 t Blower Heat 0 0 0 AED Excursion 0 0 — 0 — Total r �0 706 5,874 Heating Loads r dows&Glass DooAreaHeat Loss 'r 0 0 Duct = : lights 4 .10 0 Z6 7% ors : 4, 0 0 -- Above Grade Walls ?Vo 0 rade Walls 0 0 M � Below G, Ceiling 0. 0 _.._ Ventilation 0 0 — I LFloors tio0 10 506 fltrae:l . )� 0Infiltrationy r, '� 0 733% , k 3 835 Humidfication 0 10 ,* Hot Water Piping 0 00 Total 0_ _L14,3341� ( AED Graph Approved ACCA MJ8 x, Calculations i II Calculations are based on the ACCA Manual)8th Edition and I are approved by ACCA.All computed calculations are estimates on building use,weather data,and inputted values such a R-Values,window types,duct loss,etc.Equipment selections should meet both the latent and sensible gain as well as building heat loss.See Cool Calc Manual S Report for equipment sizing verification. �' ���'�`���";, ;�� t. ,>,�,��,��,� �, � Prepared by Cool Calc Versiorn,l 0 0 Beta�www.coolcalc comp ���� •�r,�� �,� „c•.� w t�^ ^•'s •�, Town.of Barnstable Building Department Services NAM = Brian Florence,CBO 1 � Building Commissioner 200 Main Street,Hyannis;MA 02601 www.town.barnstable.mans Office: 508-862403 8 Fax: 508-790-6230 'Property Owner Must Complete and Sign This Section - If Using A Builder , as Owner of the subject property hereby authorize c-0 to act on my behalf; in all matters relative to work authorized by this building permit application for. �7 Cl�?60�2 �o i✓r f" /e� (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. : , e S' a of Owner Signature of A qflicant I ('OeA i J, I M Q-h CIA V 0&� Print Name Print Name D to Q:FORMS:OWNE"ERMOSIONPOOIS Rev:08/16/17 Town of Barnstable 4 Building Department Services Brian Florence,CBO Building Commissioner • 200 Main Street, Hyannis,MA 02601 KAMwww townbarnstablemaus s�a� Office: 508-862-403 8 Fax: 508-790-6230 HObffA)M NER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOhH+ WNER Dame home phone# work phone g CURRENT MARMG ADDRESS: ChYADWn stsme zip-code The current exemption for"homeowners"was extended to include g ng-MMi_ed dwellines of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,prided that the owner acts as supernsor' DEFINITION OF HOMEOWNER Persons)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 bu ft 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 requh ments. Signatum of Homeowner Approval of Building Official Note: Throe-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction ConftL 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/cerbification for use in your community. Q:\WPFII.ESIFORMS%uiiding permit fo mMXPRESS.doc 08/16/17 Town of BarnstableBuilding Post This Card So That rt�s`V�sible Frorn the Street Approved Plans Must be Retained on Job and this Car'dMust be Kept snxxsewriE Z b `�$ Posted Unt(1 Finallnspection Has Been Made :: zN € Permit Where a Certificate of Occu anc 'is Re u�red,such Buildm shall Notbe Occu ied until a Final Ins ectiorr has been made Permit NO. B-19-3922 Applicant Name: MOHHMED RAHMAN All Cape Builders Approvals Date Issued: 12/13/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 06/13/2020 Foundation: Residential Map/Lot: 252-082 Zoning District: RD-1 Sheathing: Location: 47 GOOSE POINT ROAD,CENTERVILLE Contractor.'.Name% MOHHMED RAHMAN All Cape Framing: i Owner on Record: MASOTTA,CAROL ANNE Builders 2 Address: 25 RACHEL CARSON LANE Contractor Licenser173492 Chimney: CENTERVILLE, MA 02632 Est-project Cost: $8,000.00 Description: Enlarging Hallway Bathroom to add Laundry area:Also take out load Permit Fee: $90•80 Insulation: bearing wall and replace LVL Fee Paid: $90.80 Final: Project Review Req: 12/13/2019 Plumbing/Gas Rough Plumbing: ' Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized.by this permit is commenced withm`six months after.lssuan All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall,be in compliance with the local zoning by laws:and codes. - This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. ' Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Bwldmg and Fiee Officials are prouidetl on this';permit. Minimum of Five Call Inspections Required for All Construction Work: � � � � ,� r Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection g 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application Number...................... .............................. MASS. t - d Permit JID:R...................Other Fee,............. . %639. �FD Mfg q ' go Total Fee Paid TOWN OF BARNSTABLE Permit Approval by.. 2 1 c� f .. On...l.. /........ BUILDING.PERMIT 2 r, Map.........` .....................Parcel........K.. .:....................... APPLICATION Section 1 — Owner's Information and Project Location 1 Project Address 47 1�1DO,942 "P6 6 Village ��' V `I Owners Name M 2 G S S Owners Legal Address �-s C-a r.'f/-\ City C� v 11� State n^ '� Zip G32 .S o Owners Cell# �'3 6-4 Sa 1 G E-mail - Section 2 —Use of Structure : '� a Use Group ❑ Commercial Structure over 35,00, cubic f ❑ Commercial Structure under 35,0 s 0 cubicet P 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 Alarm Rebuild ❑ Deck Apartment El Sprinkler System Addition ❑ Retaining wall ❑ . Solar i'Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 - Work Description �il C.�roc®, ASSo ®v e3,0A 9e-4e VJal a rle- P 1 r, c.e w o i4, t_v L. Last updated: 11/152018 Application Number................::.....3........................... Section 5—Detail Cost of Proposed Construction 000.06 Square Footage of Project Age of Structure L► Dig Safe Number # Of Bedrooms Existing 3 Total#Of Bedrooms (proposed) 3 110 MPH Wind Zonb Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage n"Smoke Detectors E(Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom - t Water Supply Public ❑ Private , . t f Sewage Disposal ❑ Municipal O On Site P P Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: �� � >I S>o 9 cA I am using.a crane C Yes 2/No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No E( Section 8—Zoning Information Zoning District . Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed t Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 ' t 14 12 1 PTO SAR 24 "A 2 14 14 C)os Q :P)o I \\ n y { 1 Application Number........................................... a Section 9- Construction Supervisor Name YY\0,ti Telephone Number E- " 3/04 )� Address 3-0 01C) p�,),irtey L City State, M A Zip C 2 6-36 License Number License Type Expiration Date q� )�� 2-0 2-0 Contractors Email Zr,I-00a Cell # -90 �, -3�4- 1 2-9 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.Attach a copy of your license. Signature ��_ s-,� , r Date ,Z C1 f Section 10-Home Improvement Contractor ' � t Z k _ i Name w_ 1"�o�11' M o� �,•� Telephone Number S o 9 -1(- L4 6 12 e . Address 70,64 ADnAe.ys L,\ City eNs'A)t)1.e_ State 1M Zip O 2 6'30 r i Registration Number 41 q Z. Expiration Date I U Z &Z '2. N I understand my responsibilities under the rules and regulations for Home Improvement Contractors 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.Attach a copy of your H.I.C... . 2� Signature Date i )� 9 Section 11 -Home Owners License Exemption 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 APPLICANT SIGNATURE Signature Date i ► i R Print Name �40�''1b1 M fe� w`O,,,,- Telephone Number 9P� '36 `'1- 12-� r E-mail permit to: moo o `74t�k 00 . C Cly " . Last updated: 11/15/2018 r Section 12 Department Sign-Offs ! Health Department ❑ Zoning Board (if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ - A Conservation ❑ �" For commercial work,please take your plans directly to the fire department for approval Section 13 -Owner's Authorization I, Mel%SSA U1 � , as Owner of the subject property hereby authorize, C M e. Fa�)"Iow\` to act on my behalf, in all matters relativi to work authorized by this building permit application for: (Address of j ob) Signature of,Owner N, date I Print Name i Last updated: 11/15/2018 cr Application numbe Fee ...................... �.v.Y.. .... KMK Building Inspectors Initials....................................... 99 i Date Issued.:.....1.1.....lA. I.......................... Map/Parcel..�.1/CX .6 TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION j Address of Project: NUMBER STREET VILLAGE Owner's Name: '�p N SS _y� Phone Number 5709 - SDI, Email Address: Cell Phone Number Project cost$ t7 G O Check one Residential mmerc.; - _ ram; r� OWNER'S AUTHORIZATION ' . As owner of the above property I hereby authorize ' to make application f a b lding ermit in accordance with 780 CMR o —� Owner Signature: Date: TYPE OF WORK iding iJ Windows(no header change)# ,D Insulation/Weatherization Doors(no header change)# Z Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to ��� r-, CONTRACTOR'S INFORMATION 1_ Y Contractor's nameQ Home Improvement Contractors Registration(if applicable)# 1-4 3 `I 9 Z (attach copy) Construction Supervisor's License# , (attach copy) Email of Contractor Sy moo �4,�00- C01 -Phone number-S-0� Li b 2 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY-IS IN e wcrnwr nIcroirr VnII MIICT nRTdIN MICTnRlr dDDRnVAI RFCnRF d PFRM/T rdN RF/ccixn APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No f a - Flame Spread Sheet of each tent must be'attached:`Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes . No ,if yes, a gas permit is required. Natural Gas Yes ` '` No , if yes,a gas permit is:required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type r Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's 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 APPLICANT'S SIGNATURE Signature Date ` o All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �• . 600 Washington Street Boston,AM 02111 www mass.gov/dia.o . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leiibly Name(Business/Organization/Individual): Address: P ► Y1 Y) Z p 0ZC,3 (� Phone#: ��0 _ Y City/State/Zip: � ' \ Are you an employer?Check the appropriate box: Type of project(required)_ 1.❑ I a employer with y 4. lam a general contractor and I have hired the sub-contractors 6. ❑New construction ployees(full and/or part-time). , -- . 2: I am a sole proprietor or partner ,listed on the attached sheet... a 7. Remodeling,,,,, ship and have no employees These sub-contractors have g, 0 Demolition workingfor me in an capacity. employees and have workers' . Y P tY 9. E Building addition [No workers'comp.insurance comp.-insurance# required.] 5. 0 We are a corporation and its 10.E Electrical repairs or additions 3.❑ I am a homeowner doing all work° officers have exercised their 11.❑Plumbing repairs or additions;,' myself. [No workers'comp. right of exemption per MGL. 12.0 Roof repairs y insurance required.]t , c. 152, §1(4),and we have no _ employees. [No workers 13.0 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. 1 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.#: Expiration Date: a , Job'Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). t Failure to secure coverage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification: I do hereby certify under the pains and penalda of perjury that the information provided1�1 above is true and correct Si afore: ---� .. .Date: �' y , Phone#: �� � � b � •� �. I � 'aA - � F Official use only. Do not write in this area,to be completed by city_or town official' City or Town: . Permit/License# Issuing Authority(circle one): 1.Board of Health.2.Building Department 3.,City/Town Clerk 4.Electrical Inspector 5 Plumbing Inspector 6.Other Contact Person: Phone#: ` p 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 dwellipg,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)Yalso 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should . be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials - Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance,for your-cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: . � x 4 The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations , 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877-MASSAFB } Fax#617-727-7749 Revised 4-24-07 www.massgov/dia y - Commonweafth of.Massachusetts Division of Professional Licensure / Board of Building Regulations and Standards Constr ,1 ,Mj'�rvisor CS-105918 .h* R' Wires: 09/15/2020 MOHHMED S#tAHM- } 70 OLD PINNE S C' BARNSTABLE M� 02 3 Commissioner j �c��o�rivrriooziuea�i'a�CcicfucaeCYa Office of ConsuMer Affairs A'Bu§ine.'ss§Regulation HOME'IMPROYEMENT CONTRACTOR TYPEbindividual' Registrafiore__ Expiration U —+ 16/08/2020 a MOHHMED RAH DB'/A ALL GAPE 1 h4 f MOHHMED RAHM yas 70:OLD PHINNEYS� ,�9 BARNSTABLE,MA c02 b, Undersecretary' I Commonwealth of.Ma sachusetts �JDivision of Professional Licensure ' 1 Board of Building Regulations and Standards Const; tilp�rvisor CS-105918 �`' 40ires: 09/15/2020 MOHHMED S RAH } 70 OLD PINN' S BARNSTABLE. 02 Commissioner Registration valid for mdniidual use only, i li®fore the®xpiration date 4 foundreturn;to: Office of.Consumer Affairs`and Business Regulation }1000 Wasiimgton,Street :Suite 7;T0 BiSston;AMA'02T18 .. f _ Not'valld without signature , 'sf ,�..�+a-+�•,A^-.i...��^e'-.tr^.•-wire,...«c ee•!r..-^.;'.�' Bk 32476 Pg265 #57959 11-18-2019 @ 02 : 43p (quitclaim Deed 1, Carol Anne Masotta,an unmarried woman, of Centerville, Massachusetts("Grantors") for consideration paid of TWO HUNDRED FIFTY THOUSAND($250,000.00) DOLLARS grant to Melissa Morris Uhlman, individually, of 25 Rachel Carson Lane,Centerville, MA 02632 with quitclaim covenants, The land together.with the buildings in the village of Centerville, Town and County of Barnstable, Massachusetts, known as and referred to as Lot 5 as shown on a plan recorded at Barnstable Registry of Deeds in. Plan Book 249, Page 121, entitled "Shallow Pond Acres', a Sub-Division of Land in oCenterville, Barnstable, Massachusetts, for John F, Shields, et al, Charles N. Savery Co., Engineers, o revised April 19, 1971. Said premises having an address of 47 Goose Point Road, Centerville, Barnstable County, MA 02632. y 1 Said premises are hereby conveyed subject to and with the benefit of rights of way in Goose Point Road IZJ and rights to the use of the area marked"Community Beach"on said Plan. v , oSaid premises are conveyed subject to and with the benefit of rights, easements, agreements, reservations, and restrictions of record, if any, insofar as the same are now in force and applicable •o a, Meaning and intending to convey those premises conveyed to Grantors herein by deed dated June 12, U 2008 and recorded with the Barnstable County Registry of Deeds in Book 22985, Page 158. Grantor hereby releases any and all homestead rights to the within premises,whether created by declaration or operation of law,and further state,under the pains and penalties of perjury,that there are no other persons entitled to homestead rights in the property being conveyed herein. 0 MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 11-18-2019 0 02:43pm Date: 11-18-2019 02:43pm Ctl#: 1057 Doc#: 57959 Ctl#: 1057 Doc#: 57959 Fee: $855.00 Cons: $250,000.00 Fee: $765.00 Cons: $250,000.00 Bk 32476 Pg266 #57959 Executed as a sealed instrument this _day of (701V&-2 ,2019.. iiel A' arol Anne sotta by er Attorney-in-Fact ram^ John E.Masotta under Power of Attorney recorded with Barnstable County Registry of Deeds herewith COMMONWEALTH OF MASSACHUSETTS County, ss. On this day oft-2019, before me,the undersigned notary public,John E.Masotta, Attorney in Fact for Carol Anne Masotta,personally appeared,proved to me through satisfactory evidence of identification, which were_Drivers License to be the person whose name is signed on the preceding or attached document,and acknowledged to me that she signed it voluntarily for its stated purpose as attorney in fact for Caro nne Masotta,the principal. Nota u lic My Commission Expires:to(i-t W; Z Matthew R.Shechtman iNotary Pubic,Co mmmalM of Mauactmens i`v MY OOMMISSION EXPIRES October V.2025 Bk 32476 Pg267 #57959 1 AFFIDAVIT REGARDING DURABLE POWER OF ATTORNEY I, John E, Masotta of Plymouth, MA, do under oath depose and state that I am an attorney in fact or agent named in a Durable Power of Attorney dated January 7, 2018 executed by my principal, Carol Anne Masotta,,and recorded herewith and that at the time of the execution, pursuant to said Durable Power of Attorney for the deed of the premises located at 47 Goose Point Road, Centerville, MA 02632 in the original principal amount of$250,000,00, I did not have actual knowledge of any revocation or of any termination of said Durable Power of Attorney by the express request of Carol Anne Masotta,or by her death. [signature page to follow] I r Bk 32476 Pg268 #57959 Signed under the pains and penalties of perjury this day of October, 2019. Jo E. M COMMONWEALTH OF MASSACHUSETTS vim,✓ County, ss. On this day of October,2019,before me,the undersigned notary public, personally appeared John E. Masotta, as aforesaid, proved to me through satisfactory evidence of identification which was her MA Driver's License, to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his knowledge and belief. Notary Public My Commission Expires: f Matthew R.Shechtman Nalary Publk,Commonwealth of MasWusetts WYCONMISSIONEMRES Octaberq.2025 JOHN F. MEADE, REGISTER BARNSTABLE COUNTY REGISTRY OF DEEDS RECEIVED & RECORDED ELECTRONICALLY E[.4G.3 Pew. G'oosF /foiw7— ,,GO/9 D 4o'W/Z>s /.G'Soo - ap ELev. .Top' cF Lo T Ae¢ all � .2.Zo6o sq.rr. � C.Ems'T/f=/ED �°�oT Pe glv ,. Goc�+Tio�i - CE�TE.eViLGE, /'9AS5, °`S S�WN oni A PLA�/ f-o e 1✓AGCo7T AH ES NOTE- EGs✓,�+ToN� f�S�Ti .!>^/ •9a 'u�t.� .7JFiT:i AND loe-4 / &A /98 u, r Cere7-1,o y T//qr VVe' ,ou,vt�.�Tio�✓ f �rt f, 5< Shoo wN oov TW/,S P69A., /S 4aCi97'ED NEI'E"o.v" A�.D T!,AT /T G'o vFo,�MS To T!/E ZoAo xAo,_, 44 wS caf' rA/E k' TWA.- of d�9evS7�9dG.f' i"liCf/.9EG P. �o�9.�i.vo e /�'y"iTiv✓�/�'� �`� `_ ---,- - - .�'E`G: ..�si�.+�;s�V�'Y%�- - - �.�_...y_:•�-••--«•-+.t...--•--.,....�.-.,_,..`�.,...�.v�...-�...-.'U--'��w+-.�.-«...r�.--v�.•�.."^«'_"v�.f.'�""_"`."."r^,"".t-...-.....-..- -,,..«r'.,�. �,,,, ^w.-�.w—�,�-..�..-r. �.,.r.�...,+'-.-.-.r-vim. . As;pesorsw,map and lot number SEPTLC SYSTtM, VAJST ,.. .. IF STALLE . COMPLIANCE WITH ART16L 11 STATIE Sewage Permit number ....... ..6...... ...... ..... `SANITARY �QyofTMETo��o TOWN OF BARNSTA EV :. 1i BARNSTABLE. i NASL pY. .O� BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......1...:5rT.'�A*k..........R.ESN-04..................................................................... TYPEOF CONSTRUCTION ..........F. !^^E...................................................................................................... ....................... .L. .....19.).0 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location . . T-... ... ....... r.................... ................................... ProposedUse ....... .........I W Lu N. . ........ ................................................................................................. Zoning District �" .Fire District Name of Owner .hp.P.!v.. 4q... ....................Address ....,tV.tJ��+�?sD.t1........l�I�SS.......?��. t/ Nameof Builder ....................................................................Address .................................................................................... 11 ad Nameof Architect ..................................................................Address .................................................................................... VLL f�sM"T Number of Rooms .......... ....................................:...............Foundation .Ce.l4?.>;'..ag15........1��'."............�..............�. Exierior ..�.�.�� �r *.... ....Roofing ...4,Sehgd� .................................... Floors ....... IA A....................................................Interior ....b.e4..wpon4n........................................................ +,� .QP.P �f P�c Fie ating ...........�........A_jk...................................Plumbing Fireplace ....... ..........................................................................Approximate Cost ... -.�a.).Pen............................................ Definitive Plan Approved by Planning Board ______________________________19________. Area :./. z.fl.. .... Diagram of Lot and Building with Dimensions Fee ..../p�...1..�..'... .................. SUBJECT TO APPROVAL OF BOARD OF HEALTH C'.ci�". �1.ate, a►'i' � , May 14, 1975. I accept full responsibility for the fireplace construction. 61 Mason Builder .. Build g Inspector I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ..... ........ ..................................................... Romano, Michael P. , Trustee ....1762.... Permit for ••one story. + single family dwelling Location ............................................................................... � Goos...epoint. kRoad I ...... ...... ....................................... Centerville ....................................................... .................. ,a Owner X Michael P. Romano, Trusttt ..rt { a Type of Construction frame ............................ ...................... ....................................................... Plot ....................... Lot ...............�k5............. l tiK� �' March 28 75 r� Permit Granted .............. ...:.....19 • Date of Inspection ................19 Date Completed ..,/. PERMIT REFUSED 19 ............................................................................... r ............................................................................... 3 ............................................................................... .r t ? Approved ................................................ 19 r ............................................................................... 7�— Assessor's --rhap and lot number ............... ................ 3 Sewage Permit number ......... .......-......-7..... ............ b�Qy�*THEtOYyo� TOWN OF BARNSTABLE- STIELE, ..MR 1039- BUILUING INSPECTOR APPLICATION FOR PERMIT TO ...... .............Q....A.�A,:W ........................................................................... TYPEOF CONSTRUCTION ........... ................................................................................................... .......................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... .............. ......... M ...... ........................................................... Proposed Use ....... e V A. ... ........... ................................................................................................ ...... Zoning District ..................................:.....................................Fire District .............................................. P * &*7 7XuSr1FC-- ' —3 6- R4-6,4--:h��Z ' Name of Owner .,�')MDXV .....................Address ..... (A� ........ ................. ... .... .............................................Address ...... ...................I Name of Builder ...................... ........................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ...........r,)......................................................Foundation . . ........ Exlerior K n g A.2,--,� Z�.......S. 4 fe .. ...... ..............t....................... ....Roofii ..........1.�........ ......................................... Floors ....... ......Interior ................. ..... ............................................... .......... ........................ Heating ..... t tnJ...... (n, ti Plumbing .......P.14,.(?......................................... Fireplace ........ ..................................................................Approximate. Cost .... ............................................ Definitive Plan Approved by Planning Board -------------------------------19-------- - Area ` '.' '" ~?..... Diagram of Lot and,Building with Dimensions Fee ............7'! .................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ............................................ T Romano, Michail P. , TrusteJT'�: No ..17622.... Permit f ...one stor ,.......... „s,ingle family dwelling Location .. ..Goosepoint Road Q.entervi l l:e............................ / Owner ....... ichael P. Romano, Trustee ........... Type of Construction .......frame...................... ................................................................................ Plot ........................ Lot ...........#5................. i Match 28 75 Permit Granted ......... . p...........................19 Date of Inspection .....................................19 Date Completed ......................................19 PER T REFUSED ............................ 19 ................................. ............................................ ................................. ......................................... ............................................................................... Approved t ............ 19 ............................................................................... .............................................................................. I41N. Boise Cascade ' Triple 1-3/4" x 7-1/4" VERSA-LAM®2.0 3100 SP PASSED ¢ FB01 (Floor Beam) BC CALCO Member Report' Dry 1 span I No cant. November 20, 2019 08:58:20 Build 7480 Job name: 47 Goose Point Road File name: Mohhmed-47 Goose Point Address: 47 Goose Point Road Description: City, State,Zip. Centerville, MA, 026321. Specifier: Customer: Mohhmed Designer: Kevin Lonkart Code reports: ESR-1040 Company: Mid Cape Home Centers x rks .'i 10-06-00 B1 B2 Total Horizontal Product Length=11-03-00 Reaction Summary (Down / Uplift) (Ibs) Bearing Live Dead Snow Wind Roof Live B 1,4-1/2" 2194/0 793/0 B2,4-1/2" 2194/0 793/0 Load Summary Live Dead Snow Wind Roof Tributary Live Tag Description Load Type Ref. Start End Loc. 100% 90% 115% 160% 125% 0 Self-Weight Unf. Lin. (lb/ft) L 00-00-00 11-03-00 Top 11 00-00-00 1 Ceiling Unf.Area(lb/ft2) L 00-00-00 11-03-00 Top 30 10 13-00-00 Controls Summary Value %Allowable Duration Case Location Pos. Moment 7493 ft-Ibs 59.6% 100% 1 05-07-08 End Shear 2467lbs 34.1% 100% 1 00-11-12 Total Load Deflection L/279(0.457") 86.0% n\a 1 05-07-08 Live Load Deflection L/380(0.335") 94.7% n\a 2 05-07-08 Max Defl. 0.457" 45.7% n\a 1 05-07-08 Span/Depth 17.6 %Allow %Allow Bearing Supports Dim.(LxW) Value Support Member Material B1 Column 4-1/2"x 5-1/4" 2987 Ibs n\a 16.9% Unspecified B2 Column 4-1/2"x 5-1/4" 2987 Ibs n\a 16.9% Unspecified Notes Design meets Code minimum (L/240)Total load deflection criteria. Design meets Code minimum (L/360)Live load deflection criteria. Design meets arbitrary(1")Maximum Total load deflection criteria. Calculations assume member is fully braced. BC CALCO analysis is based on IBC 2009. Design based on Dry Service Condition. Connection Diagram: Full Length of Member a e e pana 1 of 9 Boise Cascade Triple 1-3/4" x 7-1/4" VERSA-LAM® 2.0 3100 SP PASSED / FB01 (Floor Beam) 4 BC CALCO Member Report Dry:1 1 span I No cant. November 20, 2019 08:58:20 Build 7480 Job name: 47 Goose Point Road File name: Mohhmed-47 Goose Point Address: 47 Goose Point Road Description: City, State,Zip: Centerville, MA, 02632 Specifier: Customer: Mohhmed Designer: Kevin Lonkart Code reports: ESR-1040 Company: Mid Cape Home Centers Connection Diagram: Full Length of Member a minimum=2" c=3-1/4" b minimum =4" d= 12" e minimum = 1" All FastenMaster screws may be installed from one side of multiply Versa-Lam beams. Connectors are: FMFL005 Disclosure Use of the Boise Cascade Software is subject to the terms of the End User License Agreement(EULA). Completeness and accuracy of input must be reviewed and verified by a qualified engineer or other appropriate expert to assure its adequacy,prior to anyone relying on such output as evidence of suitability for a particular application.The output here is based on building code-accepted design properties and analysis methods. Installation of Boise Cascade engineered wood products must be in accordance with current Installation Guide and applicable building codes.To obtain Installation Guide or ask questions,please call(800)232-0788 before installation. BC CALC@,BC FRAMER@,AJSTM, ALLJOISTO,BC RIM BOARD TM,BCI), BOISE GLULAMT"",BC FloorValueO, VERSA-LAM),VERSA-RIM PLUS@, Page 2 of 2 The Commonwealth of Massachusetts Department of IndustrialAccidentv Office of Investigations, 600 Washington Street Boston,MA 02111 www mass gov/dw Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers' Applicant Information Please Print Legibly Name(Business/Organizatim/Individual): Address: 7 O old 9 h 1 t e7s City/State/Zip: a rnS4z ) M 0 Z C 36 Phone#: S® -3 L'1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with• . 4. 0 I am a general contractor and I �ployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.CJ I am a sole proprietor or partner-_ listed on the attached sheet. 7. remodeling ship and have no employees These sub-contractors have g. Demolition working for mein any capacity.-acitY• employees and have workers' 9. ❑Building addition [No workers'Comp.in �ciman COmP•insurance.: .. . required-] . 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t C. 152,§1(4),and we have no employees.(No workers' 13.[1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowner;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. v I am an employer that is providing workers'compensation insurance for my employees. -Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00'a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: S O Ojftlal use only. Do not write in this area,to be completed by city or town gfjkial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person id the service of another under ate+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 commonwealthfor 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 permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents C r Office of Investigataaus 600 Washington Sheet Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877 IvMA.SSAM Revised 4-24-07 Fax#617-727-7749 www:mass.gov/dia rID Commonwealth of.Ma..ssachusetts Division of Professional Licensure Board of Building Regulations and Standards Constar sAiVg pyrvisor CS-105918 vires: 09/1.5/2020 MOHHMED S41A Ti? OLD PINNB S L�A�NB BARNSTABLE M��12i� 3C l➢I' Commissioner CIL ? Ofhce of:Consumer/lffair§&Bu"sines§Regulati"on } HOME IMPROVEMENT CONTRACTOR' J 1 'TYPE\-IndMdual ( xJ Exbiratii n 1'0/08/2620 IVIOHHMED RAFT AN — DO/A ALL 641 I-9Q - MOHHMED RAHM�AN }° 70 OLD PHINNEYS�I�t BARNSTABLE,MA 0263Q . �-: Undersecretiiry Registration valid for individual use only before the'expiration hate; jf found return to: 9f6ce of,Consumer Affairs and Business Regulation t '000 Washington;Street Su7te 710 Boston,MA.02118 } Rs Not valid without si " gnature. • t F---,-x '04 7 C. 6;� I Q SCANNED DEC 16 D c ►C- SOARED 'DEL 61013 gA N. 9AT14CIO 16 6 c cL L'aadl L C G ra� 2 A c E L t^ N_ Baxrtsbl®Bld .D®Pt. Approved bY° ,3 �2 C-10 1 n1- Ce r\ r V No o scC-d e -- � C, k/ Y-11 P- a e-c;�, r w CO N P 1 a c�I y L-V L— L g �- - e G�\Y\,\ -Z �g�TN gATI-+ '. Lv L 3 C2 A6) L C� G'�a� R �r- VMQ i l Sub F1aor- 2-X $ L��r�� cU1Um � nno Pr- o ? o S Lcz--� o SMOKE DETECTOMS REVIF-WFO Z_ �- P-I OATE N o A v OATE C, V A e BOTH -t3ijiArURES ARE REQUIRED FOR PERMUTING t by V L- Barnstable Bldg. Dept. Approved by*-444-J- Perrnit W, EATI-i 0 2-C L� CL 'LV L 3(A3 f CL C L -5 -6) L C-19 kC V\4e y\ c L B U ILDW S r-J,KI V AN 0,0, 2020 C o Ce � rV � � � Y (i C) a _ �5 YY\eo,_, Y-s ©c4 �- n CL open',r� CL oQ�, e ?- ��1 a me Bp1�pING pEP�. • �pN 21202® � OF BARNSTAB`� TOW