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0083 LAKE DRIVE
v a` : a i t F r i , i Ilk Ic : do n • .. � i - r .. ., _ .. s ,. � - - ,. ,. -s• _ - .... � - . . i ,. ..' 11 ��. � � � ., �� _ * _ �:: �. F. i ' c, o. . � t r. _ � � � a r, _ � _ c .. I - � - a -� ? ,� Town of Barnstable I ing / prt; Post This Card So That it is'Visible Fromthe Street Approved Plans;Must be Retained on`Job and this Card Must be Kept r MASS f _ p Posted Until Final Inspection Has Been Made. Where a Certificate of.Occtapancy is Required,.such Building shall Not be Occupied until'aFinal Inspection has been made. Permit Permit No. B-17-3990 Applicant Name: Approvals � - Current Use:.. Structure Datelssued: 12 08/2017 Foundation: Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date` 06/08/2018 Residential Map/Lot: 2307084 Zoning District: RD.-1 Sheathing: Location: 83 LAKE DRIVE,CENTERVILLE Contractor:Na.me: Framing: 1 'DON NELL RUTH.ANNE Contractor License: Owner on Record: TAYLOR, BLAIR E&O - 2 Address: 83 LAKE DRIVE Est. Project Cost: $ 25,000.00 Chimney: CENTERVILLE, MA 02632 . . Permit-Fee: $ 177.50 ''Description: Replace Windows and Door finish Bathroom Upstairs Fee Paid: $ 177.50 Insulation: Project Review Req: ENSURE PROPER HEADROOM AS REQUIRED. Date:., 12/8/2017 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the'wo.rk authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall.be in compliance with the local zoning by-laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. _ Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and,Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough.. 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to.the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit.Cards are the property of the APPLICANT-ISSUED RECIPIENT I114E r ti Application Number......`........ .. ................... '* BF►RN MABIX •' Permit Fee.......1..�.�.: ............Other Fee...................... MAS& s639. F� Total Fee Paid ...I.................................... TOWN OF BARNSTABLE ,I e�il i N ®E Permit Approval by.. On.... .... .... BUILDING PERMIT NOV 17 2017 01�30.11f Ma p..............6 ................ ............................ APPLICATION TOWN OF BAPNSTABLE Section 1 — Owners Information and Project Location f Project Address VillagO.Q/Y 6cn-V.�u - Owners Name YVl "� ��Q. -4- Owners Legal Address ` City C/�642�1 lf., State N_ Zip Owners Cell# SC39 `,5C¢V 6;0 CQ J E-mail—14100 f 7 q S- Section 2— Structural Use le Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Section 3-Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall . ❑ Solar �-Renovation ❑ Pool ❑ Insulation Other-Specify Section 4—Detail Cost of Proposed Construction o? Square Footage of Project ' Age of Structure,�p;[6 `�5` Dig Safe Number #Of Bedrooms Existing Total#Of Bedrooms(proposed) O`Z 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Last updated: 11 n/2017 Section 5 - Work Description Section 6—Project Specifics .n Wiring ❑ Oil Tank Storage ❑ Smoke Detectors Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal ❑ Municipal On Site Historic District [] Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes No Section 7—Flood Zone Flood Zone Designation } Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District �� v Proposed Use Lot Area Sq. Ft. , Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/7/2017 tA�N9TA$LE, s MASS. TOWN OF BARNSTABLE PERMIT CHECKLIST ❑ A complete permit application includes filling all sections 1-13 Sign off hours for Health and Conservation are -9 ill a.m. and.3 04:31- p� f NEW STRUCTURES/REMODELING /RENOVATION/ADDITIONS ❑ Site Plan showing setbacks of proposed and existing structures ❑ Commercial — One complete set of full sized plans one reduced 11"xl7" (plans may require a stamp by an architect or engineer). ❑ „ Residential - 4 Sets of floor Tans no larger than l 1 x 1 alerting devices P g 7 g v marked. Show cross section, framing detail. Worker's Comp. Affidavit and policy (if required) ❑ Res Check or COM check from the 2015 International Energy Cod Council (IECC) ❑b tter of financial Interest for new houses only (not required for rebuild after tear d formance bond made out for $4.00/foot of road frontage (new_ constructs only) DEMOLTION OF A BUILDING (NOT PARITIAL)/REBUILD. ❑ Everything above plus shut off letters from following utility companies: ❑ Gas ❑ Electrical ❑ Water ❑ Sewer (if required) Demolition only, the'shut off letters above plus copies of licenses, property owner's letter of permission or homeowner's license exemption. DECKS/PORCHES/GAZEEBOS/INSULATION/SOLAR/POOLS/SHEDS ❑ Site Plan showing proposed location (if exterior work) ❑ Construction plans showing framing detail (if new framing), ❑ Pools —Barrier details, pool specs. ❑ Workman's Comp Affidavit and policy (if required) 'VA yLO � f $3 L 7} Afif� � GNiG�VIL L t+ pp�� o , G o L 6� ,p,C� y0 R � 1 U�S L, okJOLLS 14C71AAL i/mrCA5 IXi2roR u�/�uS ��I %20 iosy C L es a'1' I{vor�l JP4S a LA'T j o a ;� o p T a l�l ro Vhpog. 6A 2 t 52 i P&A5-ric s SMOKE DETECTORS REVIEWED L'! 6 i �AT BUILDING DEPT. DATE rA FIRE DEPARTMENT DATE BOTH SIGNATURES ARE REQUIRED FOR PERMITTING - ' I s � --------------- i . � S s 1u 5, ��j2©cif G�-C>�UT - 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: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): _A.al,7Li Address: `fit' fo Phone#: �O-S 5 (a LE Oa q� City/State/Zip: i 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 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 g. Demolition working for me in any capacity. employees 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 3AI arts 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 employees. [No workers' 13.❑ Other comp. insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c erlik under the pains and penalties of perjury that the information provided bove is true and correct Signature: Date: 1 i 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#: 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 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 compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth.of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington.Street Boston,MA 0211.1 Tel. #617-7274906 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 - www.mass.gov/dia Section 9—Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# " I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip C� Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 —Home Owners License Exemption Home Owners Name: —�C f)Q— Telephone Number 4?a/ 64q t Cell or Work Number ' I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation requZdb780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE 1 Signature y Date ? fs- 1 Print Name p ;r7 270Q Telephone Numbersos Sci 00'lqi� E-mail permit to: Last updated. 11/7/2017 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board (if required) El Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ i Conservation ❑ i For commercial work,please take your plans directly to the fire department for approval Section 13 —Owner's Authorization I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name Last updated: 11/7/2017 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATI6N Map Parcel Application # Health Division CD/N G DEP- Date Issued. ZL/ (' Conservation Division AIN 0 8 20 ' Application fee Planning Dept. rOINIV OpaAf�N Permit.Fee •JV Date Definitive Plan Approved by Planning Board STgB�E -f- 12 1 5 I) 5-kp Historic - OKH _ Preservation/ HyannisU •6 0, Project Street Address E- lt� Village_ e '� L)/L L Owner 264A// L� 27?-14 0Q 2 Address Telephone !7 2�79 =a:0 If Permit Request ��&A C d_ /9Ac t:C Poaf A --�'Cc /e S VIAJdzaSs _1� Square feet: 1 st floor: existing proposed --. 2nd floor: existing= proposed ---r Total new �sAlig'� Zoning District Flood Plain Groundwater Overlay Project Valuati �� d� Construction Type AiQQL Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑Full Xrawl ❑Walkout Other dA�/� L� �fJ2 oG ,6_c—Afi&0L A 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: XGas o.0il ❑ Electric ❑ Other Central Air: Yes ❑ No Fireplaces: Existing_LNew Existing wood/coal stove: ❑YesXNo Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:Xexistina ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *o If yes, site plan review# Current Used L. Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) T Name /� j 07 fL.C�,� Telephone Number 7� 7 4 7 Address 6,5 4A�T c LaIL)r License# CG�� t11 �-L Home Improvement Contractor# Email a I V_ :7769 ncA--f/6 0If CAM Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN To b" SIGNATURE DATE O FOR OFFICIAL USE ONLY y -APPLICATION APPLICATION # ^DATE ISSUED MAP/ PARCEL NO. .ADDRESS VILLAGE t � r - Y OWNER DATE OF INSPECTION: Y FOUNDATION 'r FRAME '5 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ;L v ASSOCIATION PLAN NO. ,1 - a ,t f r szx The Connizorrivealth o;f?6 Massachusetts Departinezrt afl'ndacstria[Ac-cideras - _- O,fire of l'ni:-esiigatiarrs { F 600 Waslaingtort J` eel y Baston„-414 02111 wivinnu.ss gov/din Workers' Campensatian Insurance Affidavit:Bmlden/Contractursi'Electririans/Plumhers Applicant Inf4rmatinu Please Print Le�iblX Nt'iI7Te($��, a�t7anlln�+� F ' Address: 0 City/State(Zip: 0/4 O=a=Pliane Are yo•u an employer?Chee the appropriate bo= Type of project(required)•: I_❑ I am a employer with 4 ❑I am a general.contractor and I 6. ❑New consfruction employees(full andlor part-time).* have hired.the sub-contractors 2.❑ lam a sole proprietor orpartner- listed on the attached sheet. I. ❑Remodeling ship and have no employees. These sub-contractors have g. ❑Demolition working far=in any capacity employees and hate wodcers' q. ❑Building addition . [Na Ev ork-rs'comp-insurance comp_insurance-1 r IN-ed] 5- ❑ We area corporation and its 10-❑Electrical �s or additions 34 I am.a homeoumer doing all work officers have exffraised their 1L❑Flumbingrepairs or additions myself[No workers'comp- right of exemption per MGL 12.❑Roofrepairs inm=cerequired.]i a 1,52,§1(4�andwehavena employees.[No workers' 13_❑Other comp-insurance required.] 'tLay apprLc=t Qbat checks'bos#1 umst also fill out the sectionbelowshowing Theo woikeie ca®peusatian policy infbrma-darL F ameovJners who submit iris affidavit indicating they are doing all weak ani then hire outside contractors nmst submit a new affidavit indicating sstcTL fCantractorsthat rhea This box must attached an,ddifiooat sheet shotvarg the nnueof the sub-contractors sad statewhether or not Those eaddeshave employees I€thesub-contactus have employees,9hey=1stpmv--ide their workeWcomp.palicymnnbm I acre an employer that isprat dbig workers'congmnsat4on inmirancefor my employees Beloav is the policy and jah site inforaradon Insurance.Company Name: -Policy 4t or Self--ins.Lie.9: F-kpiration,Date: Job Site Address: City/Statelmp: Attach a copy of the workers'corapensationpolicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c 1572 can lead to the imposition of criminal penalfi s of a fine up to$1,540:OO andror one-year imprisonment as well as civil peaslties.in the farm of a STOP WORK ORDERand a fine of up to$250-00 a day against the violator. Be adi ised that a copy of this statement maybe forwarded to.the Office of Investigations of the DIA far imsufanct-coverage veri-Ecation- I do hereby cerhfjr miter ty pains and pertabyes of U. tatfile informa&n prm Ned above is hue and correct Sionature t, Date: Phone lr t7,Jjacial use only. Da trot avrite in thb area,to be completed by city artairu o;fficiaL City or Tanu: PernaitUcense# Issuing Authority(circle one): 1.Board of Health 3.Mudding Department 3.C itylTown Clerk 4.Electrical hmpeeter rr.Plumbing Inspector 6.Other Contact Person. phone P: Information and Mstructions ' Massachusetfs Geheral Laws chapter 152 requires all employers*to provide workers'compensation far their employees. porsaant-to this statute,an.mTkyee is defined as.°`_.every person in the service of another under any contract of hire, e)Tre'ss or mzphe cI,oral or wnffra" An anployer is defm-ed as"an individual,parfnership,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,parbam-ship,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 - dweIIing house of another who employs pemons to do maintenanm,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b e deemed to bean 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 is the commonwealth for any apptira ntwho has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,M(rL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter mto any contract for the p erf=aace ofpubhc work until acceptable evidence of compliance wish the in s,„ar,ce. re,ir2f nts of this chapter have been presented in the mntracimg auihoxiVf Applicants , > o sitnation an if Please fill.o� the worker compensation affidavit completely,by checking the boxes that apply to y rs a, necessary,supply sub-cDntra-ctor(s)name(s), address(es)and phone ninnber(s) along with their certificates)of fi cr„-a„ce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cauy workers' compensation insolence. If an LLC or LLP does have employees, a policy is required. $e advised that this affidayamaybe submitt�:d to the Department of Industrial Accidents for confirmation of m nce 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 In.dustrial Accident,-- Should you have any questions regardmg the Iaw or if you.are requ�red to obtain a workers' compensation policy,please call the Dep a taent at the nmuber listed below. self-insured companies should enter their self-insurance license nomber an the appropriate line. City or Town Officials t - Please be sure that the affidavit is complete and primed legibly. The Department has provided as pact at the bottom ofthe affidavit for you to fill otlt in.the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in.the penniVlicmse number which will be used as a reference number. In addiii-on,m applicant that must sabnsit multiple permit/license applications in any givenyear,need only submit one affidavit indicating current policy inforn-ation.(if necessary)and under"lob site A ddress"the applicant should write"all lacatiens i (city or town)-"A copy of the-afff davit that has been officially stamped or marked bythe city or t-ovm may be provided to th" ' applicant as proof that a valid affidavit is on file for fatnre permits or licenses. A new affidavitmust 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 bum leaves eta.)said person is NOT regared 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 IIs a call. The Department's address,telephone and fax number. The C ).MmCaWean-of Massachus-tM Deparimmt of 11idustdal AocZentt f�7t��f�t.�e.�figkfi.ol4� - ��4 �zshi�ptan s' t ' Bostm..,MA Q111 Tf,-1.4 617 -4900 Qx- 406 or 1477-MASSAFF, Fax 617` 27 7749 Revised 4-24-07 w W masFgo-Tld4 'down.of Barnstable Regulatory Services �u�r Richard V.Scafi,Directior � $�Idmg DivisianE - - • F F Tom parry,$umag Commissioner 200 M-da Strom Hyanda,MA 02601 `ren wwm to4en.bams ablema.IIs Office: 508-962-4038 Fa= 508-790-6230 H0IlM0w2M LTCEM ExMaTIONi ' �•y i 'PiersePtint PAIR: O CJ (� SOB LOCATION \ �✓�-7� ` lL j 41 har name �/9 �J/s =p CURRENT---- 1.SALL7rIG ADDRESS�� c�yl�n zip codc The mm-ut exemption for`�omeown ers";was extendeclto include owner-0cjigied dwellings of six twits or less and to allow homeowners to.engage an individual for hire who does notpossess a license;provided that the owner ads as soneryisor_ DON oRHolEowNEB P eson(s)who owns a parcel of Iaad on which helshe resides or intends to reside,do which.there is,or is k tee ded to be,a one or tyro- family(jw,,jlinL atta coed or detached stmctores accessory to sear use and/or farm str ci�*n-s. A person who contracts mar ean th one home in a two-year period shall not be con.iderf 7,a hamcovzaer. gush�omeown ,shall submitto fe Bmldfng Official on a farm acceptable to the BuI3mg Off L6A tb.athrlsba sbzll be respms3Ile for all such work performed unffix a bmIdmE permit (Section r 109.L1) •� . _ f The u o,&-ndgaed`homeowner"a=es respnns3hili y for compliance wifiitbe Staff,Bmldmg Code and offer applicable codes, bylaws,roes and r D9-aL-'L=- The undmsigned`�omeownea"certifies tbathdshe=d=tm&the'Tower ofB=sbbIc BmIEng Deputn=t�inspection proms nms • dre �fs she WET comply -said proceem es and emess. Si of$omcowacr } 'r . Appruy.1 ofBm7CrmgOffcial f Note. Three-family dwcnh2gs cant&iag 35,000 cubic feet or larger wMbe reFiredto comply wish tba Sta$Building Coda Section t-17.0 Ca:straction Contml_ $on�owr��s�Tox The Code sfatrs that: =Any homeowner performing work for which a bux -permit is required shaIl Ise exempt from the provisions of this section(Section 10911-Licensing of consfradion Smer pvisors);providers that i f the.homeowner engages a person:&)for hire to do such work,that sack Hameown&shall act as supervisor." Many homeowners who use this exemption are aware that they are assum*_T�g respoasrbrTiii'es of a supervisor (see Apgendbc Q,Rules&R egnlations for Licensing Consfracaon Siperrisors,Seofinn=5) This Lack of awareness often. results in serious problems,parficularly when the homeowner hires,mrkmsed persons. In toss case,oiar Board cannot proceed agafiLst the unTcensed person as it would with a licens Supervisor_ ed The homeowner acting as Supervisor is ujf telp resgoasr To eastn:a mat ffie homeowner is fal[y aware of hislher responsihniii�,many coamenities require,as part of e n,that the homeowner certify flathelshe m3wIMTtands the responsffim'es of a'Supervisor.'Oa the Lastgage Pit applicatio Of this issue is a form rn rrenlay used by. era sevl towns. you may care t amend and adopt sach a form/crrfificafiDn for use in your comramftp p=C3kfii )EXFRMS_doc R.cvised 06U 13 ofTy Town of Barnstable Regdatory Services E s�srw,c•.Rr�, f M1 W4 �, Richard V.S=H,Director- �� `` Building Division tam rerry,BmZding Commissioner 200 Maim Strcet Hyannis,MA 02601 www towbarnsEable_ma_us Office: 508-862-4038 Fa= 508-790-6230 ropeity Owner Must Co m etc and Sign'I`b'S Section Usin ABugder 4 ,as r of the Subject property- hereby antlaorize to art on.mybdaal , in all matters relative to work zT rborj e by b e=ak application for- (Address of Job '`Pool fences and alarms are the respo Jilnyof the applicant:Pools are not to be fJMed or u 716d befog f ce is installed and all final ' inspections.are pefo=d and Sig=,*•P of Owner Sig=1 of Applicant Print Name Pant Name , N Data . ��� � '.� - J _ _ � �� 'ice \ �� 230-08f \ �� #82 F! �i Sz 30 i �a # 99 I Is All ZZ 3 C / 3 %. 11 :,� /s a A OIL \ 9 t ' s d r f t �' � K� < � a r � 04 i /,.,, �, .�• rx , ` .. s Town of Barnstable Geographic Information System May 2,2013 230095 #18 ! 230082 #90 230081 #82 230078 230080 #74 230079 •.::::.:::.:......... •230094001 t .•..., #1 LAKE DR r#83 230092 371 y 230086 230050 s - It 73 #55 4 y 230086 230093 230049 #387 #33 0 30 e et v, - 230091 +#365 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:230 Parcel:084 Conservation Request for Determination(RDA) . boundary determination or regulatory interpretation. Enlargements beyond a scale.of - Selected Parcel 1"=100'may not meet established map accuracy standards. The parcel lines on ths map Abutter List Type-Property owners actually touchingOn the SUbjeCt:parCel upon .. which work is proposed. Abutters' �E - are only graphic representations of Assessor's tax parcels. They are not'true property P P boundaries and do not represent accurate relationships to physical features on the map such as building locations. -• Buffer /�' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A�C(; I DATA A w TOWN OF BARN $TAr'T,y� 'f Map. 3 co g Parcel Health Division Consery APPLICATION# DATE ISSUED MAP/PARCEL N0:- ADDRESS OWNER DATE OF FO Fz X, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Yparcel Application `t 0 Health Division Date Issued Conservation Division Application Fee J� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH `--� _ Preservation/ Hyannis Project Street Address �9 <t:`7 >Z) Village ` - /21� 2t� Owner `Jl Address Telephone 76 (_—Permit Request 1,5-, (fl>Af ikY2-647 _t�� Square feet: 1 st floor: existing 74proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay o-® ..Project Valuation 006 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes No On Old King-s Highway,m ]Y No _ A . Basement Type: ❑ Full awl Walkout ❑ Other a.. CIO . r Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) i Number of Baths: Full: existing new Half: existing n�w .e . g g Number of Bedrooms: existing =new Total Room Count (not including baths): existing J new First Floor Room Count Heat Type and Fuel: Ys�as ❑ Oil ❑ Electric ❑ Other Central Air: des ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garageXexisting ❑ 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 �/f��1��7 ' l��� Proposed Use �� APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name /J� /� } /L Telephone Number Address .- Y✓��`� ����� License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 710C< S r6 3,40f L _ 7 - 31 SIGNATURE DATE /` FOR OFFICIAL USE ONLY APPLICATION# . DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: - FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING- ' - DATE CLOSED OUT ASSOCIATION PLAN NO. i� ze Commonwealth of Massachusetts Departzrrent ref Iau6zsb of Aceidents of-Imegagafforrs_....__ 600 Washingfon Street Boston,MA 02-HI wnmmass:govIdia Workers' CampensatianInsurance Affidavit.BuildersfContra:ctors/BlectricianMumbers Applicant Infarmation Please Print Legibly Name{flosmess/6rganizationl� : &�74/� Address: ��— e Citytstatrizip: 1,(W�- o.�� �Phans `9 ` .� /C'3 Are you an employer?Check the appropriate box: Type of 4. I atn a conttracor anti I �'o'�ect(required): 1_El I am a employer with 6- ❑New construcdion he m -contractm employees{full and/or part-time).* tee h' tb 7_El am a sole proprietor or partner- listed on the attached sheet deg i ship and have no employees These sub-contractors have g. ❑Demolition , w far me in an capacity. employees and.have workers' orisang y I 9_ ❑Building addition [No'workers'comp_insurance comp-instraam- required-] 5- We area corporation and its 10-0 Electrical repairs ar additions 3_ I am a homeowner doing all work of d=have exercised their I LE]Plumbing repairs or additions myself[No workers'comp. right ofexempticaper MGL 12-[]Roof repairs ins�e required-]t e.152,§1(4),and-we have no employees_[No workers' 13_❑outer comp.insurance required-] *Aay slapti�at that checks boa*1 mast also fill out the section below shooing iheir wosikers7 compensation parks' n fi mw icir �Hnmeowneis who submit this affidavit indicating d3ey ace doing an vat and then hug outside contracmrs mast submit a new ai�davit indirm snrR lCoatcacm[s that check this beat must attached au additional sheet shag the ns�e of the snit 000>r3cmrs and state whether ocnot those entities have zmployees- Ifthe sub-contractors;have employees,they must provide teir-warkess'comp.policy number. lam an employer t1'tat is proiiding tt�orke-rs'congmrmrtion insurance for nt}employees: Below is theguilt}and job sits infot t'nathm Insur ce Company Name: Polity ff or Self-ins-Uc-9: Expiration Date: Job Site Address: Y z � � f Citylstatelzip: Attach a spy of the workers'compensation policy declaration page(shoeing 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"cri mi r al penalties of a fine up to$1,500.00 and/or one-year itrsprisonment,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 Itrtestigations of the DIA for insurance coverage veriticatitn- I do hereby c,erhfy cinder the pains andpenal ies nfpedury that the information pratzded abm�e is true and correct Signature: Date: C Phone#: (l�cial use anl,}. Da not write in fhis area,fa be completed by tat} or town official City or Town:: P'ermitUcense# 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#_ 6 1 e i 1 Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iegal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein;or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." - - MGL chapter 152, §25C(6)also states that"every state or Iocal 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 auy applicant who has not produced acceptable evidence of compliance with the insurance,coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone numbers)along with their cent ificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or parmers, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required- Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'I1ze 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. Sell 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 affida.vit 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 COmmQnWealth of Massachusetts Department of Industdal Accidents offim of kvesf gatio-As 600 Washinatan Street Boston,Imo.02111 Ttl.#617-727-4900 ext 406 or 1-M-MASWE Revised 4-24-07 Fax#617-727-7749 www ma.ss_gov/dia FVC{ Cfudd to FYaad Cuasf ucdigrr irk Hgfr Krtd Areas: 110 arptr fffnd Zayre Massachusett` Check A for CoMPHAnce(90 c;VIRs3or.7-r_r)! Laadbearing Wall Connecfons - Latsral(no.of 16d Common nails)_:__.._._..._:_----_--(fables 7)----------__.._-------:-------...... -.- Non-Lnadbeadng Waf(ConnecSons . lafera!(no.of 16d common -__.-- Lead-Bearing_WaQ=Dpenfngs_(record_largest-openhg.but_check..a[r_apenings HeaderSpans Sill Plate Spans ' - --- - - .__................(Table 9)-- ft—in._<IV Full Height Studs (no.of sfirds)__________-_----•- ---•(Table 9)---------------------.---- _---- Non4jmd Bearing Wall Openings (record largest opening but check all openings for Compliance to Table 9) Header Spans-___-- - _..-- - ---- -- (Table 9)--------- Sill Plate Spans.--- (Table 9) ------- ft—in_512" Full Height Studs(no.of studs)--._._------------_-__(Table 9)___--_•--_ _._---•---.----_-_--_-_ Exterior Wall Sheathing to Resist Uplift and Shear Simultanbausiy4 Minimum•Btnlding Dimension, W � - Nominal Height of Tallest Dppniag' -----_.-.._ � 5h'eathingType_r________-___-_._.__.____---(note 4)----- -Edge flail Spacing----------__--------:-_.---(Table 1 D or note 4 if less).--------_-. in. r Feld Nail Spacing.____ --: --- ..(Table 1 D)----- �---- _--- _ __ -. in. Shear Connection(no.of 16d -common nails)(Table 1D) ...... Percent Full-Height Sheathing..._._-_.-__--•-(Table 10}-----------•-----_-__--- 5%Add-tonal Sheathing for W9 with Opening>6'13 (Design Maximum Building Dimension, L Nominal Height of Tallest Opening2..--. - .................................------.._.......---•-. S'S' Sheathing Type-------------- ---- - - _(note 4) -- --.. -------- Ed e Nail Spacing------------_-------- -_-_--{Table 11 or note 4 if Feld Nail Spacing.-----.-_-- _..___.,.._____:_.(Table 11}:-.---_-•:-=----.___--_-_--___-_._.- in. Shear Connection(no. of 16d common nails)(Table 11-)--------.,........... -___--_:-------:_:_. Per ntFull Height5heathing--_---:_----_-.(Table 11)-----------------------_--------_-_------% 5%Add--clonal Sheathing for Wall with•Opening> Wail Cladding Rated for Wind Speed? - -- -- ------ -- - --- --------— ------- _ ' 5'1 ROOFS Roof framing member spans Rafters use AWC Span Tool,see B.BRS Website) Roof Ouefian (Figure 19 ft 5 smaller of 2'or Lf3 ' Truss or Rafter Connections at Loadbeadng Walls. Proprietary Connectors Uprrft--------- ------------.....-_-----(Table 12}-_- - -- - ----U= Plf ' Lateral....... ----_._._____--------(table 1 Z}__--_.__--------------___-L= pf ----------__._.(Table 12)---------- _ - P• Mdge Strap Connections,if collar ties not used per page 21... (Table 13)_____-----___--•----_---T= pff Gable Rake Outfo�ker-_-------------:--_:-.---.----�_---(Figure 20) -------._.--- ft 5 smaller of 2'or•L!2 Truss or Rafter Connectons at Non-I_oadbearing Walls Proprietary.Connectors Uplift able 14 ' Lateral(no.of 16d common nails)__(Table 14)--------------------------------------L= . lb. Roof Sheathing Type—__-_---:----------------__-:-(per TaD.0 MR Chapters 5B and 59).........._, Roof Sheathing Thickness---•------ ---�,—:-_-- --_--:---------.�--_.-_—in_?7116'WSP RDof Sheathing Fastening_______-._.___ (fable 2)-------------.__.._--------..----.----.._.. f, :This checUrrsf shall be met in is entirety, excluding the specific exception noted in 2, to comply with the naquiraments of 780 WR.53D 12 I.I.Item 1. if the checklist is met in Its entirety than the faQawing metal straps and hold downs arm not reguit ed per the V►rFCM 110 mph Guide: a. Steel Straps per Figure 5 6. A Gage Straps per Figure 11 ' Upfift Straps per Figure 14 d All Straps per Figure 17 Comer Stud Hold Downs per Figure 18a and Figure 18b. Exception:Opening heights of up to B ft shall be permitted when SA is adders to the percent full-height sheathing - requirements sh6wn in Tables I and 11. The boftorn si11 plate in exterior walls shall be a minimum 2 in.nominal fhiOmins pressure Ve ta-d 92-giade• -4 WC Guide to Food Consirrretiort in High Wind.4reas:110 tnph Wnd,Zone' Massachusetts CheckUst far Camp' ante (Igo cnrR530ra r.I)r - Check DDmp6zn=. 1.1 .SCDPE Wind Speed(3-ser- gust)_. _..__..._._ __----_ _..--_--. :_y : 110 mph Wind_Exposure Category--.__..-----____ ^__ _: _.-.._..----=•-------_-•---..___---__._,._.__...__.�._S Wind Exposure Category................Engineefing.ReqVired For Entire ProjeCf........................................0 1-2 APPLICABILITY Number of Stories(a roof which exceeds 8 in 12 slope shall be-considered a story) stories <-2 stories Roof Pitch _ 12 Mean Roof Height'___-_-_._-___ _-__ (Fig 2)-------__.___-- _-- ft <_-'33' Building Width,W —---__ (Fg Building uil Leng.h L --------------- -_ _ -=--- -(F9 3) ----- - -=- r.- --_-ft s 80' Bding Aspect Ratio(L1W) _.___:_ --(Fig 4j _.__•-------�---- ---- _<3.1 Nominal Height of Tallest DpeningZ .___ _._. (Fig 4) ___.......:_,-_...--. 1.3 FRAMING CONNECTIDNS General compliance with framing cisnneciions__...-------.(Table 2)_----------------- _--_--------____• 2.1 FOUNDATON Foundation Walls meeting requirements of 78D CMR 54D4.1 Goncrete__..-.._.------•-- ---------------------_.--._...--••--------------------•------•---------------- --•-- -•-- Gona Masonry --=----------------------------------- 2.2 ANCHDRAG)_TO FOtlNDATIDN"' 5/8'Anchor Bolfsvrmbedded or 5/8"Proprietary Mechanical-AnchDrs as arf alternative in concrete only Bolt Spacing-general................................ --,.(Table4).- - --- - -- in. _ Bolt Spacing from endfoint of plate...........-__-_-_--._.(Fg.5)_____----__---------------------- in.<_6'-12', Bolt Embedment-con crete--_-------__.__.-----------.(Fig 5).,._._._-- -----_- in.>7- Both Embedment-Masonry....................................(Fig 5) _.:---_-= :.___-_-• in >16" Plate Washer.. --------(Fig 5)--------- ---_----- -'-3'x 3'x Y' 3.1 FLOORS Floor-framing member spans checked :_._---._..__.___-----.(per 7BD CMR Chapter 55)------ Maximum FloarOpening'Dimenr.1Dn__-._.-.------------(.Fig 6)--------------_- ----_---------------- ft-s 12, - Full Height Wall Sb.rds at F1ODr Openings less than Z from Exterior Wall(Fig 6)............... ........... [M&Zrnurn Floor Joist Setbacks SuppDi-ing LDadbearing Wallis or 5heanwall_--._.----(Fig 7)--------- _- ----------____-_ ' ft 5 d [Maximum Cantilevered Floor J❑ists _ - Supporting LDadbearing Walls or Shearwall....... B).__ _^__._._.-------------�_-.-__.._ft _<d FloorBracing at Endv�alls---_•-----.._---_-----------.__-_ - 9 g)_ `___--- _.__—..__.__..__.__...............• FloDr Sheathing Type '_::--------------...---..__-_-----__ _ ..___(per780 CMR-Chapter 55)----_--------_:_______-___----- Floor Sheathing Thidmess -------------..__-__--_•----.�(per78(l GMRChapter55j;__.._________-:-- in. Floor Sheathing F4sterung_-----__________________ --.-----__.�__.(Table 2)__d nails at in edge I=in field 4.1 WALLS . . - Wall Height Lc adbearing waIls._.._ -_------ _ : (Fig 10 and Table 5)__.•----- ft Nan-Laadbeadng walls_._----._:._--_--- _.._�_—._.(Fg 10 and Table 5)------------•---_._.__$'s 2D' Wall Stud Spacing __.___._____.._.- --------__-.__(Fig 10 and Table 5)_--_-_:...___._in s 24'o r- Wa[[SrY Offsets -_.------•-----_._.._.__----_-.;..(Figs 7&8} --------,--------------__�.._ft s d 42 E�QR•WALLS' Wood Studs LDadbearingvrafis-------------_..__.___......_____________.(Table } : 2x -_ft_in. , Non-Loadbearing walls._._.---------------•--------_. _ (fable S).__._._----•--•----------2x ft_in. ' Gable End Wafl Bracing' Full HelgM Endwall Studs_._---_---__._ _-.---•----(Fig 1D}___-.___________-__._.___._ WSP-Attu Floor Length11)-------------------------__-- ft�:W13. Gypsum Ceiling Length(rf WSP not used}.-•=--_-_ -(Fig 11)...-.—_----_--_.:_---_--___ft 0_9W _ and 2 x 4 Continuous Lateral Brace @ 6 ft,o.c.-(Fig 11�......................_.._,_•----______--________ br 1 x 3 ce ing furling strips @ I T sparing min.vffh 2 x 4 blocking @ 4 ft.spacing in end joist ar truss bays Double Top Plate Spiica Length _-------�:_—._____.___. (Fig 13 and Table 6)__•_---- ---------•--_.._._ft Splice GDnne6Dh (nD_Of 16d common nails)..__._..__.(Table 6) _______-.- AiYC Gicide fo Wood Coax trucfron hi Hi-[ RlirzdAreas_ 1I0 naptr H,,rndZo}ze .'M- assachuset-t§ Checklist for Comghaiace (78o 4. a. From Tables 10 and I i and location of wall sheathing and 8ugdmg Aspect r� Ratio,determine Per7t Full-Height Sfieathfng and Mail Spacing requirements b. Wood Structural Panels shall be minimum thickness of VI6"and be installed as follows: 1. Panels shall be installed With strength axis parallel to studs. ---7—___.-n-._- -horimtda►joinfs shag occur over and be rialed fD framing. uf. On single story construction,panels shall be attached to botiom plates and top member of the double top plate. iv. On two story construction,upper panels shall be attached to the top member of the upper double fop plate and to band joist at bofinm of panel.Upper atfacfimeht of lower panel shall be made to band joist and lower attachment made tD lowest plate at first floor framing. v. Hor¢onial nag spacing at*double top plates,band joists,and girders shall be a double row of 0d staggered at 3 inches on center per figures batow:Vertical and HorizontaPhlailuhg for Panel Attachment S. .Glazing prof xfflDn: a)new house or hotfzontal addition—required if project is i mile or closer to shore(generally,south of Rte,26 or north of-Rte.6) b)vertical addition—not required unless there is extensive renovation to the first floor c)replacement windows—needs energy conservation compliance only(chap 93)S.Wood Frame Construction Manual(WFCM)for i iD MPH,Exposure B may be obtained from(AWC)website. the American Wood Council WHERT81S 133GE MSM CIR usEr�rta� tl ' tI I II N rf [ t O p L ..It • [[ II D t / 1 1 It rx aI It z - - L r a> i ti I Itj 1 It ED&E 11 � It tI _� 12 c.r FV i 1 S It tl V1 tc t I LCe'f r I I DCtt1FA� , STAGS 3`Mld AqN� t t A14Q YAJTEF" PRrrB PAf EDc;E DQLELF-RA1LEMESPACMDErAT- - See Detail on Next Page - Vertical and HorIZOntal Nailing De-tall for Panel Attachment vertical and I-fofizonW Naiting for Panel AffadIment . �TMETti Town of Barnstable Regulatory Services EARNSTASF ♦♦pp F 9 MASS. � Richard V.Scali,Director i639- �� . �6149. a Building Division 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 herebyauthorize to act on my behalf, in all matters relative to work authorized by this b ding permit application for. ( ss of Job) Pool fences d rms are the responsibility of the applicant. Pools are not to be ed or utilized before fence is installed and all final• inspections e p rfonned and accepted. Signature Owner Signature of Applicant Print Name Print Name Date Q:FORMS:O WNbRPF-RMISSIONPOOLS Town of Barnstable Regulatory Services ` 4oFTH ro Richard V.ScaIi,Director Building Division Tom Perry,Building Commissioner �$ 16 200 Main Street, Hyannis,MA 02601 ArEOI a www.town.barnstable.ma.us Off-ice: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: ;2— /Gz I Please Print ` JOB LOCATION: cee_ t G�dl4—L i- number y� ,�asteet village "HOMEOWNER": �G�I �— //`j yLO� `� T 2 f � name `h � �/D/ ome phone# work phone# CURRENT M4II.IN0 ADDRESS- 'P city/town s e 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 struct 1 es 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"homeowners'certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures And requirements apd th he/she will comply with said procedures and requirements. Si ogre of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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,RuIes&ReguIations 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 Iast page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certifrcatiou for use in your community. QAWFILFS\FORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable �1ME, regulatory Services do Richard V. Scali, Director s Building Division BARNSTABLE . .� MAS& ass r� Gb i639. �� Thomas Perry, CBO 1639-2014 ��ED"'Drs Building CommissionerDg 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 October 17, 2014 , Blair Taylor 83 Lake Dr. Centerville, MA. 02632 RE: 83 Lake Dr., Centerville, Map 230 Parcel: 084 Dear Mr. Taylor, u This letter is to follow up on permit application number 201404951 submitted to remodel the single family home at the above referenced address, As you may recall, a letter dated August 29, 2014 was sent by this office detailing that the application was incomplete and did not demonstrate compliance with 780 CMR. To date, this office has not received resolution to this issue. Be advised that the application shall be considered withdrawn effective November 1, 2014 unless sufficient cause is provided to keep the status as active. Thank you for your attention in this matter and please do not hesitate to contact this office with any questions. Respectfully, Local Inspector jeffrey.lauzon a,tow_n.barnstable.ma.us (508) 862-4034 Town of Barnstable �elHE rqw Regulatory Services �p c Richard V. Scali,Director �,Sz,B _ Building Division BABSTABLE MA9S v� 0 9. Thomas Perry, CBO 1639-201C Building CommissionerS�g 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 August 29,2014 Blair Taylor 83 Lake Dr. Centerville, MA. 02632 RE: 83 Lake Dr., Centerville, Map: 230 Parcel: 084 Dear Property Owner; This letter is in response to application number 201404951 submitted to remodel the single family home at the above referenced.address. Unfortunately, the application can not be approved at this time for the following reason: 1) Construction documents are unclear, incomplete and do not demonstrate compliance with 780 CMR(State Building Code). Be advised, no work'is to be performed without the benefit of the proper.permits. . Please submit the required documents demonstrating compliance within thirty days and do not hesitate to contact this office with any questions. Failure to submit the required documents to this office in a timely fashion shall be considered your withdrawal of said permit application. Respectfully, L. Lauzon Local Inspector jeffrey.lauzon@,town.barristable.ma.us (508) 862-4034 �ob � w , s-rA r->. ; Ll WALK ►d -1614 ;�L- t-� � Po IA cL(3sE-T' f3AY r�►�►90� o sm 6)Kz: � 6-3 WALK ,d / vo �I TAYLo2 anl� $3 AnL- DR ► LYC 2 3 a•" KN E C �� ]DO it �SrLps �7" KNE�� cvAL.L TAYl- OR $ 3 � A "KE DRY of a s . 67" t;7 ;-Aq ;7x4 . °^r 1 3�2 � Kd cr ydF F-3a'` S� o►J WALL wlAt4 On1 r - '62 LAKE DRl VC, PL C90 3 EgvES ®9-JIS:L4 :,5R�M C u Fa-ru NIAST110 S v i t� i. C a su�T� K K A w 1 N q SII � • W 46A f,S { �o R�PY � O1� 3 /�3 JJZ— • PERMIT PAYMENT RECEIE:I TOWN OF BARNSTABLE f ;. BUILDING DEPARTMENT \ 200'MAIN STREET HYANNIS, MA 02601 s f DATE: 02/03/12 (� � TIME 15;48 —� ---- ------------TOTALS----------------- • PERMIT $ PAID 35.00 r� AMT TENDERED: 35.00 AMT APPLIED; 35.00 — - CHANGE: .00, a v APPLICATION NUMBER:; 201200673 PAYMENT METH: CHECK PAYMENT REF: ' 1229 1 , Tdi*n'of Barnstable er Regulatory Service Date:. ► of THE Toy Thomas F. Geiler, Director Building Vivi Fee; ,3,j BA NSrABLE. Tom Perry, Building o missioner 1639. .�� 200 Main S eet, F�is, MA 02601, oI fD v A w o a nstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN F BARNSTABLE SOLID FUEL STOVE.PERMIT 4Z Owner: /JL Z-- /� /��- /� U {' Phone: Install at: _O ,j j fW1 Village: �' L. L C. , z Map/Parcel: aq oae OT- l Date; Y l�! 'y /dam Stove A. New B. Type: Radiant/ C. Manufacturer: 2�;P j OtJ p, Lab. No. W/ p D. Model No.: Chimney A. New/ (If existing, please note date of last cleaning) t B. Flue Size C. Are other appliances attached to Flue?. _yy� D. Pre-fab Type and Manufacturer OURA PI-U Hearth K1T1MP5v�v A. Materials: `T' � B. Sub Floor Construction: aP 0. o X.-10 �!r,�J�2 �� ►l� -y-e(5 ; I aller Name, Address: Phone: Location of Installation: H.I.0 Registration Con on Supervisor# OR check Homeowner Installing, no license required APPLICANTS SIGNATURE_ APPROVED 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 103107 0 , t� Town of Barnstable �o,F-c r� Regulatory Services r �rrsr�sL� Thomas F. Geiler,Director-. buss. . t65P. ,�� Building Division - Tom Perry,Building Commissioner 200 Mairi-Street, Hyannis,MA 02601 www-town.b arnstable.ma.us Office: 509-962-4038 Fax: 508-790-6230 HO1r1E0RtNER LICENSE EXEMPTION �,®v Please Print DATE: V U-'R/L� C ®o JOB LOCATION: (J K` I G671 1"G number street villa gm g '•HOMF0WNER': name home phanc# hone# CURRENT MAILING ADDRESS: CS j k-A R ld'?�ae fdIL.L -�t_�'S3® city/town states 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 HOMEOWNIY-R 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 constrgcts 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 uermit. (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/sbe 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 scction.(Soction 109.1.1 -Incensing of construction Supervisors);provided that if the homeowner engages a pmon(s)for hire to do such work,that such Homeowner shall act as supervisor. � . - Tvlany homeown='who use this exerrrption are unaware that they are assuming the responsibilities of a supervisor(soe 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 pen on is it-` ould with a1iccrrscd Supervisor. The horn:eowncr acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilitirs,many communities require,as part of the permit application, that the homeowner certify that hdshe 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 fonn/certifieation for use in your cDmmunity, - Q:forTns:homccxcmpt 1 VEr° �. Town of Barnstable ` Regulatory Services t YARNSTASL.E, r v axes �. Thomas F. Geiler,Director 'Building Division Tom,Perry,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' r as Owner o the subject.property hereby authorize to act on my behalf, in all matters relative to wo authorized by this buil g permit application for. (Addre of ob) Signature'of Owner Date Print Name If Pro erty Owner is applying for permit please complete.' e Ho eowners License Exemption Form on the re.verse,side. Q:FO RMS:O WNERPEkMISSION r The Commonwealth of Massachusetts Department of Industrial Accidents Offlee of Investigations d 600 Washington Street Boston,MA 02111 y www.mass.gov/dia Workers} Compensation Iusurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information .Please Prffit Legib Name(B+jsiac : rdividual): 46&JZ' o,15 7N L Address: K3 L kg__ l��td ��7►A �� a� City/State/Zip:6 01 oIL s— 3 ZPhone.#�.5_6 Are you an employer? Check the appropriate boz: .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. El New constriction . 2,❑ I am a'sole proprietor or partner- listed on the'attach ed sheet 7. '�f .emodeling These sub-contractors have- • ship and have no employees ;� 8. ❑Demolition e loyees and have orke , -;working for me m any capacity, mP � w rs g • Building ad [No workers' comp.insurance 9 LJ ctiti comp, insurance,# on d.re uire 5• ❑ We are a corporation and its 10.9�Electricai zepairs or additions required.] officers have exercised their 3.Xr I am a homeowner doing all work . 11:❑Plumbing`repairs or additions myself. [No workers'comp. right of exemption per MGL 12:❑'Roof repairs t . insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13.KOther jtlpp �f(r comp. insurance required,] *Any applicant that checks box#1 must also fill o.ut the section below showing their workers'compensation policy inforrmdon. t Homeowners,who submit this affidavit indicating they are doing all workand then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether arnot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. arri an employer that is providing workers'compensation insurance for my employees. is.the policy and job site yin ation. • . Insurance any Name: Policy#or Self-ins.Lic. Expiration Date: ss:iAddlob ,it- City/State/Zip; Attach a copy of the worker ' ompensationpolicy dec a ag-e'(showing the policy number and expiration date). Failure,to secure co ge as required under Section 25A of MGL c. 152 can the�positiop n of criminal penalties of a fine up to$1 .00 and/or one-year imprisonment, as well as civil penalties in the form WORK:ORDER and a fine of up 50.00 a day against the violator. Be advised that a copy of this statement may be forwarde Office of esti ations of the DIA for insurance coverage verification... I do hereby certify un er the pains•and penalties perjury that the information provided above is true and correct. Si attire: Date: 6 ^' O/a\. Phone k •Sao gs-"- S) 5 (:?78 409 -7Lr/ - Official use only. Do not write in this area, to be completed by city or town officiaG' City or Town: ' Permit/License# Issuing Authority(circle one): :1.Board of Health 2.Building Department 3. City/Town.Clerk 4.Electrical Inspector 5,Plumbing Inspector 6, Other ' Contact Person: _ Phone#: The,Commonvealth of Massachusetts Department oflndustrialAccidents Office of Investigations d 600 Washington Street f Boston,MA 02111 wi: v.mass.gov/dia Workers} Compensation Insurance Affiddvit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leffibly Name(Bweiaessfozc� R„dividual): l�T7 LC Address: City/State/Zip:6�0/L4Ar.. a pho,ne.;<#:' .5-0 -" `� ;� 'S,1..57 Are you an employer? Check the appropriate box: :Type of project(required):, 1.❑ I am a employer with 4. [] I am a general contractor and I employees (full and/or part-time). * , - have hired.the sub-contractors 6. ❑New constriction . 2.[1 I am a•sole proprietor or partner- listed on the attached sheet 7. Remodeling These sub-contractors have ' ship and have no employees ,; 8. ❑Demolition ' woridn for me in an capacity. employees and have workers' g ycom insurance.$, 9• ❑Build addition [No workers comp. insurance P required.] 5• [] We are a corporation and its 10.9•Electrical repairs or additions officers have exercised their 3.�I am a homeowner doing all-work. . 11.❑Plumbing repairs or additions ' myself. [No workers'comp. right of exemption per MGL 12.D'Roof repairs insurance required]t c. 152, §1(4), and we have no * � employees. [No workers' 13. l Other _( Q �,—' k_ 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,ornot those entities have employees. If the sub-contractors have employees,they must providb their workers'comp,policy number. am an employer that is providing workers'compensation insurance for my employees. is.the policy and job site in ation. Insurance any Name: Policy#or S elf ins.Lic. Expiation Date: Job Site Address: City/State/Zip: Attach a copy of the worker ' ompensation policy dec a aae-(showing the policy number and expiration date). Failure,to secure co ge as required under Section 25A of MGL c. 152 can the imposition of criminal penalties of a fine tip to$1 00 and/or one-year imprisonment, as well as civil penalties in the form o P WORK;ORDER and a fine of up 50.00 a day against the violator. Be advised that a'copy,of this statement may be forwarde Office of es ations of the DIA for-insurance coverage verification.- I do hereby certify un er the pains-and penalties perjury that the information provided above is true and correct, Si ature: Date: Phone# aM 6- S) `S `7L Offuial use only. Do not write in this area, to be completed by,city or town officiaL` r City or Town: Permit/License# Issuing Authority(circle one): - .-1.Board of Health 2.Building Department 3. City/ToSvn.CIerk 4,Electrical Inspector 5-Plumbing Inspector 6. Other Contact Person: _- Phone#: y Tolivn, `nfl Barnstabh,,, *Permit# 2D )��s Expires 6 months from issue date Regulatory'Services ices Fee d O� Thomas F.Geiler,'Director Building Division � Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint IN Map/parcel Number Property Address P residential Value of Work c(74M Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address M? ov 1 0 V >� � Contractor's Name 1`�>✓�10S ��y Telephone Number:j a'7>,�$a k6) Home Improvement Contractor License#(if applicable) 4 Construction Supervisor's License#(if applicable) 6 6 pat/ an's compensation Insurance X®PRESS PERMIT Check one: ❑ I am a sole proprietor MAY 2 5 2007 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 'r'Y 7 ✓W Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to ! 1% �f ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) "Where required: Issuance of this permit.does not exempt compliance with other town departmentgyfaAon�s a.e�J3i4togs,Conservation,etc. ***Mote: Property Owner must sign Property Owner Letter of Permission. py of e Improvement Contractors License is requited. ,;,UNJ ; SIC-NATURE: Q:Forms:expmtrg Revise061306 l_ Y, vidul use Board of Building Regulations and Standards before the expiration date. If found return only "I License or registration valid for return to� HOME IMPROVEMENT CONTRACTOR Board of Building Regulations and Standards Registratio 136066 1 One Ashburton Place Rm 1301 Xplrat} ti W008 Boston,Ma.02108 ti 1T D NO COREY&COREY,,� OME'IMROVEMENTS CHARLES COREY ai y ---- 1684 FALMOUTH RD, �115 valid without signature CENTERVILLE,MA 02632 Deputy Administrator , E:V The Commonwealth of Massachusetts V Department of Industrial Accidents _ _ Office of Investigations + a 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers" Compensation Insurance.Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Le 'blv Name(Business/Organization/Individual): . 47 V S Address: City/State/Zip: 0V Phone.#: T S� S Are you an employer? Check the appropriate bomell, 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.❑ 1 am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling sub-contractors have ship and have no employees These 8. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑P umbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.2Roof repairs insurance.required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then 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. Insurance Company Name: ✓S Policy#or Self-ins.Lic.#: `76R:rV6 7 M-7-eG Expiration Date: Job Site Address: 61 1►z et0 L%, City/State/Zip: C ' 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify nathe sand penalties of perjury that the information provided above ' true nd correct: Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ofjcciaL City or Town: Permit/License# Issuing Authority(circle one): . 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter-152 requires all employers to provide workers' compensation for their employees. pursuant.to this-statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two.or more 3: 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 th'iee 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 bedeemed to be an em'ployer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with`the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), addres (es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any_questions regarding the law or if you are required to obtain a workers' . compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for,you:to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple 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 addiess,'telephone-and fax number: .The Commonwealth of Massachusetts Department of Induffial Aroidents Office of Investigations 600 Washingtaii Street Boston, IuIA 02111 Tel. 4 617-72.7-490:0 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22-06 www.mass.go-vfdia AC CERTIFICATE OF LIABILITY INSURANCE �Y ; ATE,MM/DolYItYY, ._f. �m 04/09 2007 THIS CERTIFICATE IS ISSUED A,S'c 9A l l'rR OF WFORMATi 9'7 SCs lull m INSURANCE ONLY AND CONFERS NO RIGHTS UPS 1. THIS CERTIFICATE 34 df �18 *ST HOLDER. THIS CERTIFICATE DOES NOT .MEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY r;y ra.;L:3ES BELOW. YARIDU M, M 02673 INSURERS AFI:ORDING COVERAGE NAIC# INSURERA NORTHLAND INSURANCE I aul BuCkmi11®S INSURER B: TRAVELERS DBA BUCRM ELLLR ROOFING 9�lJRER C INSURER D Ryan is, 14A 02 601 INSURER e COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADM Famvirrecy"LTR Y�RO TYPE OF MURANCE POLICY NUMBER DATE PDA Y ELATION Lom A GENERAL LIABILITY CP46859503 05/15/2006 05/15/2007 EACHOCCURRENCE $1,000,000 X COMMERCIALGENERALLUIBILITY POSES(Ea �) $50,000 ..CLAM MADE- ix occUR _ .. _. _.. _. _..._-- _..-. ._ __._ ww.(Any S-EXCLUDED PERSONAL&ADVINJURY $1,000,000 _ GENERAL AGGREGATE $2,000,000 x GEMAGGREGATELIMTTAPPLIESPEW. PRODUCTS-COMP/OPAGO , $2,000,000 POLICY T El we AUTOMOBILE LIlAA LITY COMBINED SINGLE LIMIT ANY AUTO $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Par pen-) HIRED AUTOS BODILY INJURY $ NON-OWNEDAUTOS PROPERTY DAMAGE s (Pet accwwd) - s GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC S t OTHER THAN AUTO ONLY. AGG. S EXCESSf M8RELLA LIABILITY EACH OCCURRENCE S e. OCCUR ❑CLAIMS MADE - AGGREGATE ---' $ ' S DEDUCTIBLE S RETENTION S S WORMS COMPEMATWN AM 7PJOB-7430A7-06. _ 04/11/2007 04/11/2008 - X I TORE1111YLIMTTs ER B 110YY P S'LIABILITY NER/E7lECUTiVE EL EACH ACCIDENT $100,000 AN OFFICOUMEMSER EXCLUDED? _ -. -- E.L'OISEASE=ER EMPLOYEE- S-1100 -' sPECIALPROVISIOT6pabWa �_� � EJ_DISEASE-POLICY LIMIT $ 500,000 IDYM DESCRIPTION of OPERATE I LOCATION I VEHICLES I E%CLUStONB ADDED BY ENDORSEMENT I SPECIAL PROVISION$ PAUL BUCfMLLER IS EXCLUDED FROM HIS NORZERS COMPENSATION :ERTIFICATE HOLDER CANCELLATION ZOREY & CORTEY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 1694 FATiSOUTE RD DATE y"EREDF, THE AL me INSURER WILL ENDEAVOR TO MAIL 21 DAYS WRITTEN MOMMMILLE, MA 02632 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO OO SO SHALL DIDOSE NO OKJGAT= OR LIABILITY OF D UPON THE INSURER. ITS AGENTS OR REP MSNTATN AUTHORREDREPRES \CORD 26(2001108) 0 ACORD CORPORATION 998E COREY W WF The- Rs R_ cze f 1 2' 8 capo C0, 4 & 1Wqq 1 % 70 1694 FALMOUTH RD #115, CENTERVILLE, MA 02632 PROU 1,448 P77-5-814-0 CA. I NT ` J 0, 0 D, S CAP RE -� ROOFINQ PROPOSAL May 24, 2007 JANICE PATTBERG 83 LAKE DRIVE CENTERVILLE. MA 02632 Phone: 508-775-8873 COREY & COREY hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturers specifications and local building codes.' Remove and Haul Away All of the Old Asphalt Roofing Shingles from the Rear Main Section Only. Re Nail All Plywood Sheathing as needed. Supply and Install CERTAINTEED WOODSCAPE AR 30: 30 YEAR WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE RATED, ALGAE RESISTANT, 245 POUND HEAVY WEIGHT, SELF-SEALING, 80 MPH WIND WARRANTY STORM/HURICANE NAILED (6 NAILS PER SHINGLE),MULTI-LAYERED, LAMINATED ARCHITECTURAL STYLE, FIBERGLASS BASED ASPHALT SHINGLE with COPPER/CERAMIC STONES with a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT COLOR: BIRCH WOOD Supply and Install 8' WHITE ALUMINUM DRIP EDGE on the Entire Eave. Supply and Install CERTAINTEED WINTER-GUARD ( Ice & Water Shield )WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves. Supply and Install ALPHAPROTECTOR-SUL SYNTHETIC UNT-DERLAYMENT MEMBRANE http://www.permarproducts.com/onUmeform/alphai)rotedor.pdf Supply and Install ALUMINUM & NEOPRENE SOIL PIPE FLASHING Clean and Remove Debris from work area after job is completed. 1 TOTAL INVESTMENTS 0©00 Including Senior Citizen Discount Payable immediately upon completion. POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards, Plywood Sheathing,Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$60.00 per Hour. PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All Roof Work is Normally Scheduled for Completion Within 30 Days of Acceptance and Receipt of Deposit providing the Materials are Available. Please Male Checks Payable to: CHARLES COREY COEY & COREY Warranties the Shingles and Labor for 5 years. CERTAINITEED Warranties the shingles and labor 100% for the First 5 Years and then on a pro-rated basis for 30 Years Total if the shingles becomes defective. CERTAINTEED Warrants the Shingles up to a 7/0 MPH WIND WARRANTY. CERTAINTEED Warrants the Shingles to be Algae Resistant for a Full 10 Years. Any alteration or deviation from above specifications,will be executed only upon written orders and will become an extra charge,over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado,and other necessary insurance upon the above work.. This proposal may be withdrawn by us if not accepted within thirty days. CO EY & COREY carries Workman's Co Tpens ion and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ACCEPTED BY: SUBMITTED BY: JANTICE PATTISEG CIURILES CnREY HOMEOWNER COREY C L .Ae - cZ-N f L� vi 'wog f _ _ �2 /� , ►� c a-/-� y t /A SMOKE DETECTORS REVIEWED t A T BUILDING DEPT. DATE itP•VES P FIRE DEPARTMENT DATE 1 i • - BOTH SIGNATURES ARE REQUIRED FOR PERMITTING _, . t t � t PbA-- C 4 r { I 1 � IR 7 j 1 • j