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n L �d'�. i y'���� L � �.♦ v r t r c' i �- cCo � Application number.:7:. .......i.................................. ,.PAZ .00 Fee . ...................................................................... s ue. 0Cr 3 0 P-041 NAM Building Inspectors Initials.... . ................. 1�!�� �a�- �i�l-�I�15�ABLE �' .� //'���-. Date Issued.J.0.. ..3U.elt. ............................. � � a a Map/Parcel.............:.................................................... TOWN Of.BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: ER STREET VILLAGE Owner's Name: Phone Number&9_2 1.37— E 2 1 Email Address: Cell Phone Number Project cost$ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a b ' permit in a or with 780 CMR / l Owner Signature: fi TYPE OF WORK Siding ❑ Windows(no header change)# ❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# 3 7 cf-�- (attach copy) 'Construction Supervisor's License# 0o (attach copy) Email of Contracto P5 C.C�,V 64 pia AI-- - Phone number ALL PROPERTIES THAT HAW STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY.IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER....................................................."n. 's *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 201bs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date 3C �(2 All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizaf ndividual): G Address: 'go . City/State/Zip: d C Phone#: S ' -1 7�5? 2— Are you an employer?Check the appropriate box: Type of project(required):, 1.FelI am a employer with 4. ❑ I am a general contractor.and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ®.Remodeling . ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• � 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their. 1 L❑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. $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: Policy#or Self-ins.Lic.#:�AlGC . S 00 —SG l aS'9�9_'Lr I q4 Expiration Date: Job Site Address: `��/. S�- City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage'as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t pains and penalties of perjury that the information provided above ' true an/d correct Signature: Date: 3 a 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#: . 1 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 wiite"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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia I N - N N Co c �e�e �i>ru�aairureo,�/° �as�li r �e�fa . u�! CUA a�i w N �_ Office of Consumer Affairs 8 Business Regulation � 0 m C HOME IMPROVEMENT CONTRACTOR Registration valid forindividual use only to y aosl ) O TYPE\Comoration before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation c o ar � 153792 _ 01/07/2021 1000 Washington Street Suite 710 m 'r, Boston,MA 02118 o vi -�C `.� S' C&F REMODELwj ING{NC ` v ai v+ rc i 3� ' `o .5 .`✓�. Uj CARLOS H.FIGQEIROA` i o c c 20 CAPTAIN NOYE�RD - Not valid without sl �r�sg1 � grllature E ,,°-�m U U.Z S.YARMOUTH,MA 02604 Undersecretary, . IX o > c =—< 2 Uo � � o co � lz 0 M Cr" V N Cn E. - `; O ,a®. fn V U r DATE(MMIDD/YYYY) ACo® CERTIFICATE OF LIABILITY INSURANCE `� 05/02/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Deborah Kelly NAMELeonard Insurance Agency,Inc PHONE (508)428-6921 FAX (508)420-5406 AA/C.No Ext: A/C No 683 Main Street h-MAIL s: deborahk@leonardagency.com ADDRE Suite B - INSURER(S)AFFORDING COVERAGE NAIC p Osterville MA 02655 INSURERA: Atain Specialty Insurance INSURED - - INSURER B: The(commerce Ins.Co. 34754 Carlos Figueiroa,DBA:C&F Remodeling Inc. INSURER C: Associated Ind.Of MA-ARWC 26158 INSURER D: 20 Captain Noyes Road INSURER E: South Yarmouth MA 02664 INSURER F: COVERAGES CERTIFICATE NUMBER: CL195203710 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AUUL15UtJR POLICY EFF POLICY EXP - LTR TYPEOFINSURANCE INSD WVD POLICYNUMBER MM/DD/YYYY MM/DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE _ $ 1,000,000 CLAIMS-MADE 0OCCUR - - IJAMAGF TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000- A CIP383515 04/18/2019 04/18/2020 PERSONAL&ADVINJURY $ 1,000,000 GEMLAGGREGATELIMITAPPLIES PER: GENERALAGGREGATE $ 2,000,000 POLICY DPRO- JECT ❑LOC - 2,000,000 PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ 250,000 B OWNED SCHEDULED RVM277 01/18/2019 01/18/2020 BODILY INJURY(Per accident) s 500,000 AUTOS ONLY I AUTOS XHIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per acc dent $ 250,000 Medical payments $ 10,000 UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DIED I I RETENTION$ $ WORKERS COMPENSATION P I OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE ,�N E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED9 NIA WCC-500-5018589-2019A 04/30/2019 04/30/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 16 Great Neck Road AUTHORIZED REPRESENTATIVE Mashpee MA 02649 � iJ h4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Town of Barnstable F�"E'ati 'Regulatory Services Thomas F. Geiler,Director MUWSTABLE, Building Division co Z/,/,, 1639. p`� Tom Perry,Building Commissioner RFD MA'S 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us - Office: 508-862-4038 Fax: 508-790-6230 PERMIT# b W l d FEE: $ SHED REGISTRATION 120 square-feet or less Lane— Location of shed(address) , Village �C- �� Property owner's name Telephone number C)o c0 oo � Size of Shed Map/Parcel# Signature Date xV Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506. a o f LV) a /°7 p o r fo 0 �r ,LO,7 kj _ o C> �G 6 7"' CERTI E0 E D PLOT PLAN 55 L O C A T l O N: E:,�.ce. - FOR 45 SCALE: DATE. �9 S R E F E R E P1 'C E: ,�j /x/C GOTIo r.Q s P ,sd . IXD y EP�G%x'L N A D U E Y 0 R .S . t� p THE�eBf T°Dt I!Y No EaO'..,�E� r 0S#f O WN IVY 1"K f SAP C�°ANkg � r �p9 N;"YrTNE� G R�U N D xwt� HBO:YY N aHE��EO N , 1. i a r QGEMMOMAH J MNAr N' . J R a; l� SAS OCIT E' S wa.��sso N E E.R.S tq�Er;lst�R��o4 TKOWNEE pLq�Zaq_ 900 ROUTE 134 � su - 8_ �����•V gar �s�} �S` � P2{y - ac'S..Y �—A ' `'�� y , i ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ` Parcel �0 Co �� Application# Q6C66617 Health Division 2003-'030 Permit# Tax Collector Date Issued Treasurer _ -Apppplication Fee � -4 0 SX15T1No SEPTIC SYSTEM Planning Dept. LIMMM -m-i 4 e-_- - D t Definitive Plan Approved No " "j�^ � �e��f Date e e a by Planning Board n /voeyreJS'F�a, tc,yJ" cw roam Historic-OKH Preservation/Hyannis y� ,�s � sYs vy�M'S f b4 ,sadop o erl y. -Project Street Address � G (�W Village TT V '1-- Owner —P& d") Address �� �l0 Telephone // __ ��C)3� p � Permit Request o ft�X 11*117 KMVIQ ge)jej!!�� Square feet: lst floor:existing proposed 2nd floor:existing proposed Totahnew• e � u Zoning District C, Flood Plain Groundwater Overlay ! _ _ .'Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentat on. Dwelling Type: Single Fami6l"', Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes o On Old King's Highlay: ❑Yes Basement Type: C_ ull ❑Crawl ❑Walkout ❑Other �� N''�" Basement Finished Area(sq.ft.) �.�C J ��I� Basement Unfinished Area(sq.ft) �a � Number of Baths: Full:existing ` new Half:existing new Number of Bedrooms: existingt'" _ new _ w Total Room Count(not including baths):existing new First Floor Room Count w kI Ic° htlu�, Heat Type and Fuel: b Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes Fireplaces: Existing New_ Existing wood/coal stove: ❑Yes C Detached garage:__❑existing ❑new size N u Pool:❑existing ❑new size_� Barn:❑existing El new size Attached garage:Yaexisting ❑new size Shed:❑existing ❑new size_ Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes b ,X If yes, site plan review# T Current Use Proposed Use `n BUILDER INFORMATION Name T I Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 4z; DATE IGNATURE c� 1 a n r ` > FOR OFFICIAL USE ONLY PERMIT NO. , DATE ISSUED MAP/PARCEL!NO. ADDRESS VILLAGE Y r OWNER DATE OF INSPECTION: FOUNDATION FRAME f INSULATION { FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH t FINAL , FINAL BUILDING aJ41 WN m DATE CLOSED OUT o ASSOCIATION PLAN NO. O " J l The Commonwealth of*Massachusetts Department of Industrial Accidents 02 9.3 Office of Investigations ' a 600 Washington Street Boston, NIA 02111 www.mass.gov/dia Workers' Conipensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers A]2plicant Information Please Print L,e 'bl Name (Business/Organization/Individual):. Address: - t City/State/Zip: d\ 'f Phone#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ ❑ Remodeling ship and have no employes These sub-contractors have S. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9,' ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its r uired.] officers have exercised their 10.❑ Electrical repairs or additions 3. am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions K myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required,] t employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must'also fill out'the section,below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 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. 1 do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct: Signature: D�Y `- �� t/1 Date: l_X� 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.Electricsi inspector 5.Flumbing Inspector �1 6. Other Contact Person: Rhone#: Information and Instructions , r 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-contractors)name(s),addresses)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the 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' lease call the D artment at the number listed below. Self-insured compensation policy,p eP 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 Imvestigations 600 Washington Street Boston, MA 02111 Tel, _ 617-727-4900 ext 406 or 1-1077-MASSAF E Fax # 61 7-727-7749 Revised 5-26-05 vrw- .mass.2ov/cua i Town of Barnstable Regulatory Services BAMSTABLE, ' Thomas F.Geiler,Director 9 kASS. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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: ��� l Estimated Cost � ���,�� lQiv��n Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded bylaw ❑Job Under$1,000 ❑BP' dmg not owner-occupied 00wner 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 agent of the owner: t Date Contractor Name Registration No. • �,CbAOR Date Owner's Name Q:forms:homeaffidav �--- tom. ra. CIO ld7l � y - I F . 11 t, sir t�a , •. . o Ob -- uL D 3 ZoAch Zp n e-- COY i� //e-- oFt r Town of Barnstable Regulatory Services BMMSrABLE, Thomas F.Geiler,Director 9 MASS. 4,A 039• .• Building Division rED MA't A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: U 1 JOB LOCATION: vakf_ number treet village /� "HOMEOWNER': �1 > 56 i name home phone# work phone# CURRENT MAILING ADDRESS: �-- S \' 0<1 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or'two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and r�jements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z 2 9 I Pare3�� Permit# lU 1N Health Division - � n Ct i � Date Issued / �� � 'Conservation Division f P '; 30 Application Fee Tax Collector 7 Permit Fee 591 , SEPTIC SYSTEPA t� iT BE Treasurer 7 INSTALLED IN COMPLIANCE V �lON Planning Dept. WITH TITLE$ Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANLTOMI REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address 2-3 LARCy Lf}4/, Village celyre'eI%/LhP— Owner4RAO, aR tPe1'GiC'fe4l ",1114AW/1#7e Address Z 3 LA,RG40'1Ay- 4Cee7Woei1144 - Telephone ,f0o'—B62 o%l7 Permit Request .31r ,QD/QM e-A " Xd" lAD C&A, Zs , GD-WA17-AX ACcox1iL. Square feet: 1st floor: existing Y&O proposed O 2nd floor: existing proposed G�� Total new_W Zoning District Flood Plain Groundwater Overlay Project Valuation (f700o Construction Type W,001P F.QA/✓IP--. Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ido' Two Family ❑ Multi-Family(#units) Age of Existing Structure I C,Ss� Historic House: ❑Yes LI o On Old King's Highway: ❑Yes 3,M'6 Basement Type: arfull ❑Crawl ❑Walkout ❑Other i Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) F40 Number of Baths: Full: existing 2 new Half:existing new Number of Bedrooms: existing new _I Total Room Count(not including baths): existing Ir-Z new�_ First Floor Room Count 4 Heat Type and Fuel: Ck6as ❑Oil ❑ Electric ❑Other Central Air: ❑Yes L14 o Fireplaces: Existing I New Existing wood/coal stove: ❑Yes ❑No Detached garage• ,,,existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:Wexisting ❑new size _ Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes AINo If yes,site plan review# Current Use e, 62i 0& fliCi p, Proposed Use ,e BUILDER INFORMATION Name Telephone Number 77f—",'yam License# tnlO ,�A Home Improvement Contractor# 10'1011 Worker's Compensation# S402 9/90/2d G L ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO r SIGNATURE DATE e FOR OFFICIAL USE ONLY S PERMIT NO. DATE"ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME y INSULATION FIREPLACE ELECTRICAL: ROUGH; FINAL PLUMBING: ROUGH; 3 : . FINAL GAS: ROUGH'S `= FINAL FINAL BUILDING l s cj t 4 i+ DATE CLOSED OUT c. c 1 rw ASSOCIATION PLAN NO. t RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE P19- New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE /� q ^3 square feet x$96/sq.foot= I 5 CP x.0031= ZS / S plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0031= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $ 35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) / Permit Fee projcost _ h+ U jAf,'F S TABLE 2ROTMAR I I PM 06 h...ww.. Di''1....(.iSIO1Vf....... . *y� ° .. [OJO ° . -3 O - n C � t T-e A S� 20'-11' - 1 UP 41 it 24'-0' 14'-0" t Existing First Floor Plan La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-115-2815 Centerville, Ma. 0202 Page 1 Hyannis, Ma. 02601 Fax 508-115-2887 k New Dormer Add double wall 16'-0' for plumbing 6q o' '-F- - - -- - - - - - - - - - - - - --- - O BATH a i create cavity over linen closet computer below to run.FHA heat and I O Alcove plumbing to basement _Y — — — — — — — — — - — — — — — Linen Globe! I m Existing BEDROOM Bedroom I . - - - - - - - - - „ up- - - -. -- - - — — — —Half W Ste all p - - - - - - - - - - - - Existing Stairs r II OPEN BELOW I I L I I Outside line of stud below HI. .iU . _ — — — — — — — 4'-6' 4'-113/4' 4'-61/4' Front"Dog House"Dormer " Proposed Second floor Plan with shed rear dormer& front'Dog House Dormer La Porchia & Peterson Philamar Date: 1/9/2003 revised 5/10/2003 Home Improvement Specialists of Gape Cod Inc. 23 Larch Lane 25 Iyanough Rd. Ph 508-775-2815 Centerville, Ma. 02632 Page 2 Hyannis, Ma. 02601 Fax 508-775-2887 Chimney beyon k New front dog house dormer Right Side Elevation F La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-115-2815 Centerville, Ma. 02632 Page 3 Hyannis, Ma. 02601 Fax 508-115-2881 ® , 1 111111 HIPP III IIIIIIIIIIIIIIIIIII III sz-io• Dormer Rear Elevation a La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2005 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508--l75-2815 Centerville, Ma. 0202 Page 4 Hyannis, Ma. 02601 Fax 508-T15-2887, c 2(b rafters 0 16•ox.uAf 1/2"b95 . sheathing&asphalt roof singles Rl lge vent Vented drip edge` 2x6 telling joists 0 16•o.c.l w/8• R-30 flberglass Insulation 2x10'joistsb 12" ' 2x4 studs 0 16•o.t.u4 o.c.w/5/8"`ply sub 1/2'095 sheathing.w.c. / Root shingles&3112"R-13 fiberglass'Insulation 8'R-30 flbergiass Ex(sting 2x6 � ' Insulation ceiling joists/ Existin 5/6"firecode triple 1 3ia•x ®16•.o.c. g 11 "11V LNI sheetrock in garage beam(we h design report M i/16/2003) M ' 18'-0" Garage T r e / Master Bedroom without doghouse dormer Gross Section th u Garage 9 La Porchia 8 Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-1-15-2815 Centerville, Ma. 02632 Page 5 Hyannis, Ma. 02601 Fax 508-115-288-1 2xb rafters®16"o.c.w/1/2"0513 sheathing&asphalt roof shingles 2xb telling joists®16"o.c.w/e" R-30 fiberglass Insulation 2x4 studs®16"o.c.w/112"05B sheathing,w.c.shingles&3 1/2° ; R13 fiberglass insulation Existing 2xb flor jois 10'-7" 13'-10 1/2" Existing first floor kitchen& bathroom Elln Gross Section Thru Alcove l Bath area La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-115-2815 Centerville, Ma. 02632 Page 6 Hyannis, Ma. 02b01 Fax 508-'775-288-1, n• I Cn ` -BEDROOM - - - - 1 - -- - - - - - - up- Z — Outside line of stud below - I 4'-6" 4'-11 3!4" — — 4'-b 1/4" Front"Dog House" Dormer La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-775-2815 Centerville, Ma. 02632 Page 'i Hyannis, Ma. 02601 Fax 508-7?5-288-1 Dog house dormer front of house Added 2x10 Joists @ 1 6" o.c. sistered to existing 2x6 joists Existing 2x6 joists @ 16" O.C. Zz Garage below 3- 1 3/4" x 11" LYL girt Section thru front Dog House Dormer La Porchia & Peterson Philamar Date: 1/9/2003 revised 3/10/2003 Home Improvement Specialists of Gape God Inc. 23 Larch Lane 25 lyanough Rd. Ph 508-775-2815 Centerville, Ma. 02632 Page 8 Hyannis, Ma. 02601 Fax 508-775-2887 ;."�l- t cv�<i�cvrr•.:,r/!it � •. (lcu�ru'irrr��+lhi l3u 11d of Building Kcgulatiuus and standal(is - 1 HOME iMPROVEMENTCONTRACTOR Registration: 101014 Expiration: 6/24/01 Type: Private Corporation CAPE COD HOME IMPROVEMENT h�oberf NIacL:augfilin . 25 lyanotigh Road Hyannis, MA 02601. Administrator BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 010350 Birthdate: 07/23/1941 r Expires: 07/23/2003 Tr. no: 11905 rNvs L;Lvd To: 00 ROBERT A MACL.AUGHLIN / 25 HARVARD ST S YARMOUTH, MA 02664 Administrator R. k From:Joe Madera 508-862-6007 To:Cape Cod Home Improvement Date: 1/16/2003 Time:8:07:34 AM Page 2 of 2 ORIS BC'CALC® 2002 DESIGN REPORT- US Thursday,January 16,2003 08:06 File Triple 1 3/4" x 11 7/8" VERSA-LAM® 3100 SP Name CC Home Philamar.BCC: FB01 Job Name - LaPorchia&Peterson Philamar Description - Garage Beam Under Knee Wall Address - 23 Larch Lane Specifier City,State,Zip - Centerville,MA Designer - Joe Madera Customer - Company - SHEPLEY WOOD PRODUCTS Code reports - ICBO 5512,BOCA 98-52,SBCCI 9852 Misc - I Standard Load-40 PSF 110 PSF Tributary 09-00-00 — I - - AL Ak BO B1 4620lbs LL 4620 Ibs ILL 2293lbs DL 2293 Ibs DL Total Horizontal Length-14-00-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End five Dead Trib. Dur. S Standard Unf.Area Load Left 00-00-00 14-00-00 40 PSF 10 PSF 09-00-00 100 Member Type: Floor Beam 1 wall Unf1in ad Left 00-00-00 14-00-00 0 PLF 40 PLF Wa 100 Number of Spans - 1 2 roof Ur.`.,,. -id Left 00-00-00 14-00-00 25 PSF 15 PSF 12-00-00 115 Left Cantilever No Right Cantilever No Controls Summary Control Type Value %Allowable Duration Loadcase Span Location Slope 0/12 Moment 24195 ft-Ibs 65.9% @ 115% 3 1 -Internal Tributary 09-00-00 End Shear 5935 Ibs 42.8% @ 115% 3 1 -Left Repetitive n/a Total Deflection L/288(0.583") 83.2% 3 1 Construction Type n/a Live Deflection L/431 (0,389") 4% 3 1 Span/Depth 14.1 1 Live Load 40 PSF Dead Load 10 PSF Part Load 0 PSF NOTES: Duration 100 Design meets Code minimum(L/240)Total load deflection criteria. Design meets Code minimum(1-/360)Live load deflection criteria. Disclosure Minimum bearing length for BO is 1-1/7' The completeness and accuracy of Minimum bearing length for B1 is 1 the input must be verified by anyone Entered/Displayed Horizontal Span Lengrh(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing who would rely on the output as evidence of suitability for a particular application. The output above is based upon building code-accepted design properties and analysis methods. Installation of BOISE engineered wood products must be in accordance with the current Installation Guide and the applicable building codes. To obtain an Installation Guide or if you have any questions,please call (800)232-0788 before beginning product installation. BC CALC@, BC FRAMERS, BCI@• BC RIM BOARD T'°',BC OSB RIM BOARDT''' BOISE GLULAMT'°' VERSA-LAMS,VERSA-RIM@, VERSA-RIM PLUS@, VERSA-STRANDT'°', VERSA-STUD@,ALLJOIST@ and AJST"are registered trademarks of Boise Cascade Corporation. , MAScheck COMPLIANCE REPORT i Massachusetts Energy Code I ' Permit# MAScheck Software Version 2.01 Checked by/Date CITY: Barnstable STATE: Massachusetts HDD: 6137 CONSTRUCTION TYPE: I or 2 Family,Detached HEATING SYSTEM TYPE: Other(Non-Electric Resistance) DATE: 1-16-2003 COMPLIANCE: PASSES r Required UA=93 Your Home= 86 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 574 30.0 0.0 20 ` WALLS: Wood Frame, 16" O.C. 473 %-10) 0.0 .39 GLAZING: Windows or Doors .'.54 0.340 18 FLOORS: Over Unconditioned Space 252 C3.00] 0.0 8 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements 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 125% of the design load as specified in ` Sections 780CMR 1310 and J4,4. r Builder/Designer Date l--1T1Q3 MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.01 DATE: 1-16-2003 Bldg.1 Dept.1 Use CEILINGS: 1. R-30 Comments/Location WALLS: [] 1. Wood Frame, 16" O.C.,R-13 Comments/Location WINDOWS AND GLASS DOORS: [] 1. U-value: 0.34 For windows without labeled U-values, describe features: #Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location FLOORS: [] 1. Over Unconditioned Space,R-30 Comments/Location AIR LEAKAGE: [ ] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. When installed in the building envelope,recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin(0.944 L/s)air movement from the the conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. VAPOR RETARDER: [ } Required on the warm-in-winter side of all non-vented framed ' ceilings,walls, and floors. MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can ' be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be clearly marked on the building plans or specifications. r I DUCT INSULATION: [ ] I Ducts shall be insulated per Table J4.4.7.1. I DUCT CONSTRUCTION: [ ) I All accessible joints, seams,and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed i using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not i permitted. The HVAC system must provide a means for balancing air and water'systems. I TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. I ' I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is not greater than 125%of the design load as specified i in Sections 780CMR 1310 and J4.4. [] I SVVHVI IING POOLS: All heated swimming pools must have an on/off heater switch and require a cover unless over 20%of the heating energy is from I non-depletable sources. Pool pumps require a time clock. I [] I HVAC PIPING INSULATION: I HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels(in,): F PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2"RUNOUTS 0-1" 1.25-2" 2.5-4" Low pressure/temp. 201-250 1.0 1.5 L5 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 t 1 Steam condensate any 1.0 1.0 1.5 2.0 , COOLING SYSTEMS: 1 Chilled water or 40-55 0.5 0.5 0.75 1.0 refrigerant below 40 1.0 1.0 1.5 1.5 i [ ] I CIRCULATING HOT WATER SYSTEMS: Insulate circulating hot water pipes to the following levels(in:): 1 PIPE SIZES (in.) 1 NON-CIRCULATING I CIRCULATING MAINS &RUNOUTS HEATED WATER TEMP(F): RUNOUTS 0-1" 1 0-1.25" J.5-2.0"_ 2.0+" , 170-180 0.5 1.0 1.5 2.0 140-160 0.5 I 0.5 1.0 1.5 100-130 0.5 1 0.5 0.5 1.0 ----NOTES TO FIELD(Building Department Use Only) ------ n °FINE T° Town of Barnstable Regulatory Services '* snxxsTnstE, ' Thomas F.Geiler,Director 9`b1639. A g Building Division prED nw't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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: Estimated Cost Y ZOA0*ed Address of Work: l 5 44AC 4K z.Ace - Owner's Name:LAAox" f.I�e rE,e.t�i✓ /ai//LhiMJ9� Date of Application: 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 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 agent of the owner: r Date Con ctor Name Registration No. OR Date Owner's Name Q:forms:hcmeaffidav 3 The Commonwealth of Massachusetts -= Department of Industrial Accidents Office offnresUgatlons 600 Washington Street e, �J Boston, Mass. 02111 Workers' Compensation Insurance Affidavit nam .4A10 e4m ++�er'�,e,s®�✓ ® <<,g Ii2cation7 2 3 A"C& GAS city phone# ii?G 2 -z43 7 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name: �,We �Z*Opgd -g addre.:.. Z city: l�Y.�y��§ phone#•,�0��������1�" v✓cG.�o�z9/�/1v©�--- I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who h . the following workers'compensation polices: comnanv name: address phone# insurance:m : policy#' comoanymme address; city`' T phone#; insuranctco. policy# Failure to secure coverage as required under Section 25A of N1GL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/ol one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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 pains and enalties of perjury that the information provided above is true and correct. Signature Date _1.. Print name�0 � !/�C Phone#� �.,��•1$1,� official use only do not write in this area to be completed by city or town official city or town: permit/license# n Building Department E_> C]Licensing Board . 1]check if immediate response is required Selectmen's Office Health Department , contact person: phone#; I—tOther & °``HE'O�ti The Town , `° of Barnstable _ BAPNSTABLE. MAss. o Department of Health Safety and Environmental Services 1639 EOMp Building Division 367 Main Street,Hyannis,MA 02601 Iffice: 508-862-4038 .ax: 508-790-6230 PLAN REVIEW Owner: �_ So Map/Parcel: Project Address: 93 L� Builder:�oW�2 I�mp+rGV�1m nT /JrZc, C° The following items were noted on reviewing: 1 rN ICOA-a0 -tv o nn UGA I yN �'2&63 ? 2 h ad ' n. Q u glen fJev- r r� 1 v 2 t 1r h)cA a— 12 ''` O r a Reviewed by: Date: :buildin hnns:review Assessor's map and ;lot number ...... ....................... �TNeT Sewage Permit number ;:......` .'.I C... .........:?.. �. n li BA"STABLE, i House number ............. ..:.W ...�.�`.L'...:................::............ �Fp YPY TOWN OF . BARNSTABLE Bill1,LDtIH,G- INSPECTOR f APPLICATION_FOR PERMIT TO ............"l.....Q d / ...� '� . ................................. TYPE OF CONSTRUCTION" ................ ............ U t...... ./I...............19.� I ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following 'information: / .l,ra..... ....... ..:........... ..�............. ... .....Location ........CL?........... U�L.�.a'�1.:.....�� .. ��'��' bg �/ ............................ Proposed Use ................... w � , ..�f✓ °. ........ ... .... s. j(f Zoning District ................. ...................... ......:...........Fire District .... .....: Name of Owner � :Address ovo Name of Builder .Irf ,�./ ��.,/�Gh.. . !P/1L�X.!....Address ................................................................................. r Name of Architect X I Address . �� .4 4 �Gt 1 .......��. .................... I Number of Rooms ..............................Foundations!�Q!f .. . rJ'!f.4!tR.../.�R_. Exterior Roofing ..:............ CaV1 Floors ��' 11 �1. .1! ...............................intenor ........,.:... ........... Heating :.....C��.,/'............................................Plumbing ................. .. v �... 'jf - �� "f c /......�' ............ Fireplace ........................... ........................................Approzimate Cost ............. . � .............. ................ Definitive Plan Approved%y Planning Board _ X-f:a_,'?� 19 Area T �f Diagram of Lot and Building with Dimensions a Fee ' SU 'JECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....I. ... . . ..�... /... v7........... LJF• y �, Construction Supervisor's License ......................./.......... S L.S TRUST A=189-f6 OD6. 666 + No ..29166 Permit for ...1 z Story Single Family Dwelling Location .......Lot #6,.....23. Larch Lane........ Centerville ............................................................................... Owner S L S Trust ............................................................. Type of Construction Frame 3 ............................................. ............................... Plot ............................ Lot ................................ i Permit Granted ...... Ap.r.iI...$.,..................19 86 Date of Inspection .....................................19 Date Completed ...... ............ ...................19 f 1 1I 1 � _ l �..:.............. , t t Assessors map and lot number:......... 'r' SEPTIC .SYSTEM T �� e INSTALLED IN COMPLIANC C%TM E T0� Sewage Permit number ..........:..... .6.�.�� ...:. ' WITH TITLE 5........ ........ ENVIRONMENTAL CODE A • House number .... ..a. .... :Z.......... I ; e,sasTanrs. S TOWP REGLILATIONS =, OypY.a`�� . TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..............i ................/........� .. .. ...................................................... < V TYPEOF CONSTRUCTION........................................................................................................................................ .........la...............19. �0 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followin inf rmation: Location .......... . .... (G7. ...... 7. �: .. Ate,............................. ProposedUse :................ ..t11✓ .......................... ............................................................ ... ...... ...... ZoningDistrict .................1 ......... ............................Fire District ....................................... ................................... Name of Owner �..5.... /.. ............................Address ..../...`'��.... �...�....� .... GZM.l4RCl... �( /0 U L r•'' i Name of Builder .. ���. ..:& �.J�.OW;;. .. !P.VI L....Address .................................................................................... Name of Architect D ............Address :. ��.....Cam ........ .. ( � T....................a2A.:l.G� c� Number of Rooms .................... ...........................................Foundation ............R......... Exterior .... ................................Roofing .......................!::!...1.......................................:............. Floors ��1� .................................. ...............................Interior ............. .. .................................. /� e�Heating ............................................Plumbing ................. ..:. ..... t--:.. ............ , . Fireplace ......................... .. .............................................,Approximate. Cost ...............,...J..�...Y.Y,.4J.................................. I Definitive Plan Approved y Planning Board \ --------19 lS- Area .....1.. ...'. .......... Diagram of Lot and Building with Dimensions Fee �// °.... SU JECT TO APPROVAL OF BOARD OF HEALTH #s 3 2 z"- 3d 8 14 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... �. ........... s Construct'on Supervisor's License .... j/ ............. S L S TRUST No ...29166 ...... .............. Permit for ......2 ......... Sin ....................... .............. .......nil . Location ......Lqtjl.�......Z3..L;?,r.r-h...Laiie.......... . ................... ................................... Owner ...S..'.L...S..'.Trus.t................... .. . .. . . ...... ................. Type of Construction* ......Er-ame.......................... .................. Plot ............................ Lot ................................. rl Permit "Granted .... i 1...8.....................19 86 Date,of Inspection el.x........................19 Date Completed . 19 er TOWN OF BARNSTABLE Permit No. . 9166....... BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash .......... .. . �uuv HYANNIS,MASS.02601 Bond .........(p ! CERTIFICATE OF USE AND OCCUPANCY Issued to S L S Trust Address Lot #6, 23 Larch Lane Centerville, Massachusetts USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. Building Inspector �'�y��•'. TOWN OF BARNSTABLE BUILDING DEPARTMENT = a NAM, ' TOWN OFFICE BUILD ING - HYANNIS, MASS.`02601 '�o cur►• MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by BuildingPermit #........._. .. ................... ............................................................._................. _...... _ ._.. Xx issued to .. ...... .L�.�...1!?............ .: .. .. .... �9• _. . .. nJ — Please release the performance bond. I gf�vL 3 g I 20 • I N IV +� ^F O /07/ v r IV p 3 0 U o 0 o IQ Act C ERTI FIE D PLOT PLAN ttcc L O CAT1 0N: � �r� GG ..7V• F 0 R•4l&t3 EL."1SOLGO SCALE: ��/ /— � DATE: /9S� R E F E R E N C E /�,G��/,e,�C0�2rO�p AT.B•9evS"TAt3GE 8so .1 CERTIFY TO THE BEST OF MY KNOW ED E EG. LAND SUPWEYOR, AND BELIEF FROM INFORMATION ACQU EDp THAT SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. OF JOSEPM yG� M. eg MONAHAN,JR. H , J. M . MONAHAN, JR . & ASSOCIATES No.13M PROFESSIONAL LAND: SURVEYOR..S .8 ENGINEERS �9�o6s� T.OWN,.E PLAZA - 9.00 ROUTE. 134:-_S_O T`H .D. E.NNLS,M.A_S.S.. 8�/�S