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HomeMy WebLinkAbout1309 SHOOTFLYING HILL RD ��r t,= iLdJ .i'�t G ;:C th°s ,h�4+•ft '/y_�,' /'/kry �.. ,� ,y,a{ �Er -/ ;x v r ,jrr r.4'... i.,�r�„ ... 1,t n.•r 4av` .Jf:'w. �r_ ••.... ,. ..h. ,. .fl,. ,.. �,..,_.. -'c,.. e, ..r,b 'a:`1 '.i'. ,E.,. ,'.r. s..- i-....., �J�s�•r��:rr'� �.r ry+�t. a* �x t{i3.�}f6A' rC d '`I�{ �r��� Sia � „v�r txi .�•'" „ e + .,+ - zi�y r w, fa x• !- : r�.0 rf 'r� t+r3 ty:'S a ,cr r (� �, � � , i y :• u a � s . q r - �n 3 y . r a' .a c i t< 4 n ... c ° : ; o s c +' c , 0 ' o Z., s r , ! c , it , r - , .a � : '. - Y :' t to • , K r • s . u y y h a. ,.m .. • c ° u . ,♦ y n , a � q • is t,+ {x/ . .. .y o ,F } : : .- � �,5 , e , :r t ' o y n z •P „ v � c � aS� � of Town of Barnstable Permit# Expires 6 months r 'sue ate- r * Regulatory Services Fee • r * BARNSrABLE, 9 MASS.039. Thomas F.Geiler,Director Building Division D►� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 11� Property Address esidential Value of Work j Minimum fee of$'35.00 for work under$6000.00 Owner's Name&Address 6 Contractor's Name Telam Home Improvement Contractor License#(if applicable) 16 "7 0?Y l tbb PERMIT' Construction Supervisor's License#(if applicable) /O'e/O'7 6 APR 2 3 2nn' ❑Workman's Compensation Insurance Check one: `SOWN OF BARNSTABLE ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# yO g Copy of Insurance Compliance Certificate must accompany each permit. ' Permit Reque t(check box) FkrRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ 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: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\EXPRESS.doc Revised 053012 ` The C.onr►no►rn•ealth of 1assachusetis . �t¢ Deparnnent of I►►ditsirinl Accidents b, Office of Investigation s }. -►'{ 600 Washiugtou.Street Boston,' 4 0 111 , wivir•.n►ass.govIdia «'orkers' Compensation Insurance Affida%it: BuildersfConh•actorslElectiiciaus!Plumbers Applicant Information Please Print Leogibly Name(Business.Oreatuzadou.•Iudi%,idual): ;3w� Address: 7 Cim"State`Zip: I(/ r. Y RP V61 171 A Phone T: S-e)8- Are you an employer?Check t-heappropriate box: Ts-pe of project(required): 1.�am a employer with 4. ❑ I am a general contractor and I r have hired the sub-contractors 6. ❑New construction employees(full anc orpart-time)." 2.ElI am a sole proprietor or partner- listed on the attached sheet. '. ❑Remodeling ship and have no employees Thee sub-contractors have S. 0 Demolition working for me in any capacity-. employees and have workers' 9. ❑Building addition [No workers. comp.insurance comp.insurance.: required.] l e are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all wore: officers have exercised their I I.❑Plumbing repairs or additions myself[No workers' comp. right of exemption per MGL 12.M Roof repairs insurance required.]- c. 152. j 1(4). and we have no employees.[No workers- 13.0 Other comp-insurance required.] •Anp appficaut thar checks boy.=1 must also fill out the secuon below,showing rhea norbers'compensaoon polic}'infowat•.ao_ Homeowners who submit this affidavit indicating they are doing all work and then hire outside-outmctors must submit a cep•affidavit indicating such,. :Contractors that cbeck this boa must artached an additional sheet showtng the name of the sub-coctra_tors and state whether or not tbose ew,ves have emplopees. If the sub-contractors have Employees.they must protide their workers'comp.policy number. I ant an etrtplot•er t)rat is providing workers'co►npeusatioti insrtratice for ttte'entp►ot•ees. Below is file police,and job site inforinarion. ; Insurance Company Name: Z_U P� l 'L A4, Police#or Self-ins-Lic. 2­21 0,6 y0 3P F- Expiration Date: 142—,//S Job Site Address: /34r SA(9z>`eCG in 1—c/ C'ity::State:Zip:�q/7► f��� �� Attach a copy of the workers'compensation policy declaration page(shoving 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 S1.500.00 ind.or one-gear 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 DU for insurance coverage verification. I do herebt•certiji'under thepdins and petralties of petjnn•that the inforuration pro+ided above is tree and correct. Signature: Date: -a�=vim/3 Phone= 764f Via( F Official use on/v. Do not trrite in this area,to be completed br city or►own official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cin-(Iow•n Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 `w MULLIN ROOFING & SIDING INC. 'CONSTRUCTION CO'I T'RAC This Construction Contract (the"Contract") is made and entered into as or 3-6-2013 (Date), by and be-ween Arthur Bruneli Marne, hereinafter called the "Customer") and Mark M. Mullin, DBA. Mullin Roof.„g and Siding, Inc. having its principal office at 7 Connemara Way,IAi_Yarmouth MA 02673. (hereafter called the"Contractor";. Property 'Location: 1300 S1 aooffl}fine hill rd. Barnstable, [AA in consideration of the mutual promises hereafter set forth and intending to be bound hereby,.the parties hereto agree as follows: Contractor's Obligations. Contactor shall complete the following Project herein described it and shall provide supervision necessary to commence and finish the Project expeditiously, firi a workmanlike manner, in accordance with the"all applicable codes, laws ordinances, rules, regulations and orders. Description of"Work". Contractor shall do all the work in accordance with the terms of this Contract, as described: Remove vinyl soffit and install soffit vents, put the vinyl soffit back up as it was before we removed it. Remove step flashings on wall where the lead should be, and add a piece of lead to the wall/roof intersection. Remove existing flashings from the chimney, ins. it new lead flashings, and mortar them into th iie chimney. Set up a staging and tarps to protect the home and landscape. Remove all existing roofing and dispose of properly. Install ice and water shield three feet up f(Gm the fascia beard on the eaves, one foot from n L relic edges. ice and `P,rd er shield will also be put in;he valleys, by the chi€ n,, an:�any plumbing vent . GAF` roof deck armor will be used on the remaining roof area.Q:white drip edge will be installed on the entire roof perimeter. A lifetime shingle by GAF will be installed to factory specifications, hurricane(sailed, and registered with GAF for the extended 100% labor and material 50 year warranty, this is transferrable once, and 20%�%n11 be covered after 50 years. A ridge vent_;fill be installed, cobra ridge vent by GAF will be used for ventilation at the ridge, and Timbe sex 1 ridge caps will be used for the cap on the ridge. The gable vents will be blocked from the inside f or better air flow from the new ventilation system. 3 Contract Sum. in consideration of the performance by Contractor of its di ities and obligations, hereunder, Customer shall pay to contractor the sum of '�6.950 Payment tent schedule: Owner shall pay the contractor 0%of the contract sure upon signirg tare contract, 50% upon start of the job, and the remaini c 50% upon comoletior, of the contract work. € I I r Contractor's Responsibility. Contractor is an independent contractor for all Work to be performed hereunder. The detailed manner and method of doing the Work shall be under the control of the Contractor. All employees of the Contractor performing Work under this Contract shall be and remain the Contractor's employees. a_ The Contractor shall supervise and direct the Work, using Its Jest skills. ,yob Safety. Contractor shall be responsible for initiating, maintaining and supervising all safety precautions in connection with the kAJork. Permits, Pees and Notices- €he Contractor shall secure and pay for all permits and governmiental fees, licenses and inspections necessary for the proper execution and completion FF of tole Work. Such permits and licenses shall be the propery of the Customer and shall be delivered to'he Customer upon request- The Contractor shall give ald notices and comply with all applicable codes, laves, ordinances, rules, regulations and orders of any public authority in connection with the performance of the V%Ioi c and the Contractor's obligations nereurider. Insurance. Contractor acknowledges and agrees that Customer or Owner shall not be obligated to cart~; any insurance in connection with the for the benefit of the Contractor. Contractor's insurance. Contractor shall at all times maintain and keep in full force and effect, at its eXpense, anv and all insurance coverage which is prudent, necessary or desirable for the protection of the interests of Contractor. Contractor shall furnish to Customer certificates of insurance for the following types of insurance. a. Commercial General Liability Insurance', b. Workers' Compensation Insurance to coder full Iiabidity under the Workers' Compensation Laves. IN iJ` IT'NEESS WHEREOF, the parties hereto have executed this Contract as of the day and year first above written. Customer Contactor Company By: _ Sy: Print Archer Brunei! Mark ii�iullin Mullin Roofing �. Siding; Iric. 7 Connemara Way,W— Yarmouth MA 02673 508 221 8691 ,'address: 1309 Shoo'fdying hill rd: Barnstable, s/IG Cate: 3-8-13 Date: 3-1-13 Phone number CS 0 6-�� °d SO d License No._I-IIC#l67281 CSL# 104076 E:rnail address aarunellEy orcester.eryu Email address Mullinroofing@gmail_com i OATE(MM/DLVYYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 1/4/13 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: Margaret�J,Grassi Ins Agency = (508) 295-2007 TMENW, (508) 291-1707 1188 bftdl h ftreet E-MAIL ADDRESS: debmjgins@comcast.net West Wareham, MA 02576 INSURE S AFFORDING COVERAGE NAIC# INSURER A:Allied INSURED INSURERB:ColonV Insurance AqenaV Mark M Mullin INSURERC: 7 Connemara Way INSURER 0: West Yarmouth, MA 02673 INSURERE: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICY NUMBER M/DD/Y MMODCO YY LROYTS B GENERAL LIABILITY GL3818794 1/5/13 1/5/14 EACH OCCURRENCE $ 1,000,000 X COMPAERCIALGENERAL LIABILITY DAMMISE AGE TO RENTED $ ZOO 000 CLAIMS-MADE OCCUR HIED EDP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMB ident)INGLELIMTf $ ANYAUTO BODILY INJURY(Per Person) $' ALL 0 WNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED HIREDAUTOS _AUTOS PROPERTY DAMAGE $ er PROPERTY t UMBRELLA LLAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 6ZZUB-4083P83-4-11 12/8/12 12/8/13rDISEASE TORY TS1 _E AND EMPLOYERS'LIABILITY ANY PROPRIETDR/PARTNER/EXECUTIVE YIN NIA DENT $ .1,000,000 OFFICERMIEMBER EXCLUDED? N (Mandatory in NH) A EMPLOYE $ 1,000,000 If yyes describe underDESG�RIPTIONOFOPERATIONSbelow OLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Renerks Schedule,if more space is regui red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. - Il AUTHORGMD,REPRE ENTATIVE I ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: _ Office-of Cons' Affairs&Business Regalahou License or registration valid 1MPkt0YEMENT CO�NTRACTOP, g id for mdividul use only " before the expiration date. If found return to: b egistratton 167281 Type a Office of Consumer Affairs'and Business Regulation ; xpiration 8/30/2014 DBA 10 Park Plaza Suite 5170 MULLIN ROOFING AND SIDING Boston,MA 02116 I MARK MULLIN 7 CONNEMARA It-JAY � #: W.YARMOUTH,MA 02673 Undersecretary Not valid without signature 9L0voI• -J1. £LOZ/L/6 :uol;endx3 ./ ialt 869ZO`IN WtiH32 VM' 3 00 of pataaa;saB 9L060;L 'GMU90FJ ljpsl.Aldd n'g'uor1on11suo0 SPit V! 1S Pup. s*u(ii.li!ln„,)1g.;)nipl!nS 1t► 1).Ji s74 x ,)v1� t to u , 1 :I.l-:�.►..luiiul1ttjl � ti113ny»at'(1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION , t�Q�t 7co� Map Parcel Application # Health Division Date Issued Z Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project Street Address i 3 z Village C�� tivlll� Owner Address Telephone�� ?,6Z— C-1 702 i Permit Request Leo acz jf&N�- de,.— a-d 5tut4-wi S&xteS _JNke•6r f e"U-e- t"S- 44 ZNrsJ b (.c44(a! -�"�Cal-- �v�t(�-�3.j'Yd-tea._ w � �tllroo��Dc�.�1��• C•tade �yL �jta.4l �=i��2c:�' Square feet: 1 st floor: s 1 /Lc. proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure I f 41L Historic House: ❑Yes WTNo On Old King's Highway: ❑Yes kNo Basement Type: Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) fzf Number of Baths: Full: existing_ new j Half: existing new Number of Bedrooms: existing Z.Aew Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: �s ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes .2lo Fireplaces: Existing New Existing wood/e al stovepp_0 Yesi CD Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: L existing ❑.new Sze x Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: 9,!z Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ M Commercial ❑Yes ❑ No If yes, site plan review # U J 6`�a -Current.Use y - Proposed Use - - APPLICANT INFORMATION (BUILDER ORHOMEOWNER k' Name ySScCI /��G�.S Telephone Number $ Address Z q� P>�4�R� � �� License # G(/�►� �16r�- 0al6 7_�:— Home Improvement Contractor# Worker's Compensation # ALL-CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t !� SIGNATURE Gas Jute DATE Z, FOR OFFICIAL USE ONLY APPLICATION# s DATE ISSUED MAP/PARCEL NO. r ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME as 4 Li 2- INSULATION r> 3 FIREPLACE } ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 113 'J DATE CLOSED OUT S ASSOCIATION PLAN NO. r, r .. 4 K . `lienmmonwealth of Massachusetts Department of pAdustrial Accidents Office of investigations :60 Washinkton S&eet Boston;MA.02111 ` .7 www.mass gov/dia ' Workers' Compensation InsIIra_uce Afddavit:Builders/Contractors/FIectricians/Plumbers Applicant Information Please Print Legi Name(Business/orgWiZIIhon(b&ndual): 2 Address: C u Q�� 7-7 -Uip City/State/Zip: AAi S C U-7< Phone.# — Z� Are,you an employer? Check the appropriate bos: 4. I am a 'Type of project(required): 1.[].I am a employer wifh ❑ general cc�tractor and I - employees(fL and/or part-:tin*.* .have fired the sub=contractors 6 ❑New cons ructim . 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet 7. 'Remodeling ship and have no employees These sob-contractors have 8. ❑Deraq. on Working for me�any capacity, =ployees and have World rs' [No workers' comp.insurance ' comp...irsarr�e,# 9• [�BmUng addition regrrired j 5. ❑ We area corporation and� 10:[]Electrical repairs or additions 3. I am a hameowner doing iE work officer;have exercised their 11.EI'Plumbing repairs.or adci.®s myself [No workers' camp. right df exemption per MQ. 12. Roof r insurance requimd.]t C. 152, §1(4), and we have no - �� employees.{No workers' 13.[] Other comp;in�nranre required.] *Auy applicant that CbeCkB boz#1 Est also fill out the section below showing thca workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then but outside contractass.must submit a new affidavit indicating such Coahactms that check this boz must attached an addiiioaal sheet showing the name of the sub-coatiacb=and state whether ornot those entities have cmployees. Tf the sub-contcactnra bave employees,they aarstpruvid'e their workers'comp.policynumber.: ram an employer that is providing workers'compensation insurance for my employees. .Below is the poFicy grid job site information.. Insurance Company Name Policy#or Self Ins.Lic.# Expiration Date: Tot]Site Address: Ctrp/State/Tap: Attach a copy of the workers' compensation policy declarafian gage(showing the policy n=ber and expiration'date). Faze-to.secure coverage as required under Section,25A ofMG`L c. 152 can lead to the imposition of cz�al penalties of-a f ne�to $1,500.00 and/or one-year imprisonmerrt, as,well as ciy1 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 Investi 'ons of the DIA for in•�T+r'e coves verification I do hereby certify der the pains•andpenaldes ofperjury that the information provided above is true and correct s e: Date: --` --� Phone# Dffzcia!use only. Do not write in this area, tb be completed by city or.foxln offi�iol City or Towne PermitlLicense# •Issuing A�hority(circle one): �> ;6.Board of Health 2.Bm'Iding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector fi.Other Contact:Person: Phone#: THE Town of Barnstable Regulatory Services snMMBL.E, Thomas F.Geiler,Director ns�es. 9q, 163 g 9. �.� Building Division ptEo�� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: r Z✓ /�'L Z� JOB LOCATION: lry Ox Hill. C e� {/✓Z�.f�{i number ` street / village "HOMEOWNER": .509-- 1'�r?Z7 name home phone# work phone# CURRENT MAILING ADDRESS: 7- �J"^�►r' `44 / o/ S DZ67 c4/towd state . zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of sic units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and req ments. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply.with the State Building Code Section 127.0.Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a.building permit is required shall be exempt from the provisions "of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for'hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly .when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the.homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care tamend and adopt such a form/certification for use in your community. Q:forms:homeexempt f - Town of Barnstable R Regulatory Services * Thomas F.Geiler,Director ibJ� �1 Building Division . Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 Property.Owner Must Complete and Sign This Section If Using A Builder I, as Owner of the subject property hereby authorize to act on my behalf, 'in all,matters relative to work authorized by this building permit (Address of job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:O W NERPERMIS SIONPOOLS I� Cl o I t_.,,...a..: -r 47 vo �� _ �. I _. N:. c® S 1 - 1 w1v it- wile ft S REVIEWED IL DIN EPT DATE FIRE DEPARTMENT DATE Lto BOTH SIGNATURES ARE REQUIRED FOR PERMITTING 4 i Page 1 of 1 Barrows, Debi From: Schlegel, Frank Sent:, Thursday, December 20,20,12 9:46 AM To: Barrows, Debi; Heath DeptMail box J Subject: Address change for Map 189µPcl 121_> Hi Debi, t ' The contractor remodeling the'exterior of this building rnoved the front door from Fox Hill IRd". to Shootflying Hill Road. An address reassignment is required according to the town's address ordinance. . Therefore, the address has been change from#6 Fox.Hill Rd;to#1309 Shootflying Hill Roadi,Centerville. Please update an hard copies o p y p you on ths'property: Thanx, Frank Schlegel E 11 D to n Liais 9 a o »-t 12/20/2012 ' :„ 7 Water Resista 1 Barrier perma"R"Prod 606 Old Quitman 6 647 SA F�ESR-25l 6 Fox Hill Road, Centerville 10/21/2008 a _.A r 6 Fox Hill Road, Centerville 10/21/2008 , 6 Fox Hill Road, Centerville 10/21/2008 1 i'f � 4 6 Fox Hill Road, Centerville 10/21/2008 it i _r iq 6 Fox Hill Road, Centerville 10/21/2008 7:1 t , 4 • 6 Fox Hill Road, Centerville 10/21/2008 ''.^- �+',bfL�a `, t';l a�. �"�^"+ "' �k-m �� a z A �� +'�fi,n �� � L� �' yr`�� m;.✓rrf` +5;� 7-- +�..� � (�;.q+'� '� � S x�V, 1++ 'a L •ta ns�„ n C r �' t �� r ?' s .• 77 ��5a r i 11-.5,.; s'Q •s a, - a -r 9^;7 ' L:; ..:t. _ �.. sy ' Il �. -41 �- rr Y-� �� �w.;� .,�+;�,' -y�.?►.p'l`rx�ae�n +�",'h=5�' •.ig;+�--.3"t.�t-"y� a-"`� " .- f. �t�r Town of Barnstable *Permit �� � � Expires 6 months r m issue date Regulatory Services Fee 2_5 6(,) • BnxxsTAsi.e ,� Thomas F.Geiler,Director , Cos) zhIl .Z �a 9�. v TFD MA'S a Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 C. S / ,. . Z.Property Address U7( 5� ❑esidential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name �/ } Telephone Number . Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) i _P R E S C P E to It A IT ❑Workman's Compensation Insurance Check one: AUG 1 z��2 ❑ I am a sole proprietor Z�am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 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 taken to + ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers,of roof) al�-side #of doors l E3 Replacement Windows/doors/sliders.U-Value s/ (maximum.35)#of windows�y *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 quired. SIGNATURE: C:\Users\decollik\AppData\Local\MicrosoR\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 y of T Town of Barnstable Regulatory Services B" MASS, E Thomas F.Geiler,Director 1639. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: 2-- Please Print JOB LOCATION: n er street village "HOMEOWNER": C�l� K_2gs 2 (�-?Z name home phone# work phone# CURRENT MAILING ADDRESS: city/town r state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building-permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection proced s and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 Hai e Commorrrveaslth of massachulseft Depart►wit of Industrial Accide _ ©ice of Investigations 600 Washnigion.Street Briton,MA 02111 ' iPww.ntass gov/tdia Workers' Compensation Insurance Affidavit.BuilderslContractorsJ]Ek-ckrician&Tbmbers Applicant Information / y Please Print Leaibly. Name musin Oman on&dividq,ai)c Address: 2-1 f 54I rA, z�- City/State/zip: /vim v.,(� /come#: $—�7C — �z1 Are you an ernploye 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)s have hared the �- ❑New construction 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling These sub-contractors have slop and have no employees These ❑Demolition wodring for true in any capacity. employees and have woaicers' 9_ Building addition comp.insurance./ ❑ g [No cvorloers'comp.iflca�eanre �P �-,�ued.] 5_ ❑ We are a corporation and its 10.❑Electrical repairs or additions 3. a homeowner doing all work officers have exercised their 11_❑Plumbing repairs or asddatiens myself[No workers'comp- right of exemption per MGI. 12.❑Roof insurance require&]T c_ 152,§1(4),and we have no employees_[No woriners' 13_(POther > a c✓� comp_insurance required.] ;Any applia:sart that checks box#1 a=also U am the section below showing then waskeW compewatic m policy imforafftion_ llcizeawDm who submit this afaidmit indicating they ate doing all wank and the hie outs Ae contrKMrs,nmst subant a new sfftdowitt indicating synch ZUmtractors tbart rhed this box must artached an additiomid sheet shown the nee of the sub-etintructtm and state whrhha<r or mot those enteteas hwe emp9nytees. If the sob-cootrmctors bane employees,they most provide their waarkers'camp.policy number. I am an employer that isprvmUffi g warken'congmnsat&n iusumuce for awry earplaryam MOW is thepolacy aimed job site informaadon. Insurance Company Name: Policy 4 or Self-ins.1-ic_#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGI.c, 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00.and/or one-yeas imprisonment,as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to$250.0©a day against the violator. Be advised that a copy of this statement may be farvrarded to the Office.of Investigations of the DIA for insurance coverage verification. I do laertisiiy certify ter tkepmns andponabies*f pev:ftary that the in rinafian prwWded above is beta and correct. si Date: l3 2 Phone#: L-- GC 2? O ch d use only. Do rrat write in this area,to be cvmplated b_v aatg or tiatm offiiciat City or Town: PermitUcense 9 Issuing Authority(cu-clle one): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Electrical Inspecter S.Plumbing Inspector 6.Other Contact Person: Phone it: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION. Map+ Parcel " Application #Oe Health Division ' 2o o 8 '` 3 ti Date Issued a3 C Conservation Division Application Qe Planning Dept. Permit Fee 5 Date Definitive Plan Approved by Planning Board J U�23o� } Historic- OKH Preservation/ Hyannis ' Project Street Address 4- o ;1 (a Z t , Village Owner-D ebbs, „ .i3oo 4-7 b.)fb i- A ✓co k&ress G Cfj k tA i..k 1 Telephone 1 57 3 Permit Request V►% Lk►--A ,rl -C� -{-'o / 1 ou S ty 5. DobrtJS4 ,C 44A � E Square feet: 1 st floor existin J _oproposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 'e Project Valuation 0 0 6 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 �L Historic House: ❑Yes PNo On Old King's Highway- ❑Yes pfo Basement Type: Full ❑Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Owl Basement Unfinished Area (sc. ) f � Number of Baths: Full: existing �- � new Half: existing ew 0 Number of Bedrooms: existing —new Total Room Count (not including baths): existing -S new First Floor oom C60nt rn Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other n, Central Air: ❑Yes 51No Fireplaces: Existing r New Existing wood/coal stove: ❑Yes JbNo 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 *No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Named f- zoo 1 A, "ephone Number Address 4 License # ki M l- Oaf 3 . _ Home Improvement Contractor# Al w Worker's Compensation # v 1_ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY A,4PLICATION# 4 DATE-ISSUED MAP/PARCEL N0. a ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION " x�.a., ' ' ; , Old 14/604-- FRAME F, INSULATION FIREPLACE r I ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT i ASSOCIATION PLAN NO. ,i f Vie Commonwealth of Massachusetts Department of Ifidustrial Accidents Office of Investigations 600 Washington Street BOStDn, MA 02,111 www.mass.gov/dia Workers, Compensation Insurance Mfidavit:,Builders/Contractors/FIectricians/Plumbers Applicant Information L (� 1� Please Print Legibly Name (Bus inesslOrganizationr1rdividuaI): � 0 Address: o� 0,V l] ' City/State/Zip: Ct4n4_Q_Vj �� ga.(3V Phone.#; S4 Are you.an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ 1 am a general contractor and I * have hired the sub-contractors 6. El New construction employees (full and/or part-time). Remodelin 2.❑ I am a'sole proprietor or partner- listed on the attached sheet 7• Elg ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity, employees and have workers'comp. ❑Building addition . [No workers' cow.insurance �mP insurance. qu 5. [] We are a corporation and its reired.] 10.❑Electrical repairs or additions 3. I qu officers have exercised their 11.❑Plumbing repairs or additions a homeowner doing all work right of exemption per MGL myself. [No workers comp. 12.❑Roof rcp s insurance required.]t c. 152, §1(4), and we have no 13ther employees. [No workers' comp,insurance required.] 'Any applicant that chcclo;box#1 must also fill out the section below showing their workers'compensation policy information. t Homcovmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavi 11 t indicating such. XContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whcthm or not those entities have employees. If the sub-contractors have employees,they must providb their workers'comp.policy number. Tam an employer that isproviding workers'compensation insurance for ray employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declarationpage(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 rrimirial 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. De advised that a copy of this statement may be forwarded to the Office of Investigations of the 01A for insurance covera e verification_ I do hereby certify under the pains-and penalties of perjury that the information pr�ovided�ab�ove'rs true and correct. Phone#: Official use only. Do not write in this area, to be completed by city or town officlaC City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Inst 'u.&IOBS Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: efined as "...every person in the service of another under any contract of hire, Pursuant to this statute, an employee is d express or implied, oral or written." An ernptayer 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 morc than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do aintenance, construction or repair work on such dwelling house m 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 Ioeal 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 fall out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s), addresses) 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 th ran e 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 nurgber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Towtr Officials Please be sure that the affidavit is complete and printed legibly. The Departoacnt has provided a space at the bottom of the affidavit for you to fill out iu the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permiYhcensc number which will be used as a referencc 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 (Le. 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 C61nmonwean of Massachusetts - DeFartment of Industrial Accidents Office oa Layestigati.ons 600 Washington Street Poston, MA 02111 TQl. # 617-,727-4900 ext 4.06 or 1-M-MASSAFE Fax# 617-727-7749 - Revised 11-22-06 . www.mass.goYldia Yhte Town of Barnstable �op rq�� Regulatory Services • BARNSTABLE, Thomas F. Geiler, Director y .MASS. 1639. Building Division PlFO MPy A Tom Perry,Building Commissioner ' 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ------------------ - HOMEOWNER LICENSE EXEMPTION " Please Print DATE: JOB LOCATION:�p (24 number street village "HOMEOWNER' name home phone 0 A� 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 engadual for hire who does not possess a license,provided that the owner acts as ge an indivi supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on"which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures, A person who constructs more than one home in a fwo-year period shall-not be considered a homeowner. Such "homeowner" shall submit to the Building Official on.a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building pernut.. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules.and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection.procedures and requirements and that he/she will comply with said procedures and requ' en s� S , ture of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,.that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors;Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that Wshe 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 fom/certification for use in your community:;; �oftHerO� Town of Barnstable o Regulatory Services + SARNSTABM y Thomas F. Geiler, Director MASS. a`� Building ]division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town,ba rnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using), A Builder 1 , 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: .(Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. a VLAtJ LEGEND 78 PROPOSED CONTOUR c2� Menn as TEXISTING CESSPOOLS 79 PROPOSED SPOT GRADE TO BE PUMPED, FILLED W/ 6jP SAND, AND ABANDONED. EXISTING CONTOUR o x 97.22 EXISTING SPOT GRADE e° N40e25'20'E 99.89 TEST PIT z� .� 125.017 'I —W— EXISTING WATER SVC. XDCUS APN 189-1 21 7-�31.5' �{ —+JGW— UNDERGROUND WIRES 15,286#SF T PROPOSED S.A S qI BENCHMARK LOCUS MAP N.T.S._ RS n I O O 0 it TP-1 ; Q / F P_2 000 0 S � O E \ , n,, 1 � �r IPEEROP. 99.90 to ELI7 l-p �j/ /TANKC ` W W GENERAL NOTES: - I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL f CHAIN MINCE U /1 PATI�T Q BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK.AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 100— =a Q - - LOCAL RULES AND REGULATIONS. f - 100 7 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 99.82 W L TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. ., 98.58 Z PORCH � 0 _ � _ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING _ - NO. 1327 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN = ENGINEER BEFORE CONSTRUCTION CONTINUES. O _ I STY.f - 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.- WD.FRM. — T 6.THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF � T.O.F. 100.8E 99 98 = THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF / HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. _ 7. WATER SUPPLY SHALL BE PROVIDED BY TOWN WATER SERVICE. 100.27 8.THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150 OF THE S.A.S. 98.79 1 f 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED z�.40 CATCH - TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. BASIN 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 3 THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Vd36�� 70p 0,3 CONSTRUCTIONS. ` _ - STONE 2 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS [mve /AY 4 IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. AND REPLACE WITH'CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). 03.3V 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY ap8'3 �`\\ S OF Mq F9 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 2�r �yG XX PAVBdENT 9 pp o PETER T. p s 9 v McENTEE = PROPOSED SEPTIC SYSTEM UPGRADE .- ��O 9S� `' S /�D No.35 09 6 FOX. HILL ROAD, 1327 SH00 LYING HILL RD CENTERVILLE, MA RD O/sA �Q Engineering for: Glenn Szabo, 7016 Cedar Road, Sanford, NC 27332 BENCHMARK SET oo YiNG H«� Es CORNER OF CONC. PATIO su OD g by SCALE DRAWN 1 0 EL:=100.00 (ASSUMED) `�� Engie t Cr-field Road 900D SURY6Y GROUP 1"=20' P.T.M. 210-07 12 Wet Cmee6e0 Road 18 Route 6A DATE CHECKED SHEET NO. Forestdale,MA 02644 Sandwich,MA 02563 (508)477-5313 (Soo)888-1090 9/28/07 P.T.M. 1 of 2 R t yy {- Cal ZI TO _ zx 14 QL n I , 1 u. sr i e ;t t IT " Y , x I r r e4 T IR a...w+. I fi�. S Et §�Z`. °..✓. - � / I. I.; 11 4. > AN s , J s a ■®■®e■1■ �i1�illl,®1 Ii1 �►■�11/® ■ r�'�-!■ -!■: .: . ■■®1®ICI®►1�1®I■I■®IE -. 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V a - k � - 1 1 4 i .. }�ra t• �aJ�^k� "bV y a �r # .2,r ■■■■■■■■■■■■■M!!■■■■■■■■■■■■■■►■■■■■■M■■MEMO 0 No EMOMMEEMMINEEME ■■ ■■ ME■■■■■■■■■■■■ EMEMMESSIMIENEEM ■ ■0— MEN� I ■■�■■!►�■■■IC I '■■■■■ ■■■■■■■■■p:t7,14MI MEMO MEN 0 _■ i■ ■■■i■ If�■I L- m- ■■■■■■■■■■ENNE ■ IO ■■■■■■■ ■ ■ ■ O iEMMEM■■ N�/�QI■■■ ■■■ ME 'OMEEMOMMEMI!■iEMEN■■ONEE►E ■MEMO ■■M ME OEM■MMENN■I EMEEMEN■MEMI� MEN■O ONE Emoon®�ME■EME■E1 ■!-MMEMmom—mo■ mONE ME if MEEMEMEM IMEN-M-MEM o�� M M®NONE■� OONEM■■■M },, ■ r�rr■■■■M■®■■� �OO M ■E OMEN N■ EMENEMOM ail EM■M■EM■EM■ m _. M■MENN MERE Ii _ ■■■■■■■■■■■EI®MiriM ■ 10 ME■■■ E - M■MMENMEMEEME■I■No EMEEMMEMEME �M ■■■EMS R _ � ;�■■■■® ! ®M■MMEM■MEEM■■ONE NOISE mommmommom I■ EMMEEMEM■M ■MN■EMENEMI■ENE►ammo■■■■No M No OMN■ MEN MINIM , _ car EMOMMI■MENMEM NONE ■ ■ M _ MEMEEMI. __ _ ■fib■ ■N#■ Mi■■■■■■■ ■■EN ■EMI NNONE■■ I■■� OMEN MEMSMEMEMMEMEMM ■�■ ,s m■ ME■EMEM� HE. Mm ■■ BEM, EMEMEMEMEM■ ■ _ MEEM 'M ■M■EYI N■■ENE E mM■!1.!�E■mmE �■■�1 r i ■' �■■■■■■■III ' Mai■ ■:■■■■I i f "3 r� r R y 1 i 1 y t ♦ 1 TOWN OF BARNSTABLE BUILDING_PERMIT APPLICATION Map Parcel :Application Health Division °Date Issued I b 4 3AL O� Conservation Division ;Application Fee Planning:Dept: Permit Fee Date Definitive.Plan Approved by Planning Board ' Historic -.OKH Preservation/Hyannis 'P-roject Street Addre� -ss=(9 Verge C,C,4 -elu \\-e— OO.w,n_er e_ -'A Du Adress S CL rr � Telephone S/8 S-70 S�74 1 G re 5,/ Y S' D q 6 ® c Permit Request c Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Jn Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use 9 APPLICANT INFORMATIONLn rn (BUILDER OR HOMEOWNER) - - ,Telephone-Number-.��� :y Address""' License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SS IG__NATURE=C % DATE- t z FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ti yy ADDRESS VILLAGE .f OWNER DATE OF INSPECTION: FOUNDATION FRAME e INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i f oFINEl Town of Barnstable Regulatory Services + MUMSTABLE Thomas F.Geller,Director ' E16 A. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 NOTIC E TO THE BUILDI NG DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR' 1, NnY, AtV , owner of property located at CO 4:� )r 1 hereby certify that I, y r.'�y,i CAI, is no longer Construction Supervisor listed on the application for the project under construction as authorized by building permit# �©�Lliss ed on-. ' Q 200 j I understand that the project under construction must cease until a successor"licensed Construction Supervisor, is submitted on the records of the Building Division. __0 'fr PROPERTY OWNER DATE q/forms/newcontr reference R-5 780 CMR rev:080102 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):3)dY0-6� 1 i �u f-� L P o,-OL � Address: `- City/State/Zip: Phone.#: ���'` o- �� d/T f1l 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 hired the sub-contractors 6. El New construction .2.El am a sole proprietor or partner-' listed on the attached sheet T. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition workingfor me in an capacity. employees and have workers' y P �'• # 9. ❑Building addition [No workers' comp. insurance comp.insurance. Electrical repairs or additions required.] 5. ❑ We are a corporation and its 10.❑ P 3.[Q 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 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. xcontractors 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: Policy#or Self-ins.Lic,M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct, Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions µ . 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-conti•actor(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/lieense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in _(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass..gov/dia �oFtrirr.r�� - Town of Barnstable �P Regulatory Services BARNsr,BL-F, : Thomas F. Geiler,Director MASS. Building Division PlFO MA't A , Tom Perry,Building Commissioner 200 Main-Street, Hyannis,MA 026.01 vr".town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-750-6230 HOMEOWNER LICENSE EXEMPTION �./ Please Print DATE: JOB LOCATION: 6 A� number street ` village "HOMEOWNER!': �� bO� name / home phone# work phone# G CURRENT MAILING ADDRESS: C9 �e L i 5 �.:` J_�Q � 7 �o 0 0 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and: to allow homeowners to engage an individual for hire who does not possess a license? ,provided that the owner acts as supervisor. DEFINPITON OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A t person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official,on:a form acceptable to the Building Official,that he/she shall be responsible for all such work Performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility.for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations.. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and' requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will,be required to comply with the State Building Code Section127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section109.1.1 Licensing of construction Supervisors);provided.that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowner:who use this exemption are unaware that they arc assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15).This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed, Supervisor. The homeowner acting as Supervisor is ultimatcly.responsibIr. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a farm currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:fosins:homeexempt zTti Town of Barnstable Regulatory Services r a • • BARNSTABL.E. MASS: $, Thomas F.Geiler,Director iOlEn ► Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder f I, 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. (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side.. Q:FORMS:O WNERPERMISSION f ,*'THE � Town of Barnstable A. rABLE ti 2agg JAN Regulatory Services 8 A . 9; S7 ' sexrrsrn.9S. � MA ' Thomas F.Geiler,Director 9O 0p .. °pTFD bl9. a,0 Building Division Tom Perry,Building Commissioner 6� « � 200 Main Street,Hyannis,MA 02601 Office:•508-862-4038 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF WITHDRAWAL OF LICENSED CONSTRUCTION SUPERVISOR FROM PROJECT A , Construction.Supervisor License # 1°��� ,hereby certify that I am no longer the Construction Supervisor listed on the application for the project under construction as authorized by building permit # issued to (property address) �/J Fox W Z_6- J5A44, 2 Y on 1S ,.2001 I also certify that on N' 'yY ,200 ,I notified the property owner, that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building Division. LICENWHOLDER DATE q/forms/newcontr reference R-5 780 CMR TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION- Map G Parcef f Application # 2�115C Z-- Health-Division - Date Issued 12, 1 rA Conservation Division =. Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic.- OKH Preservation/Hyannis Project Street Address (o Village_ CC- L ice' Nyk 0-2- & 5 Z Owner Address Telephone 8-'� -� ( Permit Request M6 Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other_ - Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �T( ' 1 Z" Telephone Number Lf' P t Address �� 5� �� ` License# IK( qq a2_&q�Home Improvement Contractor# 1 3 � Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO I NAT /�J� ®�S G URE DATE Z "t ' FOR OFFICIAL USE ONLY APPLICATION# _ DATEISSUED - MAP/PARCEL N0. ti z t c ADDRESS VILLAGE h OWNER DATE OF INSPECTION: FOUNDATION FRAME I ' s _ ' INSULATION i FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING i DATE CLOSED OUT " r ASSOCIATION PLAN NO. ' . t } THE� Town of.Barnstable Regulatory.Services saxrtsTAsLE, Mass. g Thomas F.Geiler,Director 16.39.iOrFv��A Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us ` Office: 508-862-4038 Fax: 508=790-6230 NOTICE TO THE BUILDING DIVISION OF CHANGE OF LICENSED CONSTRUCTION SUPERVISOR I, O''jo XM k P� `1 )b o-I-h owner of property located at Ce/�lrco�I , hereby certify that is no longer Construction Supervisor listed on the application for the project under construction as authorized by building permit# ` 5�17, issued on 1 -3, 20 01el I understand that the project under construction must cease until a successor licensed Construction Supervisor,is submitted on the records of the Building Division. PROPERTY OWNER DATE q/forms/newcontrowner reference R-5 780 CMR rev:011608 °Ft rti Town of Barnstable Regulatory Services B"NSTAB9 I'E�` Thomas F. Geiler,Director ArEo;p.� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF LICENSED CONSTRUCTION SUPERVISOR ASSUMPTION OF RESPONSIBILITY I, V( �1f�1� 1 , Construction Supervisor License # 11 Tq , hereby certify that I have assumed responsibility for the project under construction, as authorized by building permit# zoogo ?--issued to (property address) to 741 on A)®V 2-5 , 200 The following documents are attached: copy of my Massachusetts State Construction Supervisor's license or Homeowner's License Exemption form (if applicable) copy of my Home Improvement Contractor registration (if applicable) Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit. Road Bond (if applicable) vp� LICEN E HOLDER DATE ' The Commonwealth of Massachusetts Department oflndustrialAccidents ^ a Office of Investigations 3 s 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): 47D 97 (1 C Address; ?,6 1'72l City/State/`Zip: AAk1,5AP&f-7 Mlll9 AIP" Phone.#: OCS 7`-7—.3 q 9 Are.yo n employer? Check the appropriate box: .Type of project(required):. 1. I am a employer / 4. I am a general contractor and I with C_— 6. New construction . employees(full and/or part-time):* • have hired the sub-contractors listed on 2.(I I am a'sole proprietor or partner- the'attached sheet. 7. Remodeling ❑ ship and have no employees -These sub-contractors have 8. (]Demolition �rorking fox me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp, insurance.$ 5. We are a corporation and its. 10.❑-Electrical repairs or additions required.] 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.F]Roof repairs insurance.required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' 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 anew affidavit indicating such. tContractors 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: 1P_V q Policy#or Self-ins.Lic.#: Expiration Date: lob Site Address' 'L �1� City/State/Zip: 6�— 4wvl1"te /tom3�— Attach a copy of the workers' compensation policy declaration page"(showing the policy number and expiration.date). Failure.to secure.cove-rage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK;ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the Office of Investigations of the WA for insurance coverage verification Ido herebycert'. under thepains:andpenalties ofperjury that the information provided above is true and correct. Signature: Date: _ Phone#: Official use only. Do.not write in this area, to be completed by.city ar town official City or Town: Permit/License# Issuing Authority(circle one): -1.Board of Health_2.Building Department 3. City/Town Clerk 4.Electrical Inspector.5.Plumbing Inspector 6.Other Contact Person: Phone#: t. {ry " an B� g , ,o. d o �t Construction,SupeYvisor License ? w i; a License GS , 81995 Exprration 1/23/2010 T# 15516 o o i- , l �� �Restnction 00 r� � , i DOUGLAS W., MULLEN . t 59.NQBBY LN r i W Y.ARMOUTH,,MA 02673}' Commissioner i 13oar0 of Buildin Rc�ulatIons and Stand:�rds y vLtcense or registration valid for,indrvtdul use onll HOME IMPROVEMENT CONTRACT ` �-' before the expiration date 3f found return to 4 OfZ 1 Board o1 tiuildingRegulations and Standards' Registration_138368 -17 I= '.One Ash�urton,Place Rm 1301 ,. Expiration-3/27l2009 Boston,lVla.02108 12?3181 . a j t Type DBA �MULLEN BUILDING&REMOOE ING _ OUGLAoaMULLEN� ..>� +r EST 1 ARMOUTH MA 02673 3 1Vot val ithtiut signature a J Administrator:' s► T � Town of Barnstable Regulatory Services �swxrMASS.' esie$: Thomas F.Geler,Director 03g6 ' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barn'stable.ma.us Office: 508-862-4038 -Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, � e\w�1n R?,Odvk , as Owner.of the subject property, hereby authorizee�, Vt-� err, to act on my behalf, in all matters relative to work authorized by this building permit.application for. l e (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License.Exemption Form on the reverse "side. Q:FORM S:O WNERPERM ISSION �oF z r � Town of Barnstable Regulatory Services • awtttvsrwar.e Thomas F.Geilet' Director rt,►.gs. i619 .,eg Building Division PlED �A Tom Perry,Building Commissioner r 200 Main.Street, Hyannis,MA_02601.. _ .. www.town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION —Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CUR.RBNT MAILING-ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the ownel acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that_he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section_(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix-Q. Rules&Regulations for Licensing C,pnstruction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require;as.p nt 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 currendy used by several towns. You may care t amend and adopt such a fomJcertification for use in your community.- Q:forms:homcexempt 12/02/2008 14:32 15087907955 OCEANSIDE INSURANCE PAGE 02/82 12-02-00 01:64m From-AIG +073 321 0600 T-119 P.001/001 F-514 eTonornp:----> <Totaxnum:50879079592, , — C:". -%�s,�M:Y• �.�. .4h4 !d �;•'1C I L'r�•I. ..•f -+ 7.ti rml . '�,.0 n-„1�"•�tJ..� 1*�•,p,p(("1 ':�F:. A4 t -iA '. a e'rf '��', ^'w' M�. fl.� IY r/"'y 1NN_ f �7`' � ,,ql' •� ' .�' ri• a^:'" ,I'' I,. ^."t' 7!1-•t, t 'l'd': ":"°I s . s"; 1 r 1 Vr i.F,,i.}•"..1• i"�i 'l �..� i� 5: � .�7. "" � x• ��G,P I. -t.•F•�i!ILh'Yi •: ��:wi .!���' 'i�•�t!' .a. PRODUCER tH1S CERTIFICATE IS ISSUED AS A AAATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OCeanef6e Insurance/ ncy Inc HOLDEFI.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 52 West Main at ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Hyannis,MA 02801 COMPANIES AFFORDING INSURANCE COMPANY A GRANITE STATE INSURANCE COMPANY INSURED Dnug Mullen Po Box 1274 Marstm Mills,MA OR6484000 '4U,a�:'a 5rl4 �Y�,'N. � 4 t t � '�C � anm ,tiy�y�.r^•!. .. .p,�tgj.,. n�'�i•.6' K/t`•" �� •.ERAGEIS�' ;� h}RZ'i:.J., =!:-.�'� •;;�'►?,S',��'�,,0•:� Gk:.;a`"ti.•�,n•'r�"s:,,1,.�;;:.�..'4' .�,�", .I t :��;•„` �;••,.,,►�`1''+'. THIS 18 TO CERTIFY THATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOT WITHSTANDING ANY REQUIREMENT,TERM OR CONPITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORD60 THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SOON POLICIES.LIMITS 6110M MAY HAVE BEEN REDUCED BY PAID CLAIMS. rP13 AOMPENSATION OWFIT LY19111TY umrm RIETOR►UXO RENEW OF 11/21/2008 11/21/2009J. AIVTORYLINfT9 rm 6388843 r''�� •I't': .P}y'. :.n". A�Appk�la NY►opyalime a+lY. M ACCIDENT 9AA9E PONCY LRIR SE�►C�LOr 8 100 08 100 0 RI ON OPE IVE KLESISPECIAI.I MS E:THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR DOUG MULI.6N. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SWULO ANY OF THE ABOVE CESORMI)POLICIES BE CANCELLED 690RE THP ATTN:BLDG DEPT EXPIRATION OAIE THEREOF.THE ISSUING cauPAinwlu 84MVOR To MAIL a ZOO MAIN ST DAYS WRITTEN NomrATo To c PrPICAf"oLooR NPMW To im LEFT,M HYAN NIS,MA 02601 FAILURE TO MAIL SUCH NOTICE SI ALL IMPOSE NO OKIGATION OR LIM ILI Y OF ANY IWO UPON THE COMPANY•IN ACE1418 OR RF.PMESENTATI 08. 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