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0006 HENRY F LORING ROAD
s r ! .., ��� ����� f v { p Commonwealth of Massachusetts Sheet Metal Permit 11111 . Map Parcel� � 1 ( Date: 10 L6 z4W, ®Cr 1 7, 2 F,19" Permit# �� Estimated Job Cost: $ ( �• � KIN J����NSTABLE Permit Fee: $ Plans Submitted: YES NO Plans Reviewed: YES NO Business License# �� Applicant License# 8586 Business Information: Property Owner/Job Location Information: Name: Air Rite HV'AG U, vAl- Name: � .��-•-�2 �) S Street: 88 West gain U Street: � lA City/Town: 'Yar " City/Town: ^-� v, I L-.� Telephone: 508-360-766 2 Telephone: Photo I.D.required/Copy of Photo I.D. attached: YES x NO Staff 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 sq. ft. Number of Stories: Sheet metal r=ershed d: New Work: Renovation: HVAC Roofing Kitchen Exhaust System Metal Chimney/Vents ' Air Balancing Provide detailed description of work to be done: f I'IVSURANCE 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 ye& indicate the type of coverage by checking the appropriate box below: A liability insurance policy Other type of indemnity ❑ 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 w,aIXes this requirement. Check One Only Owner Agent ❑ Signature ner or Owne Agent By checking this box[],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 Proiress Inspections Date Comments Final Inspection Date Comments Type of License By aster �. Title ❑Master-Restricted CitylTown ❑Joumeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: v Fee$ Check at www.mass.gay/ l Email: 1, q T1(L40 ejV6) a►r% cn oa_ inspector Signature of Permit Approval Town of Barnstable Building Department Services BAIMUrAMA ` Brian Florence,CBO XASL k� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmstablema.as Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I,0�- QW Ri\b ,as Owner of the subject property herebyauthorize VAC �� a6J%ct on m behalf;y in all matters relative to work authorized by this building permrit 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 perfopned and accepted.. Signature of Owner tore o li t �FaDQ:n�1ilYJ S. yAc Print Name Print Name Date Q•.FoxMs:oEUMstorlpooLs xe,r:09/16/17 Town of Barnstable $uilding Department Services Brian Florence,CBO Budding Commissioner 200 Main Street, Hyannis,MA 02601 NAM 1659. Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE Eg MVnON Please Print DATE: JOB LOCATION: numbcr shxet. VMW name home phone# work phone# CURRENT MAHING ADDRESS: c4howa• s e zip code The current exemption for"homeowners"was d to include own -oc 'led dome of six units or less and to allow homeowners to engage an individual for hire who do s not possess a li ` se,provided that the owner acts as supervisor. Dk Il]Nn ON OF H�MEC►WNER Person(s)who owns a parcel of land on which he/she re ' s or. to reside;'on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures'accessory7\\to such us and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. h"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be ohsible or all such work perfornied under the building permit.-(Section 109.1.1) The undersigned"homeowner"assumes responsibility for c ce with the State Building Code and other applicable codes, bylaws,rules and regulations. _ - .J The undersigned"homeowner"certifies that he/she ds the To of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply 'said pro s and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwelling's containing 35, 00 cubic feet or larger be required to comply with the State Building Code Section 127.0 Construction Control'' OMEOWNER'S EREMPTIO The Code states that: "Any homeowner erforming work for which building permit is required shall be exempt from the provisions of this section(Section 109.1. -Licensing of.construction upervisors);provided that if the homeowner for hire to do such work,tha such Homeowner shall act assupervisor."' . engages a,person(s) .,•. k, ' Many homeowners who use this exemption are unaware that they are assuming the responsibilities of�a supervisor (see Appendix Q,Rules&Regulations.for Lice r ing Construction Supervisors,Section 2.15),This lack of awareness:often results In serious problems,particularly when;e.homeowner hires unlicensed persons. In this case,our Board cannot proceed`against the nnlicensecl.person 'as it wo d with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully ware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner.ce ' that he/she understands the responsibilities of a Supervisor. On th last page this,issue" is a form currently used by several t . You may care to amend and adopt such a form/certification Al use in your community. w , Q.\WPFMESW0RIvIS%uil&g permit fm=m EXPRESS.doc 08/16/17 . MONWEA TH OF ASS. U ETTS } o O - 0 o : AOAR f3FIll r "SHEET_METAL:WORI( RS 4 k f <: ISSUES THE FOLLOWING LiCEN.SE � g MASTER UNRESTRICTED xF 330 ELLIOTT RD" Q �x s �► CEPITERUILLE,MA �. max„ -x�^ .�,`'a } �t �"• � �`f � ��� � �Ua Nz 519585 — � r5 > '� A ACHWbt-TTS �RNER1s � � �wkLICEHSE 3 t A . ( 3W, i3,7t2017 ftAE4793 Ott NON pptO/nT,,T,,CCRO��'♦ �@� C £� 3 5.: SI E -3 Y fie•. -F, M�1,�1���s.oe��� �00 a4l�I�A ReYaTP1711018 a}, The Cs nrrr0mVerrt*Of reel =et1s e,�t r�',firifrrsbzcr�liccir�er�s 7M a,f, rtv gtu�iwrs ` 600 WadrhWan S#eet Basibr4 MA 0211 '6PEYtfE.mamo IWdIa Wiarimrs' Carqpe sxff4II lunwMIM Affidavit Bmld rs/CAntractursAK6C�c_n&Tlmnber'S n• EIkantTnfarm f-m-n Pl.£asePrint _ Air Hite HVAO ,hem 88 West. Main St Cfty{Stetm�Hyanxnis, MA, 02601 Mang. 508®360-7662 Are ym an employer?Cfieckthe appropriate ban ' Type of project(rid): I.❑ I am a emplayer witfi 4- ❑I am a gemral c ctor and I �a�(��flz pie)-* hwe himdf�suer-cis 6. New oofls an 10 I am a sale pzoprietua orpartaer- hated onthe dtachad sheet ?- ❑ cdelirxg sbFg and have no emplcsyees •These sab c=fsactars have 8 .ElDemr}lition , wodziad forme in any capacity.. ��aadlrave worl�s 9. ❑Burly addifioa INOwpaze Camp-ice: _Co -ZflE7l�.I,N•P. 5- �We-me a•coaP=fmandits 1 �Fled al fepairs or aeons 3.El am a I�ameowner doing all work afucers have c"=ed#heat iL❑Plnmbiugrepairs or adchfitaas right of e�mgfou per MGI. msmamcemysidi[Na'oaYsrlors comp recidmq r _ •` c.�52,§i{4),andvrebave�a' L.❑Roafz� . emgioyew,[No wa$cese 13❑Other ��A�. cozrP.inmMm Ece mquire&] A,WagpFr�Histchedcs�ns#1mastalsofiIloa¢tl daeBoabeiow fheir�aaa7se ecmpea,etio-aperT�piuii as i ame�aers�]m=bit ffis slUdaru`is rs g fty=3--dcdn_-zU mimic audffmbi ee aum@e:tautacrosma snFrmit anew atiid t> s�di. t'E=cber3r bexmmt atta an.addWamsl sheet&-Cbgtheasmeaf&E sn7r- es=d st&e�ec armara nse eatid-11s e eapiayeea.l'ftbem*-C 5h�•e aaFTo�s,titeYmusttau+tae t e's '�P•PaE5 M=bf- 1 am an errr1vlafsr€iirrtisprmrsdurg rwrl�ers'ca srdzarr i�rszrraace f or azF enrpF�y�ee�. Seit�av is t7iepa�Cjr anti joy site i�,�orrrsotrau ' Ins==0ComparryY'€ame: Dowling & O,Neil Insurance Agency P &cy or Self-m .I.io. T 854A �n�Date:.-040 1 3/20 20. Job life Address CifglStafeFMp: Af#ach a caPy of the workers'camPenmdi0ngolicYdwhra4ian page(sh vdng the policy amber aad exp -Ainn&te). Fad to semm cavemge as required under Section 25A o€MGL a ILL caa lead to ttie imposi&n of cri-i-d peaaltses of a fim up to$15 Of}anVor onek-geaeimprisoxmxit,as we!as dvil.panl&s m fhe fG=of a SIW WORK ORDERand a Eme of up to$250-04 ga a day against the violamr_ Be advised tg a copy of this s znay be forwarded.fa the Office of Invesfitia�oft he DIAL.for iasu=ce coverage vemfimbmn,. life her* and psi s a� O:iitatilis i�arwra#iar��rro��daba��e i�bars arrd correct SiPsaat�- Phonalk t)gfci d uss arrfy. D-a nat wits ass t7ds amo,to Ire completed by reify arts irn a,Fcrat Oty or To= Perrro�ceEtse� ;n ?3r&orky(cacIeOne): L]ioand of$t2M I BmEftg Dep2r neat 3.MyfFovm Clerk 4 Mechiad Tkspectur S.Phxmbmg Emspector . 6.Other C mbct Person: Phana#- 6 Client#:21832 2AIRRI /DDIYYYY) DATE(MM ACORD. , CERTIFICATE OF LIABILITY INSURANCE DA TE(MMo19 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 any rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT- NAME: The Hilb Group of N.E.dba Puc"N eM 508 775-1620 FAX 5087781218 CNc, . E )' O 7 (Arc,Nc1�� — Dowling&O'Neil Insurance Agy E-MAIL P.O.BOX 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:NGM Insurance Company 14788 INSURED INSURER B: Air Rite HVAC Inc. INSURER C: 330 Elliott Rd. INSURER D Centerville,MA 02632 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 CONTRACTOR 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 y ADDL SUER POLICY EFF POLICY EXP — LTR TYPE OF INSURANCE INSR VWD .__ _ POLICY NUMBER _^ MM/DD/YYYY_ MM/DD/YYYY . — LIMITS -� - - �- -)1----z --- A COMMERCIAL GENERAL LIABILITY^ MPT8454A —' 04/13/2019 04/13/2020 EACH OCCURRENCE — $1 000 OOO OX DAMAGE TO RENTED CLAIMS-MADE OCCUR MI ES(Eaoccurrence)_ $SO01000_ _ MED EXP(Any one person) $10 000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 � PRO. POLICY I__^_I JECT [:)L( I LOC PRODUCTS-COMP�$2,000,000 OTHER: I $ A AUTOMOBILE LIABILITY I M1 T8454A 04/13/2019 04/13/2020 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ ANY AUTO BODILY INJURY(Per person) $ OWNED X SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY I Per accident)_ . T _ A X UMBRELLA LIAB X OCCUR CUT8454A 4/13/2019 04/13/2020 E_ACH_OCCURRE_NCE _~ $2 000 000 EXCESS LIAR CLAIMS-MADE AGGREGATE s2.000.000 DED X RETENTION$10000 _ $ A WORKERS COMPENSATION ) WCT84S4A 04/13/2019 04I13/202 X PERTU7E__ OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE�Y I N i E.L.EACH ACCIDENT $500t000 OFFICERIMEMBER EXCLUDED? i N 1 N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $SOO,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable, BuildingSHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE C 1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) 1 of 1. . The ACORD name and logo are registered marks of ACORD #S234915/M234911 RPSW1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Bwlders/Contractors/Electrimans/Plnmbers Applicant Information 1, Please Print Legibly Name(Business/Organization/tndividual)• 1 (a�J k 0 40 01N Address: City/State/Zip: 1-i Phone#: g - 3 Co° &�. Are you an employer?Check the appropriate box: Type of project(required); 1.❑ I am a employer with 4. I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached shwL 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for mein any capacity. employees and have workers' 9. []Building addition [No workers'comp.insurance msurance•t required.] S. gee a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12. Roof instuanm ]t c. 152,§1(4),and we have no ❑ repairs employees.[No workers' 13.❑Other kVA-(- comp.insurance required.] 4Any applicant that checks box#1 must also M out the section below showing their workers'compensation policy infurmatioa. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cwmractors must submit a new affidavit indicating such. rContractors that check this box must attached an additional sbeet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-cunt w1ors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: - Policy#or Self-ins.Lie.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the a lns of perjury that the information provided above is true and correct Si Date: Phone#• Ojykial use only. Do not write in this area;to be completed by city or town of L-W City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cibgown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M 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 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 constrict 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 sire 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 time 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- The Commonwealth Of M&SS&ahuseM Department of Industrial Accidents Off ce of Investigations 600 Washington Street BostM MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAM Fax#617-727-7749 Revised 4-24-07 ,&Dv/dia TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 5 Map Parcel Application Health Division Date Issued J1`{ Conservation Division Application Fee �J Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address Village 4��Gl Owner W4�?9,Q,t�B ,� Address Telephone Permit Request /d Za 1.4 Y- /2 J& L%,,,s20_ 11 G . 02,—r—g J-0 Za �& Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation f�-o 11, 3 Construction Type .,Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family C' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 2<o On Old King's Highway: ❑Yes Flo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other o Z:ZI Basement Finished Area(sq.ft.) Basement Unfinished Area`(sq.ft) T.. Number of Baths: Full: existing new Half: existing ew co Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number cO P Z7%Z i Y— Address /���',g ��� �l� License #�/�6 9 y,40 Home Improvement Contractor# Worker's Compensation # 4 AtM10 i 11TION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO G SIGNATURE DATE JA9 I Z/4- iR i r FOR OFFICIAL USE ONLY APPLICATION# E DATE ISSUED 4 _ MAP/PARCEL NO. ,i ADDRESS VILLAGE OWNER t } DATE OF INSPECTION: _FOUNDATION, FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL s. GAS: ROUGH FINAL Y FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Massachusetts -Depaftry nt of Public Safety { Bdord of Building Regulations and Standards Construction Supervisor' �fK License: CS-100988 HENRY E CASSEDiV 8 SHED ROW y s t WEST YARMOUTH� 2 Expiration Commissioner 11/11l2015 s dllXle Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 r: Boston, Massachusetts 02116 Home-.Improvement Cgntrartor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/20.14 Tr# 233831 CAPE COD INSULATION, INC I`' HENRY CASS I DY ::, -- ----------- ---- k . � 18 REARDON CIRCLE - ' - — ---- -- ---= SO. YARMOUTH, MA 02664. Update Address and.return card.Mark reason for change. 3.SCAT ii 20M-05/I1 Address Q Renewal ,� Employment U. Lost Card � - - - �T c ((arrarreterru calt v�C�/G�ti"aclu je,Cs Office of Consumer Affairs& Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: gistration: .f53.567 Type: Office of Consumer Affairs and Business Regulation. xpiration: 12/1'5I2Q14 F Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATI,ON,,II� r HENRY CASSIDY r 18 REARDON CIRCLE r _ SO,YARMOUTH; MA 02664 Undersecretary of-val• witho t nat re I , r I I i f �1 The.Commonwealth of Massachusetts Department of IndustrialAccidents W Office of Investigations J d 1 Congress Street, Suite 100 Boston,MA 02114-2017 - www mass.gov/dia Workers' Compensation Insurance Affidavit:.Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le gib Name (Business/Organization/Individual): Address: V hl 6V-Je,, City/State/Zip: ,5b 1A bwamr,ttIA4 Phone #: J DA 71 r (2 l Are on an employer? Check the appropriate box: Type of project.(required): 1. 1 am a employer with 2 �2 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6.' ❑New construction. 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ` ship and have no employees. These sub-contractors have 8. ❑ Demolition working for me iri any capacity. employees and have workers', 9. ❑ Building addition [No workers' comp. insurance comp. insurance. - required.] 5 ❑-We are a corporation'and its 10.0 Electrical repairs or additions 3.❑ 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:❑:Roof repairs insurance required.] t c. 152, §1(4),and we have no 1 employees. [No workers' 13.�Other 7� comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. I Insurance Company Name: G(�V�"►�T t� V�/�lL��d Policy#or Self-ins. Lic. WCA 00V52ci0 Expiration Date: liq Job Site Address:- B 0/~ City/State/Zip: W Y2 Attach a copy of the worke s' compensation policy declaration page(showing the policy number and expiration date). ' Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office.-of Investigations of the DIA for insurance coverage verification. I do hereby c the pains and penalties of perjury that the information provided above is true and correct. Signature: z Date: Phone Official use only. Do not write in this area,to be completed by city or town official. '. City or Town: Permit/License'# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: q spy CAPECOD-27 CVANGELDER DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/112014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE-A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Cape Cod Commercial Rogers&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/c No Ext: A/C No:(877)816-2156 South Dennis,MA 02660 E-MAIL ' ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC q INSURER A:Peerless Insurance Company INSURED INSURERS:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER C:Evanston Insurance Company 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 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 ADDLSUBR POLICY EFF POLICY EXP - - LTR TYPE OF INSURANCE J=wyo POLICY NUMBER' MMIDDIYYYY MMIDD/YYYY - LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 _ CLAIMS-MADE �OCCUR CBP8263063 04101/2014 04/01/2015 pREMISESOE occcurrence) $ 100,00 MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,00 -- OTHER: $ AUTOMOBILE LIABILITY -- - - COMBINED SINGLE LIMIT $ _ Ea accident B ANY AUTO 14MMBCKVMK 04101/2014 04/01/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED _ AUTOS rX AUTOS BODILY INJURY(Per accident) $ 1,000,00 X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ X UMBRELLA LIAS X OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAB CLAIMS-MADE RIO XONJ453512; 04/01/2014 04/01/2015 AGGREGATE $ DED X RETENTION$ 10,000 Aggregate $ 1,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER D ANY PROPRIETORIPARTNER/EXECUTIVE YIN WCA00525904 06/30/2013 06/30/2014 E.L.EACH ACCIDENT $ 1,000,00 a OFFICER/MEMBER EXCLUDED? -N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ .1,000,000 Ityes,descnbe under DESCRIPTION OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) ..- Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r t �► �' i - + _ - - PARTICIPATINGCONTRACTOR ave mass S�,fnO;erno:ipn x>1m9Y�IfkMny .. - _ PERMIT AUTHORIZATION FORM I; F— 94 U ,40e h&1—_-7 Cw �� , owner of the-property located at' 1 (Owner's Narne,printed) � v F 2_6)e1UG Ql� Q_�102 1rLLC_ 3 (Property Street Address) (City/Town). hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a bui g permit to perform insulation. and/or weatheriization work on my property. Owner. Signature Date i FOR CSG OFFICE USE ONLY . jConservation Services Group has assigned the following Mass Save Home Energy Services: Participating Contractor to the above referenced project: Ca�E C o D nAXUCA- 7v✓I Participating Contractor Date Rev.12132011 { BIKE Town of Barnstable- *Permit#�01460�09 Expires 6 m s o issue Regulatory Services Fee * snxxsTnstE • 9� i639,' ,m� Thomas F.Geiler,Director l Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-623.0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number I7JA G/ Property Address 0 1-1 t'.k ,Residential Value of Work '5 g,C7 br2 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Ad ss N\A V if, GO P� e�1 V�rT-p-\ �e �e�u� �R Contractor's Name N.\Q Telephone Number 3JA U.1 Home.Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)- ❑Workman's Compensation Insurance Check one: �� S Pei �� ❑ I am a sole proprietor ❑ lam the Homeowner I have Worker's Compensation Insurance JAN 16 2014 Insurance Company Name Workman's Comp.Policy# X-�%cog Q S ^ l' OF SARIVS-r. Copy of Insurance Compliance Certificate must accompany each permit. �8�� Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going'over existing layers of roof) ❑ Re-side #of doors ` Replacement Windows/doors/sliders.U-Value dam ` (maximum.35)#of windows \ .1-1 *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 a Home mprovement Contractors License&Construction_Supervi§ors License is require SIGNATURE: QAWPFILESTORMS\building permit forms\EXPRE .doc Revised 051811 ^ CTT/ze�pa,,vr,,o�u„ea1 o�C/�aaaaclucaet�i License or registration.valid for individul use only Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to: egistration r132149 Type: Office of Consumer Affairs and Business Regulation k 10 Park Plaza-Suite 5170 xpiration: 11t812014 Individual j Boston,MA 0211ti a n =jla DEAN F.STANLEY DEAN STANLEY =r 35R CAPT.LIJAH RD ' a - CENTERVILLE,MA 02632 ' �— Undersecretary Not valid without signature ; I Massachusetts-Department of Public Safety, . Board of Building Regulations and Standards Construction Supervisor License: CS-035037 �^ DEAN VS 359 CAPTAID CENTERVIILE i Expiration Commissioner 01/19/2014 a I The Comrrronweah*of Massachusetts Department o, I striat Acrid t77,Q`rce of lnm igadoru 640 Wwhingfon,Str+eet Boston,MA 02111 n1M mimLgov1dia Workers'Compensation Insur nce Affidavit Bmlders/Contractor&TJ[e c ans/Plumbers Applicant Information \\ 1 Please Print Legibly Name(Busmessl0rgani�tionllndividnaU_ S`Ih ti�\ Address: 3 QA,0 Af-kV-1 : b IA city/Stabeizip:��M�e�u���e N` Phone# 50 �-ko2�- 3�Co�o Are you an employer?Check the appropriate box: Type of project(required): 1.Ll I am a employer with 9, _ 4. ❑I am a:general contract"and I employees(full audlar part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑Remodeling These:sub-contractors have ship and have no employees. 8_ El Demolition working far me in any capacity. employees and have wormers' [No workers' comp.insurance rump-msuranc e-1 9. ❑Budding addition .5: ❑ We are a corporation and its, 10-El Electrical repairs or additions 3.❑ I am a homeovmer doing all.work officers have exercised their 11.❑Plumbing repairs or additions. myself.[No workers'comp, right of exemption per MOL 12.0 Roof repairs insuranceinsr •e require&]T c.152, §1(4},and we hwmno employees.[No workers' 13.❑Other comp insurance mquired.] ;Any applicant that checks boa#1 oust also fa11 out the section below showing their workeW compenmjimpolicy irr&mw unn Homeowners who submit dos affidavit indicating d*y are•doing an woak amd then hue outside contractors most submit a new affidavit indicating Such- lConb=tws that check this boa must attached=additional sheet showing the mama of the sub-cuntrachoas snd:state whether oraot those entities ham employees. If the sub-connectors have employees,they must provide their workers't:ormp.policy number. I am an employ r that is protxidbW worker$'coumensalion.insurance for my serptnfaess. Below is the policy road job site informadon �t- Insurance Camp any Nam: Policy#or Self Uc.#: V ^ '��6('o a \O�S t ' Expiration Date: '1 8—&'- Job Site Address: Qvl�Y v City1Stat&2ip: 0 (\� d'. A31 u Attach a copy of the workers'c ation p4ky declaration page(showing the policy number and expiration date). Failure to sew coverage as required under Sectiod 25A of MGL c 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andtor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER.and a fine of up to S250.D0 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 ado hereby 'n t ns nd ponabies ofpedury thatthe information.pror &d above is true and correct Si Date: l- l (o ';�o f: Phone#:. SOS' /'1 �6= t Coco ?jja'ciad use only.. Do not emits in this area,m be completed by city or town official City or Town.;, PermitiLiceose# Issuing Authority.{circle.one}:. L Board of Health 2.Buffing Department 3.CitylFown Clerk 4..Electrical Inspector 5.Plumbing Inspector 6.Other: Contact Person: Phase#c 6 CERTIFICATE OF LIABILITY INSURANCE DATE(MID1in/nal2n1 YYI) Tllil4 CER` IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A'CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: 27JDD PHONE FAX NORTHWOOD ESHBAUGH INS A (A/C,No,Ext): (A/C,No): 540 MAIN STREET E-MAIL HYANNIS,MA 02601 ADDRESS: 73K6G INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA DEAN F STANLEY BUILDING CONTRACTOR INC INSURER B: INSURER C: 359 CAPT LU INSURER D:AHS ROAD INSURER E: CENTERVIL LE,MA 02632 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-WRH-RESPECT-TO:WHICH-TNISCERTIFICATE.MAY.BE.ISSUED-OR.MAYRERTAIN.THE IN`.URANCE..._.._... 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 ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE I$ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $ PREMISES(Ea occurrence) MED EXP(Anyone person) Is PERSONAL&ADV INJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: ENERAL AGGREGATE $ POLICY O PROJECT❑LOC PRODUCTS-COMP/OP AGG I$ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE I$ LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ . SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY I$ NON-OWNED AUTOS PROPERTY DAMAGE I$ (Per accident) I!I UMBRELLA LIAB OCCUR EACH OCCURRENCE Is i EXCESS LIAB M CLAIMS-MADE AGGREGATE Is DEDUCTIBLE Is RETENTION $ I$ A WORKER'S COMPENSATION AND X WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-4869P061-13 10/05/2013 10/05/2014 LIMITS ANY PROPERITORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? NIA E.L.EACH ACCIDENT Is 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE I$ 100,000 If yes, O under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DN DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION KEVIN ELLEN ROCHE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 101 SHORE DR BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY.PROVISIONS. AUTHORIZED REPRESENT VE MASHPEE,MA 02649 ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved. • BARNSTABLE • "�"� 1639. 'Town of Barnstable 9A `0�' - Regulatory Services Thomas F.Geiler,Director Building:Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.Ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as.Owner of the subject property . hereby authorize N� 1} �2 to act on my behalf, in all matters relative to work authorized by this building permit application for: eCN�6' V�C' S (Addres of Job) 1)10 Signature o ex Date �•S��O Pr� s. Print Name t If Property Owner is applying for permit,please.complete the Homeowners License Exemption Form on the . reverse side. QAWPHLESTORWbuilding permit formSTYPRESS.doC Revised 051811 �tME Town of Barnstable Regulatory Services a�. ` Thomas F. Geiler,Director 059. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER!': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner F 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 t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 Assessor's map and;lot number Qy0F7F1Etp�o r I Sewage' Permit numbe>:" - ' G ...........,.. k NA House number : 6:. �. MU SEPTIC SYSTEM' S�' E °o�b 9 • _.'�'STALLED ih3 COMPLIANCE TOWN OF BAR, N,S, I2, L lr �a 6�dslsYa` DE 5D RUfLDIG INSPECTOR APPLICATION FOR PERMIT TO Add to dwelling•• ."•"°"••."""•" " ........................ TYPE-OF-CONSTRUCTION ......... Wood `... a` :...... .... s f 9/13/8� .....................19...84 TO THE INSPECTOR OF BUILDINGS: + The undersigned he y ap s -for•a permit,according to, the following information: •r 6' oring Road <. Location ....................:............................................................................... Den, bath,and laundry ProposedUse ....:.. .......................................... ........... .....:............................................ Zoning District RC Fire District Centerville-Osterville William „Brookbank Address .,...:6`: Henry F. Lorin Road Centerville Nameof Owner` ............... ... ....................................... ................. Name'of Builder Stanley E. ........ , ..St. Peter ......., Address ..36�1:Main Street Barnstable, Mass:,o ; . Name of Architect Norte ................................ .....................Address ....................................................................................... Number of Rooms ..........O..n...e.................... ......:....................Foundation "..,Con.cre.te...blO.ck5 .................................... ....... .... ........ ....... Exier or ..•Conventi6nal trim" WC .shingles Roofr,g' Asphalt :.shingle's Plywood Floors ............. :...................:...:...................Interior .................. ........:..:.... Heating .........F...................................rced hot Water .........Plumbing ......P.V.C., .................. ................ Fireplace ................. ...... .Approximate Cost '. ?5..,.4Oo:�.00:... Definitive Pldn Approved by Planning Board --------_-----------------------19--------- Area .......................... Diagram of Lot and Building with Dimensions Fee Z :. ... M SUBJECT TO APPROVAL OF BOARD OF HEALTH 00 I Lk rq14 / F T IV / OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree:to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction: '. 4 . .. :. A PCt4'�!� Construction Supervisor's License ................. ....�...... a , BRWKBANK, WILLL7\M 26968 Permit for ADDITION .. x Single:Family..Dwelling........................ !!...... Location 6 HenrX F'. IArinq.a .......... Centrile ................................................ .,. Owner. William Brookbank .... L-A: C Type of Construction ...Fr ...................:....... t Y, ............................................................` ............... Plot ................ , Lot. ..:............................. z Permit'Granted ..September 13,......... 9 84 Date of Inspection ................. ... ........19 Date Completed .................. } .. .19 (,3 Assessor's map and lot number .... ........................................ �Q�o�TNETo�o Sewage Permit numbe>-- 20 ^':-...%L��2�r-......f................. d Z BAUSTADLE, MAB i House number .........6.. .......................................... 9 a- 00�0 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Add :t0 dwelling . TYPE OF CONSTRUCTION ..............w00d ...................................................... 94-3/8 ......................................19.:.8..TO THE INSPECTOR OF BUILDINGS: The-undersigned he by applies for a permit according to the following information: 6 Road Location ....................................................................................................................................................................................... Proposed Use Den, bath,and laundry ........................................................................................................................................................................... Zoning District .......R...C..............................................................Fire District .......C.e.nt.e.rvl.11e.—O.S.te.rvi.l.le..... ........... .. .... .. ....... ....... .... .. .... ....... .. .... Name of Owner ...,William Brookbank ' Address .......Henry F. Loring Road Centerville .......... ....................... ..................................................................... Name of Builder Stanley. E. St. Peter Address J01 Main Street Barnstable, MassaCh ... .................................................... Nameof Architect .........None ....Address.. ...........................:.................... ..................................................................................... Number of Rooms One Foundation ,,,.Concrete blocks . .......................................... ................. Exterior ...Conventional trim WC Shingles .,Roofing ..........Asphalt shingles r .. .. ... .................................................:............. PlyWO .....................Interior. ......................... Floors .....Od....................................... ....................................................:...... Heating Force.d...h.ot...Water......................,,,,,,.,,Plumbing ......P'V'C ..... .. .. .... ..... .. .'.....................................;....................... Fireplace ...................:............................................:.................Approximate. Cost 15 000 00 Definitive Plan Approved by Planning Board --------------------------------19--------. Area .. .`..0.......................:. LA e Diagram of Lot and Building with Dimensions �� Fee � SUBJECT TO APPROVAL OF BOARD OF HEALTH '— G' I 4 fit' ys 1 we s 4 rk r llelx, A C/. I ` f OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS X 7 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Ae �r� ' ��.��.l...:..... .. Construction Supervisor's License ......................000�;�� BROMANK, WILLIAM A=172-19 No ... 69i 8... 'Permit for .ADDITION.. .......... ... ..........Single. Family.DweIli ...... ....... Location .....§J. enr......y.j:?..kpKing..BQ. ............ Centerville ............................................................................... Owner ....William. B.rookb.ank ........ . .... .. .......... .............................. Type of Construction .....Frame.................... ................. ................................................................................ Plot ............................ Lot ................................ September 3, 84 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ......................................19 AsseA- or-'s map and lot number } 1� 'SYSTEM MUST SE Sewage, Permit!number .................... /.......,. y TALLER IN COMPLIANCE I H ARTICLE 11 Sf TE[' coo PyOfTHET��y TO ♦Y N �rl��' OF BARNST J_j AND / i BA*TABLE; i 9 Mb 9,, ` RU I L D I RNG I NSPECTOR ���.:. :APPLICATION FOR'PERMIT TO ... s ..... . .................... ............................................................ TYPE OF CONSTRUCTION .. ...;.. � ....................................... ....................... TO -THE INSPECTOR OF BUILDINGS: The undersigneyereb applies for a permit accordin to the. following information: Location ........ � ........... ` ., ` ... K,... ...Proposed Use .. . .........:................................................................. ...................................................... Zoning District ................ .....................I.....:.:..:.......................Fire District ..... ........... ... Name of Owner ....... ...... ......... ...................Address ..... .. . :.... --. ........... Nameof Builder .........a.......:................:.................................Address .................:..............................:................................... r Name of Architect .........................Address Number of 4�,, s ...... ........ ........ ......... ................Foundation ....... Exterior .-.. . "C', ...... ..... ...:........... ....... .........Roofing ............................................... Floors .................Interior .... ..................................... Heating Plumbing :.... ........ ............... ......... .. ................................... 00 Fireplace .....Approximate Cost Definitive Plan Approved by Planning Board __ _________ _______________19 JAR Area✓........ ..:....... Diagram of Lot and Building, with Dimensions Fee L,� ..!!. 4 SUBJECT TO APPROVAL OF BOARD OF HEALTH f hereby agree to conform to"all the Rules and Regulations of the Town of Barnstable regarding the above construction. Na .................. ....:. r Small, Alan 18582 one story, Flo ................. PeTmit for .................................... single family dwelling ............................................................................... 'Prince Hinckley Road Location ................................................................ Centerville ............................................................................... Alan Small Owner .................................................................. Type of Construction .....................frame..................... ................................................................................ Plot ............................. 'Lot ...........#.9.4.............. Permit Granted .........Anust 13 ..........1976 Date of Inspection ..... ....................... Date Completed ..........19 PERMIT REFUSED ......................... ...................................... 19 ............................................................................... ............................................................................... ............................................................................... ............................................................................... Approved ................................................ 19 . ............................................................................... ............................................................................... Assessor's map and lot number ................ .............. f 3,10 Sewage Permit number .......................................................... THE TOWN OF BARNSTABLE , ARNSTAXE, 039. BUILDING INSPECTOR APPLICATIONFOR PERMIT TO ... .... ..... ................................................................................................. TYPEOF CONSTRUCTION ........ ........................................................................................... .............19...................................... ..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information- Location ........Z....../......... ........ ....... ...................................................... ....................... ProposedUse .......................................................................................................................................................................... i D Zoning District .........................................................................Fire strict ............................................................................... Name of Owner IF ..................Address .... .........11............................. ................................................................................ Nameof Builder .....................................................................Address .................................................................................... Nameof Architect ...................4..............................................Address .................................................................................... Number of Rooms .........7.......................................................Foundation ..... ........................................... ... ......... .................... Exterior ...... ..........Roofing........................................................... .................... ................................................................ Floors ........ .......... ............Interior .... ............................................... ............................. .................................................. 2 4ee Heating ..................................................................................Plumbing ................................................................................... Fireplace ..................................................................................Approximate Cost ......./ /(,, - .k............................................................ Definitive Plan Approved by Planning Board --------------------------------19 Area ......... ".M........... ...... ........ Diagram of Lot and Building with Dimensions Fee ................ .. .. ... ...... . ...... 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. Z2. Name- ................................................... ..... ... ..... . ........ Small, Alan A=1724�� / / ~ �/�� . . , 18582 one story, + . otmry ^No ----- P�onh for .................................... o1oole family dwelling ----------------------. . Location —.���Pri�������.��~^=�—~�"�° Centerville ------------- '' ' `` A^=" Sua ~.... | ' .,,- _ Construction_ __ ' ' � iL ` . � � / nc* � ( ' ' ' rarnnt Granted ' . � . . Date of Inspection �: . , ' ' ""= `" "p=/wu . . . . ' . � PERMIT —_ � ' lA ' . . AP ^ ' / ....... W .— .....�p~~ ............................... / � ^. �8 ' —_--~---.---...**----.~-----.— . . . ``-------'------^---~^—^----- . . ----~----'----'—^~^^^--'^----''' ' � . ' Approved ................................................ lg ' ^ ' --------------------------. . . . ' -------------------...---..—. 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