Loading...
HomeMy WebLinkAbout0084 LIAM LANE � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION h2-d*— Map �O Parcel. 0 pp .:�aq )�c ON Application # � Health;Division Date Issued Z' Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Project Street Address Y�4 '1 /��AV Village =*,&,��f�° Owner 4 Z c a Address Telephone Permit Request % ��./ ��`ras�' �/_V9,C /C 41 e 4e4l Aoez Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total`new Zoning District Flood Plain Groundwater Overlay Project Valuation - 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 L/No On Old King's Highway: ❑Yes lA No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ S2 CD Commercial ❑Yes ❑ No If yes, site plan review # o Current Use Proposed Use ? 2 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ,����d�, d � l Telephone Number z z� 1 54— Address IV XZIM4 ZT4 , License # Home Improvement Contractor# Z1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS°PROJECT WILL BE TAKEN TO �to y vto Jr SIGNATURE ' DATE r ti FOR OFFICIAL USE ONLY ,Y v APP� CATION# DATE ISSUED f : MAP/PARCEL NO. .r ADDRESS VILLAGE ` OWNER f DATE OF INSPECTION: FOUNDATIOM, :! FRAME INSULATION, 3 FIREPLACE , ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL 4 S GAS.:: _ - ROUGH ,,, FINAL FINAL BUILDING:;: k 7 'w f DATE CLOSED OUT t ASSOCIATION PLAN. NO. `yf * � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations w° 600 Washington Street v�rd y,0wa Boston, MA 02111 g www.mass.gov/dia Worker's compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I ib 2. C, o e , Address: City/State/Zip:��� 61A aa 601 phone#: -�Q Z- Z 7 Jr " /,_,Z z q 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 have 6. ❑ New construction employees(full and/or part-time).'r hired the sub-contractors listed on 7. ❑ Remodeling the attached sheet.$ 2. ❑ I am a sole proprietor or partnership These sub-contractors have g• ❑ Demolition and have no employees working for employees and have workers' comp. 9. ❑ Building addition me in any capacity. [No workers' insurance.$ 10. ❑ Electrical repairs or additions comp insurance required.] 5.❑ We are a corporation and its officers have exercised their tight of 11. Plumbing repairs or additions 3 ❑ I am a homeowner doing all work exemption per MGL c. 152§(4),and 12. Roof repairs myself. [No workers' comp. we have no employees. [No workers' 13. Other e(��� � insurance required.] t 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 attach 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: Af I C-6 r `er u rQ wc_e (..-0, Policy#or Self-ins.Lic.#: Q2CA d© � C'� 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 ma e forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here c ' under the ins and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only.Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date: 4/19/2012 Time: 10:13 AM To: Cape Cod Insulation, Inc M 1508-778-5735 Rogers & Gray Ins. Pages 002 Client#:4597 CCINSUL ACORD,. CERTIFICATE OF LIABILITY INSURANCE D4E(MMID 2YYYI THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WANED,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 NAMEA T CT Margaret Young Rogers&Gray Ins.-So.Dennis PHONE 508-760-4602 FA't 508-258-2102 434 Route 134 .(AIL Ext: A1C,No P.0.Box 1601 ADDRESS: youngma@rogersgray.com PRTDUCECUSTOMER ID#: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC If INSURED INSURER A:Peer)®SS Insurance 18333 Cape Cod Insulation Inc INSURER B:Ohio Casualty Insurance Company 455 Yarmouth Road INSURER C:Atlantic Charter Insurance Hyannis,MA 02601 INSURER D:Commerce Insurance Company 34754 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR TYPE OF INSURANCE ODL UVE)BR POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY CBP8263063 04/01/2011 04/01/2012 EACH OCCURRENCE $1 00O 000 MAET RENTED X COMMERCIAL GENERAL LIABILITY DAPREMISES Ea occurrence) $1 OO OOO CLAIMS-MADE �OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ PRODUCTS-COMPIOP AGG $2,000,000 POLICY PRO- LOC $ D AUTOMOBILE LIABILITY 11 MMBCKVMK 04/01/2011 04/0112012 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE.. X HIRED AUTOS $ - - q (Per accident) ` X NON-OWNED AUTOS - $ $ . B UMBRELLA LIAB X OCCUR 0001254514645 04/01/2011 0410112012 EACH OCCURRENCE $1 00O 000 EXCESS LIAS CLAIMS-MADE AGGREGATE $10001000 DEDUCTIBLE $ X RETENTION 10000 - $ C WORKERS COMPENSATION WCA00525902 06/3012011. 06/30/261 X WCS,TATU- 1.OTH- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORJPARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? 7 N/A (Mandatory in NH) _ E.L.DISEASE-EA EMPLOYEE $500,000 I(yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. , AUTHORIZED REPRESENTATIVE 01986-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S80552/M68179 M EE u aJ 1 C eMAO 10 Park Plaza - Su1te Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2012 Tr# 206433 CAPE COD INSULATION, INC ; x. � L ' F �.... ...-..�s:; HENRY CASSIDY : u = ly 455 YARMOUTH RD. iR -y HYANNIS, MA 02601 i r _Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS-CA1 is 5OM-04/04-G101216 Office o mer Affairs us'He Regul tion License or registration valid for individu!use en!; HOM� 6 Affairs before the expiration date. If found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation Expiration: 1.2/15/2012 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 9,10 D INSULATION INC HENRY CASSIDY,FJ , 455YARMOUTHRD;--7-,; HYANNIS, MA 02601, Undersecretary t alid ith t si tune V.ts ichusetts-::Departntent of Public Safeth Board of Building Regulations and Standar-ds" . Construction Supervisor License License: CS 100988 HENRY CASSIDY 8 SHED ROW WEST I ARMOLITH;-MA 02673 Expiration: 11/11/2013 ('onwii..i ne•r Tr#: 7620 "IMMMM m" mass save Com PERMIT AUTHORIZATION FORM zle�q, at:owner of the property located (Owner's Name,printed) (Property Street Address) (CitYffowrl) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature Da e. FOR CSO OFFICE USE ONLY L. L Conservation Services Group has'8"ig'ned'th'e foilowirig Mass Save Home Energy Services Participating Contractor to the above,referenced project:. Participating Contractor Date fi 7 Ar Rev.12132011 TOV, Off. CAPE COD ,`1, r LF INSULATION `7 ; °:_ t ! IIBER GLASS St A MEESE SPRATSOAM .SUSPENDER BATTS GUTTERS INSULATIGN CEILINGS 1-800-696-6611 Town of Barnstable Regulatory ato Services • Building Division 200 Main St Hyannis, MA 02601 " Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc.performed& completed the insulation and weatherization work at the.property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Pro eegy Address Village C Wjfl)-s &u&L. -TY b4vt kn g Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes Floors Walls Kite Fiat ( ,) , , (Y' )' ( 19 ) jy assid Jr, Pr sident Insul ion, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATIONo ' .; SEPTIC SYSTEM.MUST Map - •° � 'r Parcel ��� � •Permit# INSTALLED IN COMOLIffi4 Huth Division WITH TITLE 5 Date Issued NVIRONMENTAL CO® Conservation Division ��o �i?/ E Fee S. TOWN ECl�L4-��'i ;':'-' Tax Collector, O/a ©� Treasurer , 444 -Approved by Planning Board a, Project Street Address �, I a%� t���n ie Village Z9, ��� C~Q,Y �► �` Owner T . Address :`�2k �. oaw� Telephone Q�eo -D AAR rp e Sk Permit Request (,,Square feet: 1st floor: existing proposed 2nd floor: existing, proposed Total new Estimated Project Cost `�`���• Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size 10,963 S .F Grandfathered: ❑Yes ❑No .If yes, attach supporting documentation. ' Dwelling Type: Single Family Q Two Family ❑ Multi-Family(#units) Age of Existing Structure 1.0 yrs. Historic House: ❑Yes LAo 'On Old King's Highway: ❑Yes W,' o Basement Type: Ui/Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 1, 1Q A� 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: 2(Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes Ull No Fireplaces: Existing N e n e New Existing wood/coal stove: ❑Yes ❑No _D isting ❑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 El (9 Yes No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name ' ` ,Telephone Number Address ���gar a v _ License# / Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE _ �,oA b 'DATE `�1 FOR OFFICIAL USE ONLY iv _ p PERMIT NO. DATE ISSUED _ , i;; _ a♦ ; MAP/PARCEL NO. s �' VILLAGE ADDRESS ,. - � _ � VGJ , i .i ,mot♦ { OWNER t DATE OF INSPECTION FRAME' —, b Cy• INSUt,Aur ; FIREPLACC''E 4 Fr q 1• < — t ELECTRIGA'LY-- ROUGH FINAL 'Y PLUMBING: ROUGH FINAL GAS: ROUGH FINAL T FINAL BUILDING i� DATE CLOSED OUT ASSOCIATION PLAN NO. s ♦ < -t The Commonwealth of Massachusetts Department of Industrial Accidents -- 600 Washington Street �. Boston,Mass. 02111 Workers' Com ensation Insurance davit riirivrrr aoi.irrrrr name: location- - R city G I am a homeowner performing all ❑ I am a sole etor and have no one %/ ''n�� ,� workerscomp v. ,...:::::::.::.:}.::::::::::::.:,,.....:.:.:.. ............::.:::::.... .::..::........::.:.:.::::::.:. .:::.::.:::..:::::.. : lam an 1 �g ............:. .....,..,fir..r..:,:.M.:}::..:.::::::........ . ... �•Y•iv :�:................... .:•............:.:........:.............:..:•:::.......:r.......�''.'ski.....:..........,:::::....... ::::,.,.:..,,:;..:. am ... .... ...... ..r. ., .F. .....:v....::::::::::.�........::::::::v:::::.%%.iiiiii:{iiiiii.:::::.��•::•::w::;:::::.:.::...::...:.::................... i:;�:f{i{::%::vii:•:ti�i;'.%;;;:j:;%:;iii� .';iiYi:;i:;:y�i:v:::j:iiyy'i<;<:};;:;%:i:ii:::Y:?j:'`ii:?ii{':5::•::?:•:::•::::::.....:�:.. ............... ...-....::::::-:}ry•;••{.;•%i++iv'?::>::%%:i:}Yiyt?i}.n........,.. . a d SS .... .. ........ .::::::::��::}•:n;:{::vv:v:::::.i v. v r•v .....:::nv.:::.v::..,v.v.:.y.:%vr .............v:::::.v::::::::::::::::::::::{•ii::::::::::::::::::..:::'::'::":::::.:':'::::::;::::::::::::::::::::...... hone ::::.::.:;:;::•::::::::::.::::::::::::::.:......... ..... ..:............... .. ct ins%/% geIIe � 0r� one)and have hired the contractors listed below who ❑ am a sole �' havethe , ces.olt ensatzon :.::.,,:.:.,::..........:. P workers ............. :.::::.::.::�}:.::. .. ... ......:...:.::......:..:.........:.:......:...............,........... folio n...... ..... .. .... ..:... .. ................. ::::.::::. fir':::::....:::•.:.. n•::•::.;.:::::::::::::.:..........:,,:. }... ... •:r• :.v ;:r•.;i::• a mer :...,.. ... . iigiii comoanv :.:::::.... ..:....... : ... ......... ....... .{.... ... .:{.n JK.?: .....v:. :........... ::::v.y.:::::::.................................... :+..>:Y::L•Y:•i:Lii:Sv:4::{:.::::;ii:S:} :::............ :w;: ...::::• :{: ...r'}ti,:fi.. .::.fir•:•:+v-:•: •\., .;.•.:.. fi fir.• . . ............::... ... .. ..:::.:.::•:}-:.:rv::::::. ::::{fi}:{{;.}::�4:fiY�:i•:::•i:6:J}::•::v::•w::::iv'4i�:i%:::ii:Ji%Siii���' dress .......:........... . ................ ...�}. '3 .:.:::....:•:::.:........:.......{.:>:..;{;..�.::.:•.:'•::..... }.... .................. ......::.�:.:�:::::•:::•:::•:::{•:;•::::::•. ,or.Krd,%..... , ::.:•.::.{.,r.::•x. .:::::.+:fir,.:%;{.;�:�k�::::;;:%.};;;..,.:.;{.;.,<.:.:.;:.;}+:;•... ......................... ,,:•: r r .::�•::::::. hone.#'::.::: .. .......:,: . ......:::.::::.: .... SIN .::.::::......::::.........::fir:....;, v•.n:,. ... .x A.:.ww....... r t ns Oran . y{ ., ...r}.:..: x...:, .:.,,•::::::. ... ... .. ....,fir:.,:•:fis:}.{{:>•::...::.::}:•}:•};:�:•}:•};:•:•};:>:•}:;{•::::::•:::..�::.. ..... :•:...........:•.........k• ... . :. Tfiki........... .......... ......,.:.�:.:.....::.::�}>:•:::::::•:;•.�:::.::}:{. ...�•...,.,.....::... .x!•. firs.+-:A:.....,:,•,..:;.}•.}:.}}};{•}••:{•::::,:,•:.�:•....,....:.....,..,... .:,...:,:...................,:,.,,.....,. .... .... x .......fie .... ..fir.. ......... .. ..... „•:::::::.:::.....,r::::.,:::::..:.:::..:::::::::::::::::::::::::::::::.. .ram ..............:.,•:.:.....Yfi...}...:•.-..........r.. . ...........:............................,fir}.....r.:v.....::....f.{.....:.,v .... x.:n..::.{•.... ......................................................... ::S:+•:r:::i v:%:i}.;:t•-�:i}'��:;:;%i:'%y::i:%::i{i:�:::;'�:i'ty ]:r`:<:i+;ii:;:::::q'}i:i::: :i{Cii:+Y i:i:%��'::�:;?.:;::_:.:;y:?;i;::: r es . .- ..... ...... ..... ..n.......1.}:n .......J.. ....v.. �v1:w}}}:w:::::•:::.":r:'::::;:::::.•:�::is�!i%ti:is�i:::::;:;:iii:•;n+:::;:.i}ii}:'�i:i:•}::::•::::::::.........,. 1 '•--;��. �. hone-�'......:....................r........ ..... .. ..... .:.,.,... ...'!.!{.�}k,. •4LQy ...:. .. . .. ..........-..x,......::..........-. � -... .. fir.:.....}n...,S•...}.......:...: '. .. ..............:...... ... x.....fi.vn x gy�pp{{ .. : 1..:.w.v:•v::..•w:::; x:::n.....:........................................ ........ ....... ...... ..... :....r ..1... .v.... :,. ... yy��r: �( ...... .................................vn:;{{irr.::.:•::•:}}}i%' .. ..Tnvx.}�:::::•::::::::::•::::: ...........::::::.....v::•::n:....,..;y•.... .:.v:.v...xvx,{.}:{:..7}..��y. .: +:0...: v3^7.::.v;•.. ............. vC . ..................:::JiiYii:::\ Xr.A:.,+J/.•nY,.. .....•.•:�•::9r ia:{,+,?'�irM•,••.....,;�,p„•,•:�,,.. �i.i// ------------- Failure to secure covera;e as regtdxd mtder Seetton 2SA of MQ.1S2 eas<lead to the iutp of erint6ni penalties of a f3ae ttp to 51300.00 andior risomamt m weII as eivII peaaWa fa the form ota SLOP WOE ORDER and a tine of S100.00 a day against me. I mtderstand own one yesn'iznp be forwarded to the OIDtae otlnteatiLatitms otthe DIA for coven=e vedScation. copy of this atatementmay I do hereby certify under the ptsrres and penaltits°f penury the�mf°�QnOa provided above is tnu and correct Date AGOO Signature (� ` O5 Pit e\C��`c�a � TC \A�it� � do not write in thb area to be enm*ted by dty or town oMcW otIltiai use only perndOcense# QBuilding Department city or town: ❑Licensing Board ❑Selectmen's Office ❑check if immediate response is required []Health Department phi#, — ❑Other contact person: 01 Ormw 9i95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to the service of another workers' compensation aa i n °II'r for 17 employees. As quoted from the"law", an employee is defined as every Person in of hire. express or implied, oral or written. An ern lover is defined as an individuaL partnership, association, corporation or other legal entity, lover or the receivery two.or m eof or P g representatives of a deceased employer,the foregoing engaged in a joint enterprise, and including the legal rep to employees. Howes er the owner of a trustee of an individual,partnership, association or other legal entity, employing ' 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, con=uction 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 chaP ter 152 section 25 also states that every state or local licensing agency shall withhold the issuance o who has enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant the not produced acceptable evidence of compliance with the insurance coverage required. Additionally, commonwealth nor any of its political subdivisions shall eater into any contract for the performance of public work until acceptable evidence of compliance with the insuranceents of this chapter have been presented to the coaffacang authority. Applicants affidavit,completely,b checlang the box that applies to your situation and Please fill in the workers compensation affida omp Y� Y affidavits may supplying company names,address and phone numbers along with a certificate of insurance as all submitted to the Department of Industrial Acci for confirmation of insurance coverage. .Also be sure to sign and dents 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 DeparrMu=of Industrial Accidents. Should you have any questions regarding the "law"or if N ou are required to obtain a workers' compensations policy,please call the Department at the number fisted below. City or Towns legibly. The Department has provided a space at the bottom of the Please be sure that the affidavit is complete and printed egib y. applicant.licant. Please affidavit for you to fill out in the event the Office of Investigations has to contact you regarding m ay be returned -to sure to fill in the permit/license number which will be used as a reference number. The affidavits m the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would Bike to thank you in advance for you cooperation and should you have any questions- please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 exL 406, 409 or 375 CF THE Z • The Town of Barnstable , vsras : _ �. Department of Health Safety and Environmental Services i639. ate` Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-862-4038 Building Commissioner 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: ��� Y Estimated Costo 7 3 • L Address of Work: 014 ` f ' Owner's Name:il� Date of Application: a ° I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law []Job Under$1,000 tiding not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE ROGRAM OR GUARANTY FUND UNDER MGL c HOME IMPROVEMENT WORK DO NOT E. 142A. ACCESS TO THE ARBITRATION SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Contractor Name Registration No. Date OR a Owner's Name q:forms:Affidav 1 � JP r rso, �j. / / 4 ' �3 \ 4� � �Q S �•4t ti F N Ba�T s /g S `V IV S \Y 40, cwo S, — t' its• w�cr►� OF M,�s ' 30 F5,13 wow dug H NasuR� � CERTIFIED PLOT PLAN 40r iy 41AM <.4NF CFwr,ER✓i�.t_.._ NEW CONSTRUCTION ONLY TOP OF FOUNDATION IS 8t FEET IN ABOVE LOW POINT OF ADJACENT •. SA9. S TASLA411ASSO ROAD. SCALES /"=5v' DATES 3- z-83 -&L-QREQSC E G It A co-mo ceeu�se�E,e 1 CERTIFY THAT THE ,moo"� f>Ay0AJ CLIERT------- SHOWN ON THIS PLAN IS LOCATED EGISTERED eREGISTERM ljos No. _ ON THE GROUND AS INDICATED AND CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER %SURVEYOR OR.®Y� . Y OF BARNSTAS El ASS. 712 MAIN STREET CH.ilY$ ..�._ ._� _._...� H YA N A I S, MASS. SH99TLDf 1,_ DATE $CG. LAND SURVEYOR e � 4 " w A4 fil tv IT _ Rs q , L _ a t a , t fi a , d 14 3` Mv ,01 0 T OIL— rl i r i,'d 4 a a.Ph. - ri h40 tK Wit; AR 071 IMP VN Cie Ant f z E v � r x t No FAMi 1 OPERATE6 SIMcAt.-A 96@ a W p* < to. ' f w ff w Ww w �d 4 &4 loo W-2 ft J. Ak, 3 Jw 2 .. io 18IX416 CLASSIC #6 All 4 „ a Y " OUR NEW HAMPSHIRE CRAFTSMEN BEGIN EACHAND EVERY UNIT WITH CAREFUL , `�-• A '^'"� L k'SELECTION OF MATERIALS AND PRECISE REMENT. 4! Via 4 1-11 fill X IV t � '- I — 3 STANDARWFEAT,URES A rw of AVAILABLE WITH ALLin TYLISH AND PRACTICAL, FERRY SMALOBUILDINGS REEDS � : ra ERICAN SSIC SOL* Y OURAUTILItTY�SHED ORFECT 1 2 X 6 PRESSURE 7TREA ED FLOOR 1 6" ON CENTERti I � k � STORAGENEEDS THISBUDGET-FITTING m: = 2. 5/8".TOP-QUA 11 A 4MV _ ,S Q STYLE HAS BEEN THE POPULAR•CHOICE OF ,T ,w 3. 2 X 4, 16" ONeCENTER FRAMING ox CUSTOM ERSTHROUGHOUT OUR 35 YEAR p � " V it 4. TONGUE & GROOVE SIDING HISTORY- BUT WE'RE ALWAYS IMPROVING _ 5. HEAVY-DUTY ROOF TRUSSES, � ' 44 , AND ADDING, SO BE SURETO,REVIEW THESE 16" ON CENTER- W STANDARDFEATURES CURRENTLY AVAILABLE' " R NJ 6. ROOF SHEATHED WITH 1/2 EXTERIO � tti ' GRADE PLYWOOD (RIGHT): THISgST�YLE,AVAILABUE WALL _ may. 7 ALUMINUM DRIP EDGE ES ,RANGINGFROM 6' X 8' TO12' X 20 .� 8a A LE WITH SIZ �,_ �SVPHALT�ROOF SHING S W 1- 0 CLASSIC 4, A td � OYEAR LIMITED WARRANTY FA ' 9. ALUMINUM LOUVERS WITH SCREENS „ • ell REE = LIGHT WINDOW HINGED TO OPEN 46? LINE - Y . - 1 1 WINDOW BOX & SHUTTERS o . � , x ��' 12 S0LID�PINE DOORS DIAGONALLY BRACED w ,"'"AkA WITH 2ix 4'S AND THREE,6" HEAVY DUTY 5 D ZINC PLATE BLACK*HINGES: ro l s _ . SEE PAGE 5' FOR � ,:: � :M _. AVAILABLE OPTIONS „. CUSTOM DESIGN ANDpERMITSARE 7'I-1 �� E,CUSTOMERS MODEL FLOOR PLANS. .'RESPONSIBILITY WHERE�REQUIRED 4 4*L2 . ' ua e Town .of Barnstable -► FTME 1p Department of Health Safety and Environmental Services Building Division BAMSrABL4 ' 367 Main Street,Hyannis MA 02601 MASS. 9� 1639. 10� a Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION 1/ Please Print DATE: /"Am A�'06 JOB LOCATION: diM \tla" number street` A village ,•HOMEOWNER":Tlc:�/1o1 t ��\�! �r-cL �}c��J1 )► S I�uC��oL��U)C name home phone# -wosir phene CURRENT MAILING ADDRESS: city/town (? � i, state`3,67( zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. t Si ature 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 to amend and adopt such a form/certification for use in your community. M Q:FORMS:EXEMPTN Assessor's map and lot number ? .. ...1.�.:��.. r �%TH E � ! J Sewage Permit number ...L...... ........znl�qm................ ' Z B88dSTl►DLE, i House number ............r% t�.....r ....................................:.... s� NAM t639. �'0 YPY Or TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ................. ..... �'' TYPE OF CONSTRUCTION .............. .>.</..ia:;...�......... �,s��..,. ..............�............................... .......................... .�.<�. .=r.......19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: , Location ........................................... :.......;...?.......... ...-:.'....:::........................................................ ProposedUse .................................. !'z''%... ........... .r... ................................................................................ Zoning District .......................... ..........................Fire District ............. ...� ....v................. Name of Owner ........1G� jLf"�1,�.1............. 'Oa/,/;..Address ............... �::l..... ................................... Nameof Builder• .................... ? `1, ............................Address .................................................................................... Nameof Architect ..................................................................Address ..................................................................................... f Number of Rooms ..............................Foundation -q .':�� Exterior .......... . 4% 5....: : .'`.............Roofing ........................ yd......................................................... t� l � Floors �,f �s........:<.el.!,"..f.............................Interior ..................... ......................... Heating .......... . <'. :... .... '�t��...........................Plumbing ............... .... .,......../J`2........................................ Fireplace ......................... ..l ........................................Approximate Cost ................... :.... ..`�'. . Definitive Plan Approved by Planning Board _________ ??'??�l ------19 Area. .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ��� z, z ' 4� k J ' v1, OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding t•he above construction. Name ...................... ...................................... GREENBRIER CORP . A=167-16-- pjq ti 24841 1z Story No ................. Permit for .................................... Single Family Dwelling Location Lot #14.,....... . .... 8 4 Liam. ...Lane. . ....... . .. . .... ..... .. .... .. Centerville ............................................................................... Owner ,,,Greenbrier Corp. Type of Construction ...Frame ............................. ............................................................................... Plot ......................... . Lot ................................ March 9 , 83 Permit Granted ........................................19 Date of Inspection ....................................19 Date Completed ...........................`:.........19. �� r 4-1 As' ssor's map and lot_number ! .�7...��M. ��" //� ?�Of THE TQ� Sewage Permit number .. ` .. ........�G! ................ v o: '.�C y5rEhA L 1aL �� ♦� Gt.../......d f �� CO Z BAHB9TdHLE, i House number ........... TITLE aea TOWN 'OF B ik-N� Y �� fAit, i� BUILDING ; r. INSPECTOR C cx ,%� ....: . APPLICATION FOR:PERMIT TO :!......................... ............ ............ ............................... 3 TYPE OF CONSTRUCTION ..........:............ . ...G7.U. ' ,...,........................ ,i ...................... ..dr..19... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to thee� following information: Location ............................... .f?el.....................Z.5(........ r ( ................. :1zr.......... .......................................... ProposedUse ........................ ! ''tf�.." ......:.... /r'1 ;.;;k............................................................................... Zoning District .......................... . .............:..Fire District .....� / Nam_ e of Owner ... :`. it.r �`�lri�(a`. -::..Cd Address ................f G.i�..... .4.........................,......... Name of Builder' ...Address fn e—:....................... ............................. Name of Architect ..................................................................Address Number of Rooms ............................................:.....................Foundation ..... . $iu/' ..... '�'` .......... Exierior ............/'d.-".0...J4.1�6YS......f-'!ram.'/-t .......Roofing .............. .................... Floors ..........:: ;4�,r :.. �.`�`y. .....................Interior ..................... ...0 ........................ Heating ............. ...........................Plumbing ...............I........��.......( ............................ Fireplace ......................... ..f ........................................Approximate Cost ..................._5 ...Fa.0.U.......... Definitive Plan Approved by Planning Board ______19 Area ......,[.I.F6.....5. ........... Diagram of Lot and Building with Dimensions Fee .........3...........� ��......................... k SUBJECT TO APPROVAL' OF BOARD OF HEALTH a 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. lL- Name ...................... ... ............... ........... GREENBRIER CORP. tij tory 24841 13-2 Sc ................ Permit for .................................... Family Dwelling ... ........................................................ Location Lot #14, 84 Liam Lane ................................................................ Centerville ................................................. 0-wner'.. . .Greenbrier CorP ........... -- . . ............... ..................... Type of Construction. .....Frame .............................. ....... ................................................................................. 7 Plot ............................. Lot ............ t- Permit Granted ..March .9, 83 ....................................19 Ile Date of Inspection .....................................19 1*4j....... 4. Date Completed ........ .. . ........1, ti 1 �— / t' A:4�.iIvi a� 44 r F •yam S�- n V`(.. OF Mq 3c) -5.a' Z9874 C �a suR��-y•� CERTIFIED PLOT PLAN I-ar /y LIAkl X,4Ma CF.iy7-�-R✓j�L.- _ NEW CONSTRUCTION ONLY � TOP OF FOUNDATION IS 8.1.... FEET IN ABOVE LOW POINT OF ADJACENT ROAD. SCALES "=sv DATE, 3- z-83 c, �ur�p, I CERTIFY THAT THE _`o ,.rcArro{y CLIMUT SHOWN ON THIS PLAN IS LOCATED EGISTERED REOISTEREO �� a0. � � ON THE GROUND AS INDICATED AND CIVIL I LAND CONFORMS TO THE ZONING LAWS ENGINEER 31�R19E.0R DR. .. pF GARNSTAB E , ASS. 712 MAIN STREET : 03'o2�a HYANhIIS,. MASS. DATE REG. LAND SURVEYOR -.---,TOWN OF BARNSTABLE Permit No. 4$4 Building Inspector Cash ---------- ' OCCUPANCY PERMIT Bond _--_--_X /3-___ ' Issued to Greenbrier^Corp. Address Lot 14, ; t84 Liam Lane, Centerville Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date - - z X Engineering Department ��..a°''f �.�,� .,�'nr''� Inspection'date.f Board of Health4 - Inspection date 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. f 1 �3 Li"', �t/..�:3............... 19 ....... ...... .......................................,................................ ...».. ... Building Inspector k E.. -F—T �N �� 00 �Q a Ilk A.47.,2A. Al It 0 1 G T `N OF a o E IERG ydC)C) 1 H t ELL181 �� No. 366 0• i 2 S \,jv l i "I 'L l ci12YER`���`"� 1Q �hO SURV 'O \'IONAL ENS' " 1�� a?, LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 EXISTING CONTOUR O --- Li:-_>T 14 - L j A m . LA—it= FINISHED SPOT ELEVATION . C�L1-f�C-\,/I FINISHED -CONTOUR O -- IN APPROVEDs BOARD OF HEALTH -rRI"^�'-r�'P JL4 OAT E AGENT SCALE, I "= 5�' DATE del, I S•83 L�LD/R°EDGE ENGINEERING CQ IN CLIENTS I CERTIFY THAT THE PROPOSED EGISTERk REGISTERED. JOB NO.. &Ioi I BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS. TO THE ZONING LAWS . DR�BY� J:��::.' ENGINEER RV OF ;BARNSTAat ASS12 MAIN STREET: CH. 8Y HYANNIS, MASS. 2 - SHEET�:, OF GATE R LAND SURVEYOR