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0104 LIAM LANE
a� ��� . � � . � z a 5 y O 1 - R V ` v `. .cam' ,. o r � p w - _s_ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r,1 OF 9 A R aTr8LEI Map �" Parcel © Application # �� Health Division �` .°} ? j9 2- 111 3, Date Issued /0— f 71 f Conservation Division Application Fee Planning Dept. -.w.,.� . •A . . .o Permit Fee . - Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address Village Owner 1 o tt` S' Address ES_g,fr,C_�, Telephone 5O R Y Q-0 ' 1 Permit Request A J �C. ' 1 E t �1 � � Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 9 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 6 MI �.0 l� � ` "•Telephone Number 9 Address ' 41A 44,fA A � License # T Home Improvement Contractor# Email Worker's Compensation # q O 3'6 o ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��rw��1 SIGNATURE DATE l' 6 FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH. FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r a ... t Town ofBakostable u.eavavcrrM�:' �Z1C�lar��.$��lt;Y3�IY9Ct�C Touti'Pt'"'y;8wl ing eo�ritnisstoner 2001Vlerra�trec jrbnnis t o 02-60 �t�:tavYn �at-nst$bte.naus r . Offi-ee: 08=$62-403$ Fix 50847 0.-6230: o �ete d Sa; � S�c�o�� - • Js on i der ; f ►�1`'S DYYI S -asOftexof Elie sJexY iiex+�b�a�hoi3ze � ,, � ta.a onzay�� • in aU matters x1at ve to work by this building: 'Volicat 6 .-for: "`Pool�fence$ and'asr�eresponsra��r��: ��ci Paois - - �re xa be f arAiiedlef iez e. all d`a al sgecaozs:are pex �zmec�AnctacceptetL $' `SVuatm of Appl�c Pit dame: Fz O Nail, q:Ea :o� .z�es �ozapaors The Commonwealth of Massachusetts Mr. w Department of Industrial Accidents ' 1 Congress Stree4 Suite.100 Boston,MA 02114-2017'. t " . www.mass.gov1dia , v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumtiers. r TO BE FILED WITH THEYERMITTING AUTHORITY. Applicant Information Please Print Legibly. F - NaMP(Business/Organization/Individual):Cape Save inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone# .508-398-0398 Are you:an employer?Check the appropriate box; Type of project(required): L[D I am a employer with 5 empto .. d/orp -ti me):°. ,. 7. New constriction ees(ullinart 2. I am a sole proprietor or partnership'and have.no employees working for me in y i ' 8. Q Remodeling any capacity.[No workers'comp.insurance required.] ' 9. D Demolition 3.�I am a homeowner doing all.work myself.[No workers'comp,insurance.required:]f• , . ` 10 0 Building addition , 4.❑,I am a homeowner and will be hiring contractors to conduct all work on my property. I will - ensure that all contractors either have workers'compensation insurance:or are sole ME]Electrical repairs oradditions proprietors with.no employees. '12.❑.Plumbing repairs or additions r 5M.I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13:QRO6f repairs These sub-contractors have employees:and have workers'comp.insurance.- 6..Q We are a corporation:and its officers have exercised their right of exemption per MGL c. 14. Other.IriSUlatlori.` 1.52,§1(4),and we.have no employees.[No workers.'comp.insurance required:] *Any applicant that checks box#1 must also:fill out the section below showing their workers'compensation.policyinformation. .... ' t Homeowners Who submit this Affidavit indicating,they are doing all work and then.hire outside contractors must submit anew:affidavit.indicating such. ~Contractors that check this box:must atWhed an additional sheet showing the name of the subxontractors and state whether or not those.entities have employees. If the sub-contractors have employees,they must provide their workers'comp policynumber. I am an employer that.is providing workers'compensation insurance.formy'employees. Below is the policy and job site information. Insurance Company Name- Star.Insurance Co. . Policy#or Self-ins.Lic.# WC085540700 Expiration Date: 4/9/2017 Job Site.Address: 104 1.ram Lane ' *City/State/Zip:Centerville Attach a.copy of the workers'compensation policy declaration page(showing the policy number and.expiration date). Failure to secure coverage as required under MGL.c:152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well:as civil>penalties:in the.form of a STOP WORK ORDER and a fine of upao$250.00 a day against the violator.A.copy ofthis statement may be.forwarded-to the Office of Investigations-of the.DIA.for insurance coverage verification. I do hereby certify under A pains.and penalties of per'oiylhat the information provided above is true and correct , Signature- _ Date: I / / 6 Phone#:608-398-0308 Official use,only. Do not write in this area,to be completed by city or town ofciat City or Town: x Ferinit/License Issuing Authority(circle one): 1.Board of Health 1 Building Department 3.City/Town Clerk 4.Electrical.inspector S.:Piumbing Inspector 6.Other Contact Person: Phone#- DATE(MMIDDIYYYY) ACC>RiY CERTIFICATE OF LIABILITY INSURANCE 4/12/2016 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 ISSUINt3 1NSURER(Sj, AUTHORIZED REPRESENTATIVE OR IPRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an.ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the:policy,certain policies may require an endorsement. A statement on this Certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT.Risk Strate ies Co - NAME: g mPany Risk Strategies Company PHCIN E (781)986-4400 FAX No.(781)963-4420 15 Pacella Park DriveEMDAILSS:randolphcld@risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAIC# . Randolph 14A 02368 INsuRERA:Selective Ins. of America INSURED INSURERS Allmerica Financial Alliance Ins Cc 10212 `Cape Save, Inc INSURERC:Star Insurance do 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth NA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1641211375 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 MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE:INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE.TERMS, EXCLUSIONSAND CONDITIONS OF SUCH-POLICIES.LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR DDL SUER POLICY EFF POLICY EXP - - - LTR TYPE OF INSURANCE POLICY NUMBER MMfDD MIDD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,600,000 A CLAIMSWADE XX OCCUR PREMISES Es occurrence $ 100,000 X 91994480 10/16/201S 10/16/2616 MED EXP oneperson) $ 10,000. PERSONAL&ADV INJURY $ 1,0.0 a,00.0 GENL AGGREGATE LIMIT APPLIES PER:. GENERAL AGGREGATE $ 2,000,000 POLICY.I— I JERCOT �LOC - PRODUCTS-COMPIOP AGG $ 2,0:00,00:0- OTHER, $ • AUTOMOBILE LIABILITY OMBINED SNGL_LIM_ $ 1,000,000 Ee.accident B ANY AUTO BODILY INJURY(Per person) $ - ALL X SCHEDULED AVEA467966.00 11/6/2015 11/6/2016 BODILY INJURY(Per accident) $ NO'OVWED PROPERTY DAMAGE X HIREDAUTOS X AUTOS Perecadent $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION-$ NIL 1 101994480 10/16/2013 10/16/2016 F $ `- WORKERSCOMPENSAT10N - - Officers Included for x STATUTE :_ORH AND:EMPLOYERS,LIABILITY ANY PROPRIETORJPARTNERIF�CUTIVE YIN NIA Coverage E.L.EACH ACCIDENT $ 500 000- OFRCERIMEMBE2 EXCLUDED? N - G (Mandatory inNH) .., , Bc085540700 4/9/2016 4/9/2017. E.LDISEASE-EAEMPLOYE $ 500,000 Ifese untler a S.desentDRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 500,000 DESCRIPTION OF OPERATIONS i LOCATIONs i VEHICLES(ACORD 9O7;Additional Remarks Schedule;maybe attached if more space Is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of named insured As required by Written Contract. CERTIFICATE HOLDER CANCELLATION SHOULD.ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable County 460 Lest Main Street AUTHORIZED REPRESENTATIVE Hyannis, M 0269.1 Michael Christian/CLCv ©1088=2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are:registered marks of ACORD INS025 Q01401) r Office.of Consumet Affairs and.:Bus>ness Regulation I. Park Plaza Suite 5170: Boston,;Massachusetts 02116 Home Improvement;Contractor Reglstratlorii Registration 171380 Type .Corporation Wt M " Expiration.. 3114/2018 Tr# 41929I CAPE SAVE INC. s s WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH=YARMOUTH;:MA 02664; yV ,,,•i ,_ `) � Update Address and return card Mark reason for change. P Address }'Renewal- 0 Employment [j Lost Card SCA 1 0 26M-05111. J ea'�,�„ca,�coecr�f/e.o�Cj�i,us�,claae License or re istratlon valid for mdividul use onl Office of Consumer Affairs:&Busifiess Regulation g Y — before the expiration date. If found)return to HOME IMPROVEMENT CONTRACTOR Registration 1713g0 Type Office of Consumer Affarrs}and Businesv egulation: Expiration 3/14/2018 Corporation 1:0 Park Plaza-Suite 5170. BostonIMA 02,116 CAPE SAVE INC. s z :c WILLIAM McCLUSKEY '7-D HUNT[NGTON AVE NUE= SOUTH YARMOIJTH,MA 0261i4 Undersecretary Not valid- i `signature Massachusetts-Department of:Public Safety Construction Supervisor Specialty Board of Building'Re Regulations and Standards Restricted to: 5 CSSL-IC-Insulation Contractor �uoact.iiGiiilu-.JiiiiE•ivi Fi7' ua ty License: CSSL 102'7T6 �: WILLIAM J'MC 37 NAUSET ROAD .� w West Yarmouth MA Failure to possess a current edition of the Massachusetts E,xpiration State Building Code is cause for revocation of this license. Commissioner 06/2812017 DIPS Licensing information visit:WWW.MASS.GOVlDPS 10/12/,'2016 16:00 15085647950 PONDSCAPES STOVE CNT PAGE 02/02 Office.of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston,Massachusetts 02116 Home Improvement tor Registration r Registration: 173250 Type_ Private Comoration N �' w Expiration: 9120/2018 rr# 4197-91 CAPE COD POND SUPPLIES, INC.,d ROBERT HANFLIG a ' 'o 1220 RTE 28A, P.O. BOX 700 CATAUMET, MA 02534 Update Addres and returns card.Mark reason for change. [] Address [] Renewal Emplogment L"t Card SCA 1 Ca 20M-MI I License or registration valid for individual use only 011ice of Consumer AMirs&Bonne$$Regulatioa HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Regwtmflonk 1��3250 Type: Office of Consumer Affairs and Business Regulation. 6 Expired o a Private Corporation 10 Park Plaza-Suite 5170 m - Boston,MA 02116 CAPE COD POND�I / THE STOVE CENTF�Ft� ROBERT HAPJFUG 1220 RTE CATAUMET,MA 02534 - Undersecretary Not valid wlt of rgnatnre .j� , it $ • � Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 11/30/16 Thomas Perry CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit 16-3029 T Dear Mr. Perry This affidavit is to certify that all work completed for 104 Liam Lane,Centerville has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. f All work performed meets or exceeds Federal and State Requirements. w Sincerely, • f William McCluskey DIE?" 1001 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �f� (J l Application # - Health Division Date Issued L4 < < Conservation Division ( rh; � �l �y `Applicatio`n Fee Planning Dept. Permit Fee: 3 2 •`�� Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address O �'/ /_ r`of Ly� `_ u.0 e Village G GV7 Tf `/ Owner oyizi el fi le S AAC7/1 S Address '^/ L `sic 1?1-7 Telephone — C� C C ./ 7 Permit Request c, C4 .16 6u Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 75" )06> Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. ,rL/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 3/No On Old King's Highway: ❑Yes ❑ No Basement Type: 5d Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) 4!9— Basement Unfinished Area(sq.ft) ` L_ Number of Baths: Full: existing 3 new Half: existing new / Number of Bedrooms: existing new X2- Total Room Count (not including baths): existing new j Z First Floor Room Count Heat Type and Fuel: ❑`Gas ❑ Oil ❑ Electric ❑Other Central Air: g Yes ❑ No Fireplaces: Existing i New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: Cdexisting 0 new size _ Barn: ❑existing Elnew size_ Attached garage: O'existing ❑ new size _Shed: 0 existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION4 L� .— . p , (BUILDER OR HOMEOWNER) (o` Name O-evi 5 Telephone Number L0-a CXP7'/ Address �� �� i UL621 �0 Pq (. License# r C- e/_ relL/,`//-t( v 163 1— Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C. L IV C70 ki M �-i Lv e S' .f 13 r l�s SIGNATURE DATE 3/ 912Cl/ s r s FOR OFFICIAL USE ONLY APPLICATION# 0 _DATE_ISSUED�, T MAPS/PARCEL NO - ADDRESS VILLAGE OWNER ,a .DATE OF INSPECTION: FOUNDATION FRAME. mz 4-11-1111 INSULATION:l " 3111 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL .` GAS" "' 'ROUGH FINAL M.rEtNALBUILDING°x sx DATE CLOSED OUT' '� ASSOCIATION PLAN.NO: r.y The Commonwealth of Massachusetts I Department of Industrial Accidents Office oflnvestigations 600 Washington Street 1 llill; i ,\ .4/. Boston, MA 02111 =Y wlvw.mass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly eMarlle(Busin 0 anization/Individual): �A'ddres'`s City_/_S.tate/Z=ip= Phone # Are you an employer? Check the appropriate b Type of project(required): I.❑ I am a employer with am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions Myself.[No workers' comp. c. 152, §1(4), and we have no 12,❑ Roof repairs insurance required.].t employees. [No workers' 13.❑ Other comp, insurance required.] *Any applicant that checks box#I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site ,information. Insurance Company Name: Policy#or Self-ins. Lie, #: 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 maybe forwarded to the Office of Investigations ofthe DIA for insurance coverage verification. I do hereby ce if undgr pai and penalties'of perjury that the information provided above is true and correct. i nahire� CPhone-#_ __ 41v 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 Infoarmation 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." s 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 corn-Monwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until,,auceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely;by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,'please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please.be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant . that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of:the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call.The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Town. of Barnstable: o . ti Regul'atoty Ser'Vzces.. STABLF- Thomas F. Geiler,Director RkRN Building Division `'reo Mai� Tom Perry, Building Commissioner 200 Main.Street, Hyannis,.MA_02601 R�v.fown.barnstable_ma:us., - Office: 508-862 4038 Fax: 508-790-6230 HOMEOWNER LICFNNSE EXEMPTION 9 Please Print DATE: �C/ &0Z / JOB LOCATION: �C �� L lc n' Lcs�, L('_�Z Pi ✓y'/� number street village "HOMEOWNER": 4—le 1-✓, 5 S-�F( //,L' 24 7 3 6 7, 7S-a:�S name home phone# work phone# CURRENT MAILING ADDRESS: 16 -! L q-uen � city/town \ state zip code The current exemption for"homeowners"was extended to include owwner-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 SupCZV7SOr_ � x DEFI7iMON OF Bolymb 'NER {, Persons)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-farriily dwelling,attached or detached structures accessory to such use and/or farm st7uctures; A person who cons"Cts more than one home in a two-year period shall not be considered a hotneowar-r. 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/sbe understands the Town of Barnstable Building Department rrrinimum inspection procedures and requirements and that he/sbc will comply with said procedures and req=amentss�j t Srgnatrire of Homeowner Approval of Building Offrcial 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. HOh�O WNER'S EXEMPTION .•rne Code gtacu that: "Any homeowner performing work for which a building permit is rcquircd shall be exempt from the provisions Of this section.{Section 109.1.1 -Licensing ofcanatruction Supcnisors);provided that if the homeowner engages aperson(s)for.hire to do such work,that such Homeowner shall act as supervism' Many homeowners who use this exemption are unaware that they arc assuring the responsibilities of a svpervisor(see Appendix Q, Ku)cs&Rcgu.lations for Liccnsung Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this ease,our Board cannot proceed against the unlicensed person as it would with a liccnscd Supervisor. 7be homcowncr acting as Superyisor is ultimately responstb)c. To ensure that the homeowner is fully aware of his/her responnbilitirs,many communities require,as part of the permit.apptieation, that the hDmc0Yvncr certify that he/she understands the responnbilitics of a Supervisor. On the last page of this issue is e form currently used by several towns. You may care t amend and adopt such a form/ccrtification for use in your eorrununity: Town of Barnstable F q Regulatory Services MAIM �. Thomas F. Geiler,Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 509-962-4039 Fax: 509-790-623 Property Cw)ierMust Complete and Sign Y6S Section If Usffi A B ilder I, _ , ;, , as Owner of the subject property hereby authorize to act on my behalf, is all matters relative to rk autho d by this building permit application for. dress of job)- S. gnature o Owner Date Print Name If.Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. D ream a PO&I worgl:�� PVI D Ua t r ov, ` JOB 1�ia M�Y►t + TAYLOR DESIGN ASSOC., INC. Tp SHEET NO. „` OF P.O. Box 1313 a. Forestdale, MA 02644 CALCULATED BY Cs l DATE Tel./Fax: (508) 790-4686 CHECKED BY C��UaT C I A,1&I "t'"l J�c.c.�7- SCALE .... _ ...__. . m o: . ... . c..� _ - 'S Pa-�- �.. ..... . _. Z ........ ... _.. _ . .. t P " - - - 4 ,1 .. .i . 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RightFax N1-1 3/11/2011 6: 49: 04 AM PAGE 2/002 ' Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE 03/11/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION.ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE. OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:It the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT , NAME: PHONE FAX JOHN P RUSSELL INS (A/C,No,Ext): FAX (A/C,No): 65 PEARL ST E-MAIL ADDRESS: PRODUCER STOUGHTON,MA 02072 CUSTOMER ID 2B29Y INSURER(S)AFFORDING COVERAGE --PtAIC# INSURED INSURER A: HARTFORD GROUPd r? . INSURER B: . a PERRY CHRIS DBA C PERRY CONSTRUCTION INSURER C: INSURER D:. 5 BARBERRY LANE INSURER E: r NORTH EASTON,MA 023563610 INSURER F: --1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN61CATED. 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 POLICIEtSY LIMITS SHOWN MAY HAVE BEEN REDUC ED BY PAI D CLAIMS. - - INSR ADDLSUBR POLICY EFF DATE POLICY EXP DATE - TYPE OF INSURANCE POLICY NUMBER (MNNDD\YYYY) ' (MNNDD\YYYY) LIMITS LTR INSR WVD - GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE OCCUR. PREMISES(Ea occurrence) . MED EXP(Any one person) $ PERSONAL&&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROJECT LOG PRODUCTS-,COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO : LIMIT(Ea accident)' ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ `(Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ :. RETENTION $ $ WC STATUTORY LIMITS OTHER WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY Y/N UB-028GN350-10 03/29/2010, 0 3/2 312 0 1 1 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITOWPARTNER/EXECUTIVE Y E.L.DISEASE-EA.EMPLOYEE $ 100,000 OFFICERIMEMBER EXCLUDED? _ (Mandatory in NH) E.L.DISEASE-POLICY LIMIT $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING W ORKERS COMP COVERAGE:: THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PERRY CHRIS.. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE' 367 MAIN STREET. WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �r•.rrrrnt�rr.r.r. tips n;+.cni T-eo.. ... .—.°..r:. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION YWA MapParcel + d1 1 Application # Health`Division Date Issued -7 �`� ' d� Conservation Division Application Fee 4M Planning Dept. 'Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ��L� L i2 two Lct�t Village (f 2�Z r-e✓ y i ll-e_ Owner It 1-0( F_T7 1? (� �('/ Y/ S Address Telephone G�� CO-? Permit Request . `- 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 ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (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 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name/ ,/y)S' Ar/,4 Telephone Number , Address � � ��1 License# �5 11 Home Improvement Contractor# 12-2Z 3-5— Worker's Compensation # OV 6-02g, A1_35"`'11 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 211 i l 1 t D F FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED : MAP/PARCEL NO,. r s j Y ADDRESS VILLAGE OWNER DATE OF INSPECTION: { FOUNDATION: ti FRAME INSULATION s FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL -t GAS: -ROUGH 0A." � .* FINAL - ; FINAL BUI_L`DING`° S z F z DATE CLOSED OUT ASSOCIATION PLAN NO. a - G 0 4xb -s- T if v + w n� sv 1 y ' ilassachusetts-Department of Public Safety. 13oard.0f Building Rea.ulations and Standards Construction Supervisor License One-and Two-Family Dwellings License: CS 55939 CHRISTOPHE'R PERRY 5 BARBERRY LANE, ' tl k N EASTON MA 02356 g G— �,-G_ Expiration: 10/13/2012:_ Cnnun issionel, Tr#: 3628 _Tle -ell rno�uuea a�✓�aaoar,<ue a Office of Consumer Affairs&Bdsiness Regalation HOME IMPROVEMENT CONTRACTOR Registration--F 1z2235 Type: Expiration 81612012` DBA C. RRY CONST i t) It 1 T CHRISTOPHER PRRY 5:13ARBERRY LANES = gQ NO.:EASTON, MA 02356tL Undersecretaey 1 .. ..i. RightFax N3-2 2/15/2011 9:54 : 29 AM PAGE 2/002 - Fax Server ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ' 02/15/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:11 the,certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX JOHNP RUSSELL INS (A/C,No,Ext): FAX (A/C,No): 65 PEARL ST E-MAIL ADDRESS: PRODUCER STOUGHTON,MA 02072 CUSTOMER ID#: 2629Y INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: HARTFORD GROUP INSURER B: "y5 PERRY CHRIS DBA C PERRY CONSTRUCTION INSURER C: ., INSURER D: _ 5 BARBERRY LANE INSURER E: NORTH EASTON,MA 023563610 INSURER F: in 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. °.r NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED f OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - •ADDLSUBR POLICY EFF DATE POLICY EXP DATE v TYPE OF INSURANCE POLICY NUMBER (MMBDD\YYYY)- (MMADD\YYYY) LIMITS LTR INSR WVD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY . DAMAGE TO RENTED $ CLAIMS MADE OCCUR: PREMISES(Ea occurrence) MED EXP(Any one person) $ GENTAGGREGATE LIMIT APPLIES PER:. PERSONAL&&ADV INJURY $GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY„ $ SCHEDULE AUTOS (Per person) HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA.LIAB OCCUR . EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ _ WC STATUTORY LIMITS OTHER - WORKER'S COMPENSATION AND ' EMPLOYER'S LIABILITY Y/N UB-0286N350-10 03/23/2010 03/23/2011 E.L.EACH ACCIDENT $ 100,000 ANY PROPERITOR/PARTNER/EXECUTIVE Y E.L.DISEASE-'EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-POLICY LIMIT $ 500,000 11 yes,describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERURCATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORICGP.S'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PERRY CHINS. CERTIFICATE HOLDER CANCELLATION TOWN OF BARIV-STABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE 367 MAIN STREET WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE HYANNIS,MA 02601 Raman Ayer ACORD 25(2009/09) 1988-2009 ACORD CORPORATION. All rights reserved. The Commonwealth of Massachusetts c ^a Department of Industrial Accidents Office of Investigations 1 600 Washington Street Boston, MA 02111 c� www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): /IGvI LG v Address: City/State/Zip: Phone #: Are yo n employer? Check the appropriate box: Type of project(required): I.21 am a employer with 4. 0 I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t 7 LirRemodeling- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in.any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LE] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *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 their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name:~Y 4J�a 1�D Policy#or Self ins. Lic. #: --4(720 y "��G�.O ICjN�S Expiration Date: Job Site Address: V ,( City/State/Zip: �a 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 hereb unde th ai and p nalties of perjury that the information provided above is true and correct. Si atur ' / Date: �. Phone#: CK- ® Y�J�/b G�. C. ( � ' SD 52,9 9 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#: T T�,ti Town of Barrnstable Regulatory Services t tAxxsrAsr.E, MAss. g Thomas F. Geiler,Director `�� Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable:ma.us Office: 508-862-4038 ,. Fax: 508-790-6230 Property Owner Must Complete and.Sign This Section If Using`A Builder Y✓r-f as Owner of the subject property hereby authorize �. r e✓h. (�d,2 S IY a e/'to to act on my behalf, in all matters relative to work`authorized byathis building permit application for: h /0 q Lea<� (Address of Job) Al Signature of Owner Date Oat 4- C-�- mar Print Name i If Property Owner is applying for permit please complete:the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION 'THE ray Town of Barnstable o Regulatory Services Thomas F. Geiler, Director KA-S& Building Division PrFD}AA't h Tom Perry, Building Commissioner 200 Maid-Street,._Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state, zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does notVoss6ss a license,provided that the owner acts as supervisor. w..'DEFINITION;OF HOMEOWNER'. 1 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 constMcts 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.hr-Abe understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. 1A 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 requimd shall be exempt from the provisi ons of this section.(Scetion 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assur ing 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 responsibilitics 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 forrn/ccrtification for use in your community. Q:forms:homccxcmpt r �TME T Town of Barnstable # Y Regulatory Services Y BARNSfABLE, Q MASS. �, Thomas F. Geiler, Director Op i639 ♦0 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR owner of property located at UP.7T e z.✓ e , hereby certify that (2x f yc{ ,'H is no longer Construction Supervisor listed on the application for the project under construction as authorized by a001 building permit#J o Z/q,.issued on 201 - I understand that project under construction J pe h r ' _ t o n must cease until a su ccessor Construction Supervisor, is submitted on the records'of the Building Division. PROPERTY OWNER DAT q/forms/newcontr reference R-5 780 CMR rev:110410 °FIME 1pk� , Town of Barnstable Regulatory Services • IARNSTABLE, ► - 9 ryjpgg- p Thomas F. Geiler,Director $'DrEc vINN Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 b www.town.barnstable.ma.us Office: 508-862-4038 (Fax: 5.08-790-6230 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY I, it Ind ;r Constructionp Su ervisor License hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit # ,issued to (property address) on ! 1 , 201 . The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemption form (if applicable) copy of my Home Improvement Contractor registration (if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit, Road Bond (if applicable) LICEN E LDER D TE q/forms/newcontrb rev:110410 ` TOWN OF BARNSTABLE,BUILDING PERMIT,APPLICATION,. . a r 'Application # ` a Map Parcel 1 Health Division "Date Issued Conservation Division 1. J1 Application Fe Planning.Dept: 'Permit Fee Date Definitive;Plan Approved by Planning Board Historic = OKH — Preservation/Hyannis Project Street �Address 1—tr4M L/V Village CF�N7rl�- V i LL Owner ;AZIt I ��s�SG'� (,fir//9'f� Address Telephone Permit Request in 8 Zi S' d"d,-( , : /cLvdr7 ful �ICaG��lro�l)p ' 4 S bare feet: 1 st floor: existing �` roar 1 q g�p posed � 2nd floor: existing proposed Total new Zoning District, Flood Plain Groundwater Overlay Project Valuatio OOv Construction Type Lot Size Grandfathered: ❑Yes' ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Y Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes Urf' o On Old King's Highway: ❑Yes &+ Jo Basement Type: YFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.); � �_o Basement Unfinished Area (sq.ft) Number of Baths: Full: existing 3 new Half: existing new Number of Bedrooms: : existing new g Co Total Room Count (not including baths): existing new First Floor'ERom Coin c� Heat Type and Fuel: &'Gas ❑ Oil ❑ Electric ❑ Other wt w ri. Central Air: RrYes ❑ No Fireplaces: Existing New Existing wood%coal stoA: ❑ yes ❑ No r Detached garage: ❑ existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing 6 ne size_ Attached garage: Yexisting ❑ new size _Shed: ❑ existing ❑ new size — Other: " Zoning Board of Appeals Authorization ❑ Appeal # Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR AHOMEOWNER) ,�Cv� U Yo flame �qwr� Telephone Number (?,gn? Jig- �4 Address /U 5��� lUs' S/� License# CS l�4"II S Mt� C�26 0 Home Improvement Contractor# Worker's Compensation # 04 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE // DATE FOR OFFICIAL USE ONLY APPLICATION# r, DATE ISSUED MAP/PARCEL NO. a ADDRESS VILLAGE OWNER ' DATE OF INSPECTION: FOUNDATION I FRAME Luoy INSULATION ® 9 0 FIREPLACE t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 5 GAS: ROUGH FINAL ff FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Assessor's office(1 st Floor): px ,•. .w„ Assessor's map and lot number f Board of Health(3rd floor): ¢ Sewage Permit number ✓ W Y ®� edi�'JT�� 4w•tEy t,,.. Z DASd9?ADLL i Engineering Department(3rd floor): 5a �, � a ryua House number 'bsq Definitive Plan Approved by Planning Board 19 0 Nit'(A- APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only p PRo v zTOWN OF BARNSTABLE aw"t $crvalmcos IMILDING INSPECTOR ss> -W TYPE OF CONSTRUCTION "�4��.�Frz � 2 U-1'p. . "mod 1 S 19 Q C, TO THE INSPECTOR OF BUILDINGS: t The undersigned hereby applies for a permit according to the following information:;,,. --�-� Location A L Q CEa-TLeyILL E Proposed Use kvpaI&J y ) ik23,)� Tcs� c' . Zoning District � ' j _ Fire District 40 kf,-l / ^� VI J L.� G G Yn o�l'k Address y -S y' ��. -BIC i�A 1 k IIS F�i Name of Owrier `�� Name of,Builder AV(Sr&?-acP C1 a Address !)i 5 ia@�'ck.s 1J Qe(A Name of Architect C'1 65 Tc Afiffl `R-ASE Address :weea,'� llydr9-- Number of Rooms Foundation _Cl� Exterior (I C.A-� Roofing &S21AL — Floors '-T-1 LE: Interior 7R- K 1 1L Heating' L��112 C Plumbing 1-kLI- l v1 Fireplace ® Approximate Cost Area �y Diagram of Lot and Building with Dimensions FeeV` i i i f rrE i y A e OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable Ud* above constructionName Construction Supervisor's License 6401( SMITH, JOHN R. & LYDIA G.. 4` t No 33910 Permit For 14rBuilid. Addition Single Familylduel i g Location 10 4 L am rL j4he `r Centerville, r John R. - Owner &.Y ji dia G. Smith ` -f Type of Construction _ Plot Lot � r u - Au st 15, `'.19 '90 Permit Granted g Date of Inspection 19 Date Completed —19 i� 24 t > r 5 _ e `1 .So F�ivA7G wA1� �4 i IAA L c�PC�NT'i+ IZ::> PZ?,A `IW UuDISiU ' p6E 47 of WZ"NDS vQ5 P� �CE c FI t0 PE SrPrTE WECiI� � lv o1 V k 'fs aL pG, ,�-� � 2. q =�•i BAcK, 6 Li.1 1 � .1, �, �l •,• for ` N I 3 r, z�, s,�`✓ / 0 Qf O NI �/ 1 !\ Ohs:: . .Z; H Of d/ illy o ` H `16, 1¢, Np SURV� i W ? e o,000 -s. F. i 25' W l Dru �o F s.. B. erg. CERTIFIED PLOT PL.. C R v/ L IN SCALES = SO / DATE , �NGL�RT 1 CERTIFY THAT THE t- DGE ENG11VEtRI 0 C4•�N CLI�NT....�--�••� gNO�IN ON THIS PLAN IS L{ IS- TE HLpISTERP.D � $z iq 1 ON THE GROUND A3 INDICATE row No• �•.�-�*4 CONFORMS TO THE ZONING I CIVIL LAND /f �9; OF SARNSTA E, ASS. OINEER gUR11EY0R DR.By 712 M A I N •STREET DATE R 0. LAND SUR HYANRIS, MASS, 14HEETl—or..--- r e. 4 N J ? , tu J V\l y 2 3 i i a I _ ....,.q......._.r....--,..u.._.....-«< ..�... ,....,.e.�-.-.� Jm..».5..:.,�...�,r...._...,...,..............,..„..»...._...,.�..«...,...,.. >,,.�..:,.�ma.:a....�,..;,,...�..r.�...�...Mw......,:,a,-.��,.......:..�...a-::.,�.w9.<-.... -,....m,.�..n:-a+�-.,.,,..._.,«Rv..�.-ss�_.:= N 2 � 9 c � h � J 4� J J ` Eton - f tj a'4 l.� l��h� i •�i �• v t � i V i } �i 1 I it i 1 r 3 e AL- t i +JV i II k" ++,..,..�ri�..alpj',gct►,1o.w•.k<.++w.`;� "I r '?� .*.#Y a ""'l' :9,Vf•iV4's1 s`"-+`«t.,.e�.t�r t:R;a'v{'"K.s•;;,',.Y'� Assessor's office(1st Floor): ,/} f°►.. Assessor's map and lot number �tC a � fr O�TNf TO Board of Health(3rd floor): i Sewage Permit number '^( y � Z D H i Engineering Department(3rd floor): 9TABLL C-.k,ua House number GO i639• Definitive Plan Approved by Planning Board 194��r d' APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only Cr TOWN OF BARNSTABLE r 4 �^ BUILDING INSPECTOR _ APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION j-(N—0 A-(/,? 19 �a TO THE INSPECTOR OF,BUILDINGS: ' ' ' ' . ' ' ' The undersigned hereby applies for a permit according ito the following-information:,, i Location l C)q L t A L 0 CeA TEO-yILL E' Proposed Usec Zoning District j` r Fire District AP/ Name of Owner O ti 1`• •� ...,r , G Cam- �, yn r} Address J �► r�G 1. V 1 Name of Builder Q I5TQ1-'At I%'_ Address Name of Architect C kA-e>T0,A+(.—;V- C(}A5C AddressW�t-- Number of Rooms Foundation y>Lask< Exterior Roofing A- ML Floors ' ; L EF Interior- I HeatingL���L� �' Plumbing --R-"`yt-�- t: d° Fireplaces Approximate Cost Area y Diagram of Lot and Building with Dimensions Fee 4 ; s I ~ Y 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., L 4 Name Construction Supervisor's License �`� SMITH, JOHN R. & LYv-LA G. " j17-011r.,Olo A=167•-016-010 Noy 33910 Permit For Build Addition � Single Family dwelling Location 104 Liam Lane Centerville Owner John R. & Lydia G. Sm::.th Type of Construction Frame Plot Lot Permit Granted August 15 , 19 9"") Date of Inspection 19 Date Completed 19 PERMIT COMPLETED 1/1/-2L map and lot number ................. .. ...... THE O� Sewage Permit number ...<... .... d`�P ♦� House nu M ABH9TIIB i/ 8 B E. number ........................ ......... .................................... rasa T 900s,1639 `e00 CFO M a A . TOWN " . OF =BARNSTABLE F BUILDING INSPECTOR r APPLICATION FOR PERMIT TO .C.l. .............................................. TYPEOF CONSTRUCTION ................. �1. ........14 ...................................................................................... .19U.1.. TO THE'WPECTOR OF BUILDING'S: The undersigned hereby aE . ........ s for a permit according to'the following information: , VILocation .,....:.�:V, ;...:..... �? ............................ I....................,.........:.................................................. Proposed Use ............r�-1..r. .u.�'1............................................ ........................... ......... ........................... .............................................. ..,.. .. ... Zoning District ... ..........Ra_A.�............... ........................Fire District' ................... .. ............. ......:... Name of Owner ...�,O�n .....sue?..: !4 � Address' ........1..6 1.. ..... .� u I ')e. y. .. . . . h 1r l �C,�Sep D Name of Builder ......... �. ..............................Address �.. , .... SS Name of Architect ....:........ .............................:::....................Address Numberof Rooms ..................................................................Foundation .....,....:..............:........................:........ Fxlerior .....................................................................................Roofing ........................................:...................... . Floors ..........................................................Interior .................................:.................................................. a g ...............................................Plumbing s Fireplace .........:...............................:........................................Approximate. Cost ..,� �:..; ...I................ :..:...:........ -Definitive Plan Approved by Planning Board ____________________------------19________. Area .......a............ . ................ ,Diagram of Lot and Building with Dimensions R Fe � 'u �✓ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations o e To of Barnstable reg rding the above construction. No ............ Construction Supervisor's License . ............ ... .............. EiVGLERT, JOT-RAT J. 2635�, Permit for BUILD SWIMMING POO't, j Single `Family...Dwelling......................... Location 104 Liam. r,- .. .... ..4q r............ CE11t2n71 �,4......................... ............ .Owner .... ............................. Type',-of Construction ...EKaIM........................... T., ................ ......................... ...... .................. - .. yr' x� `Plot ............................ Lot ................................. 7/ w Permit,Granted April 30, ......19 84 r� ................ ......... Date of' 6nspection ...:................................19 1,9zs- Date Completed .�...'...�2..-.7:.......... _ - - _ r . HENDRICKS POOLS, INC. 304 Taunton Avenue SHEET No. __ of SEEKONK, MASSACHUSETTS 02771 (617) 336'7410 CALCULATED BY_______ DATE— CHECKED BY--_— _ _ DATE_-- SCALE _ — I : I ........ ..i.... ..._.... .. .i_..... i...... ........._ :._. .. ...... .. _.. .. ....... .... ... ....... _-. ..... .. ...... ... ...._ .. �¢ ........ _. ........ ........ ..... ._.. .�7.. .._.- ..... ........Q_.... ........ ......... .......:.......: - ...... ..... ..... ...... Q ..-._. :. .... ...... _ .- - ...... .._. _.... f_ .. ...... ....... \ ..... ..... ...... ... .. — — - ..... ........ ;..-. aC... .. p ..... ... .... ... .... .. . W ..... .. ... :.... .... wi tip V ►� c r FORM 204-1 Available from LMe�n�J Ina,Grolor,Mass-01450 Assessor's map and lot number ?�O*THE Sewage Permit number .......... ro / Z 33AUSTADLE. i House number 1 G /1 MAO& A............. 90o i639. \00� EMOa' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT. TO \ }I. )1..KV-) Yr �'C�/► .. .........t.....................,................................................ TYPE OF CONSTRUCTION a 1 Imo. ... lc)..e�.............. ................19........ I TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ ......... � � / ! �. . .. .............. • . .. ............... ................................... ProposedUse ............�Ct( �.P A L.l�:. .................................................................................................................... ... Zoning District ........................................................................Fire District ............................ Name of Owner ... � .... .............................Address ........ �`� ..... ...4.. -. +!..... 7` �. .....rp, .'?, U1� £J Name of Builder �.. A..Y.'JI,1 � L � ............Address ............`� .�� ...... :....................a i Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ..................................................................Foundation ............................................................:................. Exierior ...........Roofing .............. Floors ......................................................................................Interior .................................................................................... Heating ..Plumbing................................................................................ ....................:............................................................ Fireplace ..................................................................................Approximate. Cost lay. C3`� p. .� .................................... ............... Definitive Plan Approved by Planning Board --------------------------------19--------. Area . ........ ....•................................. Diagram of Lot and Building with Dimensions Fee �a`............................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the To �n of Barnstable regarding the above construction. Name ..........................;F�.......................... Construction Supervisor's License >.,.�.......... ENGLERT, JOHN J. No 26359....... Permit for Swimming Pool Single' Family Dwelling Location 104 Liam Lane Centerville Owner ...John J. Englert Type of Construction Frame.............................. Plot ............................ Lot Permit Granted .....April..3�.i 19 84 Date of Inspection ....................................19 Date Completed ......................................19 k . Assessor's map and lot number .. ,� � / x Sewage Permit number ....,, � to�� BAHd9TAX i House number ........................ ........j a`�':......... - rasa E URI d� TOWN OF BARNSTABLE BUILDING INSPECT ' R APPLICATION FOR PERMIT TO l Q- ,,,, , ..........., , a TYPEOF CONSTRUCTION ..................................................................................................................................... ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location LOA I ..........`.... . .�. t. ►..... .. ?�� v I .............. kq�n.�... ............ ..................................................................... ProposedUse ................ :.. �. {:Y?... ......................................................... ......... ......................I......................... Zoning District ..... .` ...`.....) .... �`. F'�ir�e'District .. ......:::................ ........, ^Vt Name of Owner ,. tY1. .' :nG Address ��... ,;�,t1(, ? ...� ....- ..... .. ki ?fi Nameof Builder' ....... �..... .�`��.........................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ......................................Foundation .........".U:..........-.d............................................. Exterior ....... 1. ........................... i. ... Roofing ........ � .. . .. : ........ ,... ...v Floors .........� .d.... F.q ....... ...................Inferior ...................��C� Heating '` ..................................... ..... ...... .Plumbing ......... ..... ".......................................................... Fireplace ............ ... ........... . `Approximate Cost ........ z. ...........................�.t:.......Definitive Plan Approved by Planning Board -------------------—-----------19--------. , Area .....,�� F .......... 9 Diagram of Lot and Building with Dimensions Fee. SUBJECT TO APPROVAL OF BOARD OF HEALTH f ✓s r ' OCCUPANCY PERMITS REQUIRED FOR NEW DW€LLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. r Name .. :: �9........ ................ .... ;'�!� :' ....... ........... ............... ENGLER, ARLES 6'10HANN A=A7-16 47 24563 12 Story No ................. Permit for .................................... Single Family Dwelling ............................................................................... Location Lot #18 104 Liam Lane ................................................................ Centerville ............................................................................... Owner Ch.arles. . . ... ... & Johann. . ...Engler. ..... .. .... .. .. .. .. ....... ..... ....... .... Type of Construction Frame ............................................................................... Plot ............................ Lot ................................ Permit Granted ....Noy.,, 16,i...............1982 Date of Inspection ....................................19 Date Completed ......................................19 ses ka an?� J Assor's lot number t . !p .... /.... ... j Sewage Permit number .... :. ... ...r.................... Housenumber .....................................Zq`f ..........:............... TORN OF BA �� °y4& ze'E N . WITH TITLE bENVIRONMENTAL ODDE BUILDING SPEC ; _ I RULATICR� � APPLICATION• FOR PERMIT TO ..... TYPE OF CONSTRUCTION ..... The undersig ed h reby] applies for Ia permit according t(o�the fo -wing infor{nat(ion: Location ....... Q 1.... .... ........ .....h A.Q hn.... .�:...... :!!.1 . ..l.......................................................... Proposed Use .............&..t. .......... Zoning District ..... ............. .... ............. ..... ......`Fire District .................. .U .... .. Name of Owner(,..�1 ` s?.`�-�t� r1 ....'W..Address�3 �.�6. ..�l ..... �, . Nameof Builder" .......� ^......................................Address............ .................................................................................... Nameof Architect ..................................................................Address ........:........................................................................... d Number of Rooms ....4.............................................................Foundation ......... ....... .........:.................. ............................... Exterior ........ �!� ............................................. Roofing ...... . .. .. Floors�,• ......... :.�.�:..................................Interior ...........IS... . ........:.. ...... ......................... 4 HeatA•'M.tl} d� ty.. �_ _� . ....................................... .�. .... ....�.......... Fireplace ............� L h . ..................................................Approximate Cost U d U t.................... . ......... Definitive Plan Approved by Planning Board _____________________,______19_______. Area ..../ - r ........ �... Diagram of Lot and Building with Dimensions -Fee .......... ........... SUBJECT TO APPROVAL OF BOARD OF HEALTHt�r r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the To4 of Barnstable regarding the above construction. Name ..... ........ I;NLER CHAR & J _. OHANN VOW" 24563 -,. 1� Stor` o ........... hermit for .............. .4.......... Single Family; Dwelling........ . ...................................... .... .................. . ��" Lot #I8 "10� Liam Lane Locatlon ......................... .. .............................:..�. I ............................................Centerville ............ _ Char . .. .!. Owner ......... ,les ...._.Johann.•Engler; �, ,3 Type of Construction Frame ..................................................... ................ Plot '` ......... Lot ..............................� ..�. r Permit Granted .......NoVeuber...1.6.,..19 82. 9f Date of Ifis ction .............. . ......`................ 9 ....19 . Date Completed r • +I 1 . y` * —�. ffir fi QaJt'�`ir l UuQ+S►L.P$ v. -�pGE of WtA N D5 U1.i l ?S l oo FPvnn r E1JT Ft Utz`3�PcTr- W CZAwQ� t t I. L N D� ol Zia V i e a Q gL pG %tin .� L, � t �. �' 3,3 w '� N b�'4r , � 1 n � -.\ E� OF to INmo Np SURV �F M v 125 W� 3o FS• B. CERTIFIED PLOT PLAN t 1 IN �y •' r4 AS SA - � �3�T�{- q+`3 yre{t#r r Y� £�t;� � �, 5ti, � + r tr,; y ��` SCALES ���. o DATES x.A' tir/'r y �K'. cqf ,k }-i," :¢ �•4 F , �y4F ru �tir�A-77 v I CERTIFY THAT THE : � fdE`OGE ENGIN R/NQ`CO.IN: , CI I911 SNOWN ON THIS PLAN IS LOCATED " '` a�q./. Old THE GROUND AS INDICATED AND EGISTERED Rrr01STERED s n`s> �0 ." ..�w 'n� CONFORMS TO THE ZONIN4 l.Ahti 9 LCIVIL LI1Nl OF ®ARNSTA E, ASS EMOINEER SURVEYOR °, 712 MA1 N STRET �,aY, ® !y« �' ' m �: DATE R 0. LAND SURVEYOR , S; N YA:N R iS, MAS �x � �t^ aF to D r. , I a I AL I � lI 0 _,F2 DN = s d allI iill Q �r �-1 I I .1192 TNT I I � �s� y LA a m I I r- -j S'i I. II W INIi,BTEEL BEAM �•o . 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DATE TO ERRORS NTNE NO ATIONS/REMODEL ASSOCIATES NOT G BE REPRODUCED DRAWN OR SiRUCRmAI D67C�1U6 N CHANGED OR COPIED IN ANY Dip`" " C AD"� f NORRIS RESIDENCE FORM OR LIANNER WHATSOEVER AT KETONE [NOR16 OO11SiROOTION. 3/21/11 NANs aE�JAmN TO ram La6LL DISTINCTIVE RESIDENTIAL&COMMERCIAL DESIGN WITHDUT FIRST OBTAINING THE A.0 DFPAR1yEHf ANp/m a9rcroR 104 LIAM LANE AND WRITTEN PERMISSION OR REYE.9 AND APPRDTAE RECARDIN9 ANY 141 MAIN STREET•YARMOUIHPORT•Ma o2876 CHECKED o N srAlxnmAE CENTERVILLE, MA. 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