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HomeMy WebLinkAbout0078 KATHERINE ROAD 1. - 4y S� 741, 'oe TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- pp Parcel Application Health Division Date Issued Conservation Division Application Fee cC�� Planning Dept. Permit Fee iJJ� 6 6 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/.Hyannis Project Street Address 7f eX�/)l e Vgl Village 1. e,,eb,;,ham Owner a '6�� Address ��y� -.0 Telephone 7 Permit Request f.,��",a✓,�//� �i2 kf7 e-,Of s Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type ems/ Lot.Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family- a' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes .2'No On Old King's Highway: ❑Yes LI-No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ 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 Address J dc- ,�2;� r��� License# %!�Z_) � UI-ez Home Improvement Contractor# , s'�-S Email 411,wl Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE f FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston, MA 02114-2017 www.mass,gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING ALITHORITY. ApplicaUlMirmation Please Print Lezlblv Name (Business/OrganizatiorAndividual): Cape Cod Insulation Address; 18 Reardon Circle City/State/Zip: South Yarmouth,MA 02664 phone#: 508-775-1214 Are you an employer?Check the appropriate box: . I am a employer with 4s Type of prefect(required); I © p employees(full and/or part-time).* 7. 0 New construction 2.Q lam a sole proprietor or partnership and have no employees working.fbime in $, :Q Remodeling any capacity.(No workers'comp,insurance required,) 3 J71 am a homeowner doing ell work myself.[No workers'comp,insurance requ-Ind,)t 9. ❑Demolition 4.Q 1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole. I I. Electrical repairs or additions proprietors with no employees. 5.M l am a general contractor and I have hired the sub-contractors listed on the attached shoat. 12.0 plumbing repairs or additions These sub-contractors rm have employees and have workers'comp.insucat .13.F1 Roof repairs 6.[]we are a corporation and its officers have exercised their right of exemption per MaL c. 14.M Other W eatherization 152,11(4),and we have no employees.[No workers'comp,insurance required.) 'Any applicant that cheeks box#1 must also fill out the section below showing their workers'compensation policy Information. t Homeowners who submit thIUVIdavit,indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraotors that check this box must attachod an additional sheet showing the name of the sub-contractots and state whether or not those entities have employees. If the sub-eontractors have employees,they must provida their workers'comp,policy number, lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Atlantic Charter ' Policy#or Self-ins.Lic,#: WCE00431902 Expiration Date- 06/30/2018 Job Site Address; /7 ,�( �Pn ity/State/Zip:J � QZ� 7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c, 152, §25A is a criminal violation punishable by 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,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer*under the pains and penalties of perjury that the Information provided above is true and correct, .Hen CBSSid i'�'w.w"'��'«w`"7r�wn..«�w.w..,wew,�..-a.,ua,.u� Si-enature: ry y ....:c ,�«. Date: 7Z)2 Pie#, 508-775-1214 Offletal use only. Do not write in this area,to be completed by city or town officlal City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector.,&Plumbing Inspector 6.Other Contact Person: Phone#: Massachusetts Department of Public Safet � s Bpard of Building Regulations and 9tandar yy d Lloenset Cs•100988 ' Conetruotlon Supervisor, i HENRY E OA8 810Y; 8 SHE0 ROW WEST YARMOUrH A // I1 +t 111 1d . '^ �-�- Hxplratlont ' Oo mlaalonor 111111201T 4 Office of Consumer Affairs and Business Regulation. 10 Park Plaza •,SUlte 5170 Boston, Ma '; .,b, usetts 02116 Home Improveme,;:0,,©,,t raot -•a xr,t:.,w�,;vstnn?,;nr,rh»�; . °r Registration 'w "Oor o ra tlon..; 1pe,0ap TyInuatlo , nc e on 1687dxplratlonl18 Reard�M Clrole UIT 12/14 2 So,.Yarmouth �aca,r �'+ QOM,oan� Updats Address and return oard, �.,,�,....__,._.._._....._., „,.......�..•. Mark reason Ior ohanga. �e�a7fr�coot+uorr�i`/oyo�l`ctaJrro/cwv6tJ ,. ...1�,11,sau71„n!_(v�1.F.•tt:pl4�/r7sttt_�l_1.�,4#.0��.. ollloe of Oonsumermairs&Buslnese Regulation HOME IMPROVEMENT OONTRAOTOR Rgistration vaild for indlvlduai use only r' 1' ' e Oorporatlon before the ex Iratlon date, l�S,rii'st; P xal_ ration - OHIO'of Oonsumsr Afialra andun al as pa9ulatlon r'',: s'y t •I,� r +87 12/14/201`8 10 Park Plaza, a 6170 •• C'ape Cod Inawlht' � 't ' 1-'1 Boston M 11 Henry Oassldy' 16 Reardon Iro' so.Yarmouth,3� ''{"�4} Underseoretary - t rat hout sl atu B cAPEcod.27 � CERTIFICATE OF LIA BILITY ILITY INSURANCE DATa(MINDD/YYY 03/30/2017 THIS CERTIFICATE IS ISSUED AS T MATTER OF INFORMATION ONLY AND CONFERS NO RIQHTS UPON THE CERTIFICATE HOLDER,TH CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAQE AFFORDED BY THE POLICI BELOW, THIS CERTIFICATE OF INSURANCA DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING S REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, INSURER( ),AUTHORIZE IMPORTANTt If the oeHltloate holder Is an ADDITIONAL INSURED,the polioy(ies)must have ADDITIONAL INSURED provlelone or be endorat If SUBROGATION IS WAIVED, subject to the terms and Conditions of the po loy,certain policies may re this certlfioate does not confer rights to the certlfloate holder In Ileu of such endorsement a quire an endorsement, A statement, PROOVOER AOT � ' Wore&3Oray Insuranoe Agency,Ino, 9OUth Dennle,MA 02060 ' $ e ma ro ery re room N t 877 816.215E Ji iiiii e NAic INOVAINauRec ° IS sir n u u n o a 24198 Cape Cod ineulatlon Ino, Oc 39454 p Endurance American 8 solalt Insurance Oom an 4 718 18 Reardon Clrole South Yarmouth, MA 02884 lNQvAvADAtIqmtIcInsutanoe Company, 144126 OOVERAGES INSURER P t ' IF THIS 18 TO OERT I THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISBVED TO THE INSURED NAMED ABOVE FOR THE POLICY PERT( INDICATED, N MAY BE IsSVE Nv ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE8PEOT TO WHICH'I'F 9XOLv ICATE MAY BE ITIONO OR MAY PERTAIN, THE INSURANoE AFFORDED BY THE POLIOIEs DEscRIBEO HEREIN IS SUBJECT TO T THE TERM EXCLUSIONS AND CONDITIONS OF SUCH a: THE LIMITS SH WN MAY HAVE BEEN REDVOED BY PAID CLAIMS, e TYPe 0'INAVRAN06 POLIOYNVMBER PO . X OOMMEAOIAL OBNEAAL LIABILrrY P- UMITa ODUMS-MA08 1 X 1 OOOVR 1,OOC R/0 CBP8283083 04/01/2017 04/01/2010 o Teo 10C • en h 5 LA00R LIMIT APPt aPtif, PERSO A&AOV INNRY1,000 X POLICY OTHE3 2,000 ' P 2,000 AUTOMOBILE,LIABILITY ANYAVTO " " CO B C T 9NIONLY X AST08ULEC 8232707 COM Ot 04/01/2017 04/01/2018 IL N en X Me ONLY- X A A ffi en 1,000 �tpP=8I ?WAQU6J-'2' X VMBRRLLA L'IAB X OCCUR EXOE88 LIAR CLAIM$-MADe R/O EXC10008838001 2,000 04/01/2017 :014V:/011240J$ s D80 RETENTIONS �"r�NA01 NMI A71�gf 4 � 2,000eOVTI Ve WOE00431902 n � ��'e��td�� N/A 08/30/2018 06/30/2 d�torlbeVn a 1, Ilya 000 EE T 198 a ,000, 1,P=I$ 1,000, �18kA0r or Go OF OPeeAon no O Be N�oory orV (pRelo 101,Addlllonal R�merkt 8ohadvir,MIY b1 elleohid II more 1pgo ��gvlredl I a Oompeneatlon 61o,08AT;ntoera or PrOpr store, . Wdltlonol Insured III la provided under the General Liabllity and Auto LlBbillty when required by written Contrac or agreement wilh the' t Certllloate Hold For informallonal purposes BRONCO ANY OF THE ABOVE OESOAIBED POLICIES BE CANCELLED BE:FOR E p THE BXPIRA11ON DATE THEREOF, NOTICE WILL AN DELIVEREDDBEF 1 ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED AEPRBsBNTATIVB ACORD 28(2018/03) , The ennft.. i Town.-of Barnstable 4 `Rf&atQry Services 8wIFLesrwa� Richard,V° SeaU Director. Build J*Division, Tom Perry,BuildirLg Commisiioiaer NON NONE=ssrefet`Hy a' :nz6Q1 _wit Aowd:baenstab emams': UTfc:e: S0$-862-4Qa8 Fax: :5:08='�90=623Q rC1 ?C der USX.: If Using A Buildc MARK SOARES T; � ,"a.�(:3vaaie�U proP :y 1e �Qaize Cape Cod Insulation ro eta of rnlehalf;; in.a�I�aLT�rs-��,ats�'e:to�'ra�`kaur��ized b�'tliic.�ba�Iciin��er� .a�glic.a�on for: 78 KATHERINE ROAD CENTERVILLE P6ol fences,and.Lu= are the ge5pormIltvpf'. Lee,app caia . Pools are-,aot"to bef Eled cruvEed bef ore 'fric .i < stial :azat ah:fl' �x.spect oxzs a�_-:Ferfr�rrried and.aecegt� _ SAL S 9nature o ' -er. .Sig atuxe of. )pkai C t k�ame: P ii t,I�Taxi e J Date Q:FORMS.OWNTFRE'FR1AM;.QNP(X-)L5 09/1242017 20:39 5087785731 CAPE COD INSULATION PAGE 02 _ CAPECOD-27 AC R DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE ---L0613012017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLFY AND CC XTEND OR ALTER NO RIGHTS UPON THE THE OVERAGE CERTIFICATEHALDER CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT- It the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED pravisionu ar be undols6d._ If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endo this certificate does not corner N hta to the certificate holder In lieu of such ��endorsamont s. PRODUCER AMI::.OT _AY ranee Agency,Inc. F�CG Nd EIK Gra insurance Yr Ro ets St y 9 .J g a .com 434 Rt9 134 .mail ro ®rs r . South Dennis,MA 02660 INSUREgI§i APFORDJ�If�ERAOE_' NSURET+n:PeerieAf Insurance Company .. . #24198- 9454INSUREDINSgRERaad� Insurance Com-paML•_ Cape Cod Insulation,Ina rNSuW c;Endurance American Specialty Insurance Com • 718 - 18 Reardon Ciro la INsuRERo:Atlantic Charter Insurance Company. _ 44326 South Yarmouth,MA 02664 mtsuRER E " INSURER F COVE SAGE RTIEICATE NU _ REVISI N NUMB THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 7p THE INSURED NAMED ABOVE FOR THE POLICY PERIOD STANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT - EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, . INSR ADDLSUBR pOL1CYNUMBER ICYEFF PDUCYEICP LIMITS LTR TYPE OF INSURANCE 1,000,000 A X COMMERCIAL GENERAL LIABILITY rAl: C•CURRENCE� E TO RENT>=D 100,000 CLAIMS-MADE L^I OCCUR CBP8263063 04101/2017 04101/2018 .ocaaRea sF�NnLe•ADy�IJ RILv s 1,000,00 ENERALA.S�REGATE - .S01 2 000,000 0 LAGGREGA LIRMOITAPPLIESL�. _= Z;1)OO.000 X POLICY "E001 UU P�?DLICTS-:CO. P/ P nGG 'S: OTHER: COMBINED SINOGE LIMIT a f,000,000 AUTOMOBILE I.IABIUTY lEa®CddBfltL_i - ANY AUTO 6232707 COM 02 04101/2017 000112018 8%11LY INJURY(F--PM2n $ OM SCHEDULED BODILY INJURY(Per accldern) s— ALrrQ6 ONLY X AUTN08y� VOPErVY gAMACE X AUTOS ONLY X AUTO ONLY _Perecd enq S s y Fs� C+ 'UMBRELLA LIA X OC'UMBRELLAa s -7 =2.000,000 EACMOCCUtiRFNCE lr--Xr- D10006635MV I0410112017 041011201E b 3s X EXCESS LrAB CLAIMC IADEAGGB TE DED RETENTION$ p S woRKERs COMPENSATION X SE]liTlLL — I QTH AND EMPLO s'LU161UTr YIN IR10 WGE00431902 06/3012017 0613012018 1,000,000 ANY PRO�PMREIETgO�RRARTNER/ExECU NIA TNE rr I E.L.EACH ACC,ID. T _........ .. Ieatory�nMNN)EXCLUDED? LJ EL.DIgF$gP- em UT.C ..If as q;IW& 6 UUXlnder I EASE-POLICY�IM T S 1,000,000 IPTION OF O ATIONS below DESCRIPTION O'P OPERATIONS 1 LOCATIONS I VOIICLES IACORD 101.Addlpolnl Ramarks 6ehedule,may M attaehad If mom spaea Is mqulredl -----— 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, CER-1711FICAMOLDER CANCIE, ION SHOULD ANV of THE ABOVE DESCRIFIFO POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED. IN Thielach Engineering Inc. ACCORDANCE WITH THE POLICY PROVISIONS, 196 Franoes Avenue Cranston,RI 02910 AUT110RIZED REPRE6ENTATNE ACORD 25(2016103) ®1988-2019 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATIONt--�>_ 4- Map Parcel Permit# Health Division , HR4 �5/4/0) Date Issued —3a /�� Conservation Division S } f ' Fee. S 7 Tax Collector - ����i/�/� �.` MA R-2 9 Zo Treasurer .,..,., Pl'IC SYSTEM MUST BE IN' TAL ED IN COMPLIANCE Planningt. _� '�'. ��� Dept. � P WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address 7 e2 /1-1�140AA6 =10� 6Idv.0 Village�� �T`���//�� �f Owner Address 7?- GA9�y G,Vy Telephone Permit Request XIO�ZW L1_ 6 /,Z4�5 lit/JLU®dGI,X /A) /S, l Square feet: 1st floor: existing proposed 2nd floor:existing 0 proposed Total new Estimated Project Co oning District Flood Plain Groundwater Overlay Construction Type GL0CJ Lot Size Grandfathered: ❑Yes U.No If yes, attach supporting documentation. s Dwelling Type: Single Family 04 Two Family ❑ Multi-Family(#units) Age of Existing Structured Historic House: ❑Yes 0 No On Old King's Highway: ❑Yes %No Basement Type: ❑Kull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing Z new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas Q Oil ❑ Electric ❑Other Central Air: ❑Yes Ji'&No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:Cl existing ❑new size Pool:❑existing ❑new size'' Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size 0 Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name_/G 0�,�/'GG]— GLd�J��— Telephone Number���`� Address License# Q 32 (S�c zli Home Improvement Contractor# /� Worker's Compensation#kG CAD ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 42 SIGNATURE DATE -� �� FOR OFFICIAL USE ONLY / gyp r• , PERMIT NO. - DATE ISSUED ` MAP/PARCEL NO. -` s I ADDRESS ���333AAAe VILLAGE OWNER. „. • ' DATE OF INSPECTIOI 'FOUNDATION FRAME �� INSULATION ��U l�J" ✓ I I2CJ� .FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH, # : FINAL r FINAL BUILDING .; - DATE CLOSED OUT "" •= .• ASSOCIATION PLAN NO., r III Y• ..y'--. t r t , t .:I°:• � r .:,r.r pit)y,. -t r\ i�t t'.� �; t. �.1 ,t�'r�Y�� i.. - � _ ,.t �t i � 1 tl - .1 its-t V. C li -.f t �i / i! � aft s -�•,�'`\ y r ..p, w �. S s �� i.T : 't ► � 1 a. V r { �,ja:fad ' is �.5., yl H: ;- s\- •C>s � `V. t t '�F e f �1�f t ':x� �i ti i iT .' V (f� �P 1 -t'it f ` i9 ♦CF !� Y y-.j '� ..1•y �,,-.l V � •i' - 1. � t. F.,. !- Q t t ) }t` is' C 11y�4 t • ;�s,sADMINIS�iAlO •. � 4' �r �' - 1 f i y 1 - f � � j t,� v f -f t ♦ f CF. a. I y The Commonwealth of Massachusetts •+si� --- _= Department of Industrial Accidents O111Ce 0/10YOS11ya11011S 't�- �)#; y',�` 6i'IPII�QSh/nt','tonStreet a- Boston, Mass. 0 111 Workers' Compensation Insurance Affidavit w _�nlican reformation• _ _^_ _ : _ Please PR1NT legtb Y._:,� name.• ✓'� location- �V©�i 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I 7 :.?�E!-•rtSF1�4Mr-n•R+VRS..•- + . .►>r•T .NS�C"-* -.r. -�,,.,.,,•. ' 1 am an employer providing workers' compensation for my employees working on this job. om rev name � `> �.ag � 'D die v �� 6 addr • tnhone insurnnee co. � � �� policy# .�,�C • ^- 0 I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: r company n•tmc• F•� �/" 1�� address: - sty - nhonc#• insur•Jnce co Policy# _.. ,.. ,.. - ._. om.•t:::.+...',y,e.,-e-r, y >:•: --1'•:;t"'t^t.� ^r•-c-•�ART?^�v ?�,t'7�tr�.►7!n!TSv'?a}'� 1L "...,'.'eR�9 �! errs _..-.._+_-..:_=..ter:. ..�•___. - ••,tea•. ,._:,..-...:;. _• .••: . 1.aw+ �!^'t`_.•. = -= ...... - cnmpam•name• iddress- city phone#• insurance co Rolicy# _ .Attach addititinsl shcct if necessary s....� i,_Y^t_�r'`f�# •_ __zi'r.. ::,•:'l£•:� o.y; �� _.. • Pnilurc to secure coverage as required under Section 25A of i11GL 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 andlur one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the Olrcc of Investigations of the DIA for coverage verification. I do herebt•certifi it a Wins to rj •t to to 'formation provided above is true and correct. S)_nature Date Print name g jam+ , � Phone# A.. Echcck niv do not write in this area to be completed by city or town official + permitAicense# riBuilding Department Licensing Board mediate response is required �Sdectmen's Office �licalth Department n phone#• rlOther (revised 3195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted tom the "law'". an emphti,ee is defined as every person in the service of another wider any contract of hire, express or implied, oral or written. An rmph rcr 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 arounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter I been presented to the contracting authority. r �_. .. .....---..•r,..r....—. •....•.,..•,++�'.""—+��r!sTr""�-.+r {. `wil 4.,'y.i:..•:4 �' IJlil.t��..: . 7!.f77 ... 77 Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to 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. 7-7 17 City or Toivns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of re the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding b the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 OF THEY . .� The Town of Barnstable WANSMBM Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to°any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by remstered contractors, with certain exceptions,along with other requirements. jjJJ n Type of Work: 0� Est.Cost Address of Work: Owner's Name Date of Permit Application: ® � « „� °•� I hereby certify that: Registration is not required for the following eason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the age f the owner: Date Contractor Name Registrati n No. OR Date Owner's Name THE The Town of Barnstable MUMSTAISM MASS& $ Department of Health Safety ety and Environmental Services i659. p�0 Building Division eo r�'t 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: wdllvp��4�L Estimated Cost O-� Address of Work: Owner's Name: / �d 00"1 Date of Application: c y -D—7 I hereby certify that: + Registration is not required for the,following reason(s): ❑Work excluded by law. ❑Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE TION PROGRAM O GUARANTY FUND UNDER MGLE ACCESS TO THE ARBITRATION c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2 . 0 Checked by/Date CITY: Hyannis STATE: Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 3-29-2001 DATE OF PLANS : 3/27/01 TITLE: enclose orch PROJECT INFORI ION: MARK AND SANDYSOARES COMPLIANCE: PASSES Required UA = 81 Your Home = 80 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 288 38 . 0 0 . 0 9 WALLS : Wood..... xame, 16" O.C. 392 11 . 0 3 . 0 30 GLAZING: f'" ows or Doors 48 0 .360 17 DOORS 30 0 .350 10 FLOORS : OvOr Uileonditioned Space 288 19 . 0 14 ---------------------------------------------------------------------=---------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted c� th the permit application. The proposed building has been designed to meet the regUikements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code . The HVAC equipment selected to heat or cool the building shall be no greater than 1250 of thie0lesign load as specified in sections 780CMR 1310 and .4 . Builder/Designer Date � ��� The Commonwealth of Massachusetts • '�; = - Department of Industrial Accidents Office O111dYBs119811OOs 600 Washington Street _ Boston,Mass. ,02111 Workers Com ensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole praphictor and have no one workils CaPicitv %%//%/%/%'�l/////O%%/%%/%%%%%%%%%/%%%%%%%////%%%%//%%%%%%�%%%%%%�%%%%//G/�///%/�%%�//% I am an employer providing workers' compensation for my employees working.on this job.: :;:>. sm company name ��t .� -: «:: :::;'::<: ::: . address.. led instirance co. ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: :... ..... .. ..:. .. ;:::: :.::. .......:.:. address _:. :::::.. . r:%': ::'G: : : ::�;ir: :�:::� : i:::•::»>:.::>:.>:<.:>:�>:::i:::ir:::::::;�::j:::''.' :.:�. ......:: one.#: _- rlty� :. ca any'name::'::;,:.;;>:::::<>::>;>::;::»:•.:.:;::;::;:.; :.;:::;.:><:;.;;:. _ address: :.;:.:...;:.:::.:.::::.:::..:.:::::.::........ .............. `::done#: :::::. lip* in�iirance 0 Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby certify under the . ' and penalties at the information provided above is true and correct Date al? Signal Pun r�-7 t name �o d/ Phone# / t�—' l 1 official use only do not write in this area to be completed by city or town official city or town - -- permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; Other 0eyned 9/95 PJA) AZI. Information and Instructions . Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do mail tenauce, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the perauttlicense number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would lice to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. FBI The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents 8MC6 o1 Invesduadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 EST/MA TED PROJECT COST WORKSHEET LIVING SPACE Value (high end construction) square feet X$115/sq. foot= (above average construction) square feet X$96/sq. foot= (average construction) square feet X$57/sq. foot GARAGE (UNFINISHED) square feet X.$25/sq. foot PORCH square feet X$20/sq. foot= DECK square feet X$15/sq. foot= OTHER square feet X$??/sq. foot= Total Estimated Project Value K. MF cOivsvivnvFOAoro aches ,State: whdin ,Coe 0 en BetioDL J The Massachusetts State Building Code(780 CAM) includes provisions to ensure that houses and house additions meet energy efficiency standards. This supplemental CONSUMER INFORMATION FORM is to be filed as part of the building permit application when a builder/contractor or homeowner, constructinglinstalling a house addition with very large percentage of glass to opaque wall,seeks to utilize a special energy conservation exemption option for "sunroom" additions jo,an existing house (780 CMR, Appendix J, Section J1.1.23.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom"of any size, configuration, orientation,form of construction or percent glazing,but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a"sunroom"addition. The connection of "sunroom" structures to residential buildings may create comfort and energy consumption issues due to uncontrolled solar gain or uncontrolled radiation cooling of the main house. In the selection and construction/installation of"sunrooms", included below is a non-required, open-ended list of product and design considerations that a homeowner may wish to consider before actually constructinglinstalling a"sunroom". It is recommended that consumers carefully review these options with their designer, builder, or contractor, in order to minimize potential energy consumption and/or house discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired are important considerations. ~PRODUCT AND DESIGN CONSIDERATIONS RELATED TO"SUNROOMS" • Solar Orientation and Natural Shading • Type of Glazing . • Insulating value • Solar heat gain • Frame materials - • —Glazing to frame sealing and gasketing materials/seal durability and/or weather tightness of the sunroom �" x• Adequate ventilation-Operable windows and fans • Applied Shading Systems • Insulation level in floors,walls,and ceilings -�--- • -Possible Sunroom isolation from the main house via a wall and/or door or slider Heating and Cooling Methods: Efficiency,Zoning and Controls Homeowner Acknowledgment The Massachusetts State Building Code, Section J1.1.23.1, requires that the actual property owner(not the owner's agent or representative)acknowledge receipt of this CONSUMER INFORMATION FORM prior to issuance of a Building Permit for a project that includes "sunroom" additions to an existing residential building. In accordance with this requirement, the undersigned hereby acknowledges that she/he has read the information in this document concp 'ng sunroom comfort and energy conservation. g Owner of Actual Building . Print Name Address of Permitted Project Owner Address(if different than project location) Owner's telephone number J �lae viomvncorcuieac ��✓ aaarizuaelt Board of Building Regulations and Standards V` HOME IMPROVEMENT CONTRACTOR Registration:_111157 Expiratiow."12/09/2002 Type: DBA R.GLOVER BUILDING CO. ROBERT GLOVER PO BOX 703113 CURTIS BOG RD � ,�fu✓ MARSTONS MILLS,MA 02648 Administrator ✓fie �omxma�uuea o�✓�aaaac�euael�a BOARD OF BUILDING,REGULATIONS License: CONSTRUCTION SUPERVISOR • Number. CS 039868 Birthdafe: 05/24/1954 l Expires:05/24/2002 Tr.no: 23091 Restricted To: 00 ROBERTJ GLOVER _ PO BOX 703 MARSTONS MILLS, MA 02648 Administrator•' License or slid for individ1, t,¢o registration t+:* before the expiration dite.. if found return .°hly Board of Build►n to, One Ashburton Place Rmt1301• +nd Standards Boston,?►!a.GZ108 l Not valid K'jthoUt • ---- ._..._. , S�(yRatU re 00.35000 d enclosed space y (MGL C.112 S.80L) 1A-Masonry onNHomes 1 G-1&2 'amity a cx►rrent Will of the t Failure to P uuilding Code Massachusetts� of this license• i is cause for rev on .i 7233 • 8a813aa DIG SAFE.CALL - TER. CEN oc 1 PIZ rl mfzj Rom% t� o�v a � ✓NST��L c�o�4S � G� ELLS t wr��uc5 �� �� Engineering Dept. (3rd floor) Map , Parcel 44dPermit# 7 a. House# ?�", ,,,/, _Date Issued Feel limit IKE BARNSTABLE. MARSL TOWN OF BARNSTABLE Building Permit Application Projec t Address Village C,t /7Jl1i�G } Owner /`��'✓ j �-�,� `� Address Telephone f Permit Request S 06/1-0 X" ', First Floor �� T square feet Second Floor square feet <_ Construction Type DO Estimated Project Cost $ mz> Zoning District Flood Plain Water Protection Lot Size ® Zs Grandfathered ❑Yes ❑No Dwelling Type: Single Family] Two Family ❑ Multi-Family(#units) Age of Existing Structure 3 Historic House ❑Yes OfNo On Old King's Highway ❑Yes A.No Basement Type: 2fFull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing --`� New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ,5-Oil ❑Electric ❑Other Central Air ❑Yes allo Fireplaces: Existing " New Existing wood/coal stove ❑Yes &No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) �]None ❑Shed(size) ❑Other(size) i Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name ��<� '� tJ � Telephone Number Addresses License# 06-5� �' x f� l�� �J'✓ �r/��4:::� A Home Improvement Contractor# - -� l[� Worker's Compensation# c/0 ybo 7� NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO liC� ✓� SIGNATURE _+{ DATE /C�7 BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) r I FOR OFFICIAL USE ONLY PERNOT lip. DATE ISS&D! MAP/PARCEL NO;" W ADDRESS VILLAGE OWNER DATE OF NINSPECTION: f FOUNDATION FRAME f r INSULATION FIREPLACE • f ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL , FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO.