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J�, """7 ""';;,,_,�,��"_, _"'_ ",_,"',_�,:_'__�, ,I, , """, , .'� " � �,,-,,,,,�,,-��,_,�-,,,,��,,��,�,���,,,,,��,',',-,,', ­"�""­�`,� �� ��-��,,,,�""���;,'�"",.-�'.,-�,,t,,'�,��",.�,-�,�,,��_,�,i"""''!",",�, , � -__- � � , -____- , - , , � � !, _�, --,---,,--, ,o�*_,',,klty',;�,,� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 210 Map b r Parcel Application # 1 G 1 `� Health Division "',Date Issued 5" Conservation Division hr,&�Uj MESS Application F ' Planning Dept. = Permit Fee 6� Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project treet Address 215 -So U"� /oV Village CC--NTEQ VjG C, Owner L**',AYkM1A 10ARRE1.64 Address PD QoX 493 WIUSMt f, MA 02"0 Telephone Permit Request L(� iYl�Ri�OC iZoo�_ !?gP�. 5k11NbtPcx1 gsft - q WiNwws Rf ptn,Ewck�fF bf FRoNr �fifiQ. 152PS, RF+n#EPt- 4EDAk siO MAGE aoo12 RWoD" K11Lf4E,v. 34W, A�bTtl I?P Arb b I V X 10'4 AaCK 5e7yE W 6612ME f I4Ws E f/wo xi ocve Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Q b 00 Construction Type Lot Siz, 0.3� A2_ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 4' Two Family ❑ Multi-Family (# units) Age of Existing Structure y� Historic House: L Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ' Gull ❑ Crawl ❑Walkout ❑ Other �r Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) b VD 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: JyGas ❑ Oil ❑ Electric ❑ Other p ' _n 2! U-1i Central Air: VYes ❑ No Fireplaces: Existing New Existing wood/coal stove:❑Yes ❑ No Detached garage: kf existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ exisg Xpew 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 y Proposed Use _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number ��D�'2YV�� Address Po fty 1483 License# 1157W,E IVA oZW Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO y /►1 i fl 5TATIoN VIA- N1t�Ome S ata,SI GNATUR .a 'Gl C-'_.DATE- ,.�,. E � ��" r 47 FOR-OFFICIAL USE ONLY t ` ;APPLICATION# z DATE ISSUED : MAP/PARCEL NO. ADDRESS VILLAGE ' OWNER r' f DATE OF INSPECTION: FOUNDATION FRAME 'INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL , f r _GAS: _,•,$; ROUGH =rt= FINAL FINAL BUILDING :.DATE CLOSED OUT !•. - ASSOCIATION PLAN NO �s The Coin monwealth of Massachusetts I Department of Industrial Accidents Offzce of Investigations ti tj ;' r 600 Washington Street Boston,MA 02111 r www.mass go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): y47M Address:— lop .6bX 4K City/State/Zip:_Ad r A�JMQ i T, /'RYA-a ? . Phone#: -air- 2,�" Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am'a employer with 4. ❑ I am a genera]contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. T 7• WRemodeling ship and have no employees These sub-contractors have S. [-1 Demolition working for me in any capacity., workers' comp, insurance. 9. ❑ Building addition [No workers' comp, insurance 5. El We are a corporation and its quired.] officers have exercised their . 10.❑ Electrical repairs or additions 3. I am a homeowner doing all work 'right of exemption per MGL 1 1.❑ Plumbing repairs or additions . myself. [No workers' comp. C. 152, §1(4), and we have no 12.,q-Roof repairs insurance required.] t. employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of[he sub-contractors and their workers'comp,policy informatom I am an employer that is providing workers'compensation insurance for my 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 declaration page(showing the policy number and expiration date). Fai lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form.of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herby certify under the pains an na&es of perjury that the information provided above ' tru e and dcorrect 0-7 Si ature: �l- nl Phone#: �l\ Official use only. De in this area,to be completed by city or town offccial City or Town: Permit/License# Issuing Author772. Buioldiezif : I. Board of He Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. OtherContact Person Phone#; Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner.of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who,.,empiays persons to do mainte iance'construction or repair work on such dwelling house or on the grounds or building appurtenant tlieretb shall not hecause of such employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal-of p,license or permit to`aperate a business or to•construi tttbuildl-gigs in='the'cpu rn.onwealth for any applicant vhd,has not pr6duced 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.evi den cd 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-contractors) 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 Iisted 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 D.epartment has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"lob 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 Iicense 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 Gaston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-9 7-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.m,ass..gov/dia f �ofT, r Town Of Barnstable Regulatory Services stxxsrwste, Thomas F. Geiler,Director t659. 16 Building Division Tom Perry,Building Commissioner 200 Main-Stroet;._Hyannis,MA_02601 WWW-to wn.b arastab l e.m2-tss Office: 509-862-4038 � Fax: 508-790-6230 HOrrMOWNER LTCrL1\'SE Ekp- t11ON Please Print DATE $ 3a l JOB LOCATION: 21,5 S, f1?i4/Iy C�iu'j I�L�J/(,G� number street .fir,` � p. c. - /� r ' ,�/ ! village "HOMEOWNER": C.Y& 1 T��Pf Pf4p a.L.4 .7 iff-2,"—iD(Cs name /�_v home phone# work phone �7D # C TRREN-r MAILM ADDRESS: Job /� 493 . ,t>�h2l�k7�3l�� /M� �2�0• c7 .. rtatz zip code Tbc current exemption for"homeowners"was extended to include owner-occupied dwellings of Six uUits or Iess 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 HO7aOwlr'ER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to- be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structtat:s. A person who constr-gcts more than nee home in a two-year period shall not be considered a homeowner, Such "homeowner"shall submit to the BrOding Of5cial 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".asstm cs 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 rm irruirn inspection procedures and requirements and that he/she will comply with said procedures and requirements. �SiT of Horneowncr `�� Approval of Bulding Ofncial Note: Three-family dwellings containing 35,000 cubic feet of larger will be rcquimd to comply with the Stott Building Code Section 127.0 Construction Control. HOMMOWNER'S EXEMPTION .The Codc states that: "Any homeowner perforrning work for which a building parnrit is required shall be cxcmpt frmn the provisions of this seetion.(Section 1D9.1.1-Licm-siirg of construction Supmzsors);provided that if the homeowner engages a persons)for hire to do such worms that such Homeowner shall act as supervisor." }many homeowners who use this czcurpticm arm unaware that they are assuming the resporrstblities of a supervisor(see Appendix Q, Rubs&R.cgulations for Licensing Camstrvction Supervisors,Section 2.15) This lack of awareness gftrn results in serious problems,particularly when the homeowner hires unlicensed persons. In.this case,our Board cannot proceed against the unlirumsed p=on as it wrould N,*'a licensed Supervisor. The hom'towner acting as Supervisor is uld=tciy Trsponmbla. To ensure that the homeowner is fully¢wart of his/hcresP0=bilities,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the rrspo=bilitics of a Supervisor. On the last page of this issue is a form currently used by several towers. You may care t amend and adopt such a fomVecrtifim6on for use in your community. Q:forms:homccxcmpt Town of Barn-stable { { Regulatory Services ♦ �AHT7SLrART� { Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstab le-ma.us Office: 508-962-403 8 Fax: 508-790-6230 ,�: Property Owner IV us complete and Sign This Section , r- { If TJs4u , as Owner,of the suect . Jbj .property hereby 11-60rize to act on my behalf, in all matters relative to work authorized by tbis binding 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:OWN RPERM1SSlON Moe 16 S�4 Cor*% I-W 'CEuc/w ' D7 , ffvr�/4 ',e'ort 2)CIC,PT 16''oC.: w/&*IwNW► WO 2xlo RlrASotsT� CAG4CD w/CA.LV• /6oC, • C HasE+GA�I{GE - • M A-X '57 SP T��4 D t 8ll�r MORTGAGE LNSPECTION PLAN (THIS PLAN WAS NOT CREATED FROM AN INSTRUMENT SURVEY AND IS FOR MORTGAGE PURPOSES ONLY, MACDOUGALL SURVEY WILL NOT ASSUME LIABILITY FOR ANY OTHER USE). PARCEL ID: \\� . 208/082-001LO N Of CEO PARCEL ID: �62 207/086 ,79• \ PARCEL ID: \ 208/082-002 70 \ _= #215 \ _==__ po5 .6 , Ppr-n0/p er PARCEL ID: 207/087 I CERTIFY THAT THIS MORTGAGE INSPECTION PLAN WAS PREPARED IN ACCORDANCE MATH 250 CMR SECTION 6.05 OF THE MASSACHUSETTS RULES & REGULATIONS FOR THE PRACTICE OF LAND SURVEYING. THE BUILDING SHOWN IS NOT AFFECTED BY A SPECIAL FLOOD HAZARD AREA AND DOES _CONFORM TO THE LOCAL ZONING BY-LAWS IN EFFECT AT THE TIME OF CONSTRUCTION WATH RESPECT TO SETBACK REQUIREMENTS OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 40A SECTION 7. REFERENCED DEED SUBJECT TO AND WITH THE BENEFIT OF ALL RIGHTS, RI Y, ENTS, RESERVATIONS AND RESTRICTIONS OF RECORD, IF ANY THERE BE AND INSOFAR AS THE SAME ARE OF LEGAL FORCE AND EFFECT. #215 SOUTH MAIN STREET TOWN: BARNSTABLE (CENTERVILLE) DATE: 08/10/11 APPLICANT: CYNTHIA H. PARRELLA ., CERTIFY T. : EMERALD FUNDING, 'INC. SCALE: 1"=30' ` ��OF*,q sq TITLE REF: 24007/246 MacDougall Surveying fDWARD cy� PLAN REF: 95"7 F2 9 , t FLOOD ZONE: " & Associates. o -+ COMMUNITY PANEL: P.O. BOX 2428 STONE �' 250001-0008—D Mash ee, o No.28980 DATED: 07/02/92 P Ma. O.2649 /ST CURRENT ZONING: "RC" ph, (508)419-1086 fax. (508)419-1087 �cN L email: macdou gall survey JOB# 10781 ®comcast.net t T M If • � � i � ,__+_ fit , ��— � ��- ,�—' , s— o _ ( r ?.Arl Iq , , { (.r._.#_ �-.. !. ......_i 4 _.j-....._?. } _.�� �..,�.i .....! !___._t i�l� i j ~ _.•� �-•-•1 - _�_ '^� � � i I 1 1 I...�i_.�T. r � (.._.-.' -'_, �. 1 5 � _ .,V�' ' 04215-1 ._._,; _�S' 1! .� j ;_.. 4� p ' I 77 _ 1 ._,_-4 S r' ._ '� r,.......__r....._ '1 t ; 1 ° �i ( t l t - S ? j k^��/✓I+�NJ/It 12 7 �� ��•r 1 it r � f Ji _r i ' I r_ W I� t r ....._-,--�.....-...�}'� � f i 1 � 1 f 1-_�..... S P � t �� ? � � � j� i � � j � � j !!� .3._...�j ;. _.� ;__ i_"' �.�........_,2•_._--,---i Ilk ZZ 1 _ .__,_,... It_ _,.. _{t. ' 4 _►_� IC. G.C. !.. 1 1_.. Irv,-10A, s __' _ " t j 1 ! , ! 1 i 1 I .._._. ..._........_';-7- _�t �.._. .._.__ i_._...5._�._._... ',..._'t_.._._'..._.+r,._._._._.i +._.-..., ..�:} fTf S�.il�,l i- -f-•- 1 - - TOE'►I I OF BAP.NISTABLE ' S c� �a'( to SI a t i �, f Oh 4-i IA IL 17 �� _I�_'�E�i� ! l---l�_%��_�.�.I� I I _; I . ' ____'� i i r.' � �. '�- � _N-r--�__1.�. Y1.�1.___�_._} �_--�j--j !-�----,��_�. ��^ i ? �� 17 !j Its& PAI P-4 A. VrX 2`1 5_66vtw op via S_ 115 T A je _ 1 , 1 1 1 3 - : 1 f J �i _ r. 1 1 ! I M t _f 12 ` �i _,.f_,i i_.,_...i.-,__�.:Iy��l.w_- { ._1 Ii�(�- �e I _^1 � i I,_..-���._- ! i}', 1,-___1....,_�._ ���--,-.�•...,.><�^---_ �t____��..�.......�._ { _4_ � ��_,;_�_.._ r ! #� � i + ? y � ? t � 4 1 �'�~ i _•_�___' `• i I i ( I i � � �`! i i , }�� 1- f "-- I 1 ! i ? , ? i __- 1 ---� .. # � —�_ � ' ' fT _r ? ? -�--f--•; �....�---�t._._;.._.� � � _i_..� {��� ', �i � ....i � l:._._� i i { ( »' G'�I �_ocfT?�-1/1/��/ oN S. b-AAA -qT • III Home Energy Raters LLc BTorrey @Energycoaexerp.com Box 989,E.Sandwich,Ma 02537 888-503-2233 Duct Leakage Test Address 215 S Main St, Centerville Ma Date - Oct 5, 2011 Test Type — Rough-In - Total Leakage =' Conditioned floor area = 1560 Sq FT To comply with Section 403.2.2 Of the 2009 IECC Code in this home the, Maximum duct leakage CFM = 93 CFM ( 1560 /100 x6=93) Duct leakage tested = 73 CFM This Home complies with Section 403.2.2 Of the 2009 IECC Code Date of Test 10.5.11 Technician: Larkum Test File:Untitled Customer Building Address: 2.15-5 Main StV Centerville,MA Test Results 1. Measured'Duct Leakage: 73.0 CFM 113.8 sq.in.(;1-0.0 Ole) 2. Duct Leakage as a Percent of System�Aididw. ' 3. Duct Leakage as a Percent of Building FloorArea: C&7-°% °. . 4. Leakage Split: Supply Side: . Return Side: 5. Duct Leakage Curve: Flovr Coetficient(C): 10.6 EXponerti9(n): 0.600(assumed) 6 Test Settings: Tess Mode: Pressurization Test Pressure: 25.0 Pa Equipment: Series 8 Minneapolis Duct Btastet Test.Type: Total Leakage (Duct Blaster Only) Contact our office with any questions, Bruce Torrey, : . Certified HERS Rater ' Home Energy Raters LLC I - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel690 Application # 061/11JS3 `L Health Division Date Issued f �' Conservation Division Application F Planning Dept.t. Permit Fee - Date Definitive Plan Approved by Planning Board 1n�E'►� Historic - OKH _Preservation / Hyannis U Project Street Address D 5 Sov-774 IV A-)0 Village &0AA ®C L,r— Owner CA ai)A 1_� � �i � Address Po ab)( 4C>_> 0 vF_ 0 Telephone Permit Request V n 5 t a (l a Gi 0 -1 O Y 0—n e H V A c 011 -E I -n L h P ba r � e�� feS s h � a�I vyi C dfi-P\ dF F5Ct avva x 1,p�10s W dS k o-41 o Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new Zoning District Flood Plaim Groundwater Overlay Project Valuation 10-OW 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 _C11 x 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: 2Yes ❑ No Fireplaces: Existing New Existing wood/coal stove, ❑Ves ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑dxisting never size_ Attached garage: ❑ existing ❑ new size __Shed: ❑ existing 0 new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT IN)F'ORMATION - (BUILDER OR HOMEOWNER) Name l eX bfOgq C JCS a 85-4`+• T Telephone Nu ber 7 Y' `f — `0S 1 q 1gc1ter Address 0 50 License # l(C ! f - UI X0 YX -In 4 0) 6 o / Home Improvement Contractor# Worker's Compensation # W Ca—3 [5-3 7 b?&J ®10 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ®v1M SIGNATURE DATE 1A q11 I FOR OFFICIAL USE ONLY . APPLICATION# DATE ISSUED -MAP_/PARCEL NO. t ADDRESS VILLAGE t OWNER 'g DATE OF INSPECTION: FOUNDATION FRAME INSULATION a FIREPLACE 4 - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: '. ROUGH FINAL FINAL BUILDING ° IOhl c DATE CLOSED OUT ;r ASSOCIATION PLAN NO. - . l , ZN The Commonwealth of Massachusetts - Department of Industrial Accidents �,.,l• Office of Investigations } ;NJe J 600 Washington Street Boston, MA 02111 c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers' Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): y CL 5 o, 'P/U n 601k- Cf ftd( dt, Address: R oC ®lQ ,7 L l/'� I t o City/State/Zip: ya V1 -Vt`5 (ra . `Phone #: Vreouan employer? Check the appropriate box: Type of project(required): I am a employer with_ 3 . 4. ❑ I am a general contractor and I 6: ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 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 area corporation and its , officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 1.❑ 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' 13.0 Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. k Insurance Company Name: C �h e 5C lec,e/ Policy#or Self-ins. Lic. #: VU CQ ` 3 t5— 3-7� YyJ —®10 Expiration Date: 3 ra Job Site Address: �5 S®(/ �q( V� 5 City/State/Zip: Cplt G e r✓( P /uVT C9q 6 3 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 cert' u t ains and penalties of perjury that the information providla�e ' tvae and correct Si ature: .Phone#: Lth only. Do not write in this area,to be completed by city or town official n: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector son: Phone#: k 1t{ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "..,every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual, partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not-more than three apartments and who resides therein, or the occupant of the dwelling-house of another who employs persons-to'do'mairitenancc, 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 bean employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance, requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided'a space at the bottom of the affidavit for,you to fill out in the event the Office of Investigations has to contact-you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition an applicant P � PP 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"tlj applicant should write"all locations in (city or,,, town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone'and fax number: The Commonwealth of MassaChu.settS Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ILIA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass..gov/dia CERTIFICATE OF LIABILITY INSURANCE D ATE(MM,DD/YYYY) 02/28/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES . BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT . CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may. require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Schlegel & Schlegel Insurance Brokers Inc. PHONE I FAX 34 MAIN STREET EfiA1Lo Et): -_-_ — --- ;(A/C,No): ADDRESS: ..PRODUCER ......_.... ------ CUSTOMER ID It: West Yarmouth, MA 02673 —_ - INSURER(S)AFFORDING COVERAGE NAIC# INSURED - INSURERANGM INSURANCE Alex Braga Dba Braga Bros Plumbing & Heating INSURER BPROGRESSIVE 2 Mountwood Rd INSURER c INSURER D: Marstons Mills, MA 02648 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. a SUII.R LTR TYPE OF INSURANCE i INSR i WV I POLICY NUMBER j (MM/DD/YYYY) ' (MM/DO/YYYY) ; LIMITS GENERAL LIABILITY 1 i A 4 MP03439T !02/17/11 ;02/17/12 ,EACHOCCURRENCE $1,000,000 X f ( -DAMAGE -RENTED-- -- - - -----._-. COMMERCIAL GENERAL LIABILITY ! I , PREMISES(Ea occurrence) s 500,OOO f —_—_ CLAIMS-MADE ',OCCUR _ M MED EXP(Any one pe(son) $1 D,000 i PERSONAL 8 ADV INJURY S1,000,000 'L __ .GENERAL AGGREGATE j2,000,000 GEN AGGREGATE LIMIT APPLIES PER i i ( PRODUCTS-COMPIOP AGG 1 S 2,0 00,000 - POLICY ^i JECT 1 !LOC B AUTOMOBILE LIABILITY 109574174 - 02/24/11 102/24/12 �COMBINED SINGLE LIMIT i S 1 I I(Ea accident) - ANY AUTO BODILY INJURY(Per person) — I S inn ,000 ALL OWNED AUTOS ! , -- -- BODILY INJURY(Per accident) i S 300,000 • X SCHEDULEDAUTOS i - I PROPERTY DAMAGE A HIRED AUTOS j i(Per accident) I S 100,000 NCN-OWNED AUTOS UMBRELLA LIAR i 1 OCCUR I EACH OCCURRENCE S EXCESS LIAR f CLAIMS-MADE ' ( 7 - - 1 j i AGGREGATE �$ DEDUCTIBLE RETENTION S S C WORKERS COMPENSATION WC2-31S-376462-010 03/04/10 !03/04/11 iX WC STATU- IOTH- .AND EMPLOYERS'LIABILITY Y/N i i j TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE j03/09/11 I03/09/12 E.L.EACH ACCIDENT S 100,000 OFFICER/PAEtdBER EXCLUDED? - NIA _. (Mandatory in NH) E.L.DISEASE.EA EMPLOYEE S 100,000 • If yes,describe under DESCRIPTION OF OPERATIONS below E.L,DISEASE-POLICY LIMIT $ 50 Q,0 00 - ! IESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - THE WORKERS COMPENSATION POLICY DOES•NOT PROVIDE COVERAGE FOR ALEX BRAGA :ERTIFICATE HOLDER CANCELLATION GOWN OF BARNSTABLE 3UILDING DIVISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE .THEREOF, NOTICE WILL BE DELIVERED IN ?00 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. IYANNIS, MA 02601 AUTHORIZED REPRESENTATIV !PAX # 508-790-6230 ,TTN: PLUMBING DEPARTMENT ©1988-2009 ACOR CORPORATION. All rights reserved. .CORD 25(2009/09) The ACORO name and logo are registered marks of ACORD ' i ..,yr Town of Barnstable Regulatory Services R � LlAN6TABi.y s MAas Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property OwrierMust Complete and Sign This Section If Using A Builder • as Owner of the . subject.property hereby authorize I f- BYqq q C Bs-q a ®S; to act on my behalf, M all matters relative to work authorized by this building permit application for: f S , IVAiPJ �� (Address of Job). . �i 5 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 WNEU ERMISSIDN ��pp THE rp�y Town of Barnstable y� o Regulatory Services Thomas F. Geiler,Director t�stiss g - 0.19• Building Division PrED µAil" Tom Perry,Building Commissioner 200 Maui-Stme t,_Hyannis,MA,02601 www.town.barnstable-ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOl\9E0WWER LICENSE EXEMPTION Pleare Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: cityltown states 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 OFHOMEOWI\'ER Persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to- be, a one or two-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 r, minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. i ` y . r 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,(Scction 1 D9.1.1 -Licensing of canstruction Supcnisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homcowncs shall act as supervisor."' }r{any 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 awanaress 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. Tbc homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responnbilitics,many communities require,as part of the permit application, that the homeowner certify that hrlshe understands the msponnbilitics of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:for ns:homeexcmpt I ------------------ ---------- -------_ '�• r COMMONWEALTH OF MASSACHUSETTS LICENSED AS A JOURNEYMAN PLUMBER SAFETY CERTIFICATE . ISSUES THIS LICENSE TO _ Alex B. Braga ALEX B BRAGA Has completed Excellence In Safety s,P`owered Industrial Tuck Operator Training at Botello 2 MOUNTWOOD RD Home.Center,Mashpee,MA..- Richard Hughes,C.E.C.M. January 9,2008 MARSTONS MILLS MA 02648-2111 Trainer Training Date 315.24 05/01/12 757564 C©Mi�0NV11EALTH OF MASS,4C US-ETTS O ® o 0 0 •o o :o •o 0 ai' IN PLUMBERS AND GASFITTERS: aoo.62�.9ai9 LICEn(�'�cE0 eIL'E TG:LU.M.BER . 1S�Lw 7'r;�"ABt�Vt' f7bC Name: Alex Braga Registration Number: 169165 A L E X B BRAGA 2 MOUNTWOOD RD Date: 12/10/2009 Rinnai Tankless Water Heater MARSTONS MILLS MA 02648=2111 Installation Training Course r : COMMONWEALTH OF MASSACHUSETTS Gastite METAL WL)KKERS • • • The"system is the Solution' AS A MASTER-UNRESTRICTED The tollowing person has successfully completed the Gastite ISSUES THE ABOVE LICENSE TO`. Certification Training Program and is hereby recognized as a Qualified Gastite Installer A L E X B BRAGA Alex Braga Bill Van Norman —, Name I^siuctor 2` MOUNTWOOD RD N Braga Bros�;g E Htg _ _10%07/200.9_ Company 08G438610 Date MARSTONS MILLS MA 02648-2111 i Cerifica to No. 169525 Authorized to purchase and;:;stairGastite=lexib!e Gas Piping 6717 08/28/12 977645 . 1-80M62L208 www.Gas-,i'e.com -Liti ficatz Of 60IYL4bon or The person named below has completed the Tracfte 44'd training program and is hereby awarded the AIita OBiBraga Certified by by CERTIFICATE OF TRAINING. ng (�, (��. dy,a EPA Approved Q p September 30,1993 A I ex B} 7 agg � ggQ GJ?OS.(j ,J Technician TYPErUNIVERSAL Installer's Name Company ds d Go o C' R'82 Su/pa q UCert' 13 3 9 6 8 3 3 2302994 3/29/2U11 te No. certificate Number Date President VGI halning Div Year Month Day --- f y. Town of Barnstable �FTME1 Regulatory Services er 'r t, « �; v!ABLE , a,1b Thomas F.Geller,Director ALE Building Division ? %FEB .` 7. -B sT 2: 4 p v nrnss Tom Perry,Building Commissioner jEct*�0 200 Main Street, Hyannis,MA 0260.1 www.town.barnstable.ma.us I1OPd Office: 508-862-4038 F c: 08-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: ]1 q )Q ro ��✓ Name: Phone#: Address: S AA R i Z5-t L510—P—+ b Village: Name of Business: s Type of Business: ! Se. Map/Lot: V D W INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. - • Any need for parking generated by such use shall be met on the same lot containing the Customary Home_- Occupation,and not within the.required front yard. • There is no exterior storage or display of materials or equipment • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: U t O d _ LW Date:—�1 `� �o Homeoc.doc Rev.5130103 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in townt(which must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 St FL., 367 Mi Street, Hyannis, MA 02601 (Town Hall) DATE: Fill in Please: �e - •: APPLICANT'S YOUR NAME: t�VL� i A N2 VO L� BUSINESS YOUR HOME ADDRESS: IS An Rt N SfitngG'.T ' TELEPHONE # Home Tele hone Number NAME OF NEW.BUSINESS c'j1 Li R n �rr Fdr S TYPE OF BUSINESS LeS IS THIS A HOME OCCUPATION?_.,/_YES NO Have you been given approval from the building division? YES NO 2 v U ADDRESS OF BUSINESS MAP/PARCEL NUMBER c When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable This form is intended to assist you in obtaining the.information you may need. You MUST GO TO 200 Main St.—(corner of Yarmouth Rd. & Main Street).to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM ER'S OOFFIThis individuIh s n infny permit requirements that pertain to this type.of business.0 orized * COMMENTS: S ry - BO4115D OF EALTH z his indi idual has been i f rmed of th p mit re e t that pertain to this type of business. a. f1� 0- "}� ` Authori Signature** COMMENTS:_ a L ' . -CSUMEi AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. . r Authorized Signature*..* COMMENTS: