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Permit: u7 �TME �Qn Building Department Services ate: . Brian Florence,CBO BARN L.E. Building Commissioner ee:MASS. s 200 Main Street, Hyannis,MA 02601.., www.town.barnstable.ma.us A Office: 508-862-4038 `` Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: WILL K4.6 UA1 L Phone: 50,f 7 7f- if 7 4 t Install at: Sir 4i 6I4 C ✓ 1� � V 2—P2 Vr�,Lc' Village: Map/Parcel: �- Date• 'VA-Al 2- col 9 Stove A New Used B. ype: Radiant/Circulating C. Manufacturer: Vzfr�or 4-. MS Lab.No:OM(h 0 L 1 6)- � �p �a00) D. Model No.: Chimney A. NqW Existing (If existing,please�notedate of�Iasteaninp�_ B. Flue ize C. Are other appliances attached to Flue?A)b Pr Type and Manufacturer Q 1 2niy: Lined/Unlined Mrials: Sub%Floor C nstruction: o JL staller 1amc Address: VPhon�' Location of Installation: H.I.0 Registrati # Construction pervisor# OR check_Homeowner Installing,no license required LICENSED INSTALLERS SIGNATURE- APPLICANTS SIGNATURE: GI/APPROVED BY: BY: Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev:08/16/17 1 77te Commomveakh o,f lifasyachusdts , Department o,f rnih sin-Acc iden& - - Office of Inrestigatiaxrs 4 600 WasIThrgton,Street - Boston,VA 02111 wrtnumasLgorrldut Workers' Compensation Iusurance Affidavit Builder-dCuntractursMechicians/Phunbers Applicant Inform;atian Please Prints A&kes 5-5 li GN,-4AJ8 6 City/Statef ro 2. C E-�Av/i L��Z t`i tii /Lj,4 p�aane S'o c 7 7T dF 7 V Acre}you an employer?Chechthe appropriate bow: " Type of project(required)- LEI lam a employes vdth 4 El am a general contractor and I 6. ❑New cons&u�io� employees{ftalf an'&or part-time),* have lured the sub'-coaara s , 2.❑ I am a sole grropcietafr orgartuer- listed an the attached sheet. 7. ❑Remodeling - ' skip and have no employees These sob-contractors have $ ❑Demolifioa^ wa�r,{n,i,,n�g for mein emprloyees aadbmre worms' ' "`�"'J''b �� � '. � ❑B.uilding addition. .. Q lYdlkQ[S' camp.[sfcatsan e r- comp.ingi2i�ntp �_ We are a corporation.and its 10❑Elechical repairs or additions . required-] of tens]save PRR1Y'fsed t13Cir 1L ' Plumbin r any or additiens. , 3. am a homeommer daisg all v�orlr ❑ g eP o vmrkers right of exemption per MGL €� - 12_❑Roof repairs _ insurance required-]i C.152,§1(41 andwe have n o- employees.[No'w ' 13_❑Other cop-insurance, .] *Any appEi=t dwt ched box AI mast also SIl omi tL.e secdanbeIaw sharwiag&ei &wows'c==enmfimF 1-Eky iufiFms6am #Idameoer�ers Wlm sah�t dris af6dat�F in�catimg tLey axe china all wad sad Hies Lv<re antside cenhacta�sxnnst submit a new off dz¢it indicating sncTi =Caansctm Yha1 checlr this boar mua oxcheds=addid—I street shaaeffig the mane of die and state whether or inn thmse entiflesbne empk"es.Ifthesuh-con eshaveempIoyee%diey=xstpnm&tbeir warken*wmp.palicymmibeL I am an errrgloyer Mat is pranading workers'coff7ertsahien iasrtrance for my enwkvyres. BeIVIV is f lepvticy artd jab site+. ' ETf�iPt'Rtaj101L a' � Insurance Company Nam: . . Policy or Self-ems.Lit. MjiratibnDite: Job Site.address _ : .. cifylstafi&4: Attach a copy of the wGrkers'comapensatiou policy declaration page{showing the poPiey number and e=iratioa date). . Failmre to secure eaFecage as required:undrr Section 25A of IuIGL c l52 can lead to the imposition of criuiimal penalties-of a. fine up to$1,540OD andror one-yearin43risorwWWA as well as civil penalties in the form of a STOP WORK ORDERaud a fine of up to$250_00 a day against fihe-violator.,Be advised&at a copy of this statement snap.be forwarded to the Office of Imvestigatiom of the DIAL for insurance coverage caticm.- I do hereby cerlsf,a"Or thapaitis andg�r�alks o,f' ry,thatthe infonna#i�v p m�dabm'a is tare and carrea Simista . !�v 1 -� r Daley Phoneme fo<f 77J` 7 yap .. t3joWal use only. Do slat write is this. xea,tra be-'campUl ad by city artawn ofjrdrat T _ or Town.: Permit;ff&ense;g Issuing-Authority(ch de one): 1.Board of Health Z.Building Department 3.CitylTuwa Clerk 4.Eiectrical Inspector S.Plumbing Inspector .6.Other Contact Person: Phone 9i = - 6 Information and Instructiolas Massachusetts Geizeaal Laws chapter 152 regoaes all employers o provide wart c&compensation for their euzplayees. Pur=z=NB this sbtote,an employee is defined as.`°_.evmy person in the service of Eaod=r under any contract afhfir, p.. express or=01)lied,Dial or wriftim.7 An epIayer is i-fned as"an i a.dEvidma par[nmmbip,association,crnpora#ion or other legal entity,or any two or mare of the foregoing engaged in a Joint=bzprim,and including the legal representatives of a deceased employer,or the receiver or trustee of an individnal,parfiership,association or other legal entity,employing employees- However the owner of a.dwelling house having not more than th=apartments and who resides therein,or the occupant of the - dw lIin house of another who employs persons to do maitmance,construction or repair wad on such dweIIing house or on the grounds or building apprr�thereto shallnotbecarse ofsach apploymentbe d=aedtn be,an employer_" MGL chapter 152,§25C(6)also states that"every state or local licensing agency shallwitllhoId the issuance or renewal of a Bemuse or permit to operate a bvsuress or to construct buffdkgs in the comm onwealth for any applicant who has not produced acceptable evidence of compl-tanee,with the Insurance.coverageregmirred-" AdditionaIly,MGL chapter 152,§25CM states-N=ther the commonwealth nor jay ofits political subdivisions shall enter into any contract for the performance ofpobho work,u fR acceptable evidence of compliance with the Vices.. requirements of this chapter have been preseniad tin fire eof�¢aahoiity_" - APPlican fs Please iol out the wo3ieas'compensation affidavit completraly,by checlong to boxes that apply to y0m r siination and,if necessary,supply sub-contraCtar(s)name(s), address(es)and phone ntimber(s) along unit their ceriffim±e,(s) of insurance. Limited Liability Companies CLLC)or Limited Liability Partaeaships(LLP)withno employees other than.the members or partners,are not required to carry workers'compensation insuran e. If an LLC or LLP does have employees,a policy is required. B e advised that this affidavit may be submitted to the Department of Industrial Accidents for confnmation of insurance coverage. Also he sure to sign and date the affidavit The affidavit should ' beretimme--d to the city or town that the application for the pemut or license is being requested,not the Department of Tarim c t77_a_l A._ccidents. Should you have any questions regar-dmg the law or if you.are requird to obtain a workers' compensation poky,please call the Department at the number listed below. Self-roar companies should enter their self-jamce license number an the appropriate line. City or Town Of t _ Please be sure that the affidavit is complete and prinied legibly. The Department has provided a space at the bottom of the affidavit for you in.Ell out in the event the Office of Investigations has to cozdact You regarding the.applicant P lease be sure to fill in the perm.Wliccmm mrmbear which will be used as a reference number. In addition,an applicant that must submit multiple permitUcense appli-cations in any given year,need only submit one affidavit indicating current policy infom.ation.(if necessay)and under"Job Site Address"the applicant should write"all locations iu (ciLY or town)-"A copy of the.affidavit that has been officially stamped or narked.by the city or to may be provided to the - applicant as proof that a valid affidavit is on file for fndnre permit or licenses. A new affidavit must be filled Dirt each not related to business or commercial venture or citizen is o a license or any year.Where a home owner bfaining permit to Ie#e thus affidavit e o ' to Iran leaves etc__ said arson is 1�IQT comp (i_e. a dog livens or , ) p �� The Office of Investig-dtims would Irke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give m a call. The Departmenf's address,telephone and fax mmber_ Th�C=jonweattk of Maswrhu s , D-_garment eIn A00ident% Office of hve9fio_4a �4 T�a�hinn Stre�� T(,-L 4 617- -4 Qxt 4,06.or I-M-MASSAFE Fax 9 6I7 727 7M Revised424 D7 W.V, 9WIffia. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. I+ .. 76?'�, �,�.��'r.F DATE: �fii� f,ri: N r /1 Fill in please' rb'R!`s�lai�W��9F �' 1 J APPLICANT'S YOUR NAME/S: Srf / L Y�+'L(2ki/7�} ��J ZA H/ f ' BUSINESS 'YOUR HOME ADDRESS: L.qN �2 nflyn+ y JJdlJ�3p TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS -;I. /Q IS THIS A HOME OCCUPATION'?: YES NO ADDRESS OF 8U51NESS_:' MAP/PARCEL NUMBER U (Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (Corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to leg siness in this town. 1. BUILDING CO MI SI ER'S OFF E MUST COMPLY WITH HOME OCCUPATION This indivi a e Of r e a er it requirem nts t at pertain to this type of busineVAJLES AND REGULATIONS. FAILURE TO Aut r' gnature* COMPLY MAY RESULT IN FINES.-- C MMEN : t j 2. BOARD F HE TH / L�`—'� r This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** v , COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** . COMMENTS: F Town of Barnstable ��' oFtHE r Regulatory Services Richard V.Scali,Director Building Division EAMSr LE, i Tom Perry,Building Commissioner 9� 639. �0 ''lEn►u•<a 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Approved: Fee: Permit#: . HOME OCCUPATION REGISTRATION Date: `T d Phone j�u Name 4,4 �J�ig- J VU 740 ! �5 ? Address: Vill %�2 o i, ` Name of Business: Type of Business: /141 lIF//V6 Map/Lot L 1NTF11T: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual.alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions:. • The activity is carried on by the permanent resident'of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance'heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be.met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van dr one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot*containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation.- If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No per on shall be employed in the Customary Home Occupation who is not a permanent resident of the dwWad I,the undersigne d gree with the above restrictions for my home occupation I am registerin r Applicant Date: 0 7 O x Homeoc.doc Rev.1 113 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma "lr� Parcel Application #rw/ ( Health Division Date Issued ;Z- Conservation Division Application Fee 5 Planning Dept. - Permit Fee Date Definitive Plan Approved by Planning Board 3 h Historic - OKH _ Preservation / Hyannis Project Street Address Village GiL Owner �9 2 ULAYI'(, Address Telephone Permit Request ✓� �O z--�_.. Square feet: 1 st floor: existing T7 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation _i � Construction Type Lot Size wQ- Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 3r-'---fwo Family ❑F Multi-Family (# units) Age of Existing Structure 0 f Historic House: ❑Yes qt�Io` On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new -; Total Room Count (noZas g baths): existing D new First Floor_Room CoUr t Heat Type and Fuel: ❑ Oil ❑ Electric ❑ Other ' t `' Central Air: WB es ❑ No Fireplaces: Existing I New Existing wood/coal stove: 0 Yes A o' Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: J.existinC'U new size_ Attached garage: xisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial AYes ❑ No If yes, site plan review # Current Use 912d Proposed Use �� f -APPLICANT INFORMATION__. (BUILDER OR HOMEOWNER) r - Name Telephone Number Address �d 1�11 C .,✓� C.X 1 w License # Home Improvement Contractor# QA- Worker's Compensation # - G 6 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ll ^ SIGNATURE `' �- DATE 116 k FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: f FOUNDATION FRAME INSULATION x I! FIREPLACE w ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL I GAS: ROUGH FINAL FINAL BUILDING DATE-CLOSED OUT t ASSOCIATION PLAN NO. t The Commonwealth of Massachusetts rw Department of Industrial Accitlents t` Office of Investigations 600 Washington Street t � = Boston, MA 02111 www.mass.govMia , Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name (Business/Organization/Individual .I di L -Address: City/State/Zip LIP , Phone#: q28-7W,ID Are y an employer? Check tl a appropriate box: Type of project(required): 1. I am a employer with 4. ❑ i am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction ?. listed on the attached sheet 7. ❑ Remodeling El I am a sole proprietor or partner- ship and have no employees These sub-contractors have- g. ❑ Demolition working for me in any capacity. employee's and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance..- required.] 5. ❑.We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their , 1 1:❑ Plumbing repairs or additions myself, [No workers' comp, right-of exemption per MGL 12 ❑ Roof repairs insurance required.] ' c. 152, §1(4);and we have no employees. [No workers' 13.0 Other ,. COMP. insurance required.]' *Any applicant that checks box#I.must also till out the section below showing their workers'compensation policy information.,'; Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new attidavit 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 emplgver that is providing workers'compensation insurance for my emplovees. Below is the policy and job site information. � R . . Insurance Company Name (AM MUAI VF I I � �. Policy#or Self-ins. Lic. #: SIIoq Expiration Date: 1A.1 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 Investigation fthe DIA for ins u nce coverage verification. „ I do lrerehy e if c , tJ p ri and penalties of perjury that the information provided above is true and correct., Si nature: Date e2- 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. Buililing'Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other- ' Contact Person:, Phone#: , ® DATE(MMIDDIYYYY) ACORE0 CERTIFICATE OF LIABILITY INSURANCE 07/06/2011 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 CON TRACT,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: Germani Insurance Agency PHONE FAX 908 Main Street c o Eat: 508)428-9194 AIC No: 508 428-3068 E-MAIL - ADDRESS: Osterville,MA 02655 PRODUCER CUST MER ID#: INSURERS AFFORDING COVERAGE-_. .. NAIC# INSURED INSURER A: SAFETY INS CO g. Scott Peacock Building&Remodelling,Inc. P.O.BOX 171 INSURER B: _ Osterville,MA 02655 INSURER c INSURERD: National Union Fire Ins.Comp. - 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 ADDL SUBR POLICY EFF POLICY EXP - - LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY - LIMITS . A GENERAL LIABILITY CP00001152 s 7/5/2011 7l5/2012 EACH OCCURRENCE $ 1,000,000 _CO OMMERCIAL GENERAL LIABILITY ` ' AMA E RENTED PREMISES Ea occurrence $ CLAIMS-MADE F—IOCCUR - MED EXP(Any one person) $ `- a :' `+'' „- - PERSONAL&ADV.INJURY $ GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ PRO $ POLICY 7 JECT LOC. AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ - (Ea accident) ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS .PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS a $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE. $ EXCESS LIAB CLAIMS-MADE n . AGGREGATE $. DEDUCTIBLE $ RETENTION $ $ D WORKERS COMPENSATION WC5815464 6/22/201.14 6/22/2012 WCSTATRY T- OTH- AND EMPLOYERS'LIABILITY Y/N _ ' - - ANY PROPRIETOR/PARTNER/EXECUTIVE _ E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? NIA - - - - - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under F�. - - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)'- CERTIFICATE HOLDER CANCELLATION Scott Peacock Building&Remodeling,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Fax#"508-428-7625 ACCORDANCE WITH THE POLICY PROVISIONS. - AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved._ ACORD 25(2009/09). The ACORD name and logo are registered marks of ACORD 1 I - - Massachusetts- Department of Public-Safety Board of Building; Regulations and Standards Construction Supervisor License License: CS 94500 _ t Nm •. JAMES S PEACOCK PO BOX 171 OSTEVILLE, MA 02632 Expiration: 7/22/2012 ('unuuisiuncr Trti: 29233 /ze �o�rzireooxu.eaLCLi a��ieac�ivaella ' ' Office of Consumer Affairs&Business Regulation License or registration valid for individut use only = HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 0151853 Type: Office of Consumer Affairs and Business Regulation Expiration: -7/7 10 Park Plaza-Suite 5170 /2012 Private Corporation j- Boston,MA 02116 Sc TT PEACOCK BUILDING&REMODELING INC JAMES PEACOCK , 1046 MAIN STREET',SUITE,TA- -- OSTERVILLE,MA 02655 Undersecretary Not valid with ut signature •,• � ' if , e } Town of Barnstable .: Regulatory Services E M E& �Thomas F.Geiler,Director - 9� 16g9• �tm qr '°rfn► Building Division Tom Perry,Building Commissioner 200 Main Street;Hymmis,'MA 02601 wwwaowmbarnstable.maxs Office: 508-862-4038 Fax: 508 7906230; Property Owner Must x Complete and Sign This Section If Using A"Builder I, ; M Owner of the subject properly b here authorize' toWact on"mybehalf, in all matters relative to work authorized bythis'bunging permit application for s R Address of Job): .1. S' e of Owner. Date, Print Name x G * . if Pro etjy Owner is apply'n fors ermit ' lease complete the° r g P e ` P Homeowners License E_genipdi n Form on the reverse side '.Q:FORMS:OwNERPERMM SIGN a tHE _Town of Barnstable Regulatory Services s�xtvsr , : Thomas F.Geiler,Director i639. �•� BniRing Division OFF Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 50r1-862-4038 Fax: 508-700-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village . "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. 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 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 perfom ing 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. 6 Q:forms:homeexempt F�fAo L� - w uY ti a r WF ,---•-¢--ate .. _ - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION,., q0 Map- Parcel.- "':Application # f7� _3 Health:DivisiOn Date Issued n. "".Application ee Conservation Division F 'i Planning Dept' Perrit Fee Date Definitive'Plan Approved 6y Planning Board S-1240 l Historic _.' OKH Preservation Hyannis Project Street Address !:5 D ah 1&(d bnm LJ Village -Y Owner'Jarsit :R,,a7_A Address a -Aaffliand 1, Telephone Permit Request vv� Square feet: 1 st floor: existing 0-proposed d 2nd floor: existing proposed Total new �0 Zoning District Flood Plain Groundwater Overlay Project Valuation A-400 Construction Type MIT" Lot Size Grandfathered: LJ Yes LJ No If yes, attach supporting documentation. Dwelling Type: Single Family TO Two Family U Multi-Family (# units) Age of Existing Structure Historic House: U Yes X.Ur' XNo On Old King's Highway: U Yes LJ No Basement Type: Full LJ Crawl Ll Walkout Ll Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing, 2­ new Half: existing new Number of Bedrooms: existing —new A Total Room Count (not including baths): existing b new 2,, First Floor Roo m_ ,Count 6 Heat Type and Fuel: 11Gas Ll Oil U Electric Ll Other Central Air: Yes U No Fireplaces: Existing LNew Existing wood oal st&& L)Yes XNo Detached garage: L3 existing 0 new size_Pool: U existing LJ new size Barn: ❑ xstng 2] new size Attached garage). (existing LJ new size Shed: U existing Ll new size Other: < co C;> X- Z Zoning Board of Appeals Authorization Q Appeal # Recorded LJ Commercial L3 Yes No If yes, site plan review# all -Current Use =Proposed Use 15�� APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number A Address 1640 License # /1 Home Improvement Contractor# ��7w! OWE- Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN T04 SIGNATURE DATE _(V4 'k 7 FOR OFFICIAL USE ONLY E, J APPLICATION# DATE ISSUED , j MAP/PARCEL NO. ADDRESS VILLAGE f OWNER 'DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE s ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL `FINAL BUILDING i i DATE CLOSED OUT ASSOCIATION PLAN,NO. The Commonwealth of Massachusetts ` Department of Industrial Accidents 92 Office of Investigations 600 Washington Street Boston, MA 02111 .Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name(Business/Organization/Individual): 1 Address: 06- I'A City/State/Z1p:Q1 ')V ��/ Phone.#: � 2" _� Are you an employer? Check t e 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 sheet. 7. 0.Remodeling. ship and have no employees These sub-contractors have g,. ❑"Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. ❑ Building addition required] 5. ❑ `7Je are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp: right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 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 anew affidavit indicating such. XContractors 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. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: A-&- wxml �tJ Policy#or Self-ins. Lic. #:�{)C � Expiration Date: Z2, Job Site Address: L) / City/State/Zip—eakn /t` ,M/-i 62632— 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 tip to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ti der t ep ins and penalties of perjury that the informatzon provided aboveis true and correcC Si ature: Date: Phone Official use only. Do riot 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#: 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." er is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more employer An y P of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states 'Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of,cornplia-nce vzth 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), addresses)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 require to carry workers' compensation insurance. If an LLC or LLP does have members or partners, are not 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 Sile 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 fo 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 Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-490.0 ext 406 or 1-977-MASSAFE Fax# 617-727-7743 Revised 11-22-06 www.mass..gov/dia ',G.:... A U , (MMIDDIYY) Iry Ty 8/26/2008 PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER or INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 908 MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OSTERVILLE, MA 02655 COMPANIES AFFORDING COVERAGE COWMY A SAFETY INSURANCE INSURED COMPANY SCOTT PEACOCK BUILDING&REMODELING B AIG AMERICAN HOME ASSURANCE CO. PO BOX 171 CO.WANY OSTERVILLE, MA 02655 c COMPANY D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTVVITVISTANDING 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 0 Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTR TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER DAYS(MMIDDIM DATE(MMIDOM) LIMITS GENERAL LIABILITY 07,05,09 GENERAL AGGREGATE 2,000,000 A ICPOODOI152 07/05/08 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGO CLAIMS MADE L_JOCCUR PERSONAL&ADV INJURY 15 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE 16 1,000,000 FIRE DAMAGE (Any one(We) 15 MED EXP (Anyone Damon) IS AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT I s ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) HIRED AUTOS I BODILY INJURY i$ NON-OWNED AUTOS (Per accidunt) ....... PROPERTY DAMAGE $ GARAGE LIABIUTY I AUTO ONLY-EA ACCIDENY ANY AUTO OTHER THAN AUTO ONLY! EACH ACCIDENT 6 AGGREGATE S EXCESS LIA131LITY I EACH OCCURRENCE 16 UMBRELLA FORM AGGREGATE 15 i OTHER THAN UMBRELLA FORM we FE) WORKER'S COMPENSATION AND ER,�* EMPLOYERS'LIABILITY IWC 696-76-62 06r2VO8 0602JO EL EACH ACCIDENT THE PNERV R0 ROMETO ?ARTEXEC-I)TIVE iNCL EL DISEASE-POLICY LIMIT S 500,000 OFFICERDME: id EKCL* EL OISEASF-EA EMPLOYEE 1 100.000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSfVEHICLESISPECIAL ITEMS COVER PROPERTIES AT:MARCEL R.POYANT 269,274,282 BARNSTABLE RD.HYANNIS,MA 02501- 1620-72 FALMOUTH RD.CENTERVILLE,MA 02w2; PLAZ TWENTY-EIGHT NOMINEE TRUST, 181-195 FALMOUTH RD.HYANNIS,MA 02601;CENTERVILLE SHOPPING CENTER I NOMINEE TRUST, 1676-1698 FALMOUTH RD.CENTIERVILLE, MA 02632:20-30 OPECHEE RD.CENTF-RVILLE,MA 02832 SHOULD ANYOF T"F!ABOVE DESCRIBED POLICIES OF CANCELLED BEFORE THE ATTIC: SALLY EXPIRATION DATA THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 — DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE To MAIL SUCH NOTICE SHALLIMPOSE NO OBLIGATION OR LIABILITY TOWN OF BARNSTABLE OF ANY KIND UPON THE C-QmPAwv ITS AGFNTS OR RWRESFNTATWA. FAX#-%508-790-6230 AUTHIQPO�p REPRESENTATIVfl j:; '66A Amd AM i'S rlil�,r,,.�.!",...*,,,,,,-!,,",,,,!,,*,, 1. a. License: CONSTRUCTION SUPERVISOR s*'` Number: CS 094500 p w Birthdate: 07/22/1962 Expires: 07/22/2010 Tr. no: 94500 Restricted:`00 JAMES S PEACOCK PO. X 171 4 OSTEVILLE, MA 02632. /J— Commissioner / n IKE t� Town of Barnstable BARNS"LY, MAS& Regulatory Services 1639 ♦4'� prfo MP1" 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 (J' PeoJoL to act on my behalf, in all matters relative to work authorized by this building permit application.for: (Address.of Job) nature of Owner Date Print Name Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 Town of Barnstable - FTHE TQk - o� Regulatory Services sMtxsrnar E Thomas F.Geiler,Director 9q, "�: ,� Building Division ArFD MA't A Tom Perry,Building.Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038_ 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 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:\W PFILES\FO RM S\homeexempt.DOC Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrati n 151853 Exgirpati9n 7f7,12010 Tr# 271501 4 t Type PnV,ate Corporation SCOTT PEACOCK BUILDING&REMODELING INC JAMES PEACOCK ' <i 1046 MAIN STREET-SITE'7 ?` w OSTERVILLE,MA 02655" Administrator"' pp s 14 i2p 1A O 1 I � r, Fl . 95_ _a 2 N N na ?4 - xl ed"`''�'��;;fy, .n:r w F 3 30 31 _ 3 39i �o" 3a �i " t' 64 s 4Z _ • 27 Vc jw 56 12.ky.• ._- 'f;� 11 .. 1f c. dry t 1 '' 2 g IPA.•- � -� �`'_�I � ,• m k x�k /r4 a y n ` �. i,%t'�MY1FN l� r,b. F T+r� Y•I; '1''� ~,}�7+f. N 336 1! �•�. li,Yt -70 10 p 5 { 4611it U r ZT 5 3 o,,` 1 P i i 24. IR.T' iik—?1'±.'citcs�sl � ... r-. � ; e,.Y T,.. �.e•-••••+• ...�...,.•... __. _ J. 36 I 27 27 "5 ._ _. s,..A. a..,.a,�„�„m, .w....�, _... ..,d ..,...h.�ta' riatt+. -- ._ �,r �r , %f'�+�'� _ i'�•r :kir7.. 5CALF : i�s0 i t 5