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�oM oMeWok BUILDING KEPT.
r1- n FEB :� �oz,
Energy, Inc a
TOWN OF BARNSTABLE
Permit Cancellation Request
HomeWorks Energy is requesting the cancellation of the following building permit:
Permit Number: EXPR-21-38
Address: 17 Patricia Street Barnstable Massachusetts 02601
Reason:The customer has declined to move forward with the insulation and
weatherization work. We will no longer be planning to perform any of the
originally contracted work at the associated address above at this time. Please
cancel out this permit that is attached to this notice. Please reach out to the
specified number below if you have any futher questions regarding this.Thank you.
Sincerely,
Scott Veggeberg
HomeWorks Energy Inc.
CSL#103832
HERS Certification#3081658
HomeWorks Energy
101 Station Landing,Suite 110.
Medford,MA 02155
wxpermitting@homeworksenergy.com
(781)205-2201
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application#
Health Division
Conservation Division Permit#
Tax Collector Date Issued 1 tt 7 66
Treasurer _ '- Application fee
Planning Dept. Permit Fee S D
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address / 7 1)n f A1GL (/-{
Villag ���T@r
Ile—
Owne7 z_o �� Address cC/ /4ww /1
Telephone e i 2 7 �- 2- 1
Permit Request ,C l�i�� 1 L. lhl�7 JEY[ $ //4(_4eaL d 4e"td.,
/At 4 h21yi A oco_ Ti n&f Al fa
P
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new
Zoning District Flood Plain Groundwater Overlay71
Project Valuatio � j �.�� Construction Type
1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting ct umentatltln.
Dwelling Type: Single Family & Two Family ❑ Multi-Family(#units)
4- co
Age of Existing Structure Historic House: ❑Yes 6No On Old King's Hig way: ❑-Yes
Basement Type: ❑ Full ❑Crawl alkout ❑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 0
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas it ❑Electric ❑Other
Central Air: ❑Yes & o 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 6'No If yes, site plan review#
Current Use s 1--f. c-.r e-k. On(G"I-C Proposed Use
BUILDER INFORMATION 761- 2-�',3.
Name = /2 Telephone Numbe<hG1- 41 r
Address c �-/'� /1 License# eee / 2. S� I,
�/ ��'12or✓1`�� �l ��- 3 6 CD Home Improvement Contractor# y Z
Worker's Compensation# 3 f:114 Y�
L CONSTRUCTION DEBRIS RESULTINq FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR n DATE
FOR OFFICIAL USE ONLY
E
S ,
PERMIT NO. ;
I
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE,
¢ OWNER
3
f
S
DATE OF INSPECTION:
i FOUNDATION
FRAME
INSULATION O U h 3 JO-2
FIREPLACE
¢ ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
's ASSOCIATION PLAN NO.
r
The Commonwealth-of Massachusetts
Department of Industrial Accidents
�' f '� Office of Investigations
1°fryV 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): l�6�
Address:
City/State/Zip. y Phone #:2tj
Are you an employer?Check the appropriate box:` Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hiredthe'sub-contractors 6. ❑New construction
2, am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
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.❑Electrical repairs or additions '
3,❑ I am a homeowner doing all work right of exemption per MGL 11.U 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.]
OAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such,
kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am an employer that is providing workers'compensation insurance for my.employees. Below is the policy and job site
Information.
Insurance Company Name: /(I (�
Policy#or Self-ins.Lie.#: s 4146 7 T E 14 Expiration Date:'0 3' -3-0 G
fob Site Address: r Gi l� . City/State/Zip;
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a .
.me 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
)f 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.
do hereby certify he pains and pen ties of pe j ry that the information provided above is true and correct
3i afore: Date:
?hone#: — 3 Z® �' �G - C -:- 3 p?
Official use only. Do not write in this area,,to be completed by city or town of
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 empl yer is defined as"an individual,partnership,association,corporation or other legal entity/Sha
or any two or more
of the foregoing engaged in a joint enterprise,and including the legal represen of a deceased e lover, or the
receiver or trustee of an individual;partnership, association or other legal entiloying emplo ees.,However the
own-,r of a dwelling house having not more than three apartments and who reerein,or occupant of the
dwelling house-of another who employs persons to do maintenance, constructepair wo on such dwelling house
or on the grounds,or building appurtenant thereto shall not because of such ement be erred to be an employer." .
MGL chapter 152�§,25C(6)also states that"every state or local licensing aghall thhold the issuance or
renewal of a license�or permit to operate a business or to construct buildith commonwealth for any
applicant who has n�O4t produced acceptable evidence of compliance with t ance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth of its political subdivisions shall
enter into any contract for the performance of public work until acceptable ev of compliance with the insurance
regrirements of this chapter have been presented to the contracting authority.
Applicants
Please fill out the workers' c mpensation affidavit completely,by the ' g the boxes that apply to your situation and,if
necessary,supply sub-contracter(s)name(s),address(es)and phone ber(s)along with their certificate(s)of
insurance. Limited Liability Co panies(LLC)or Limited Liabili Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compen tion insurance, If an LLC or LLP does have
employees, a policy is required. B,,e advised that this affidavit ay be submitted to.the Department of Industrial
Accidents for confirmation of insurance coverage. Also be re to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the p t or license is being requested,not the Department.of
Industrial Accidents. Should you ha°V,�e.any questions ieg ' g the law or if you are required to obtain a workers'
compensation policy,please call the Department at then bier below. Self-insured companies should enter their
self-insurance license number on the a ropriate line.
City or Town Officials
Please be sure that the affidavit is complet and ted legibly. The Department has provided a space at the bottom
of t le affidavit for you to fill out in the even Office of Investigations has to contact you regarding the applicant:
Please be sure to fill in the permit/license n ber which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license a pli lions in any given year,need only submit one affidavit indicating current
pol_cy.information(if necessary)and er"Jo Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that h been o ially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affid it is on file r future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or ci' n is obtaining license or permit not related to any business or commercial venture
(i.e.a dog license or permit to b leaves etc.)sai erson is NOT required to complete this affidavit.
The Office of Investigations ould like to thank you advance for your cooperation and should you have any questions,
please do not hesitate to giv s a call.
The Department's addres elephone and fax number:
The Commonwealth of Massachusetts
department of Industrial Accidents
Office of Investigations
6O0 Washington Sheet
Boston,MA 02111
4
Tel, ##617-727-49G ext 406 or 1-8.77-MASSAFE
pax.##617-727-7749
Revised 5-26-OS
www.mass.govfdia
f �TME p� Lvrrli v1 1JalXL0L LyA%;1
Regulatory Services
ar sTaeEE. *' ' Thomas F.Geller,Director
1659. Building Division plFc rah`
Tom-Perry,Building Commissioner.
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Rce: 508-862-4038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
-SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requiTes that the"reconstruction,alterations,renovation,repair,modernization, conversion,
irnprovement,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 Vr&other
requirements.
Type of Work�{� �l� � ����Arm Estimated Cost
Address of Work:. Z 7 &7 yf f J4 �5 a
Owner's Name•/i'�i �����"�=_..1'` �G'
Date of Application://— 1.3 — 0
I hereby certify that:
Registration is not required for the following reason(s);
[]Work excluded by law
F Job Under S1,000
MBuilding 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 FIKALTIES OF P Y
I hereby apply for a permit as the agent of th
Date Contract ignature Registration No.
OR
Date Owner's Signature
Q:wp:Mes.forms:homeaffi day
Rev: 060606
Mass. License k 061251 'R B E M O®E L I N G Mass. Registration # 112216
781-293-2078. 1-800-286-2078 �9 �j 3 ® F
P.O. BOX 316
HALIFAX, MA 02338
I/We the owner(s)of the premises mentioned below, hereby contract with and authorize Kirby Remodeling(hereinafter referred to
as the "Contractor') to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements
according to the following specifications, terms and conditions on premises below described with references to which I/we warrant
that I/we are the record holder(s)of title: /
Owner's Name i � �� `� � Tel. ,?-Z!$ 2 f _
Job Address 1 4�',/ UQ, 14 .—City A 2 State
SPECIFICATIONS ��-�7 / '� A0LR.� �/ G� / Lc/s L _ C_ , .
721
8zi
C--,7 e-e L✓�.d
r
lH Vto ` Y_7
In consideration of the labor and materials furnished by the Contractor; the Owner(s) agree(s)to pay the Contractor the sum of:
30' posit (331/3%); $ Day Job Starts(331/3%); $
Day of Completion(331/3%); $ Est. Start — Est. Comp.
It shall be the obligation of the Home Improvement Contractor to obtain such permits as the Owner's Agent. The Owners who
secure their own construction-related permits, or deal with unregistered Contractors will be excluded from the guaranty fund
provisions of MGLC 142A.
All work performed by the Contractor is fully covered by liability insurance.
This Agreement constitutes the entire agreement of the parties and no other agreements, representations and/or warranties,
expressed or implied, shall be binding on either party hereto unless in writing and signed by both parties.Any alteration or deviation
on the specifications listed above involving extra costs of materials or labor will be furnished and performed only upon written order
and will be in addition to the cost price of this contract.
The Owner(s) hereby certify(ies) that he has (they have) read this Agreement, that the terms and conditions and the meaning
thereof have been explained to him (them) and he(they)fully understand(s) them.
The Owner(s) acknowledge(s) the receipt of an executed copy of this Agreement at the time of execution hereof.
If any provisions of this Agreement are in conflict with any statute, re(j ulation,ordinance or rule of law,then such provisions shall be
deemed null and void to the extent that they may conflict therewith, but without invalidating th2 remaining provisions hereof.
COMPANY'S GUARANTEE:The Company guarantees its workmanship for < years. It will replace
defective material within the period of guarantee free of charge.All requests for service must be in writing!
This Agreement may be cancelled by an officer of the Contractor,but only within three(3)business days from the date of execution
and in a similar manner of the Owner(s) right of cancellation.
You may cancel this Agreement without any liability to you, provided that you.send a written notice to the Contractor by midnight
of the third business day following your signing of this Agreement, by ordinary mail, posted, by telegram, or sent by delivery.
WITNESS our hands and seals this_ J- day OeE Alls 20 d (o
KIRBY REMODELING Do not sign this Agreement before you a it.
(Owner)
(Owner)
Accepted by: /
u orized 0 T
(Owner)
IPA
If 17
Board of Building Regulations and Standards 'License or registration"valid for individul use only
HOME IMP OVEMENT CONTRACTOR? before the expiration.date.jf found.return to: 1
f Boafd of Building Regulations and Standards
k Re ig stratson 2216 One As Place Rm 1301 "
m r�a rs / 007 . Boston,Ma.02108
. . T 'r_ ;A
1
KIRBY REMODE>z
GERARD KIRBY
115 NEWFIELD ST.
PLYMOUTH;MA 02360 Not valid wit out signat e
"Administrator . . -�-
It �t o�
Lice BOAC'p®F BUILDING
ONSTR�U TI'O h�NS
g' r ��: �� N'SaUPR<UIES®iR
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" l3i�rtFdat T g
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r�Re;t�i�� '� I<� Tr.no,, &80
$"0
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