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Town of Barnstable *Permit#
Expires 6 mo, the from issue date
Regulatory.Services Fee
. L+xxsTestE.
1 `� Thomas F.Geiler,Director
,_ Z
0k ��/ rs�
Building Division �/
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number lJ U
Property.Address _ -5 b. `d C
❑Residential Value of Work 19600.0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address (A N,Q ,5 C H t�
Aj
Contractor's Name 3—A 5 Telephone Number �' .�
Home Improvement Contractor License#(if applicable)_ 0 S7 i > (P a —55_ e)O i
Construction Supervisor's License#(if applicable) �{, � ,S' { ', 1 i. D Y— f
❑Workman's Compensation Insurance r X-PRESS PERMIT
Check one:
❑ I am a s proprietor JUL312012
❑ I e Homeowner
have Worker's Compensation Insurance
Insurance Company Name TOWN OF BARNSTABLE
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Requ (check box) _
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to I�( (/ 1" C�'') ��-�
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the home provement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
Q:1WPFILES�FO uilding permit formslEXPRESS.dOC
Revised 053012
•
The Commoriw eakh of Masse chaseth
Diparftnent of Industrial Aca i dents
Office of Investigations.
600 Washington Street
Boston,MA 02111
WWMmass govlelia
Workers'Compensation Insurance Affidavit:BmMers/Contractars]Ek tricians/Ph tubers
Applicant Inform tion Phase Print 1, blY
Name Musmess,?4zga�ooli&Muau_
Address: 6 6(..C.77A D A _
city/statefzii ;' Fq pv /-1 q Phonej l 0 J C)
Are n'employer?Check the appropriate box: T of project r
c 4. I am a contractor and I y'l� p . ] (required):
1- I atn a employer with `;Z ,❑ 6. ❑New construction
employees(full an&orpart-time).* have hired the sub-conhctora
2.❑ I am a stale proprietor or partner- listed on the at#at1wd sheet. 7- ❑Remodeling
ship and have no employees. These sob-ctmtractors have 8- ❑Demolitica
wadcing for me in any capacity- employees and have wodcers' . 9- ❑Budding addition
[No woiloecs'comp.msmtance comp-insurance,reqim7
.5. ❑ We are.a corporation and its: 16.0 Electrical repairs or additions
d] officers.have:exercised their 1I. Plumbing airs c r additions
3_❑ I am a ltomeowsaer doing all vaoc3r. . ❑ g repairs
myself [No wcrioers'comp_ . . tight of exemption per MGL 12.❑Roof repairs
;nor �e t C.152, §1(4�and we have no
retlnired.] employes (AIo yPvrltess' 13.❑Other Or 0601 q(l` ar
cgip. nsurance required.i.. j -
•�J ny apphc fat checks box#1 mast also fill oat the section below shavring their wa keW compensation policy mfo
Homoeoarmers arho subunit this affidavit indicating they are doing all wok and then hire outside contractors most submit a new affidavit indicating such._
FContcactors that cbeck thisbox most attached aa<additional sheet showing the,name of the sub-camtsuacs and state whetbm drnat those entities bme
employees. If the sabtozmactors have employees,they must provide their wenitets'comp.policy mmiber.
lam an etnplayeir that fs pro,tdita workers,conrpertsalivrr,insurcrRce for my earpta)Wes. ;Below is the prrTicy arad job situ
information.
IrssvcanCe Company Name:
Policy#or Self-ins.:Ltc.#: Expiration Date:
Job Site Address".f j C j.a w if/ 1.4 r L C
citylState/zip: L9: ' v
Attach a impy of the worke&compensation policy de claration page(showing the policy number and ezpi mtion date).
Failure to secure coverage as required under Section 25A of MGL e; 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 audlor one=year imprison t;as well as civil penalties in the form of a STOP WORK ORDER and a fine
ofup to$250-00 a day aga os€the violator. Be advised that a copy of this statement may be fiarwarded to the Office of
Investigations.of the DIAL for mi sivance coverage verification,
I do hereby csrhfyp sttdae t its and pe naftias er.�pedury�that the ii formation proWArd above is true and correct
Sim Date:
Phone
tit„�irial use only. Do not wrfte in this area,to be coxrpiteted by racy or town affictad
City or Town PermitlLicense#
Issuing Authorityf drele one):
1.Board of Health 2.Buffifing Department 3.City/Town Cleric 4..Electrical Inspector 5.Plumbing Inspector
6.Other
contact Person: Phone#:
6
• snaxsresi E, •
9� ' ,�� Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building:Division. M1
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ina.us . .
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete' and Sign This Section
If Using A Builder
5C,0AW6A1ekj as.Owner of the subject property
hereby authorize TIA A-V s / to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date -
Print Name
If Property Owner is applying for permit;please complete the Homeowners License Exemption Form on the
reverse side.
QAWPFILES\FORMS\building.permit forms\EXPRESS.doc
Revised 051811
DIME Town of Barnstable
Regulatory Services
9K,+ssAs�� Thomas F. Geiler,Director
16t&`0 Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnsta ble.ma.us
Office: 508-862-4038 4. Fax: 508-790=6230
HOMEOWNER LICENSE EXEMPTION < ...
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homecwners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persor(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling, attached or detached structures accessory to such use and/or farm structures. A person wbo 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 urdersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaw.,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signaturz of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as"supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 051811
R� CERTIFICATE OF LIABILITY INSURANCE
7/31 12
THs CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER TICS
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.
IMP ANT; It the Certificate holder is an ADDITIONAL INSURED,the polley(jes) must be endorsed. If SUBRO ATION IS WAIVED,subject t0 the terms and conditions of the policy,certain policies may require an endorsement A statement on thus certificate does not confer ri his
certificateb the
holder in lieu of such endorsemen ®. rig
his
NAME;
United Insurance Agency, Inc. PFIONE
199 Main Street �eAr 508 759-6595 AX Mal, (508) 759-3622
P.O. Box 1013 MASS:
Buzzards Bay, MA 02532 INSURE!PIS►AFFoRnw- COVERAGE NAICC
INSURER A:Lloyds,,London
INSURED
INSURER e:AEIC
James Moore
Moore Carpentry INSURERC:
15 Goeletta Dr INSURERD:
E ralmouth, MA 02536 INFER E:
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 ANDCONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
—. AWL
LT TYPE OF INSURANCE213a OLI CY NUhmER MIDDnE MMIDO/YYYY UMITD
A GMERAL LIABILITY IIMA002088 6/14/12 6/1d/13 EACH OCCURRENCE $ 1 QOO 000
X COMMERCIAL GENERAL LIABILITY OAMAGET 6 RENTED
MISEs1F�cs�,rronC. $ _100,000
CIAIMS�AADE ❑X OCCUR NEDEXP one parson) $ 5 Q00
PERSONAL&ADV INJURY _$ 1,OOO'OOO
GENERAL AGGREGATE S 2 OOO OOO
GEN'L AG GREGATE L MII T APPLIES PER
PRODUCTS-CON
AGO $ OOQ,0OO
X POLICY PR ' LOC `
AUTOMOBILE LIABILITY
a_ocdOEerDt I IT $
ANY AUTO S -- + .BODILY INJURY(Per person) $ '
AUTOS SCHEDULED
BODILY INJURY(Per accltlent) $
NON•OMEb
HIREDAUTOS AUTOS-, FPROPDAMAGELa
UMBREL AUAD. OCCURURRENCEEXCESSUAD CLAIMS-MADE
E: $
DED RETEN ION$ .
B A DRE PL COMPENSATION NCC5010124012011 6/14/12 6/14/13 X wC STATU- OTH-
AND EMPLOYERS UASIUTY YIN N MI,T
ANY PROPRIETORIPARTNEWE XC-CUTIVE
OFFICERMIEMBER EXCLUDED7 N I A EACH ACGDEW 100,000
(Mandebry In NH) -
Ifyyeee daecrlDeuntler E,L.DISEASE•EA EMPLOYIsE S 1OO 000
DE9GLRIPTIO N OF OPE RATIONS below
E.L,DISEASE-POUCY LIMIT S son 000.
DESCRIPTIONOFOPERATIONSI LOCATIONS IVEHICLES (A4achACORDIDI;AAMoonel.Rerterke3ehadule,lT more space leregWrrd)
Remodeling contractor
t
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THIN ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVERED IN
Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS,
Building Dept
Barnstable,^ ma AU 0 EDR PReS NTh
Kris Dexter
(0 1938-2010 ACORD CORPORATION. All righter'reserved.
ACORD 25(2010/05) The+ACORD"name and logo are registered marks of ACORD . .
)hone. • '„ ,�,
Fax:. (508) 790-6230 E-Mall;
- I��ilS Sill llU ll"U,1- VCllal UIICII! UI rU111IC ItLl CIS
Board cif Buildin(.Regulations and Standards C✓ a.� >� � egulatioii[O
Office of Consumer Affairs&B sigess'Regulahon
Construction Supervisor License HOME IMPROVEMENT CONTRACTOR T _
One-and Two- Family Dwellings I Registration: =120592 Type:
License: CS 45959 , # Z Expirationl5/2014 DBA
urn / i E CARPEN
M k3Y r a
JAMES S MOORSRE
t�F2� V a
Ji�l WIFE
15 GOELETTA DR
E FALMOUTH, MA 02536 " JAMES MOORS
_ 15 GOELETTA DR `�, a}' A-V � s
EAST FALMOUTH MA 02536. Und secretary
Expiration: 11/24/2012.
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('unuuissiunii Tr#: 6209 r
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�ESIGNIIJG
. a p /� p
7�ssessor's map and lot number ... C(.. .........(/..,.. ...0..,,... 1E ENGINEER I%4UST FM E T
3TALLATION AND CERTIFY'
Sewage Permit number ....... ....� ..... ...................
—1 w ,,, c � HE SYSTEM WAS INSTAL '� O �. 31 off,
,COORCANCE TO PLAN. 2 339Ba9T/1BLE,
House number .......................... ....... ..!�...... NAB&
O 0 1639.a\0�
o o ST a8�° P I MU yNOS .
OF B A R N SI OMPLIANCE
WITH TITLE 5
� MENTAL CODE AND BUILDING I N S P E N REGULATIONS
IMPLICATION FOR PERMIT TO ......:.. u.!o.. .I,n... ...................6.... ........... ......................................................
.TYPE OF CONSTRUCTION .......... ?. .. .. ......... ....(......: .............`....`P .........................................Se �
fr..._� 19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...... . .....S 6 .``.. `..... .:...�....Sf'........0 .�. .P.�..r.t...t he .....................................................J S�r
Proposed Use �T� �c.............................................✓ 3 0 .' t' [_ ti `� '
..................... !!..... .. ............................................................I....................
Jq-4.........................
Zoning District .........................l..l..2.......1.............................Fire District ................... .
Name of Owner .`"` .t«��' .f�� � gyresAddress 55..6....Sm-��j .. ... e f(L
.......... ........................ ........ .........................
Nameof Builder 0 `A' `` C `� ........Address........... ............................................... ....................................................................................
Nameof Architect ..................................................................Address .....................................................................................
Numberof Rooms ..................................................................Foundation ..... ...........f+........................................
Exterior ...................1..rX77.'.1 MR49..............................Roofing ........ �i`.... ....................................................
n ...............................Interior ....................
Floors ...........................� rl�.��'�. ................................................................
Heating ..................................................................................Plumbing ..................................................................................
Fireplace pp // k.�0 0 - �
.................................................................................A roximate Cost ...'f:....... ..................................................
Definitive Plan Approved by Planning Board -------------------_------------
19________. Area ...O..b.T.. . ....................
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 . `..........`..�... ,... t..�e ..Y•••••`.......—�
\5 Construction Supervisor's License
`"SCHMEGNER, EDMUND
E�Rld- arage
No ................. Permit for ..g"_....... ..................
Accessory,., q ling
...................................0. A ...................
)v e ling
Location ....556 Sottl
MP�a Ytreet
--S
.............. ........ .
.......................
Ceff ' l e
-v-
.............................. ... ...........................
IV
E q-A SchmegnerOwner ........ ........Type of Construelion . .....Frame . �- l.,
..................................
.................. ........ ...........................................
Plot ... ....... ................ Lot ................................
86-
Permit Granted ......December 24 ,.......19
Date of Inspection ....................................19
Date Completed .................... ...........19
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/ —� SCALE . ..��.=.30�.... DATE
I, PLAN REFERENCE L qw D
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. . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . .
I CERTIFY THAT THE
- SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON;
DATE . .. . . .... . . . .. .
REGISTERED LAND SURVEYOR
Assessor's map ,and lot number ... .-. .., ~<
THE
Bpi tp�y
< •1 1yQ O
i Sewage Permit number ........................ ................
Z BAUSTADLE, i
House number ..!...... ` ' rues
Opo�1639. \00
'F0 YPY a
To,W,,,AOF ,BARNSTABLE
BUILDING INSPECTOR
APPLICATIONFOR PERMIT TO ....t ...................................... .....................................................................
l
TYPE OF CONSTRUCTION ............... ?.` ` .. .. .. ..'-.......:��...`�.'�.. ...:.......................................... ,
f. .............................. ......19........ `f
TO THE INSPECTOR OF BUILDINGS: -�-"
The undersigned hereby applies for a permit according to the following information:
Location ......✓. .....- !s?. .. j.....r ...... ..................... �./... . ...001 .,...rr.C.r......1Aj. . S.0 ...C�.1<.. ..z
ProposedUse .............Q... ............ ..r4..�s .......................................
Zoning District .........................[.. . .......�:............................Fire District .................1.r, .r i.1.. .L.........................
Name of Owner�� •�--. �`. s<l � ``�/Address S 6 a3...6 .'"7,a�.... ..................................�
-........................ ....
Name of Builder "� `` c Address................................................................
Nameof Architect ..................................................................Address ...............................................:....................................
., �� 7 r e.�
Number of Rooms ................:.........:.:.:....................................Foundation .........�.,.�...1..................................:.
Exterior ...................0144&- z.. P..............................Roofing ........... t� , .................................................
Floors -Q IC. r ......................Interior ..........................................................:.........................
Heating Plumbing,,,.:. ............................................... ..:::..............................
cs> to
Fireplace ................ .......,.:: ....: ......................... .. ... ............Approximate. Cotes; ,. ........... ..................................................
Definitive Plan Approved by Planning Board ___ __'---_-_ _______ __19_ ____ . Area AJ.. !. .............
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH /
r
k
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. -
Name ... :..� . ......` f� ...-.----� �_
.
Construction Supervisor's License ..........:....:....................
SCHMEGNER, EDMUND A=186-�048
— , Aldo
30327 Build Gara g
No ................. Permit for .............................g.....
Accessory,,.to,,,Dwelling,.........
Location ......556 South Main..5e. „
..... ................... . ..
Centerville
Owner ........Edmund Schmec-rner...............
................
Type of Construction ........k'.1:'s1Me.....................
................................................................................
Plot .......................... Lot ................................
Permit Granted ..,,December 24 , 19 86
Date of Inspection ....................................19
Date Completed ......................................19
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