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0211 PARK AVENUE
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N ^f A* ,) t 1 P �i � , ,r..m, a m m r r4 Town of Barnstable Building .p �.«- �.,.�.�� w--^r,--`s�,a ...+.».,.-• .`Vie. �r" ro"�^�st m �,,: *�ry w�._. .»� .:�,. ..� ?' .; **� Po°st This Card So That rt is Uisible,From the Street Approved Flans Must be Retained on Job and this Card Must be Kept PostedgUntil,Final Inspection Has Been MadeTermit 39. 'Where a Certificate of Occu' anc "is.Re";wired,such Bu�ldmgtshall Not:be Occupied unt�la Finalln`spection'has been made -.,ras9p.�..�, � Permit NO. B-19-4170 Applicant Name: HOME WORKS ENERGY INC. Approvals Date Issued: 12/18/2019 Current Use: Structure Permit Type: Building—Insulation-Residential Expiration Date: 06/18/2020 Foundation: Location: 211 PARK AVENUE,CENTERVILLE Map/Lot: 187-046 Zoning District: RD-1 Sheathing: Owner on Record: BISENIUS,THERESA A Contractor Name,: ..HOME WORKS ENERGY INC. Framing: 1 Address: .211 PARK AVE Contractor:License: 181138 2 CENTERVILLE, MA_02632 Est Project Cost: $ 10,079.00 Je- Chimney: Description: insulation.weatherization Permit Fee: $ 101.40 Insulation: Project Review Req: Fee Paid: $ 101.40 `� Date 12/18/2019 Final: Plumbing/Gas R Rough Plumbing: ' t � (• ° Building Official v Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within s,i onths after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents:for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structbre�s shall be in compliance with the local zoning by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. I° t Electrical' The Certificate of Occupancy will not be issued until all applicable signatures,.by4be Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:, ` : Service: 1.Foundation or Footing ' Rough: 2.Sheathing Inspection . .. 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: .4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). - Building plans are to be available on site Fire Department Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT - d j.e ..W 'o T ..1 m ........ application nu be ,. .......... .. ...:..i!!�v.......................... - Fee ............ .� .............. Building Inspectors ectors Initials... •••• : w� t t .......... NAM �bg. ♦ Date Issued:...k. ~v ( n ............. .... L�2................... Map/Parcel......1. .... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOwS/DCORS/TENT PROPERTY INFORMATION (Zk_ AUK Address of Project: 2 I 1 PAVILLAGE NUMBER STREET n Owner's Name: 1S 2✓►I J S Phone Number �n� -��� A 1 • rn` hnQ i C,0 M Cell Phone Number Email Address: / Project cost$ i 0 A� +1 Check one Residential V Commercial OWNER'S AUTHORIZATION t As owner of the above property I hereby authorizeMCRN to make application for a building permit in accordance with 780 C Owner Signature: Date: TYPE OF WORD # insulation/Weatherization ❑ Siding ❑ Windows (no header change) ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 2S(b CCa n be('�'� h t u W Aq �,14Cp kEVVA t CONTRACTOR'S INFORMATION Contractor's name f z Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# 1 C), 3 _ + i ' '--(attach copy) � S�2q9 4 Email of Contractor Phone number 9s VC vcnvc n1 n nRJF)THE SUBJECT PROPERTY.IS IN i APPLICATION .NUMBER.............................................. ....� � *For Tents Only* Date Tent(s)Will be erected Removed on number of tents total Does the tent have sides?Yes_ Dimensions of each Tent No dyes please attach floor plan with exits marked X Additional tent dimensions can be attached on a separate piece of Purpose of Event P paper. Check one: this event i�a:!for profit__non- rof Check one: Food served Yes P it event Flame Spread Sheet of each tent must be attached, provide a site Fuel source being used LP tank 20 lbs. or> yes plan with the location(s) of each tent Natural Gas Yes No N0— .if yes, a gas permit is required. i f yes, a gas permit is required. . If food is being served at.your event please obtain a Health Department a of 8:00am-9:30 am or 3:30pm-4.30p, Commercial events may require rre al between the hours Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D, Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date 'OPLICANT'S SIGNATURE Signature _ Date All permit applications are ub ct to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations ' 600 Washington Street a Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Homeworks Energy Address: 101 Station Landing Ste 110 City/State/Zip: Medford MA 02155 Phone#:781-205-4520 Are you an employer?Check the appropriate box: Type of project(required): 1. ■❑ I am a employer with 200 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).*. have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers'. comp.insurance comp.insurance.+ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions` 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers'comp right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑■ Other Weatherization comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M Mutual Insurance Policy#or Self-ins.Lic.# #2000552 Expiration Date.1/1/2020 Job Site Address: �l` ` Avg City/State/Zip: got AStC4 M 02-02 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the s a penalties of perjury that the information provided above is t ue and correct. Signature: I �V Date:' ---'-fit_ Phone#:781-205-4520 / wxpermitting homeworksenergy.com Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: 1 I in-r- nn. Energy, To whom it may concern; Scott Veggeberg is a current employee of Homeworks Energy Inc.and operates under our insurance policy. Policy numbers that Scott is covered by are as follows: Commercial General Liability:793006065002 Automobile Liability:6244378 Umbrella Liability:7930060660002 Workers Compensation and Employers' Liability: MCC-200-2000552-2019A All H m W rks Energy permits are pulled under his CSLlicense. The insurance provider is AIM Mutual Insurance Company. If you have any questions or concerns please contact Director of Weatherization Adam David Glenn at 774-365-2446 or adam:glenri@homeworksenergy.com. Thank You, Adam David Glenn Director of Weatherization HomeWorks Energy. rf Page 1 of 2 0 rr- -o er mass save Energy, Inc PARTNER 101 Station tonding5te 110,Medford,MA 02155 (781)305-3319 ext.120 Customer Name:Ann Bisenius Email:Not provided Phone:508-775-9189 Premise Address:211 PARK AVE,BARNSTABLE,MA 02632 Mailing Address:211 Park Ave,Barnstable,MA 02632 Project ID:3878271 Date:Aug.22,2019 Job Description Measure Description Location Quantity Unit Total Cost Customer Cost - AIR SEALING Living Space 24 hr $1,920.00 $0.00 WEATHERSTRIP DOOR &ADD SWEEP Living Space 3 each" $240.00 $0.00 ATTIC FLAT-9"OPEN R-33 CELLULOSE Living Space 536 SF $804.00 $80.40 ATTIC DAMMING- R-38 FIBERGLASS Living Space 50 SF $123.00 $12.30 12 MUSHROOM ROOF VENT Living Space 4 each $483.00 $48.30 VENTILATION CHUTES Living Space 66 each $230.34 $23.03 VENT BATH FAN THRU ROOF Living Space 1 each $118.75 $11.87 KNEEWALL: FG BATT+2" RIGID BOARD Living Space 356 SF $1,869.00 $186.90" KNEEWALL FLOOR-8" DENSE R-25 CELLULOSE Living Space 444 SF $888.00 $88.80 KNEEWALL HATCH: INSULATE&WS Living Space 2 each $85.00 $8.50 Total Contractor Price and Payment Schedule HomeWorks Energy, Inc.agrees to perform-the above described work,furnishing the material and labor specified for the listed total price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature:_ Date: I n12812019_ Customer Phone: Specialist Signature: JuLn�za C Date: 10/28/2019 _ UMITED TIME OFFER: The prices and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers. Proposals can be sent to:Inbox@HomeWorksEnergy.com Page 2 of 2 III n a o rr n ® mass save Energy, Inc PARTNER 101 Station Landing Ste 110,Medford,MA 02155 (781)305-3319 ext.120 Customer Name:Ann Bisenius Email:Not provided Phone:508-775-9189 Premise Address:211 PARK AVE,BARNSTABLE,MA 02632 Mailing Address:211 Park Ave,Barnstable,MA 02632 Project ID:3878271 Date:Aug.22,2019 COMMON WALL:FG BATT+2" RIGID Living Space 120 SF $630.00 $63.00 BASEMENT SILLS: R19 FG BATT Living Space 208 SF $455.52 $45.55 REMOVE EXISTING INSULATION- INCENTIVIZED Living Space 2301 SF $2,231.97 $223.21 Project Total $10,078.58 Weatherization incentive ($7,126.72) Air sealing incentive ($2,166.00) Total Program Incentive $9,286.72 Customer Total $791.86 Total Contractor Price and Payment Schedule HomeWorks Energy,Inc.agrees to perform the above described work,furnishing the material and labor specified for the listed total price. Payment of the balance of the customer contribution is expected upon completion of the work. Customer Signature: Date: 10/28/2019 Customer Phone: Specialist Signature: Jrlaoia _Date:_ 10/28/2019 LIMITED TIME OFFER: The prices and incentives in this contract are subject to change in accordance with the sponsoring utility MassSave Home Services Program offers: Proposals can be sent to:lnbox@HomeWorksFnergy.com I Insulation/Air Sealing Permit Authorization �o Specialist: Christopher Boc Company: HomeWorks Energy Email: christopher.boc@homeworksenergy.com Address: 101 Station Landing Cell: (617)827-8218 Medford Ma 02155 HomeWorks S , cnert7y,Inc Phone: 781-305-3319 Customer: Bisenius Address: 211 Park ave Email: 0 Barnstable Site ID: 3858079 Phone: - I,the owner of the property identified above hereby authorize HomeWorks Energy Inc.,or their Partner to act on my behalf in obtaining any building permit that maybe required to perform insulation and/or Weatherization work on my property and all matters related to the work authorized by said permit if one is obtained. Any related permit application cost will come at no additional charge provided that the agreed Weatherization Work is completed. Customer Signature: �y Date: 8/22/2019 Bisenius .�/i( rf_1(.`lilli!!'ll/!'!`rs!//! /�'� ,f( ,�;/ci•.r"�!/i'�/!s/��i Office of-Consumer Affairs and Bust Mss Regulation 1000 Washington}Street=Suite 710 Boston,Massachusetts 02118• - Wome Improvement Contractor Registration ._ Type, Crrpgroilan - - - Rr.�istri3ti4r1: 1+31i3A - - - HOM,E WORKS ENS RGY,INC. E,R($tetidn. 63 6Zi202.i 101 STATION LANDING STE 3 i0 - - - - - RAEDFORD,NIA 02155 Updale Addr=apd R91—Cerd. - airs-A Ccasumm AH�Irr 8 9v51n�sa Rep919?ion: R SfraliOn raliA Farindividd0l U6a mdy - H6MfRAPROVEMENTGUNMACTUR. TYPE:.Co waten before the expiration Aato..if found wtf to: RcaisNat�ti g&Wm.,j n LHiice at Cansutn9r Aria,,mand 9uslnae6 Rcgulation- 18113 73�02:2U?5 - 1 owwavh[ryoN Street-Suite 710 - - - 14OMF 71ORKS ENERV..NG. Boon?+,to 0211 - M XNEGGEBERG 101 STATfUN LANDING$TE 110 valid WittFOUt 31Bn3Wr8 "IUVORD,NA 32`iSS Undatser_x8iap` r (;0rn TIOn Wealth Ot MMSRACNASe.tt-s5 r ConsuIuctio'n Supeevisor Specialty Dlviston of Professional Llrelisure Soard of Building Regulations and Standards Restricted to: ti V t CSSL-IC-Insulation, Contractor Cat,tstiesetltsrtiat a rvtsctx spcciait CSSL-103832 E_i pines:10d13i2021 SCOTT VEGGESERG` I 8 COVINGTON ST#9 _ , 0. BOSTON MA.D2127 -= w' S 4 Failure to possess a cui dMon of'the Massachusetts State Building Code is c, or revocation of this license. l Gcsrnmissidrier .._.. For inforrnatlo,t about this license *;,{w,:�t:: .,•-• .• �� Call(617)727-3200 or visit www.mass.govldpl. • HOMEW-1 OP ID,.L' CERTIFICATE OF LIABILITY INSURANCE DA'rEtMM(DoNYYY) 03/29/2619 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS NO RIGHTS.UPON THE CERTIFICATE HOLDER:THIS . CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND;EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN:'THE:ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ......... - ------ --'— IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies);must have ADDITIONAL.MSUR ID provisions or be.endorsed: It 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). 1 FIR DUCER - - 97"86-2266 'c:. NNperLisa Lariviere -- Foster Sullivan insurance PHaNI C_No,a g7g 686.2266 FAx 978 686-6410 163 Main St �a �: ac No: North Andover,MA 01845 EMAiL Ceee i ca es ostersu ivan rou com Foster Sullivan Insurance LLC ADDRESS: _.9 P• _ INSURER(S)AFFORDING COVERAGE ___ NAIC:IL_ i INSURERA:SAFETY'INDEMNITY INS CO' 39454 INSURED Homeworks Energy Inc. _ !.INSURERB:A.I.MMUTUALINSCO- 33758 101 Station Landing Suite 110 NSURERC,Homeland Insurance"Co of.NY 34452 Medford,MA 02155 ---- -'--—= 1 INSURER-0: INSURER.E': INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED.BELOW HAVE BEEN ISSUEDTO THE INSURED.NAMED_ABOVE FOWTHE POLICY.PERIOD -i 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 (,DOI$UBR POLICY NUMBER FODCY EFF POLICY EXP 1 LTft _ _IHSo.NN —_.___._ _ I(M /DDM'YA I. LIMITS I C �X ICOMMERCIAIGENERAL LIABILITY 1 EACH OCCURRENCE _1 1i000,000 III DAMAGETORENTEO SOO,000.CLAIMS-MADE X;occuR I '7930060650002 0410112019.04I01I2020 S MED FXP(Anyone rson 101000 _— I PEgSONAL&ADV1H.)URY1y000 OOO 2;000,000': GEN'L AGGREGATE LIMI�APPLIES P'eR: I GENERAL AGGREGATE -S� - • I POLICY'_ PR !LOC 1 I o 2 000.000 !_ F.CT ,—, i i ,. PRODUCTS AGG is i.OTI IER__. _.,.- '. �". ;. --:- ,COM88 dfIN(EaDDu _- 1,000,000 ..._.._—. A _AU_TOMOBILE LIABILITY I -- - ANYAUTOI62443711 'I 0410112079 0410:112020:1 BODILY-INJURPe_pe,,,_) ._ OWNED ^J SCHEDULED — __�AUgqTE�O��S ONLY X AUUTOS ED I_. : �eRQDfLV IN;UBy lRer accident)Is p X A�TOS ONLY F X. AUTOS ONLY i �11Pa>°aPocMe r C i i — 2i000,000 �, :UMBRELLA LIAR X OCCUR 7 1 EACH CCURRENCE i$ . --- X EXCESS LIAR CLAIMB-MADE I '7930060660002 104/01/2019L0410112020 AGGREGATE 2,'OOQ000 _ .1 �. .S DED I X RETENTIONS �I _ + I . — B iWORKERSCOMPENSATION' X.._PETUTE._ FR OTH• AND EMPLOYERS'LIABILITY YIN - MCC 200.2000552.2019A 01101/2019 01/01/2020 T;000 000 ANY PROPRIETOR(PARTNERIEKECUTIVE - I El-EACH ACCIDENT :S OFFICERIMEMEER EXCLUDED. `NIA. — I(Mandetory In NHl ` I - lEliDISEASE-EA�EMPLOYEB: -1;000000 I if yes,describe Under ! 1,000 000 ... . —DCGCRTTIQN0fLO(1MTiONS'bolow_—_' !'. _. .!E:L:DISEASE-POLICYIIMIT-S: I E°vE Inn0N F PERATIONS I LOCATIONS I VEHICLES(ACORD 191,Additional m Remarks Schedule,may be attached if ono apace Is required) �`d�nCC BnPy 1 CERTIFICATE HOLDER- CANCELLATION 'SHOULD ANY OF THE ABOVE I DESCRIBED POLICIES BE CANCELLED BEFORE t : THE EXPIRATION:. DATE THEREOF.. NOTICE WILL BE DELIVERED IN - - ACCORDANCE WITH THE POLICY PROVISION& : - Homeworks Energy 1015tatioil Landing Ste 110 Medford,MA 02155 AUTHORIZED REPRESENTATIVE J. / ) ACORD 25(2016103) 11 v�©&1'888r[20115/AJCORD CORPORATION All rights reserved The ACORD:name and logo are,registered!marks of•ACORD I . 2-) �o HomeWorksBUILDING DEPT. nC Enefgy, Inc - JAN 1:49012P TOWN.OF Bq, �E�`� Insulation Affidavit HomeWorks Energy has installed insulation at the following address that meets or exceeds Massachusetts building code and IIC requirements. Project Address: Permit Number: B-19-4170 Ann Bisenius 211 Park Avenue Barnstable Massachusetts 02632 Location Material Addt'I Thickness Final Assembly R-value Attic Floor Green Fiber Cellulose 6" 49 Attic Floor Owens Corning Fiberglass Batting 6" 49 Knee Wall 3"Owens Corning FG+2"Dow Pol, 5" 27 Enclosed Knee Wall Floor Green Fiber Cellulose 81, 25 Basement Rim Joist: 6"Owens Corning Fiberglass Battip 6 1.9 Sincerely, .. Scott Veggeberg - - HomeWorks Energy Inc. CSL#103832 HERS Certification#3081658 HomeWorks Energy 101 Station Landing,Suite 110 Medford,MA 02155 wxpermitting@homeworksenergy.com Town of Barnstable - *Permit of - ,,p�' Expires 6 m hs fr n 9" issue e yT Regulatory Services, Fee • snxxsrnsi.E, • M" i63� Richard V.Scali,Director ♦0 - Building Division 3)2X4 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 o _ a Not Valid without Red X-Press Imprint Map/parcel Number Property dress �^ esidential Value of Work$ 3lmimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name / Telephone Number- 5�6� �� / Home Improvement Contractor License#(if applicable) Email: ' e� Construction Supervisor's License#(if applicable) C—5- 0 700 ❑Workman's Compensation Insurance _ g Che one: k, YelO1IF �� NUII� Il [�I am a sole proprietor ❑ I am the Homeowner MAR 0 4 2016 ~ ❑ I have Worker's Compensation Insurance . Insurance Company Name TOWN OF BARNSTABLE Workman's Comp. Policy# ` Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be to ❑ Re-roof(hurricane nailed)(not stripping. Going over r existing layers of roof) ❑ Re-s eplacement Windows/doors/sliders.U-Value (maximum 32)#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, y of the Home Improvement Contractors License&Construction Supervisors License is r fired. SIGNATURE: Q:\WPELESTORMS\building permit forms\EXPRESS.doC Revised 040215 27ie Commonwealth of-Wassachusetfs Depm-t rent o,f lfndWsh ial Accidents - - @,f ke o,f In stigations 600 Washingion Street Boston,MA 02111 k6'Fi*1n mamgovldia Workers' Compensation Insurance davit:BuildersiContracturs/EIectricians/Plumhers Applicant Information Please Print I.eQibIy Name(BusiaessMrganizatianQdiM&M1): Acl&ess: / a Ci fstatel one Are you an employer?Check the appropriate box: T of project r uire - I am a general contractor and I Yl e ] ( ' 1.❑ I am a employer vE�th. 0 e 6. New construction yees(full an- Vor part-time)-* pave]sired.the sub-contractors 2. I am a sole etor or partner- listed on tale attached sheet. 7. ❑Remodeling l�lm 1� i s p and have noemployees. These sub-contrac#ors have mP $. ❑Demolition working for one in any capacity. 'employees and have woikers' co 1 9. ❑Building addition. [too workers' comp.i*���1�++�e ff_insurance. required-] 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3. officers have exercised their El am.a h�ameowner doing all work 11.❑Plumbing repairs or additions myself [No workers'comp_ fight of exemption per MGL 12.❑Roofrepairs insurance required.]F c.152,§1(4h and we have no - employees.[No workers' 13.0 Other comp.insurance required.] `Any WBcaot ttaet cbecks box 91 mast also fill oat the section below showing their workers'compensa&n policy informadon. 1 Homeowners who subunit this aifc3as9t indicating they are doing all wait gad then hire outi dde contractors amst submit anew affidavit indicating such. Icanttactors that check ibis boar must attached sa additional sheet shouting the name'of the sub-contructm and state whether or not those entities have employees.Ifthesubtaatmctumbs a eUIpIoyees,thepmustpmr-ide their workers'—p.policy autnber. I arft are enrplo}�er that is prerrzdirtg yvorkers'coarpertsalicrrt i�tsurattt a joy arSs enrp£ay es Be£ow is the policy road jab silt: informa6piL Insurance Company Name: R Policy#or Self-ins.Lic.#: E,pirat on Date: . } Job Site Address: CitylState/7ip: Attach a copy of the workers'compeusatiorip.olicy declaration page(shoving the policy number and expiration date). Failure to secure:coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penahi s of a fine up to$1,500.0D andFor one-year=gmsonaueut,as well as civil penalties,in the form of a STOP WORK ORDER and a fine' of up to M0-00 a day against the-,,aolator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ofthe DIAL for insurance coverage verfrcation. I+fa£ter el>y certcf tzr the pants and psnah�ies o p ry that the irtfonuatiorrpront a v is b7w grid correct Sit�mah�re: Date: Phone#: � _7 2) 0J / Official acial use only. Do not write in this area,to be campLietesd by city or torn n official ciaL City or,Tomm.: Perr dtff kense# Issuing.Authority(circle one): 1.Board of Health 2.Building Department 3.City{rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 f -Information and Instructions Massachusetts =,neral La chapte �r 152 re: all employers to provide warkPds'compensation far then employees. Law ' t pmsuautto this staltt\e,��an.�loyee is defined as."-.every person in the service of another under auy contact of hire, express or implied,ord or wtltt� An employer is defined, "an individnA partamsbip,association,corporation or oth legal entity,or any two or more of the foregoing engaged oint enterprise,and including the legal reZs esenfati�e of a deceased employer,or the receiver or trustee of an ind- partnership,association or other legal entity, loying employees. However the owner of a dwelling house having t more than three apartments and who reside therein,or the occupant of the - dweTling house of another who emplo elsons to do mahtman ce,=Suemp 0 repair work on such dweIIing house or on the grounds or buz7dmg appmtenaat ereto shall not because o yment be deemed to be an employer" MGL chapter 152,§25C(t7 also sites that"ever'ygate or loc-a.l Iicensimg ag cy shah withhold the issuance or renewe of a license or permit to operate a business. or to construct burl ' gs is the commonwealth for any applicant who has not produced acceptable evidenceof compliance - th-e insurance.coverage required." Additionally,MGL chaptrr 152, §25C(7)states"Neitherth�cor manor nor any ofitspoliiical subdivisions shall enter into any contract for the perfbanance,ofpubhc work Qkacceptabl evidence of compliance with the i„sura cd. requirements of this chapter have Been presented to the Applicasrts Please fill out the workers'compensation affidavit completely,by the boxes that apply to your situation and,if necessary,supply sob-contractar(s)name(s), addresses)and phone t er(s)along with their certificates)of jugurance. Linritsd Liability Companies(LLC)or Limited Liab _ e`rsh. s(LLP)with no employees other than the members or partners,are not regrined to cauy workers' compens -on ins ce. If an LLC or LLP does have employees, a policy is regnired. Be advised that this a$da-vit m be sub to the Department of Industrial Accidents for confnmation of finmanee coverage. Also be sur to sign in date the affidavit The affidavit should be retsmm(--d to the city or town that the application for the p or license is Bing regvested,not the Department of TrrhL,.cfri al Accidents. Should you have any questions the law or if y ere regua ed to obtain a workers' compensation policy,please call the.Department at the numb listed below. S -insured companies should enter their " self-fi suan.ce license number on the appropriate line. 0 ffi vials C' or Town O �y Please be sore that the affidavit is complete and printed I ly. The Department ovided a space at the bottom of the affidavit for you to fM out in the event the Office ,f Investigations has to con you regarding the applicant Please be sure to fill in the peunit(license nu ib x whi wM be,used as a reference er. In addition, an applicant that must submit multiple pen itlIicense applications any given year,need only submit e affidavit indicating current policy i:� imation(if necessary)and under"Job Site AT the applicant should�r rite" Zocations>n (city or town}_"A copy of the;-affidavit that has b=n officially stamped or marked by the city or town ay be provided to the applicant as proofthat a valid affidavit is on file for permits or licenses Anew affidavitmus�t be filled out each f� to an business or ctimm ermal ventm"e year.Where a home owner or citizen is obtaining /license or permit not related" y . on is NOT to co Ie e,Ibis affidavit (ie. a dog license or permit to bum leaves etr.) d pens regrured comp lee, would like to you in advance for your cooperation and should you have aay questions, . The Office oflnvestigati please do not hesitate to give us a call. The Depertm.enfs address,telephone and fax ern The CG.MM0nWMj- E of Massachusetts Departiaent of 1-adu&tial Aooi ent% offl=o,f ve g tto 1500,w ton st=t Bwtojo MA GPI II Tf,-L 4 617-7274WO cx- 4-06 or I-a77-MASRAFF Fax#617` 27-774 Revised¢24-07 -mass-gavldia a 1 * . MASS. 1639. Town of Barnstable ���' Regulatory Services Richard V..Scali,Director y Building Division . t Thomas Perry,CBO . Building Commissioner 200 Main Street, Hyannis,MA 0260 V., www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must `-Complete and Sign This Section I .Using A Builder 4 l�fl P 6t 4( e h I CfO' , as Owner of the subject property hereby authorize_� �. �U �/� to act on my behalf in all matters relative to work authorized by this building permit application for: (Addressof Job) w • t ell- Signature of Owner Date sa,. 0 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESTORMS\building permit forms\EYPRES&doc Revised 040V5 r Town of Barnstable Regulatory Services a �dFIMME Richard V. Scali,Director r Building Division BAMSrABM Tom Perry,Building Commissioner 1639. `0� 200 Main Street, Hyannis,MA 02601 ATEo www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street vill e "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 wh does not possess a license, rovided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/s a resides or intends to/ieside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures ac ssory to such use and/or farm structures.'A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such/homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall Ae responsible fo�all such work performed under the building permit. (Section 109.1.1) 1 The undersigned"homeowner"assumes responsibility f compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. ` The undersigned"homeowner"-certifies that he/she unders cu the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply wi LXaid procedures and requirements. Signature of Homeowner J Approval of Building Official r Note: Three-family dwellings containing 35,000 cubic feet or larg will be required to comply with the State Building Code Section 127.0 Construction Control. H MEOWNE_R'S EXEMPTION, The Code states that: "Any homeowner performing work for which a\building permit is required shall be exempt from the provisions of this section(Section 109.1.1-: icensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that suh Homeowner shall act as supervisor." Many homeowners who use this exemption Ire unaware that they are assuminj,the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for-Lic ensing&nstruction Supervisors,Section il5) This lack of awareness often results in serious problems,particularly when the ho�eowner 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 communes require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\FJG'RESS.doc Revised 040215 Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-078000 Construction Supervisor SCOTT H QUIL.TER PO BOX 727 * y WEST HYANNISPORT MA,T02672 Expiration: Commissioner 02/03/2018 -- t s (LCa77Y�'7tC�rcuctlLLJz o���ab:rr��ci�e(,1�� , Office of Consumer Affairs&Business Regulation. ° OME IMPROVEMENT CONTRACTOR egistrat►on �132691 Type: ,xpiration 3/23/201:7 Individual y i # SCOTT QUILTER ' SCOTT QUILTER t - 247 STRAWBERRY HILL CENTERVILLE, MA 02632 . e � _ Undersecretary `. i Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-078000 Construction Supervisor k SCOTT H QUILTER `+ PO BOX 727 WEST HYANNISPORT MA,02672 Expiration: Commissioner 02/03/2018 License or registration valid for,individul use only before the expiration date-'If found return to: Office of Consumer.Affairs.and Business Regulation 1 10,Park Plaza.-'Suite 5170 - i Boston,MA 2116 i Not valid without signature' y v7- y�*THE Tp�I TOWN OF Br1RNSTABLE i 3ARNSTAMLL i 9o� Q�Y.a�e� . BUILDING INSPECTOR 0 APPLICATION'FOR PERMIT TO . .. .C3 ....... ...... .................................................. TYPE OF CONSTRUCTION .......` .. ,..........��-...R.A.kn. .................................. t ......... ............19-7- Y.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....a l.0....... .9 0....... .�,d.. ... ��.. ............ :. .................................. ProposedUse ...... ...... a._�-� ... �....................�........ ?. ...........................................I......................... Zoning District ....T.,,. ................ .... ....................Fire District Cawa..a.1 ....... 7�Q-R�11rL� Name of Owner ......Address t� ,>.. , lF•v... .�.Ak. .... �.� �. Name of Builder .Address 3 3° Nameof Architect ..................................................................Address .................................................................................... f Number of Rooms .............d..........:............... ...................Foundation �3 C912[ 1^Ce i� c� ...... .. ........................................................................... Exterior ..... ... . `j '...... . ''�r. ...r....................Roofing .... toll Floors .Interior " Heating ........ �'.��. .. .��.�. .............................Plumbing ....../......t� ........................... ................. Fireplace .................. :. ..................................Approximate Cost .............V�p...t... '�- v..�.. ........ Definitive Plan Approved by Planning Board ---------------__-___--_______19 Diagram of Lot and Building with Dimensions �P SUBJECT TO APPROVAL OF BOARD OF HEALTH PAS -" --- - � J ` Ctd CWh o Lj- ,d (" M 0�7. W zX� co LL, W 0, O Q OJm 0_ i1J M I t i W ::D �- U) - f � < C) 0 � Z U) ¢ � W F- a. WAGE i . < Z Q d �� (n Q J► I hereby agree to conform to all the Rules and Regulations of the of Barnstable regarding the above construction. Nam .. � ::��...... Ham_inond, Dr. George 15557 add to single No ................. Permit for .................................... family dwelling .......................... ......................... 211 Park Ave. III Location ................... ......................................... Centerville ............................................................................... Dr. George Hammond Owner .................................................................. frame ' Type of Construction .......................................... i ................................................................................ Plot ......................... .. Lot ................................ } Permit Granted ...Oct9ob, r 2 19 72 ....... ............ �Z6 ����91' Date of Inspection . ..... 9 Date Completed .. ...............19 } PERMIT REFUSED f } ................................................................ 19 ............................................................................... r 1 ............................................................................... ............................................................................... 1 Approved ................................................ 19 ............................................................................... ...............................................................................