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0039 MUSKEGET LANE
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C � e a r o _ u e i. � r � :. � n n r - a. s� ' co . ,,, � �. wowonlSolar.- 695 Myles Standish Blvd Taunton MA 02780 BUILDING DEPT C:561.271.7029 DEC 3 0 2020 TOWN OF BA p C� Ivod v Request for permit(s) cancellation :Attention Building Departme�"!°$TAB�E i� Dear Building Commissioner, I am sending you this written notice to request the cancellation of the listed permit(s) below.The customer(s) have determined that they no longer want to move forward with their solar installation at this time. Permit Number(s) Project Address 9 z:57L L o � ciI`-Izg� cen `lam Thank you, Steve J Spengler Construction Supervisor MA 3 Boston South steve.spengler@vivintsolar.com , C: 661.271.7029 � 4+ 2 fir Fs 44 ( `• Application number �� , �. QaL(1]w ,tJp: Fee ........:...................................................................... 'a ` AU Building Inspectors Initials.. Date Issued.:...6/1.2........................................... Map/Parcel.......... t.l TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREE VILLAGE Owner's Name: ca5 o t l Phone Number_• -50gj ' `�a_ 5'1 7 4Y r �n Email Address: Ect s 4 << die ►-,�"O le y/f-q.a Cell Phone Number Project cost$ Check one Residential L/ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Q Siding 0 Windows (no header change) # � Insulation/Weatherization. ❑ DD ws(no header change)# Commercial Doors require an inspector's review Lr Roof(not applying more than I layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION ` Contractor's name U/'hAeq ". �'" lya C- vS ' .M t.,,YQ_ s Home Improvement Contractors Registration.(if applicable)# 1 Q 6 "79'O ! (attach copy) Construction Supervisor's License# l _(attach copy) Email of Contractor j N ?C �a. • ( OWL Phone numberO ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A NICTnRir nI.STRirT- Ynll MINT nRTA►N HLSTnRI[APPRnVAI RFFnRF A PFRMIT[AN RF IM IFn_ APPLICATION NUMBER ' *For Tents Only* . Date Tent(s)will be erected Removed on .e number of tents total Does the tent have sides?Yes No (If yes pleaseattach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event ' Check one: Food served Yes No Flame Spread Sheet of,each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. ' If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature r Date APPLICANT'S SIGNATURE Signature �` Date ao r All permit applica ons are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly /� Name (Business/Organization/Individual): I �i' CaS� (0Yk4r?,c&Y-5 Address: 06 '�o 40 �_re'-) F City/State/Zip: ca"(16-fou c4L i kt-,A Phone#: ��=7 Q50 Are you an employer?Check the appropriate box: Type,of project(required): 1.❑ I am a employer with 4. am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6.�❑New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P t}'• 9. ❑Building addition [No workers'comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doin all work officers have exercised their I L❑Plumb' g repairs or additions myself. [No workers' comp. right of exemption per MGL 12. of repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other' comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: �t Policy#or Self-ins.Lic.#: "f D 0 o�o� �`® �� Q T Expiration Date: oC y Job Site Address: 1 U e C,'e ! City/State/Zip: /1 14 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$2 0.00 a against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of for insurance coverage verification. I do hereby c f i de he pains penalties of perjury that the information provided above is true and correct Sip-nature: Date:?- j Phone#: 2 CpSL4 .-IR t) Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other ' Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number; The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax#61.7-727-7749 Revised 4-24-07 www.mass.gov/dia NORTH09 OP ID: DAN ,aCORO" CERTIFICATE OF LIABILITY INSURANCE DA03/0TE 4/D/19 03/04/2019 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 WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). • PRODUCER CONTACT Segreve&Hall Insur.ASSOC.InC PHONE FAX One Tech Drive A/C No Ext:978-975-1300 (A/c,No):978-975-7596 Andover,MA 01810 E-MAIL Sean Segreve - ADDRESS: ' INSURER(S)AFFORDING COVERAGE NAIC k INSURER A:Ataln Specialty INSURED Northeast Roofing Contractor INSURER B:Commerce Insurance Co. 34754 Shane McGuire 9 Royal Crest Dr INSURER C: Marlborough,MA 01752 INSURER D: 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. INSR TYPE OF INSURANCE WDDL UBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY M/DDNYY A X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE a OCCUR CIP353069 02/09/2019 62/09/2020 DAMAGE TO RE TED 100,00 PREMISES Ea occurrence $ MED EXP(Any one person) I$ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICY❑JECT PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,00 PRO- ,. OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accide $ 1,000,000 nt B ANY AUTO RXL738 02/21/2019 02/21/2020 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY accident)nDAMAGE $ HIRED AUTOS AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE-I ER ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ' R CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED .IN ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main St Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE .« ®1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD t ��,acoRO® CERTIFICATE OF LIABILITY INSURANCE rMIDDNYYY)ATE(M 04/03/2019 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 WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: danlella franca STEPHEN W GERSH INSURANCE AGENCY AICC,N Ext: (508)485-1926 ONE A/c No: E-MAIL ADDRESS: dfranca@ ershinsurance.com 9 MONUMENT AVENUE INSURER(S)AFFORDING COVERAGE NAIC H MARLBOROUGH MA 01752 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: POWER CONSTRUCTION LLC INSURERC: INSURER D: 232 POND ST 3 INSURER E: NATICK MA 01760 INSURERF: COVERAGES CERTIFICATE NUMBER: 385523 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. TR TYPE OF INSURANCE INSD WVD POLICY NUMBER - OLICY PM/DD/YYY MM/DD/VYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE O RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO ❑ JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY P DAMAGE $ HIREDAUTOS AUTOS $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LtAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION STATUTE OERH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED? I NIA1 NIA N/A AWC40070322772019A 03/24/2019 03/24/2020 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Northeast Roofing Contractors LLC ACCORDANCE WITH THE POLICY PROVISIONS. PO box 145 AUTHORIZED REPRESENTATIVE Hyannisport A MA 01672 Daniel M.Cr y,CPCU,Vice President—Residual Market—WCRIBMA @ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD r �j <.r .,Commonwealth of Massachusetts r; i �" ornm"Wella w Division of Professional Licensure _ Boaed of Bbildiri Regulations and.Standards Offtce of ConsumerAffeirs&.Business Re ulatlon l Canstructig � 5 'cialt' ' IMPTYPE.'- Eorporatt n' OR w , • 'HOME C O ACT r, , ,, .,Reaps��• onExei� k-CSSL-106123 <" E�pires: 07/14J2021190720 ' 4,02j20/2020 NORTHEi S'T 80.OFING CONTRACTORS LLC SHANE D MCCaU1RE3 r o 8 ROYAL CREST DRIVE;UNIT 3 rR 9 =Y . MARLBOROUGHIMA 01752' � ��'� RE �> YAiCRl;SF;I?FitVE UNIT 3 w r. . QU3N1gw0 , s - Ar P- Undersec :r l retar'' ` commissioner r r ' � > Town of Barnstable- Building Department Services - KASL Brian Florence,CBO ,1 61 Building Commissioner 200 Main Street,Hyannis;MA 02601 www.iown.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If Using A Builder as Owner of the subject property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application for. lop (Address of Jo ) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. S' tore of Owner S e o pplicant evl f � � 6 Print Name Print Name Date Q:FORM&OWMWERMISSIONPOOLS Rev:0&116/17 Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner S 200 Main Street, Hyannis,MA 02601 + MAM www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HON0OwNMr: I name home pbone# work fe# CURRENT MAILING ADDRESS: city/town starve lip code The current exemption for"homeowners"was extended to include owner ied dwellin f six units or less and to allow homeowners to engage an individual for hire who does not ossess a license, vided owner acts as ervisor. D OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides intends to reside,on w ' h ere is,or is intended to be,a one or two- f anily dwelling,attached or detached structures accessory to use and/or farm . A person who constructs more than one home in a two-year period shall not be considered a homeowner. uch"homeowner" submit to the Building Official on a form acceptable to the Building Official,first he/she shall be •ble all such work. or under the building enmit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance the S uilding Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of B le Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or will be to comply-with the State Building Code Section 127.0 Construction Control. r HOMEOWNER'S ON The Code states that: "Any,homeowner performing work f r hich a building pe it is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of co ction Supervisors);p vided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner i ll act as supervisor." Man homeowners who use this exemption are unaware this -the are assuming the res onsr ' •ties of a supervisor X P Y , g P P (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack awareness often results in serious problems,particularly when the homeowner hires Inlicensed persons. In this case,our rd cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supe%ppart ultimately responsible. To ensure that the homeowner is fully aware of his/her r�ssponsibilides,many communities require,athe permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the lasItIpage this issue is a form currently used by several towns. You may a to amend and adopt such a form/certification for use your community. Q:\WPFRM\FORMS\building permit fomis\EXPRESS.doc i 08/16/17 I Town of Barnstable *Permit al 45 SIZE,0�1�_ Fxpires 6 m hs ue at� ntrss Regulatory Services Fee IMOMMIA MM& Thomas F.Geiler,Director 039. D" Building Divigion Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 9 7 U Q Property Address �!/S �� L7` �� C-�i���/C IW, PResidential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name v v ti Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) t�rWorkman's Compensation Insurance Check one: I am a sole proprietor `�(//�/ ❑ I am the Homeowner 1.1 2013 ❑ I have Worker's Compensation Insurance 7*OWY ' Insurance Company Name C>�/�e'.� �V/V OFB�Ae._ . T c Workman's Comp.Policy# �i�AW C�23-6 20�b 1- 3 "/3 Ae`` Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) R Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken toT ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: %�1 QAWHILESTORWbuilding permit forms\EXPRESS.doc Revised 060513 S T ie Commonwealth of Massa hush Depwim4ent of Indushial Accidmis OOrw-e refImestrgadons 600 Washington,Street Boston,MA 02111 n :masS.gou�/dia Workers' Compensation Insurance Affidavit:.Builders/Co ctor&Tlectric ans/Pbimbers ApiphcautInf6rmationt Please Print Legibh, Name ak sit>ess/Organization&&vidual.}.: ' La&X-:Jt Address:: City/Stat--�. <.,-,i'�I- t* Phone,9- 98-305-1-Me Are you an employer?Check the appropriate bozz Type L❑ I am a 1 with 4- ❑ I am a general contractor and i 6. E of project con(required): �P * have hired the sub-contrac om 6. ❑New construction employees(full a�(arpartrtime). 2.FI am a sole praprietor or partner- listed on the.attached sheet 7. ❑Remodeling ship and have no employees These gab-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp insurance comp insurer , 9. ❑Building addition mod] 5..❑ We area corporation and.its 10.0 Electrical repairs or additions i 3.❑ I am a homeowner doing all work officers have exercised their 11_❑Plumbing repairs or additions myself v work=.'CoMp 12.right of ememption per MGL ❑Roof repairs insurance require&]I c.152,§1(4�and we have no ar employees-[No works' 13.0 Other comp.insurance required.] *Any applicaatthat checks box#1>zmst also fill out the section below showing their wotkets'compensation polity infammatim I Homeowners who submit this affidavit indcating:they are doing all wal,aod them hue outside eo uttwk ms— solrmA a new aMdavA.h dicMmg such. tContractms that check this bwc must attached on addict nil sheet shaming the mane ciao smb-coubmw a and stare whedw ornot those eofities have employees. If the sub-contmctars hwe emboyees,they nmst provide their wmkess'comp.policy number. lam an employee:thatisprvvidkg workers'compensation insurance for nay anqiayem Below is thepolicy andjob ske informadom. Insurance Company Name L el 1P-S Policy#or Self-ins.L c.#: Expiration Date: e Job Site Address: Mb k"4 City/StatelZip: (e014 .,v Attach a copy of the workers'compe'.nsatina policy declaration page(showing:the,policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL Q. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andfor one-year imprison,as well as civil penalties in the form of a STOP WORK:ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hers fY under the pains and pemaliies that the information,proa i above is and correct SiOna Date: /t now#: ed Offidd use only. Do not write in this area,ib he compIRfad by city or tower ojoiciat City or Town: Permitf kense# Lssning Authority(circle one). 1.Board of Health 2.Building Department 3.C ityft'own Clerk 4.Electrical'Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6. 1VHD-CAPE ROOFING 11 RUSSO ROAD WEST YARMOUTH,MA 02673 508-775-3799/508-385-8801 Barry Merrill Paul Merrill Job Site Address Mailing Address Name: Name: Street: Street: City: City: Telephone: Telephone: We hereby propose to furnish all the materials and all the labor necessary for the completion of. roof replacement of the dwelling at the above address. Mid Cape Roofing proposes to remove and dispose of the existing roof. The roof will be replaced with Certainteed landmark Woodscape 30yr shingles. Aluminum drip edge will be installed.along the gutter line. Ice&water.shield.installed on bottom edges to protect ice back up. 15 pound felt paper will also be applied. The shingles will be:installed using 11/4 inch roofing nails. New pipe vent collars will be-instal ed. Ridge vent will be installed.long the ridgeline of the roof to provide proper venting of the attic.space. Mid Cape Roofing guarantees the workmanship fora period of 10_years. All walls and landscaping will be protected from damage;the property will be raked and cleaned of all debris. All material is guaranteed to be as specified and the above work is to be performed in`accordance with specifications submitted for above work.and completed in a substantial workmanlike-manner for the sum of $ 3 706 .00 -All discounts have been applied. Payment made as follows: Deposit of. $ .60 the day the job is started and remainder to be paid on completion. Any alteration or deviation from the above specifications involving extra costs will become an additional charge.over and above the estimate and will be discussed with the homeowner. Respectively Submitted by Mid Cape Roofing NOTE: This proposal may be withdrawn by Mid Cape Roofing in not accepted within 30 days. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby accepted. Mid Cape Roofing is hereby authorized to perform work as specified with payments made as outlined above. Accepted: �� Massachusetts - Department of Publir.Safety } .; F 'B' oard of Building Regulations and Standards I. Construction Supen isor is License: CS-054.428 �. IS BARRY B NITRRVE'L . 312 SKUNNKETiRW f �. CENTERVH LE RA Expiration ' 05/21/2614 ' I Commissioner r OftiA Co s mer AYtlairs&Bdsmes o HOME IMPROVEMENT CONTRACTOR i Registration:;od 6145$ Type:r ; .Expiration FQ/20/2014 Partnership ' l M APE RO.OFIf�O a 13ARRY MERRILL 1 E wk t � .. •1.1 RUSSO RD 2l WEST. MA 02673 i Undersecretary v 1 ' Mir- Massachusetts -Department of Public.Satety Board of Building Regulations and Standards Construction Supervisor License: CS-054428 BARRY B MERRI# :312 SKUNNKET'Ir", ( CENTERVILLE MA 02 �,•G.. JJ/5l ' ,� i���` Expiration'.:; 05/21/2014 Commissioner ti f 111cense or registration valid"for individul use only +' ;before the expiration date. If:found return to:: Office of Consumer.Affairs and Business Regulation. 16.Park Plaza-Suite 5170 Boston,MA 02116 < t Not alid withou signature r p> TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel D Application # C:;�o L Z Health Division Date Issued Conservation Division Application Fee , v Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 31 AA US Village Jery I Owner M a.>c 114d Address Telephone_ .<7-0 f5,,=2- :z -:k 9 Permit Request Z 2 ✓�� �E�I Square feet: 1st floor: existing IC 'qproposed r��`� 2nd floor: existing �U��proposedl1000 Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ©00.00 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 /g 70 Historic House: ❑Yes M No On Old King's Highway: ❑Yes rd No Basement Type: 3/Full ❑ Crawl ❑Walkout ❑ Other Pasement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing. new Half: existing o new d Number of Bedrooms: 4 existing _new Total Room Count (not including baths): existing /G 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 .0 s Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing C!new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ✓� f Name Z ' Telephone Number Address : G% �o � ' mac_. License# 16®;70/ 11111*,14n41e0e,4K 0 Home Improvement Contractor# /L �✓ � Worker's Compensation # a)ca�3,15::?V31.5� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE Zo l( l FOR OFFICIAL USE ONLY r .,,APPLICATION# DATE ISSUED *� MAP/PARCEL NO. r r ADDRESS VILLAGE i : Y - ? OWNER i DATE OF INSPECTION: FOUNDATION:! FRAME o 6�?.aiQlL INSULATION. S FIREPLACE t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 1 `2 GAS: ern - ROUGH a:` -= j FINAL +FINAL BUILDING? °2�4 ll i* DATE CLOSED OUT ASSOCIATION PLAN NO The C-OmIrconwe liar of Mcrssachuset�s Deperrfinerc! of Ii�dust�'i��ccirlents Office of fjnvestigalions 600 FYa�h�ngtort Slreef 130Sto AL4 Wil '` �s�t-N>,-�;irtass,gd U/airs , •. . b 1 P Workers' Com ema6on Znsrtrance ;davit; � hers/Cobtractors/Electriciatis t de a Please �r A ' licant Information' �C slOdi --- - Name pusioosrganu /In �tionv�du • � —��. _. City/State/Zip: f i/u0& ®25' Phone.#, Awl "on an employer,? beck the°appropriate box: L project(required). 1. am a caiploycr vrith �- 4• ❑ 1 am a general contractor and Tew constr Gtion baYc hircd.thc sub-contractorsmodcling'- cmplayccs (fu-U and/or part-time);* listed ou the attached shcct Z, E am a•sole proprietor or parh7cr- Thcsc sub-contractors haYd LnDHpn Ship and bavc no employees. tMployccs and have rvorkcrs g addition sworling for znc in any capacity. clomp. [n urancc. ;[l�o workers' comp, insurance ectrical repairs oT adcWeare a corporation andmbing repairs or adc3, []'E am a homco.vncr doing all work tof exem tion er MGLmymLE [No workers`:co pofrcpairsmP: 1(4), and wc;ha-n no incriranceregliired] er, . cmpl oyc c5. No workers' comp,insula-mc roquired.J:. 'Any kpPlieant thztchcch box Ul must also M out the section below showing thcu workera'eompM�74on Po}jey�{o�nabon. t Homcownci l who rubrn( this stfidza twin Ong tb anal ch�gcho Wong th anamnc of the su'b conl�db can Lctrn s and ziDr Atic whether or fffhosc m6d.15nhgvc tConb-,Lr on fiat check thin box trust P cmploycc5, Itthcsubconkactnrrhaycnnploycct,thcymurtpravidbthcrworkcrs co o� n b� oyees BeCoty the poCiry arrdj6b rosrt wt eaxployer zhrzt isprovCdukgworkers'compensafiorl [nsuraitcefor my errtpl Is si la surancc Compare-92mc: (mot! Ze��. la Policy# or Sclf--ins, Lin, #: L city�statclzip: fir_ _ ask 14, Job site AddrCss: Attach a copy of the workers' cdmpensa�on policy deClara{oort:page(stiowing$thepoiicp ntsmber and expiration d: Failure to'spcurc coverage as rcquircd under s;cction ZSA of MGL;c. I SZ can IcadCt �formo�STOP WORK O LR and find lip to 31,500,00 �nd%or one-year mapr-sonincnt, as well as ei nl pcnalti'cs m of up to �250.00 a day against tho violator,, 13c ad)-is,cd that a copy of this staLmcnt may bo forwarded to the Of�cc of Envcsti ations of the IDEA foi insjealcz covcra c VcHfication Z`do hereby ce h' ri di aitd penaltLespfperjury llc.crl the irrforatation provided above is h ue arro'corretr Phone ' / lS•�( O ( �� `� Officiafwe only, Do rro! wrt�e in IJrCr arco, fo be completed by crly or town offtciaC City or Town: - PermitlLicense # ' Zssuiog Authority (circle 1, Board of PTealth 2, Building Department 3, Cif`y/TDWM Clerk d. lectrlc.21 Inspector 5, Plumhiog Inspector information and 111stru tts Gcncral Laws chapter 152 requires all employers to provide workcrs' compcnsa-r a for thcir,omployo, Massaehuse rY crson in the sernec of anotbcrunder any contract ofbir°, pursuant to this slatutc, an e/aplAyee is defined as "...cYc P express or irnph'ed, oral or written- co oratio❑ or other legal. entity, or any two or more . An e�ep/�yer is dtfcd as "aa indzvidual partr,crship, association rp the 1c al rc rescntativcs of a deceased employe[ or the of the foregoing engaged in ajoint enterprise and including g p e to ces. However the arincrsbi association or other Jcgal entity, employing Y zccclvcr or tzusteo of an iudiyidual, p p, C owner of a dWclliag bOusC baying DO more tbaa three apaztmcnts and wbo resides therein, or the occupant o� house dwelliu bouse of anotber wbo effrployn SUC s persons to do Inyintcnan o of such employment OIIS be deemod to bedan employer." g or oil the gzo Inds or building appurtcnani thereto shall not bccau 2 25 also statLs thal "'--Very strafe or local licensing agcncYn hlcoornbmoOr althsfor any r MGL chapter 35 , § �� e re aired." regePYal of a J.lcense or permit (o operate a business or to construct boil tngs r cithcr the commonwealth nor any of its political subdivisions shall • applicantYY.h° has notpr°duced•acceptable evidence of compliancePlh the lnsu-rznce coYerag Additxonal]y;MGD ohaptcr 152, §25C(7)states N rmcc q'Lh the ia:LIZ,race cntcr•into any contract for•ncr performance of public WD k 11Il1�1 acccptablc cvidcacc of compli rcguircraonts of this cbaptcr hay'-bccn prescatcd to the contracting authority." AppLi can ts• Please fill out the workcrs' corupcasatioa afdayit completely by chcclang th c boxes that apply to your Situation and, pCCC83 Supply sub-eontractor(s) namc(s), address(cs) and pbone numbers) along with their ecrTjoyres of �Y, p c imitcd Liability Coznpanics(LLC) or Limi.tcd Liability i'artncrships (����Do o aLP do C°�Ythcr than the tnsuranc L rnombcrs °ipartncrs, arc notxcguucd to carry workcrs' compcnsalioninsuran p cnt of lndustnal employees a policy is required. pc adyiscd that thisAalf6 tso s mca to sign nd date the Dafflda Th°afsdarit Should Accidents for confirmation of insurance coverag cd to the city or town that thc•application for.the permit or license f bo uaoFogL&rd to obtain aeWIDIkcCS' of bo rcturao cstiow rc aiding the law or>f y u�r in trial Accxdcpts. Should you hay c any qu g cow ensation okcy,p1�0 c��6 pGpazlment at the ztuzrlber listed below. Self-insured compan-tcs shpj-1-ld enter thou' self insuranGo license number on the a roprlatc Dino. City or T.-ff>i OfIlcials ou zc aiding the applicant. Please be sure that the affid�Yit is complete and printed legibly. Th tiDrpb�cat �Prynde da space at the ottom of tho a£�davit for you to fill out in the event the Oi�cc o'f I1 csttg _ (icant r�'�f� davit indicating current Plcaso bo $urc to JU a the pCrIIllt�llCGDSC nilIDhCr WhiCll�ll by a 7darsn cd only s bmitonP a�iddttion, an app that must submitrwltiPlc Pcccnsc applications an Y the cit or town may be proYidcd to th° olic' information(�Poccssary) and under"Job Sile Address" Iho appliccdabt should write"all locations In (city or P Y ko ten) „A copy Of the a�davit that has bccn off cially stalupcd or mazk Y rant as roof that a valid affidavit is on file for futuze perrnits or liccnsacd fo an business orobmmcialoycntvrc appb. aliccnsc or crn�ltnotr 1 y year.'Vi'hero a home owner or citizen is obtaining p• (j e. a dog licG�° °x Permit to bum leaves etc.) said persoA NOT rcquirad Co complcfe this affidav7t c ucstions .'1 bo Office of InYestigabons Would hke to thank you in advance for your cooperation and should you ha Y Y 9 plcaso do not hcsitat° to giYc us a call. The Dcpartmcnt's address, tcicpboac-and fax number. The Commonwth of m_whusct c_, . ts Tic ept Of Iudus�Da1 Accidcn�s Offzcc of Z>�vestZgaf .ass 600 Washin., S1�ect Bpston, MA 02111 TGI; # 617-727-490.0 ext 4.06 Pr 1-877-MASSA-FE Fax# 617-727-7749 RcYiscd 11-22-06 wV W.masS..govldih ' AAll c -6s0U. OEpartthen'v A�Pub#tc�S.if`e`�� - - �- :���rd'of B �t7tei��`lt��tttatti�'«t�acl S�ttt2lstrot�� �- tCor #vu611 p UFerwspr S Liceiisek s s"„� aLicense'. CS' 100701 - .. :kk ANIEL��!TOUSfGNANT � . 30 GOLT LANE.' _ _ �• `PLYMOUTH, MA O'e36C 1 �,« ,c-�..! .�.•s-`��.,,e^�, �+ "� ' �xpirabo�► '6/SII012 ,� _ ,. � .. .. . 0,1 - '�-,fiJGc,,,.,..-..��xcawn, ":� s.�•.v;;wm a h-r.,e+aa. ,^ar'...a+ ...:,( ....�i. - Ur .r."►Cens i)r re istration valid for individu'I use oft'! office of Con�n0 er ffidm& a +s g svi�on i w,: g ` Ol1�E IMPROVEMENT COIVTR CTOF? ";; ' befpre the expgatioii`date. If found return to , - 'Offics of Conss=mer Affairs aod,Bus`iriess Rc at'atiori Registtation fi 144032 Tye =. Expiration: �131�1012 Pnvati Corptira 10 Park Plaza-Suite 5170 _ Boston,MA 02116 C COD CARPENT K1Ci , _ bANIEL TOUSIGNA 12 REMINGTON LNf PLYMOUTH,MA 0236 . Undersecretary v d out signature AC ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE I12/20/2011 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: If 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT F. Cordaro NAME: FA Andrew G. Gordon, Inc. PHONE . ('781) 659-2262 A/C No: (781)659-9725 680 Main Street Epp IL gESS.bill@agordon.com P. 0. BOX 299 INSURERS AFFORDING COVERAGE NAIC# Norwell MA 02061 INSURER A:Preferred Mutual Insurance 15024 INSURED INSURER B:Liberty Mutual Ins. Co. - ARWC Cape Cod Carpentry, Inc. INSURERC: 12 Remington Lane INSURER D: INSURER E ,Plymouth MA 02360 INSURERF: COVERAGES CERTIFICATE NUMBER:Sample 122011 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 RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 A CLAIMS-MADE a OCCUR PP0100591897 /23/2011 7/23/2012 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-COMP/OP AGG $ 2,000,000 }{ POLICY PRO LOC $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCAUTOS HEDULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WC STATU- I OTH- - AND.EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A - .7/30/2011 7/30/2012 (Mandatory in NH) Cl-31S-343139-031 E.L.DISEASE-EA EMPLOYEq$ 100 000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) SAMPLE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. SAMPLE SAMPLE, MA AUTHORIZED REPRESENTATIVE F. Cordaro%CORWIL (,t//L�i�t rs-ti liN�-Ll.tut� ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD �I 0pTH6r Town oaf Barns.tab.le Regu' 12tory Services +STA D LZ Thomas F. Geiler, Director $riding ]�ivisio.n Tom Per'y, Building Commissioner 200 Main•Street, 14yannis, MA 0260] wtYw.town.barn"siable.me;us ' Fax: 509-791 Of iae: S08-862-4038 rop ertY 'O Wt Ct Must Complete and si xtl 'Ihh section If Us llg A B uildei as Owner of the subject property hcrcby aut6;or7ze _ to act on my behalf, in all rnatters'relati-�e to_v�otk authptized b.y this bddingperraitappEca iota for (Adct-c s of Job) Signature of DW z Date, Ge Print Name If Property Owner is;applying for permk please complete the Ho'M. owners T icense Exerimptjon PorM on9,,th'e'xevetse side: Towu of B arustable �P pfYNE r c Regulatory Services _ Thomas F. Geiler, Director t B""STABLE, Mass• Building B YisIOD n Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 nryyjy,town,ba.rnstobl P.m 2-us 508-790-6730' Office; 508-862-4038 J3bi1E0WNER LICENSE EYEMIPTION Please Print DATE: Ylllagc 10B'LOCAT)ON: strcct n u rnb cr work phonc# "kIOMBOWNLR": home phonc N ,• ri a mo CURRENT MAiL1N0 ADDRESS: • zip code sLalc city/town UTI ts or Jcss of six. em lion for cc "hozne�Ts''was cxte ed to ' elude oAvncupcense} d d that the lowner acts ads The current rX p to allow homeowners to engage an individual for hir w does not possess supervisor. DEF7N'ITI OF H0hfF,01''NER owns a excel of land on'which he/s c r sides or intends to r toiduch uschich and/o cre is, or is f�sti-uctures intrndrd to, Pcrsoa(s) whoP be, a one or two-family dwelling, attached or de ched i ucrj.od accessory son who constructs more than ope home {i/o yea period ehtableall oto tlic Buit bo ading Offs ato t hcS he shall be per Y homeowner"shall submit-to the Building fieial on.a rrnr (Section 109r 1 r 1) res onsible for all such wbrk crformed der tho buildin rsi ncd "homeowner" umcs responsibility for c mpliancc with the State Building Codc and other The undo g applicable codes, bylaws, s and regulations, cp Th'o undcrsig ncd "h cowncr" certifies that he/she understands e To 0 of Baams Saba procleddu es�axid went minimum inspecti n procedures and requirements and that he/sh tiv> c P y requirements, Signature of Nomcown- Approval of Building Of£ciA) ' otc; Tbrcc-family dwellings containing 35,000 cubic Icct or largewill be required.to comply with the N n Conrol.7.0 Construct"' MPIOState Building Codc Scch n12 RO�DYER'S EXE homeownu performing York for which a building permit is required shall be exempt from the provisions me Cod state that: "Any a cs a ason(s)forhirc to do such or this sect on (Seeeion 1�9r1r1 [secnsing of eonrtrvcdon superYisors);provided that if the homeowner cog g P work, Lhal such Nomco)s'ncT shA)1 Act►s superY,sorr"' the res onsi111ities of s supuvis'r(see appac�ix Q ly Many homeowiers who use this exemption azo�snscction 2.)5)ty arc Thisala k-of m;niwarcnes often results in serious roblerru,p Rues &'Regulations for Licensing Construction SupeTvi when [hc homeowner hires unliccnscd persons.. In this c;-6tcl uicspondsib)�not proceed against the unliccnscd person fith`oc)�Nnth app)ic.non supervisor. The homco�#acting As Superrisor is ulhm Y P unities rc uirc, As Par' P PIE currcnfl used by To ensure that G'lc homeowner is fully awxrc of his/her responsibilitics,many comet , f /c..hi(c,lion for„sc in your community. that the homeowner certify thal hejshe undcrslands the responsibilitics of a Supervisor. On the Iasic of[his issue is a form r + .1 j 6 { � t^P c I , l 77 + { , w � s T i 4 i + , ? • r } _ it Jr cr i ' t, � + 4 f • s 114 f � { , Vca rt ' Y f , d ` � 1-9 C7 7 } r p `r ! W} W . 4 e L � f VD • Y _ f v N + d r • tt _ .. 1 �,&.: a 7p, e ! t } 5 I i i t , 1 Map Parcel Q� CAS Permit# , -House# �� ��} � _ Date Rued a Board of Health(3rd floor)(8:15 -9:30/1:00-�@) r 0- � Fee/ �-r1C -2 Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) � Planning Dept. (1st floor/School Admin. Bldg.) Definitive Plan Approved by Planning Board 194r,�y y jV / •'@ARNSTABLE TOWN Off'BARNSTABLE Building;Permit Application Project StreetAddress -3 9 U -e C-1 Village Owner Ala'X i- 36 1 t^.I-C-`/ 11-W rfl_I-e- Address �o /,1�P Telephone Permit Request Q e ez�.� , First Floor -j :2 clt I square feet Second Floor �./j4 square feet Construction Type____LU t"A E Lru AA Estimated Project Cost $ Q,[�}` (7 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ,XNo On Old King's Highway ❑Yes *No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other , r& t^o VT-fL� j ( yet vw.cpo Basement Finished Area(sq.ft.) ,/V. Basement Linished Area(sq.ft) Number of Baths: Full: Existing New ,nli7 At.Q Half: Existing New &VALe No. of Bedrooms: Existing ?2 New WL Q Total Room Count(not including baths): Existing New r' .J-- First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes lNo Fireplaces: Existing New aLQ&�Q- Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) M None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes XNo If yes, site plan review# Current Use_v j2 �_ „/1�-n Proposed Use V L P �, i Builder Information Name��Jl �`I v 4- 2e./K0A 2 tt`-v!; Telephone Number '-( i-4 0�e _ .n g, Address '(y ed !:1i SJ, License# p dwSJ'�I �o Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE C DATE c s l UILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) r„ ' FOR OFFICIAL USE ONLY PERMIT NO. _ DATE ISSUED _ MAP/PARCEL NO. ADDRESS y ' VILLAGE' OWNER DATE OF INSPECTION: - Q 4 FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL:• ROUGH FINAL PLUM4131NG: tg� ROUGH ' FINAL y + GAS: C`ROUGH FINAL - - FINAL BUI DINS'. '• _ - _ - -• •y � ; I IA Fes• � f,F, � ! '. � ' DATE CLOSED OUT ' ASSOCIATIOMPLAN NO. r' The Town of Barnstable �e8 Department of Health Safety and Environmental Services �,r,�• Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosser Office: 309-790-6227 Fax: 309-790-6230 Building Commission: For once use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT-CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization. conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type otWork•/V �(.4;� V`-eeZ,�¢�.�-y Est.Cost � Address of Work: �01 Owner's Name i�'`Q l Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS .PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a.permit as the agent of the owner. -u Date Contractor Name Registration No. OR Date Owner's Name 1 , a � t t t YVv 5fwv�5 1 I t a t I { r � � !� .. '. 4 i � e � - }�� i � � � �. 1 - ' ' 9� { i� � r � v � � , . . � _ t _ .. -- . - - - i __. _. _:' _�. � 5 5 [ "' � s ., _+v.. :w.� �_ .. .. r .-. ....__. ., _ . ..._._ .. ..�., - - .._.,�� .....�_...SAY. �. � .,. ._. ..__ _ � � � .. ._ ' � + +. t f•i fix.. ..._ _ _y _ ... r. ,..- __ ,_ �. _- r - � _ ... -- - . .- � .. .._.- __. . � .. �..,. . . . . -r. _.. .. ...t. ._ `T' � , � k � i i � f � i � �� _ i i R � � � - _ - ` IIt i �' �- i _ t� s � � ��� r i � 9 S.(/u A14- Ale / 4 M 'o \V �� 'ay Lo: c G o T i3 � j N CERTI FIE PLOT PLAN L 0 C AT 1 O N 5CALE- / 30 DATE 4= 72 R E F E R E N C E �N�'7 �o i �3 .q s CS�ro��✓ ✓o 872Z 7z 2AT- E / I HEREBY C E R T I F Y T H AT' THE SUILDI N G R E G. L A N O S U R v Y O R SHOWN ON THIS PLAN IS LOCATED ON T H E G R O U N D AS SHOWN HEREON AND THAT 1T -J-4-S C O N F O R M T O T H E ��AOFjW.A4 yG ZONING BY - LA*-VV-S- , OP...TH E TOWN OF W.HEN CONSTRUCTE D,�4A,y 4 JOSEPH M. MONAHAN,JR. H BARNSTX&LE SURVEY CONSULTANTS,. INC 4cisTEft`' WE"5T YARMOUTH,.M ASS . h� SUR`1E'y 1 I ' I • j 1 _ 71- i r _ } - Vi « I f i :rr +.ter ' rm I • a -j i { - - rz-! 01 1:/40 p �7 0 I , l �t T i hG AA lip - / 14— a n L--"� %a A ! � T I �L���d�i: ' i � t>4 L 1`,t.t r��,� �.� � � I �Z X, ��U r7� a d ,"Z,ti��,-r�►- �i r�v r t�--. rV IbL I .�' I � 11 '' y °.yZx G: �'.•�. h it L �'' �—r-.-�:__ ( � — �_.._� � ------- [CV �L'.ram j I'�(�� I L V 1/4 Cb 12 J xT. QQ Q DATE r7 P DONALD I. MEYER REVISED z _ Professional Building Designer PO7 Ek-)x 532 -Yarmouth, MA 02664 DRAWING NUMBER z u (5t?8) 394-5296 ., ;1✓ �� j x � ,.:.-- � ..,.: .. ...q.:. �,.. _ .,.... ;:.. 1 _;.-... .. �.:: :. •.`'tea .�^' S + a a 4' ,�", �-; _tom. • c.�. a '... .. _ fir. - r z s >.. ram .�.s.4:e: .a u�`9e... ,c;. .. '. ... . � ✓b .r ! _.. ., ... ..._. .. a x. .. ..- A x�..' ..+_ ...: * il -... N.: .:... Iy .,1:1•YGW.' -..*. ... dF '-�..... ,.....J.�.°3. x, 1 t '�.. . y(��, -. Y.m ..W., ¢. ...�. � .. 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