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0518 SOUTH MAIN STREET
o u a , 6 Town of Barnstable Building "��;a:;. d a b,.v C` NFL :"ir ,�.',. � h..S ,. E� , � E" "^.. i5�R°,�'f 1', ;'�` .:. sry*`.H^Y i;rr^a, t ,aa€ J' ,1:'." '> '*i ;".t +tea, `ttiF` -'7 "t _ iPost This Card;Sd That it isU�sible;!From:the Street; ,Approved_Plans Mustbe',Retamed onJob andthis Cad,Must be Ke„t °' ;,-Ps -,.'` €, f�1Sr e's t rIG r"ii A •, .: i 4 x"s." - '# ', a F+G. �$,a,, r•Q�y a"s aN Ey "+- ._ u, :r Ir i9 , ° ,16 T ,.u!y r..' �Posted,U,ntil°°Final Ins ection:Has Been.Made r ->-- N•->� Y N> { > � >1 ;,# �� - r�' . 39• .♦ *.� . uk'i4 B , t,&'�a m.. ':' `r E a..i:. .1 iaa,'.° '. ,�, r�.;ari r ;�' .h4 �V� .. ?.',' a nkV, ,.ai o-d r, �,�.' x .. ° Where ajCelrtificate of°Occu Banc �sFRe uared,such Builtlm shalFlNot;•be.Occu ie$d until a}Finahlnspect on has'be°en made _ Permit p q .�", 4k4k .,�g�Am'-.� .,, .,k ti.:t dupe a.a,.w x,A= a.. _, ,. ,_d1. r� ..*:k. � " Permit No. B-18,594 Applicant Name: GERLOVIN, MARK s Approvals Date Issued: 03/30/2018 Current Use:, Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 09/30/2018 Foundation: Location: ,518 SOUTH MAIN STREET,CENTERVILLE Map/Lot 207-001 001 Zoning District: " RD-1 Sheathing: Owner on Record: GERLOVINMARK. g �' Contractor Name Framing: DK ,jo8 T; P Address: 192 WINCHESTER ST APT I r °� Contractor license �✓� �' dR ..y T�M� � I "ti BROOKLINE, MA 02446- , rEst Protect Cost: $5,000.00 r � � Chimney: Description: Remove and replace header and window second floor for hanger. Permit Fee: $'85.00 insulation:. header and window replacement. Beam Installation`attic Removal , F,.e`ePaid $85.00 of doors and header.1st floor for replacement of larger header and � ' � a k Date 3/30/2018 Final: p�,C to slider - � � � �� Project Review Req: t Plumbing/Gas Rough Plumbing: Building Official• i , . _. Final Plumbing: This permit shell be deemed abandoned and invalid unless the work authorized by this permit is commenced within six n%onths after issuance. m f Rough Gas: All work authorized by this permit shall conform.to the approved application and the approved>construction documents for which this permit has been granted: t _ ; is x All construction,alterations and changes of use of any building and str:,uctures shall be in with the local zoning by-larws and codes: Final Gas This permit shall be displayed in a location clearly visible from access street or fioad1and shall be maintained open for public inspection for the entire duration of the a , work until the completion of the same. fi p r p� Electrical The Certificate of Occupancy will not be issued until,a11 applicable signaiures�by,'the Building and Fire Officals aro,provided on his-permit. Service: Minimum of Five Call Inspections Required for Allr Construction Work: r r� � 1.Foundation or Footing �r * Rough: 2.Sheathing Inspection - " " N 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed- Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) • Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All'P.ermitCards are the property of the APPLICANT-ISSUED RECIPIENT.._ 0 Application Number........................................................ • d :.D4A88. � Permit Fee. ...: ................Other Fee........................ 6A1TotalFee Paid................. ............................................. ...... TOWN O F BWTABLE Permit Approval by..................................On........................... BUILDING PERMIT b .......... �. .L.":..Q. ..�....... APPLICATION Section 1 — Owner's Information and Project Location Project Address J a 2 ,,' +A S Village AY)�&a�W( Owners Name ;APT �+b Owners Legal Address toll MAR v S City�©pCC�►�c►�State tLbc TOWN e R-1 , MU Owners Cell# E-mail Section 2-Use of Structure Use Grroup ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet E/Single/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System Vdition ❑ Retaining wall ❑ Solar ovation ❑ Pool ❑ Insulation Other—Specify. Section 4 -Work Description 6.� V\C L✓ G vJ��C�b � \C-.� q In 1t C T act imdmted•2/92018 Application Number............................................. Section 5-Detail ` Cost of Proposed Construction Square Footage of Project Age of Structure '3 L Dig Safe Number #Of Bedrooms Existing Total# Of Bedrooms(proposed) 110 MPH Wind Zone Compliance Method ❑ jMA Checklist❑ WFCM Checklist ❑ Design Section 6-Project Specifics ❑ Wiring ❑ Oil Tank Storage Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney '❑Add/relocate bedroom Water Supply 2Public ❑ Private Sewage Disposal ❑ Municipal "1YOn Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility. b� I am us' a crane ❑ Yes ty. Section 7—Flood Zone Flood Zone Designation �f , Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Z Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes No Lastimaatea 2/92018 GENERAL NOTES 1.ALL STRUCTURAL WORK SHALL BE COORDINATED WITH ARCHITECTURAL,MECHANICAL,ELECTRICAL,AND PLUMBING SPECIFICATIONS,INCLUDING THE FOLLOWING GOVERNING STANDARDS: A.THE MASSACHUSETTS STATE BUILDING CODE,8TH EDITION(FOR ONE-AND TWO FAMILY DWELLINGS)AND ALL OTHER AGENCIES HAVING JURISDICTION. A.THE NATIONAL DESIGN SPECIFICATION FOR WOOD CONSTRUCTION(NDS),LATEST EDITION. B.SPECIFICATION FOR STRUCTURAL STEEL BUILDINGS ANSI/AISC 360-05. 2.THE CONTRACTOR SHALL PROVIDE TEMPORARY SHORING AND BRACING AND MAKE SAFE ALL FLOORS,ROOFS,WALLS AND ADJACENT PROPERTY AS PROJECT CONDITIONS REQUIRE. 3.ALL CONSTRUCTION IS TO CONFORM TO THE MASSACHUSETTS STATE BUILDING CODE AND ALL APPLICABLE PRODUCT AND DESIGN STANDARDS. ABSENCE OF SPECIFIC ITEMS FROM THESE DRAWINGS DOES NOT INFER THAT THE CONTRACTOR IS RELIEVED FROM THE STATUTORY CODE REQUIREMENTS. 4.ALL MATERIALS AND METHODS OF CONSTRUCTION SHALL CONFORM TO THE APPROVED RULES AND STANDARDS FOR MATERIALS,TESTS,AND REQUIREMENTS OF ACCEPTED ENGINEERING PRACTICE AS LISTED THE MASSACHUSETTS BUILDING CODE. 5.THE CONTRACTOR SHALL VERIFY ALL DIMENSIONS AND CONDITIONS IN THE FIELD PRIOR TO COMMENCING WORK.ANY DISCREPANCY BETWEEN WHAT IS SHOWN ON THE DRAWING AND ACTUAL FIELD CONDITIONS SHALL BE REPORTED BACK TO THE ENGINEER IN WRITING BEFORE PROCEEDING WITH ANY WORK. STRUCTURAL STEEL NOTES 1.STRUCTURAL STEEL ROLLED SHAPES SHALL BE NEW STEEL CONFORMING TO THE FOLLOWING ASTM DESIGNATIONS: ASTM A36 ALL ANGLES,CHANNELS,PLATES AND MISC.FRAMING MEMBERS, UNLESS OTHERWISE NOTED,(MINIMUM YIELD STRENGTH FY=36,000 PSI). ASTM A325 ALL BOLTS CONNECTING STRUCTURAL STEEL MEMBERS. ASTM A500 GR."B" ALL HSS TUBE STEEL COLUMNS(MINIMUM YIELD STRENGTH FY=46,000 PSI). 2.ALL STRUCTURAL STEEL DETAILS AND CONNECTIONS SHALL CONFORM TO THE STANDARDS OF THE CURRENT AISC SPECIFICATIONS FOR DESIGN, FABRICATION AND ERECTION OF STRUCTURAL STEEL FOR BUILDINGS. 3.ALL WELDING SHALL CONFORM TO THE CURRENT STANDARD OF THE AMERICAN WELDING SOCIETY(A.W.S.).ALL SHOP AND FIELD WELDS MUST BE MADE BY APPROVED CERTIFIED WELDERS. 4.ELECTRODES FOR ALL FIELD AND SHOP WELDING SHALL CONFORM TO ASTM A233(CLASS 70).ALL WELDS NOT SHOWN SHALL BE AWS MINIMUM. ALL WELDS SHALL DEVELOP THE FULL STRENGTH OF THE MATERIAL BEING WELDED. S.SPLICING STRUCTURAL MEMBERS WHERE NOT DETAILED ON THE DRAWING IS PROHIBITED. 6.DURING THE CONSTRUCTION PHASE IT IS THE RESPONSIBILITY OF THE CONTRACTOR TO PROVIDE ALL NECESSARY,TEMPORARY SHORING AND BRACING TO MAKE THE STRUCTURE STABLE AND PLUMB BEFORE COMPLETION OF CONNECTIONS,STEEL FRAMES,SHEAR WALLS AND FLOORS. 7.TEMPORARY BRACING SHALL NOT BE REMOVED UNTIL THE STRUCTURAL FRAME IS PROPERLY SECURED TO THE LATERAL LOAD RESISTING ELEMENTS IN THE BUILDING.THE STABILITY OF THE FRAME DURING ERECTION IS THE CONTRACTOR'S RESPONSIBILITY. 8.ALL STEEL SHALL RECEIVE TWO COATINGS OF SHOP APPLIED PRIMER PAINT.TOUCH UP ALL WELDS,SCRATCHES OR SCRAPES IN PAINT AFTER ERECTION. WOOD FRAMING NOTES 1.ALL FRAMING LUMBER SHALL CONFORM TO THE LATEST EDITION OF THE AFPA"NATIONAL DESIGN SPECIFICATION FOR WOOD CONSTRUCTION"(NDS),AND SUPPLEMENT"DESIGN VALUES FOR WOOD CONSTRUCTION",LATEST EDITION. MAXIMUM MOISTURE CONTENT SHALL BE 19%. 2.THE FRAMING LUMBER SHALL BE OF THE FOLLOWING MINIMUM GRADE AND SPECIES FOR THE SPECIFIED USE.ALL LUMBER SHALL BE GRADE STAMPED BY A RECOGNIZED GRADING AGENCY AND SHALL BE KILN DRY. ALL WOOD WALL FRAMING(STUDS,SILLS,PLATES,BRIDGING,BLOCKING ETC.SHALL BE 2x6 SPF#2. H OF MSS 3.LUMBER WHICH IS SPLIT,CRACKED,NOTCHED OR OTHERWISE ALTERED OR DAMAGED SHALL BE IMMEDIATELY REJECTED AND NOT ALLOWED FOR USE,UNLESS OTHERWISE APPROVED IN WRITING BY THE STRUCTURAL ENGINEER. �O LARS ANSEN 4.ALL WOOD PRODUCTS SHALL BE STORED IN A DRY LOCATION.ENGINEERED LUMBER PRODUCTS WHICH ARE NOT KEPT o STRUCTURAL DRY WILL BE IMMEDIATELY REJECTED AND REQUIRED TO BE REPLACED BY THE CONTRACTOR AT NO ADDITIONAL COST. U N0.50WN u~i 5.IN NO CASE SHALL JOISTS,RAFTERS,BEAMS,POSTS,STUDS OR ANY OTHER FRAMING MEMBER BE CUT,NOTCHED, POD GIS7 DRILLED,OR OTHERWISE MODIFIED WITHOUT THE WRITTEN APPROVAL OF THE STRUCTURAL ENGINEER OR SPECIFIED ON THE DESIGN DRAWINGS. C INGHOUSE 2017 03 06/20f? inghouse.rc PROJECT TITLE: DATE: 03/06/2017 M ..h 18 SOUTH MAIN STREET CENTERVILLE MA Ma,claos Mills.MA 02648 �5e pho..:508-M-2C80 1 PROJECT#: ING16048 CK_1 Q web: www.wgho�ce.oet J 1 1r9r SHEET TITLE: GENERAL NOTES - DESIGNED BY: LI structural design &ingenuity DRAWN BY: CES PAGE I OF 3 2" FROM FACE OF CHIMNEY TO EDGE OF PLATE EXISTING CHIMNEY ' P� ►' vy ► 1 1'-0" x 0'-1 ' x %" TH K. STL PLATE (18) i6" DIA. OLES FOR MAS N RY SCREWS = o 0 o 2 HSS7x4x1 BEAM o Ln �' _ (1) 4 ' ASTM A325 ° ° 2 ` THRLI BOLT 11 ° ° ° - 4'11 x - 2 x � 1AII STL PLATE CONNECT STL PLATE g AP TO CHIMNEY BET 'EEN SIDE PLATES VIA. (18) HILTI AND SS IYP. EA. SIDE "KWIK-CON II" 7-7 MASONRY SCREWS, NOTE: 3%4" LONG W/ ALL PLATES SHALL BE WELDED W/ FLAT HEAD AVOID GROUT %6" FILLET WELDS ALL AROUND JOINTS, TYP. CONNECTION ELEVATION_ SECTION @ CHIMNEY 2 Scale: 1"=1'-0" V2"GAP EXISTING 0 .—I —� A 11 l 7, X 11/1 2Y2" � � I TYP. 6' EXISTING KNEE WALL CONNECTION SECTION 2"FROM FACE PLAN VIEW OF CHIMNEY TO EDGE OF PLATE EXISTING CHIMNEY 1 1'-0"x 0'-1 'x Y2"THK. STL PLATE (18) 16" DIA. OLES FOR MAS NRY S GREWS 3" I o = _ jHSS7x4x1,, BEAM EXISTING AOSLMA325 EXISTING I (2)-2 x 4 STUDS - 2x4 STUD ",�7U'-b4"X U STL PLATE 2 x V NEW HSS BEAM 5 " CONNECT STL PLATEa qp (2)-2x6 (2)ROWS OF TO CHIMNEY BETJLJE EN SIDE PLATES BLOCKING 5"LONG VIA.(18)HILTI .EA.SIDE SIMPSON "KWIK CON II" 2 x4 BLOCKS �--SDWS22500DB", MASONRY SCREWS, NOTE: STAGGER 3V4"LONG W/ ALL PLATES SHALL BE WELDED W/ FLAT HEAD NA AVOID GROUT 3/6"FILLET WELDS ALL AROUND I(2)ROWS OF JOINTS,TYP. I I I 5"LONG SIMPSON m "SDWS2 ", `� � , CONNECTION ELEVATION STAGGER "' AMR o5 2 ' : SECTION @ CHIMNEY 7- 21' . scale: 1"=1'-0" O►yN®�� rb fiMlU�1� :� SNOFAll ELEVATION VIEW LABS JENSEN o STRUCTURAL ' 1 CONNECTION @ GABLE END No.50602 Scale: 1"=1'-0" �'� FGIST 03/06/2017 6 INGHOUSE 2017 inghouse.rc PROJECT TITLE: DATE: 03/06/2017 M �'°' 18 SOUTH MAIN STREET CENTERVILLE MA P.O. 1 Mills.Mh0IE48 ,ye ph',,,;W8-221-2V80 t 1 PROJECT#: ING16048 C_{ ro web: www.n8houu.net J J r9 SHEET TITLE: CONNECTION DETAILS DESIGNED BY: U structural design &ingenuity DRAWN BY: CES PAGE 3 OF 3 ��. �w G�,als A"D (�) k tni G Sr4fl�1 cL Lu tool TTI 'av .' / BL/a h k •C 9�.� Ate/ G- m5�, oAj xr-s`' 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 hi 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-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 listed below. Self-h=ed 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 permiVlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of MassachuseM Department of Industrial Accident Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4M ext 406 or 1-877-MASSAFE Fax#617 727-7749 Revised 4-24-07 www,mass.gov/dia The Commonwealth of Massachusetts .fment o Department Industrial Accidents P Office of Investigations 600 Washington Street Boston,HA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: 6_j60 S P 141A) , City/State/Zip: C FAII ERv LL�F 1 0 L63Z Phone#: �6 r7 �- 71 n f Are.you an employer?Check the appropriate b 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. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. RRemodeling These sub-contractors have 8. Demolition ship and have no employees � ❑ employees and have workers workin for in an capacity. g Y P tY $ 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbing 3.El I am a homeowner doing all work g 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. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: l -5 "14/0 GA>� City/State/Zip: � VIZ-L b 2 b rjZ 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 cl under the pairndpenalties of perjury that the information provided above is true and correct: Si ature: —` Date: Phone#: 17 S 7 t__ O ffi cial 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#: Town of Barnstable Regulatory Services of tG�,r Richard V.Scali,Director Building Division BARNSTABLE. ` Paul Roma,Building Commissioner MASS. �e39. �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: Please Print �Jj� JOB LOCATION: �! a y"►GL� 11 S�• CeY!*r U1 II e number a n /� /' /7 street /�y village �° "HOMEOWNER": M ,1!,IC— `-6—P �V I`v `1d !7 5 —0I tl 6 name home phone# .}— ) work phone ('j # CURRENT MAILING ADDRESS: 0 2 ` I � 5'er S Gka �4 / brook 1'. VL_ "A 02 YA � 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. 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 ustk 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 res and requirp9ents 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 01/25/17 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct_bur7dings 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line.' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. x 4 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 Commmwealth of Massachusetts Department of Industrial Accidents ;office of Investigations 600 Washington Strut Bostan,ILIA 02111 TeL 4 617-727-4900 ext 406 or 1-977-MASS Fax#tti 617-727-7749 Revised 4-24-07 www.m=,gDv/dia=,gav/dia 1 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 F ��,c� ,� , _ Please Print Legibly Name(Business/Organization/Indivi dual): , �\r\SAP hC� S e,,,SS Address: i`\2 C<D G,\^0v-)t /.c , City/State/Zip: V,3LI Sk fAl)c Phone#: '�(� `� Z�)l O Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I employer with 4. ❑ I am a general contractor and I ployees(full and/or part-time).* have hired the sub-contractors 6. ❑New onstruction 2. am a sole proprietor or partner- listed on the attached sheet. 7. modeling ship and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• 9. ❑Building addition [No workers'comp.insurance comp.insurance 2 required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#] 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. tContactors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. ' Insurance Company Name: Policy#or Self-ins.Lie.#: 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: �� / t I f 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#: Diniri Area. , 24.x9 K1tChEri: CL co -� 14,x'5'; \ cL FIRE7_SfOOKE droom Living i5,X27. Room 4X29 1 2 ' . .- Q . CL co } Bedroom l Y3' -17" - 11�X16'' FIRE/SMOKE Image Image 1 C Bedroom' R co �f FURNACE Q' Room: *q 24'xg2' TO R Q Lndry tVIV 7 X40, L,, - /1 CL All measur er is area rozi not a .-This ill" f ion ssProv'ided or markef - ilidependently r Image 2 Dining Area_ 24,x91: Kitchen CL �o 14'x15 FlREBMOKE droom Living i5!x2�' :Room co Bedroom=; _ _ Bedroom il,x16" FIRE/SMOKE IT c>< Image Image 1 c Bedroom iy= FRNACE 'a Room 24X32' L--ndry _ U14 7'X4o' DING FIRE V 0,6 �t ®F� - CI r.. All measur ents area roxi not` a :Thls ill' f ion'is.provided or marketi independently Image 2 t # y R ..,.. `- ..�= �;• s» .' )`f ".fit"( g a �` � � �4+,,:• btu i � r � r. . a TT ip rm IL AP ,t AN NX - Ni _ ' � > kA b �+ s • � ] ��^ ` via ; WIN MEW on Noslims S!MOB W '� -, + .� �!' f BrYt•'j/:. 4 'r? c_,�;^ 1rkf... �`�_,!— -•sllr V 1 — ————— —— — ——— — — —— S-3 o e W J L X —— ———— —— ——-- -Z' — --� EXISTING GABLE r^ — O ;40r END WALL — — —— — v Ln O LL z > 3 EXISTING KNEE Uj u o u Uj WALL —————— ————----- :R--�-- � EXISTING O � ) FRAMING ROOF 2 S-3 EXISTING CHIMNEY PLAN EXCERPT Scale: 1/4"=1'-0" EXISTING ROOF FRAMING TO REMAIN ADD 2 x 4 @ 16"O.C. BLOCKS BELOW EXISTING RAFTERS, NAIL W/(4)-10d TO FACES OF COLLAR TIES NEW HSS BEAM,PLACE TIGHT SH OF M AGAINST BOTTOM OF COLLAR TIES;JACK LIGHTLY TO RECEIVE ROOF LOAD �O LARS JENSEN EXISTING KNEE WALL O STRUCTURAL —I No.50602 SECTION THRU NEW HSS � AScale: 1"=1'-0"aG INGHOUSE 2017 03/06/2017 inghouse.pc PROJECT TITLE: DATE: 03/06/2017 %02 18 SOUTH MAIN STREET, CENTERVILLE, MA Meg.: ,M-2dAO]64a — ,ye pMne:50&3Z1-i9a° PROJECT#: ING16048 9rp win wwr.ivghwse.net SHEET TITLE: (::::::!�r PLAN/ ROOF SECTION DESIGNED BY: LJ structura ddesign &ingenuity DRAWN BY: CES PAGE 2 OF 3 ,� F® R T E " MEMBER REPORT Level, Wall:Header k PASSED • IG 2 piece(s) 13/4" x 7 1/4" 2.0E Microllamp LVL Overall Length:9' + + o -- -- — - o 3 3 3 All locations are measured from the outside face of left.support(or left cantilever end).AII dimensions are horizontal. Design Results Actual @ Location Allowed Result LDF Load:Combination(Pattern) System:Wall Member Reaction(Ibs) 5286 @ 6' 9188(3.50") Passed(58%) -- 1.0 D(All Spans) Member Type:Header Shear(Ibs) 712 @ 6'9" 4339 Passed(16%) 0.90 1.0 D(All Spans) Building Use:Residential Moment(Ft-Ibs) -647 @ 6' 6403 Passed(10%) 0.90 1.0 D(All Spans) Building Code:IBC 2009 Live Load Defl.(in) 0.000 @ 0 0.096 2�9+ 1.0 D(All Spans) Design Methodology:ASD Total Load Defl.(in) 0.006 @ 7 3 7/8" 0.144 Passed(L/999+) 1.0 D(All Spans) Deflection criteria:.LL(L/360)and TL(1.1240). Top Edge Bracing(Lu):Top compression edge must be braced at 9'o/c unless detailed otherwise. Bottom Edge Bracing(Lu):Bottom compression edge must be braced at 9'o/c unless detailed otherwise. Bearing Length Loads to Supports (Ibs) Supports Total Available Required Dead Total Accessories 1-Trimmer-SPF 3.00" 3.00" 1.50"" 161 161 None 2-Trimmer-PSL 3.50" 3.50" 1.50" -7 -7 None 3-.Trimmer-PSL 3.50" 3.50" 2.01" 5286 5286 None 4-Trimmer-SPF 3.00" 3.00" 1.50", 346 346 None Tributary Dead , Loads Location(Side) Width (0.90), Comments 0-Self Weight(PLF) 0 to 9' N/A 7.4 1-Uniform(PLF) 0 to 9' N/A 80.0 Residential-Living Areas c 2-Point(Ib) 6'3" N/A 5000 Weyerhaeuser Notes 1`SUSTAINABLE FORESTRY INITIATIVE Weyerhaeuser warrants that the sizing of its products will be in accordance with Weyerhaeuser product design criteria and published design values. Weyerhaeuser expressly disclaims any other warranties related to the software.Use of this software is not intended to circumvent the need for a design professional as determined by the authority having jurisdiction.The designer of record,builder or framer is responsible to assure that this calculation is compatible with the overall project.Accessories(Rim Board,Blocking Panels and Squash Blocks)are not designed by this software.Products manufactured at Weyerhaeuser facilities are third-party.certified to sustainable forestry standards.Weyerhaeuser Engineered Lumber Products have been evaluated by ICC ES under technical reports ESR-1153 and ESR-1387 and/or tested in accordance with applicable ASfM standards.For current code evaluation reports,Weyerhaeuser product literature and installation details refer to www.weyerhaeuser.com/woodproducts/document-library. The.product application,input design loads,dimensions and support information have been provided by Forte Software Operator N OF Mks Gerlovin Residence (ING16048) 518 South Main Street, Centerville, MA L-ARS JENSEN o STRUCTURAL -+ NEW HEADER ABOVE GABLE END WINDOWS, (1). " No.50602 " EXISTING WINDOW & (2) SAME SIZE NEW WINDOWS. ��o��`�GIsT J s io Est°� 11/06/2017 Forte Software operator Job Notes 11/612017 11:14:51 AM LarsJensen Forte v5.3,Design Engine:V7.0.0.5 INGHOUSE gable end header size.4le (508)221-2980 jensen@inghouse.net Page 1 of 1 Application Number-,...............:.......................... Section 9—.Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10 —Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC... Signature Date Section 11 —Home Owners License Exemption Home Owners Name: /uh P' Telephone Number 17- 5 7/D Cell or Work Number 6(7 —0 ?, I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation re ed by 780 CMR and the Town of Barnstable. Signature �— l�► Date 2-ZS— �y APPLICANT SIGNATURE Signature Date- Print Name �R_k- /2 1,0y 1A) Telephone Number C/7—5 7/- V1 E-mail permit to: q iE—: t,L D U l A-) YA Ht)D, CO /-I T-..O....Ai -A.•f In^A1 0 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department Conservation For commercial work,please take your plans directly to the fire department for approval. Section 13—Owner's Authorization I, i� L _� , as Owner of the-subject property hereby authorize C 9/.S to act on my behalf, in all matters relative to work authorized b this building permit application for: Address of'ob �251`20/ Signature of Owner . date IN k- L-ZvI� i � r Print Name rYF u j Last undated:2/92018 Town of Barnstable �,7 200 Main Street, Hyannis MA 02601 508-862-4038, Application for Building Permit Application No: TB-17-224 Date Recieved: 1/26/2017 Job Location: 518 SOUTH MAIN STREET,CENTERVILLE' ' Permit For: Building-Insulation-Residential Contractor's Name: Carl J Rebello State Lic. No: CS-084358 Address: Swansea, MA 02777 Applicant Phone: (508) 567-4109 (Home)Owner's Name: GERLOVIN,MARK Phone: (617)571-0146 (Home)Owner's Address: 192 WINCHESTER ST APT 1 , BROOKLINE;MA 02446 Work Description: Insulation&.Air Sealing. Total Value Of Work To Be Performed: $4,196.00 + 0, Structure Size: . 0.00 ` 0.00 0.00 Width ', Depth otal Area, CO rn I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other,work'er before he/she engages in work on the above property in accordance,with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. w Signed: Carl Rebello 1/26/2017 (508)567-4109 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $4,196.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $85.00 _ 1/26/2017 µ$95.00 ._.. Paypal __..,.:.. µPaypal Total Permit Fee Paid: $85.00 �� � T� � �I�S �IS�N�(�►T A 34P�I� ��� �I�T'�� .�� �- ��..�P� .£._ _ ekcz'aC•3A�.:�wt 4.✓aw. v..».-...W.e..mw:u. ae ..�a�..,,�� .<l�_ 'uiECb�* ,�. -,Assessots m l p, and lot number .... X Sewage"Permit number -7..... ..................... ........... e� '* ' '} ZOB,o A�RN ST A DLE' House umber .................. .f . 'M1 �T M6g .... .A ..........: t39• i �0 'f0 MAI M1 TOWN OF BARNSTABLE BUILDING INSP CTOR APPLICATION FOR PERMIT TO ........ .........'.............................:.....:....................................................... ��TYPE OF CONSTRUCTION .............��.................:..............................................................,.................................... ............ ,9........ TO THE INSPECTOR OF BUILDINGS: The undersigned thereby applies for a-permiift�according to the followin information: location .. �'?�...4.........J l� . ...................i ............ ^ v . './. ........Proposed Use ....-�.:.�.�.l..C�.:................................�...............:�-:....../.....�..............................,. ............. Zoning District ... 1.� .� .. .....t..... ....... ..................Fire District .....���.�?.�.......................................................... Name of Owner :. .�`L+. � ....'�!i.iU,(..�.. D. :..Address -6 ................................................t4�s, ' �` Nameof Builder ........................:!......:.......!...........................Address .......................................... ...... .,............................. Name of Architect ..................................................................Address ..............................: Number of Rooms / .. ...Foundation .................... JJ ........`...................................... / U%�d .... b11. l„ .. . ' `.Roofin { �.../..S ...........I...�..Exterior ......� ... .. ... ........... g..... ... t.. Floors ..... ....... . . .p.�^ .... f Interior . ' --+..v ... Heating �(...� . ..::.... 7 -2� . ................Plumbing .............. .�D!r�e. .......................................................... _ , , Fireplace ...... . ......................................... .........................Approximate. Cost ............ .(/,(_/.. ... ........................ Definitive Plan Approved by Planning Board -----------_-------------------19________. Area ../......`......... ... r.........:::...'.: Diagram of Lot and Building with Dimensions Fee .. SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. _ Name ......11 ,. ✓... . . ......................` ; ✓,/„, �„�.. Construction Supervisor's License ...... '' vN J ANCHOR BUILDING CO. , INC. / 28879 Remodel Dwelling No;................. Permit for .................................... y -'=�Single Family Dwelling South Main Street Location ..........................................:..................... Centerville ............................................................................... k Anchor Buildin Co Inc. Owner ........................................$.. ....:............... Type of Construction .....Frame,,,,,,,,,,, ,,,:,,,,,.,,, ................................................................................ Plol............................ Lot ................................. January 24, 86 t Permit Granted ................ .. ....................19 Date of Inspection ....................................19 Date Completed ..................... ................1-9 Imo/' I � { 1 �oFt1KWE T Town of Barnstable *Permit# pExpires 6 months from issue date Regulatory Services Fee 1 Y t M Y v� MASS. SS•. Thomas F.Geiler,Director L QS)14 09 L& ESS IT Building Division C T _ 9 Tom Perry,CBO, Building Commissioner 2009 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF BA'RN,��`.AB�e_ Fax: 508-790-6230 Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY n ,�^ Not Valid without Red X-Press Imprint Map/parcel Number r I 001 I001 Property Address �� (1 9MMA Uun 81 0�0 t tic! Residential Value of Work �Z �;e� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 2 P A)1460 . i'I') 1 0/ ')O Lj Contractor's Name (�( �ZC� Telephone Number Home Improvement Contractor License#(if applicable) U • (1 r( . r Construction Supervisor's License#(if applicable) ��) �� —` 0 PlWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ' n I Re-roof(stripping old shingles) All construction debris will be taken to `��f �' (❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.44) *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 is required: SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\MY7NB4ILTXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information 6y Please Print Le ibl Name(Business/Organization/Individual)r �.n Gt /°��� �,,, / Address aL cJ�iU U� f 1-7 1 (.� k V City/State/Zip: _ MA Q2� Phone#: Ar you an employer?Check t appropriate box: Type of project(required): L. I am a employer with 4. I am a general contractor and I 6 ❑New construction C� employees(full and/or part-time).*. have hired the sub-contractors . , 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling , ship and have no employees These sub-contractors have g; Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp:insurance comp.insurance.t required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑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. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors 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.#: VV hAV 1' 73 ' Expiration Date: Job Site Address ) 1 1�{, . `-'�' City/State/Zip:(4 � ��1' V( ,'�- -t /t T oze Z, 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 S 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 Investijzations of the DIA fo urance coverage verification. I do hereb c under a pa ns and penalties of perjury that the information provitted above is true and correct Si atu Date. l Phone#• `l ���(.(✓ Official use only. Do not write in this area,to be completed by city or town ofliciaL 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#: s � � � � ° DATE(MM/DD/YY) ACORDrM CERTIFICATEUF LIEABILITY�INSUR4NE � 7/14/2009 ,..�M PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI INSURANCE AGENCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 908 MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OSTERVILLE, MA 02655 COMPANIES AFFORDING COVERAGE COMPANY A SAFETY INSURANCE INSURED COMPANY SCOTT PEACOCK BUILDING&REMODELING B AIG AMERICAN HOME ASSURANCE CO. PO BOX 171 COMPANY OSTERVILLE, MA 02655 C COMPANY D ,_ ..�, �w �,,. a 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 B Y 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. CO TYPE OF INSURANCE POLICY EFFECTIVE POLICY EXPIRATION LTR POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY CP00001152 07/05/09 07/05/10 PRODUCTS-COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS " BODILY INJURY "$ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKER'S COMPENSATION AND TORWCY LIMITS ER B STATU- OTH- EMPLOYERS'LIABILITY WC 007 45-4805 06/22/09 06/22/1 O EL EACH ACCIDENT $ 100,000 THE PROPRIETOR/ INCL ". EL DISEASE-POLICY LIMIT $ 500,000 PARTNERS/EXECUTIVE _ _ - OFFICERS ARE: HEXCL - EL DISEASE-EA EMPLOYEE $ - 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS CERTI 4s,: ' CANCELLATION 3""" I ,. r._�.. _ �_....w:. .._..__.., E_......... 5,... .,. '. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO-MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHOPOEP REPRESENTATIVfj JU LOILPi ......,.� �. E � , �f r s* m �,.,a�', "� .� ACt1RD25tiS it/95 ..'ram : s.. i?,. .. , ,. T. ,�,q, :,; ... ..; ACORD.C,O,RPORAf10N,..1988= I r • :'/<�B��i�'d�'�i5f�t�u�rj�ft'!t`it�Ff��`� ' - License: CONSTRUCTIONSUPERVISOR% - Number: CS 094500 Birthdate: 07/22/1962 Expires:07/22/2010 Tr. no: 94500 Restricted: 00 JAMES S PEACOCK PO: DX 171 OSTEVILLE, MA 02632. Commissioner 5 ,� �.T e lno�rurnaouueal�. a����oac�u�deG76 Board of Building Regulations and Standards License or registration valid for individ►►I use only Y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration 151853 Board of Building Regulations and Standards Ex iration One Ashburton Place Rm 1301 t, P 7/7/2010 Tr►E 271501 Boston,Ma.02108 Type Pfivate Corporation SCOTT PEACOCK BUILDING&REMODELING INC i JAMES PEACOCK 4 1046 MAIN STREET SUITE 7 *. OSTERVILLE, MA 02655 Administrator Not valid without signature 4 ``NSTAB Town of Barnstable MASSN tb}qL63g �' Regulatory Services 1� A Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 l MU ' Vel-,nht� as Owner of the subject property hereby authorize 2' ��/� to act on my behalf, in all matters relative to work authorized by this building permit application for: go . thato 0&q-ow lkx-p (Address of Job) Signature of Owner Date IM Print Name Q:Forms:buildingperm its/express Revised 123107