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0055 SUMMERBELL AVENUE
r - �' .� I L.__------�-- THE 1p� (. — I `J�� Application Number.. ... �� Permit Fee.............. * BARNSTABLE, * � —. MASS. /1 �� � 3t r�1...........other Fee........................ 16 '�Fn nnp�a ✓.IV �4 �� ®J� Total Fee Paid............................................................... ...... TOWN OF BARNST E `_` "^•°��� BUILDING PE Permit Approval by...... .On.RMIT APPLICATIONMap........................................Parcel............................................. Section 1 — Owners Information and Project Location Project Address SS 5UAI44679f Village C,6&j C-4�I I, [, Owners Name Owners Legal Address S S 5L,~64ZC-St-L City t,G^-tT6e-+'1 L LE State nIVIV Zip c"3 Z Owners Cell# E-mail TC-010G*Le=6 ,1V6= " Section 2 —Structural Use Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet 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 ❑ Addition ❑ Retaining wall ❑ Solar N Renovation ❑ Pool ❑ Insulation Other—Specify Section 4—Detail Cost of Proposed Construction—5 0 066) Square Footage of Project L/00 Age of Structure Dig Safe Number I # Of Bedrooms Existing Total# Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Last updated: 11/7/2017 i Section 5 - Work Description - O�6M OrC- 1A)ML 1�E�GV(.E"� �C t 17hEEti �3 L-►y)A41 12CVM ZAJ*7 r1A'V .L SYa-yc,TAf- 57-C-.6L DE21AA o N Nr�w i Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: YA44()dVi WZAA, I am using a crane C Yes E3-No Section 7—Flood Zone Y' Flood Zone Designation Within or adjacent to a wetland coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. 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 El No Last updated: 11/7/2017 r age. ..: ... ........ � ... .;. Id 16, ... r7 f ni � . Boise Cascade Triple 1-3/4"x 11.-7/8"VERSA-LAMO 2.0 3100 SP Floor.BeamTB01 mom Dry 1.1 span I No cantilevers f 011.2 slope. October 26,201''10:20:43 BC CALL®Design.Report. - A�.q Build 61080 File:Name:: BC CALC Project Job Name: Axo%ov c-1 Description: Designs\FB01 Address l( eve . Specifier: Tim 55 Svrnrh�� • City,State Zip;, �t,��}e.�vti ale, A: Designer: Customer. D.tsv M✓!I dal Company: Shepley Wood Products Code reports: EIR-1040 Misc: tt.'075. D.5 044: 105x/8 /•°� it�f SU.S, * J A'i 414 }2S«9'w:'oL 14 04.00 9'1". Xev WbA`l.A M ?0.rr TtiNnznYalP t nt -o a o o Product Le h 94-04-00 9. Reaction Summary(Down/Uplift) (lbs) Bearing Give: Dead Snow _ Wind. Roof Live 130,3-1/2" 5;3Z5`/0 2,351 10 B1, 3=1/2" 5,37510 2,35110 Live Dead Snow. Wind Roof live Trib:: Load Summary Tag Description. Load Type Ref: ,Start End 1006% 90"/0; 115%. 160% 125% 1 Standard Load Unf;Area.(lb/ft^2) L 00-00-00 14-04-00 40 10 12=06-00 2 Unf: Lin. (ib/ft). L 00-00-00 1:4-04-00 60 n/a 3 Unf. Area (ib/ft^2) L 00-00-00 14-04-00! 20 -1 0: 12-06-00 Controls Summary Value %aAllowable Duration Case: Location Pos. Moment: 25;943 ft=lbs 81:,3%a. 160% 1 0.7-02700 End Shear 6,345 lbs 51 % 100% 1 01-03-06: Total Load Defi. U271 (0.614") 88.4% n/a 1 .07-02-QO Live Load Defl. L/390(0:427") 913% n/a 2 0.7-02-00 Max.Defl.. 0.614" 61.4% n/a 1 07-02-00 Span:.!Depth 14. nia nla 0. 00-00-00 Squash Blocks Valid %A Iow %Allow Bearing Supports. Dim.tL:x m. Value Support. Member Material: BO Post. 3-1/2"x 3-1/2" 7,726 Ibs n/a 84,10% Unspecified 131; Post. 3=1/2"x:3-1/2" 7;726 Lbs n/a 84:1% Unspecified Cautions Member is not fully supported at post 80. A.connector is required at this bearing.. Member is not fully supported at post B1.. A:connector is required at this bearing. r Design meets Code.minimum (U240)Total:load deflection criteria. Design meets Code minimum(U360).Live load deflection criteria: I Design-meets arbitrary(1 )Maximum Total load deflection criteria.: I :s 'I i +L Calculations assue member is fully braced,. o t 3533 m j Design based on Dry Servrce Condition. ,r ,51 Fastener Manufacturer:TrussLok.(tm) '� &L Page 1.of 2 i Swanson Structural. Inc. Paul W.Swanson;P.E. ,Ungineering Services 9,2 Acre Hill.Road' commercial Barnstable,,-.MA 02636-1529 residential Phone: 508=446,4042: heavy:timber PahQSh ansonStructural.coat l AJ Yll' rNG !�/: 4 :.. bf f .. : T d - .......... € J .., _ s r . Z t r Y. .. ".- E a 7 F ' 1 t1•i� { �o 14 - _ .,. - a 4 C 1 ,�TRGCT� . : 1 ' i .A r41 ...... • Crs�l-Y40�IaPS tTit, � irV d . K 117 i 4 F i. .:,...,.. :! .. .. S 1 E it t } a: 5 Job:Name.��r ® � C Job Number Location VLj . Sheet of. Client.. PV M V 4!." By . (� Date :. : Nx 2A. It .... : . ..:... CP F1 �9 -.._.t. ... ..i. _t-_- ...... _. .-::..... _. .: ... ....._.._ _ ._ -......_. ._ ... ._ ... Swanson Structural, Inc. Paul,W.Swanson,P.E. Engineering Services 92 Acre Hill;-Road commerdat Barnstable,MA 02630-1529 i residential Phone 508=446-I04Z heavy dneber Pau wansnrtSErrrctura4rom ve: - tpgl ate: �:�� �,f .: gp# - ". ..........; , f _._..__: ��PMr i __ . 3 , IV _... b > � ICJ F i t ....... ........ t p ........... ..... ....... .......... < > : S M t a < .......................... i. t i i .. SUOMI t F i ¢yl v r 40 F • S M : _ ..... .. f 3 a i ......:.�.._......i+. : ..:..., ._._ ..... .., .. ... .. .,. .... i :..,... a ........._.. ... ..-. ...._....... T...... .... _... .._ I,.. , .�._.., .r... Job Name 415M 00a L Job Number Location 5 5 SVMA449.jZ GCL ,,t A V C f'p ri 4 Vj 4t Sheet of Client. DOM V t.L BY E pate Zjapi7 MeoiseCamde Triple 1-314" x 11-7/8" VERSA-LAW 2.0 3100 SP Floor.13eamT1301. r Dry I 1 span No cantilevers 10/1.2 slope October 26,201710.20A3 BC CALL®Design Report � � Build 6080 �! File Name: BC CALC Project Job Name: 14~44#1 Description: DesignsiFBO1 Address: 55 fVvwne._ Alt Aw"_ Specifier: jim City,State,Zip:, e�,�4 psi Ell, Designer. "wX e 0). Customer Company: Shepley Wood Products Code reports: .ESR-1040 Misc: Jltlo t'J .M�j ) IA.: 4745 k >:6..Y', r'� oaf, s � � � '" L v � '°• •� m 'P. o_.Y � � �2� ®� .=�' � Q �' `Y F/ Ne—''®..,s s .d �, s ® W.. ®_� 3 s 'Or 4 f 1 f 14-04-00 t3oI,4x4 WbALAM rosy 4xd B1 Total Horizontal Product Length=14-04-00 � poor Reaction Summary(Down!Uplift) (ibs) Bearing Give Dead Snow Wind Roof Line B0,3-1/2" 5,375/0 2,351 /0 B1,3-11.2" 5,375/0 2,35110 Live Dead Snow Wine} Roof Live Trib. Load:Summary Tag.Description Load Type Ref. Start End 100% 9011/6 115% 160% 125% 1 Standard Load Unf:Area(lb/ft"2) L 00-00-00 14-04-00 40 10 12-06-00 2 Unf. Lin.(ib/ft) L 00-00-00 1.4-04-00 60 n/a 3 Unf.Area (1b/ft^2) L 00-00-00 14-04=00 20 10 12-06-00 Controls Summary. value %Allowable Duration case Location Piss. Moment 25,943 ft-lbs 81.3% 100% 1 07-02-00 End Shear 8,345 lbs 53.6% 100% 1 01-03-06 Total Load Defl'. U271 (0.614") 88.4% n/a 1 07-02-00 Live Load Defl. U390(0,427") 92.3% n/a 2 07-02=00 Max Defl. 0.614" 61.4% n/a 1 07-02-00 Span:./Depth 14 n/a n/a 0 00-00-00 Squash Blocks Valid %Allow %Allow Bearing Supports Dim.{L x M Value Support Member Material BO Post 3Al2 x 3-112" 7,726.Ibs n/a 84.1% Unspecified 81: Post. 3-112"x 3-1/2" 7,726 lbs nta 84.1% Unspecified Cautions Member is not fully supported at post B0: A connector is required at this bearing. Member is not fully supported at post B1. A connector is required at this bearing. Notes4 Design meets Code.minimum (U240)Total load deflection criteria.. , Design meets Code minimum(L/360)Live load deflection criteria. Design-meets arbitrary(1")Maximum Total load deflection criteria. Calculations assume member is#ullybraced,Design based on Dry Service Condi#ion, Fastener Manufacturer:TrussLok(tm) YV , Page 1 of 2 _- ...... Id EJ nt : ,Slyanson ,Struct'urd Inc. Paul W.:Swanson,P.E. Engineering Services 92 Acre Hill Road commercial Barnstable,.MA 02630-1.529 residential Phone. 508-,445-1042 heavy Amber PaulMvansonSiructuraLcom : s ........... i i I . , I .. - - i ; f ; i .......... _...... .._.._.... ... z r �. ... ...... .. .,., ., 1........,. i s e ._ r ` 31 � f u i >.._................... _., t .. M. # I s f.... ...._...:� .. .. ..... .... ._ n } ._. _._. _... _...._ ,... _. _ ......_.u.......... E 3 � i ......... ...........i._._.. ._.. ...._'_.... f i , 3 e j......... :... _ ,a :... i i }YYyr y¢ ' ..,:.. ,y.. '¢:�sTb � I 7 ...- i_..,.... •.___.. .. r, i. -..._. f tom•tt; y�l ._.. _ .... .... .. .:•M. } ... , a .... t '� .... i L. $ r.., IV ROJA F f 1 { :.___... i :. ..............e.........e. Z'. 8 .. ..:... 5 ..... _.. ... _ _ i . .....,. ..........J .. t i t t : ..w............ ..,........-_............. Job Namel:o +a' . f Job Number Location 5VMA4 1Z14C1,1' Sheet of Client. AQU s U I.OV By Date ZIOJ 7 Solseeawade Triple 1-314" x 11-7/81' VERSA-LAM@ 2.0 3100 SP Floor.Beam1FBOI V Dry j 1 span j No cantilevers 10/1.2 slope October 26,201710:20:43 BC CALL®Design Report ��� ® e _ Build 6080 Fite Name: BC CALC Project f Job Name: PA~Apt Description:DesignslFB01 Address. y 5 SVIM406e l( ;4.-- Specifier: jim City,State,Zip:, C�k. �sy(leA Designer.-NI X ` Customer. Company: Shepley Wood Products Code reports: .ER 1040 Mist: ts , �K MA.: 41.5'' >2'5�,-I siL <> w v v a a v 'T Sf e tl O Q S A � 1► 'H. 'O ® II 'S' A .N` .O 1�'� � II 4T '9i 'f' �.' 9 9 W � P' �ti' WO H [' 14-04-00 61 Total.Horizontal Product Length=14-04-00 "'°' Aj Reaction Summary(Down t Uplift) (lbs) Bearing Live Dead Snow Wind Roof Live B0,3-1/2" 5,375/0 2,551 /0 B1,3-1/2" 5,375/0 2,351 /0 Live Dead Snow Wind Roof.Live Trib.. Load:Summary Tag.Description Load Type Ref. Start End 100% so'k 115% 160% 125% 1 Standard Load Unf:Area(Ib/ft"2) L 00-00-00 14-04-00 40 10 12-06-00 2 Unf. Lin,(lb/ft) L 00-00-00 14-04-00 60 n/a 3 Unf.Area(lb/ft^2) L 00-00-00 14-04-00 20 10 12-0"0 Controls Summary, value %Allowable Duration Case Location Pos. Moment 25,943 ft-ibs 81.3% 100% 1 07-02-00 End Shear 6,345 Ibs 53.6% 100% 1 01-03-06 Total Load Defl'. U271 (0.614") 88.4% n/a 1 07-02-00 Live Load Defl. U390(0,427`) 92.3% n/a 2 07-02=00 Max Deft. 0.614" 61.4% n/a 1 07-02-00 Span./Depth 14 n/a n1a 0 00-00-00 Squash Blocks Valid %Allow %Allow Bearing Supports .Dim (L x Al Value Support Member Material BO Post 3.112"x 3-1/2" 7,726lbs n/a 84.1% Unspecified 81 Post. 3-112"x 3-1/2" 7,726 Ibs nfa 84,1% Unspecified Cautions Member-is not fully supported at post B0. A connector its required at this bearing. Member is not fully supported at post B1. A.connector is required at this bearing. Notes Og 4 Design meets Code minimum (U240)Total load deflection criteria.. f cif y, 4x a z gi ?.�7 "tat Design meets Code minimum(U360)Live load deflection criteria. r:,ev , Design meets arbitrary(1").Maximum Total load deflection criteria. i Calculations assume.member is fully braced,. Design based on Dry Service Condition. �8 Fastener ManufacturenTrussi-ok(tm) Page 1 of 2 �e tpaavimoozwea�o�CaclictaeC� �f r - Office of Consumer Affairs&Business Regulation lugHOME IMPROVEMENT CONTRACTOR � . TYPE:LLC F Registration Expiration 1 05/02/2019 MULLEN BUILDW6ELGNG,LLC. DOUGLAS MULLEN'.. -E1� '- r V .2 a 87 HICKORY HILL OSTERVILLE,MA 02655 Undersecretary, Massachusetts Department of Public Safety ® Board of Building Regulations and Standards License: CS-081995 Construction Supervisor DOUGLAS W MULLEN 87 HICKORY HILL CIRCLEfi pSTERVIL LE MA 02655i , 11 Expiration: /Commissioner 01/23/2018` The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress Street,Suite 100 Bost©n,AU0211.4 2#1 7 www.mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERNUT TING AUTHORITY. Annlicant Information Please Print LemMy Business/Organization Name: M VGL6n1 BU 1 vU Mel jL&4110P Address: p D -&&r City/State/Zip: M1 U-1 - 0hk Phone#: �O� 137-37-`161 Are you 'employer?Check the appropriate boz: Business Type(required): 1. I am a employer with -employees(full and/ 5. ❑Retail or part-time).* 6.' RestaurantBar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. 0 Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers'comp.insurance required] 8• ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152,§1(4),and we have 10.©Manufacturing no employees.[No workers'comp.insurance required]* ql.❑Health Care 4.❑ We area non profit organization,staffed by volunteers, . with no employees.[No workers'comp.assurance zeq:] 12D-Father A-M 0 'Arty applicant that checks box#1 must also fill outthe section.below showing their.workers'.compensation policy information.. *If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I: I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy information. Insurance Company Name: �) L Insurer's Address:_ City/State/Zip: N`7 MIU,5 . 'V44 � Policy#or Self-ins.Lic.# tA) e)- ;;t_j 1-7 Expiration Date:- / d i Attach a copy of the workers'compensation policy declaratton page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL 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 andpenalties ofperjury that the information provided above is ue and correct. Si ature: Date: n Phone#: 7 7y— Y -,"S . Official use only. Do not write in this area,to be completed by.city or town officiat City or Town: Permit/License Issuing Authority(circle one): . 1.Board of Health 2.Building Department.3.City/U"wn Clerk 4.Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.Ums.gov/dia 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.bu ldings in the.commonwealth for any applicant who has not produced acceptable eWdence 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 cbmplianbe 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 your insurance company's name,address and phone number along with a certificate 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.permitt.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). A copy of the:affidavit that has been officially stamped or marked by the city&town may be provided to the applicant as proof that'a valid affidavit is on file for future permits or licenses..A new affidavit must be filled out each year.Where a home owner or citizen:is obtaining.a license or permit not-related to any business or commercial venture(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel.#617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised 02-23-15 ACORU® DATE(MMIDDNYYY) A. � CERTIFICATE OF LIABILITY INSURANCE 5/15/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Ashley Paiva Southeastern Insurance Agency, Inc. PHONE (508)997-6061 acNo):FAX, (508)990-2731 439 State Rd. ADDRESS apaiva@southeasternins.com P.O. Box 79398 INSURERS AFFORDING COVERAGE NAIC 4 North Dartmouth MA 02747 INSURER A Arbella Protection Insurance 41360 INSURED INSURER B AEIC Mullen Building & Remodeling LLC INSURERC: PO BOX 1274 INSURERD: INSURER E: Marstons Mills MA 02648 INSURER F: COVERAGES CERTIFICATE NUMBER:2016 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE AD L UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD M/D LIMITS X COMMERCIAL GENERAL LIABILITY 1,000,000 EACH OCCURRENCE $ _ A CLAIMS-MADE ❑R OCCUR DAMAGE TO RENTED $ 100,000 PREMISES Ea occurrence 9520043214 - 9/8/2016 9/8/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 x POLICY❑PET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY Ea "INED d.n SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED AUTOS B AUTOS 1020024224 11/12/2016 11/12/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ Uninsured motorist Ell split limit $ 250,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED?B ❑ N/A (Mandatory in NH) WCC50050133082017A 4/30/2017 4/30/2018 E.L"DISEASE-EA EMPLOYE $ 1,000,000 H yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) l , CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Purposes Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - -� Ashley Paiva/AMP ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014�11) The ACORD name and logo are registered marks of ACORD INS025=121nl t f •-'� X�- �Y -�" ] +x.`r�x��� � � �r ¢- � a�$ �}� r q ss:� x. § s � �" � _ 3 a, '` � 'r '�rs +a � �� ,��7 a t1, x•v��f�� � a � �,;v a� Z� z- 3 �e:a �>r �.� .�` 5Y a � �'v } �3� � ,<-� s ' •'� �-�v s �#"c M.4 GCE � c :~ � Y ! fta aet 4�}121. fi�eha�f � u s h k � pp4 j f Y 9 f i a z r e fi'! Section 9— Construction Supervisor ,' `► Name L�Uh l&5 M y L t&� Telephone Number - 7 7q- b 77 5 Address`7 lit"V tflU- G'f, City_a5 vU,Lrz,- State /vVA- Zip 0-2--427 License Number(5- License Type Expiration Date Contractors Email J-bIA(A M yLC&,l$w U7 W A . t avh Cell # -77!f-�S 7-6 7?S 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 111 I7 k i Section 10—Home Improvement Contractor Name kyA(*ec> M y(,l N Telephone Number 7 -("tff?-L'175 Address j?7 P t4IW Y U, City State /14e"V Zip_ Registration Number 17 53 1-1 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.I.C... Signature Date J T A� /17 Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number 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. Signature Date APPLICANT SIGNATURE Signature Date �1� �/7 Print Name_?Oy�7 /Yf'&�ti Telephone Number E-mail permit to: �LIAO ,dVL t6;Aj 9v1!jt?u✓'h tcjA+n Last updated: 1]/7/2017 i n 12—Department Si Sect n-Offs o p g Health Department ❑ Zoning Board (if required) ❑ J I 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, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date ' Print Name Last updated: 11/7/2017 Town of Barnstable Building" I� �unH. �na�t•] Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept %1639 ,m��/ Posted Until Final Inspection Has Been Made. ��� �. Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final-inspection has been made. Permit No. B-17-3882 Applicant Name: . MULLEN BUILDING & REMODELING, LLC. Approvals Date Issued: 11/27/2017 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 05/27/2018 Foundation: Location: 55 SUMMERBELL AVENUE, CENTERVILLE . Map/Lot: 226-063. Zoning District: CBDCV Sheathing: " Owner on Record: SHEEHY,THOMAS& MARTHA S Contractor Name: DOUGLAS W MULLEN Framing: 1 Address: 185 STANFORD DRIVE Contractor License: CS-081995 2 WESTWOOD, MA 02090 Est. Project Cost: $50,000.00 Chimney: Description: Remove Wall Between Kitchen & Living Room. Install Structural Permit Fee: $ 305.00 Steel`Beam on New Kitchen Cabinets. Insulation: Fee Paid: $305.00 Project Review Req: Final: �Date: 11/27/2017 ZG�? _ Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the:work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and.codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public in for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:. Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed -4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 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). Building plans are to be available on site Fire Department All Permit-Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: 14 2016 09,24AM Tupper Construction Co. 15087785010 page 1 TU PPE R� CONSTRUCTION CO. u."c 546A Higgins Crowell Rd,WEST YARMOUTH,MA 02673 .PHONE: 5U-778-0111 FAX: 508-778-010 WWW.TUPPERCO.COM Date: Town of Barnstable Thomas Perry CBO 200 Main Street Hyannis, Ma 02601 (508) 790-6230 fax Re: Insulation Permits Dear Mr. Perry This affidavit is to certify that all work completed for permit application Issued on { has been .inspected by a certified Building Performance Institute (BPI) inspector. All work performed meets or exceeds Federal and State requirements.: . Sincerely, S'c�mr�erbel( Ov(? /e- v ie„ Richard Tupper License # CS-69058 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ��Y Parcel � � TOt4il �� ���'` ST1�B�.E Application # �r� —1 40'q Health Division I �, ' ? ?..i ! 5 Date Issued //6//6 Conservation Division Application Fee Planning Dept. _ ,y Permit Fee o Date Definitive Plan Approved by Planning Board ' Historic - OKH _ Preservation/ Hyannis S EN-" Project Stree ddress Jr r �`�Village e C�ls/ At, Owner S v Address Telephone Permit Request - ; ch c 47'_Fs ha Zt s --� CA L eA6e_ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation::?O //Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. Dwelling Type: Single Family ©''' Two Family ❑ Multi-Family (# units) Age of Existing Structure 71qp Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Q Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) r Number of Baths: Full: existing new Half: existing new Number of Bedrooms: 4 existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: YGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ErNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ^ J /c w . / Telephone Number Addres 4 � L' ense # CY 03 1APYI Na 7� Home Improvement Contractor# / 7 T C 9 7 Email iYl Q o.CL,�n Worker's Compensation v ^ / ALL CO STRUCTION DEBRIS RESULTING FRO THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. r t ,C ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE rt ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT 'ASSOCIATION PLAN NO. r es W i S ibi;Dr4Wwr Office: 5 2-443 .. Fwa wne mat lb. ..ice. iii.allmacoers:�elav+e ca.diVaztI ;.pmtCplCat[va: c S w MAa G g( .. . f Fv[ ZA�Cr ItAA 02t.3�. vvLL D . The Commonweakh of*ssackusdts 07 Department of ladushiel Accidents Office of Investigations 1 Congress Street,Smite]00 Boston,X402114-2017 www Mass you/die Workers'Compensation:Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busittessf0rganization&dividtW): TUPPER CONSTRUCTION Address-546A HIGGINS CROWELL RI3 - City/State/Zip-WEST YARMOUTH MA 02673 Phone-#:508-778-0111 Are you an employer?Check the appropriate box. Type of project(required): 1.© I am a employer with 1 o 4• ❑ I am a general contractor and! to * have hired the sub-contractors. 0• Q Ne►v construction emp loyees Ices{full and/or part-tithe). 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1. []Remodeling shipand have no employees These sub-contractors have 3. 0 Demolition working for me in any capacity. employees and have'workers' 9. Q Building addition [No workers' comp.insurance comp.insurance required.] 5: We are a corporation and.its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their. I I:Q.Plumbing repairs or additions myself. [No workers' comp. tight of exemption per MGL 12.0 Roof.repairs insurance required.] t c. 152,§i(4),and Nye have no employees.(1vo workers' 13.011 OtherWEATHERIZATION comp.insurance required.] *Any applicant that checks box t1I must also fill OW the section below sbo%Mng their wogs compensation policy infotmation. t Homeownets who submit this raft'idavit indicatin4 t they are doing all u+ork mtdtben him outside Mors trust tiiihmit a new a iiid:rvit indicating such: Contractors that deck this box must attached an additional sheet.sho ving,the name of tine stab-eontra ctm and state whethar or not those entities have employees. if the sub-coattactors loavo wnjpioyees;il'ey nu Lsl proYadc their workers cow poliq number: I am an employer that is providing workers'eoanpensatiian insurance for rtt y employees Below is the policy and job site information. Insurance Company Name:AEIC Policy#or Self-ins.Lic.#:WCC500&%3012015A £ ration Date 10/3116 55 Summerbell Ave cisy�ste/Zip; Jab Site Address: Centerville MA 02636 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,ffi v ell as civil penalties in the£orrn 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 f e coverage vedflcat on. I do hereby certi,fy r t pains art penahks of pe#ury that the,iarformadon provided above is true and correct: Signature: Date: 5/16/18 Phone#: Ofikial use only. Do not write in this area;to be completed by city or town o icial. City or Town: 1PertnitlLicensc# Issuing Authority.(circle.one): I.Board of Health 2.Building Department 3.City/Town Cleric 4.Elenctrial Inspector.5.Plumbing Inspector 6.Other Contact Persona Phone#: r AC RO® DATEIMMIDD{YYY1r) `� CERTIFICATE OF LIABILITY INSURANCE 12/1/2015 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 13 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 t0 the certificate holder in lieu of such endorsement{s). PRODUCER CNAWMcyLora Fitzaerald Southeastern Insurance Agency, Inc. . (50E)997-6061 FAX (509199D-2731 E4•na (i��!?L 439 State Rd. ADI �IfLtz@southeasternins:com -I P.O. Box 79398 -- ��W S)AFFORDINGCOVERAGE i NAIC0 North Dartmouth 'MA 02747 BISUFMRA Arbella Protection Insurance 141360 INSURED e1SU.REReSoston Insurance Brokerage Inc Tupper Construction Co LLC CNSURERC' ' 546A Higgins Crowell Road UISURER D: INSURER E- 1 West Yarmouth HA 02673 1 INSURER,: COVERAGES CERTIFICATE NUMBE"015-2016-1 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 7HE POLICIES DESCRIBED HERSN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. TLTR N-SR TYPE OF INSURANCE A POLICY NUMBER IMAM1 IWAAW LIMITS :.% COMMERCIAL GENERAL LIABILITY _ ff J EACH OCCURRENCE 19 1,000,000 OANIAGE TO RENTED A F CLAIMS-MADE 7 OCCUR i i 100,000 {PREMISES{Eaotxurreneel S t 9520045208 12/1/2015 111/1/2016 f MW EXP(Arty pug Peryror) s S 5,000 PERSONAL 8 ADV INJURY S 1,000,000 GENL AGGREGATE LIMIT APPLIES PER i! GENERAL AGGREGATE I S 2,000,000 g POLICY E JEC F-1 LOC i _ PRODUCTS-COMPIOPAGG i S 21000,000 Y OTHER: i1 5 AUTOMOBILE LIABKJTY 1102000930 .. _ e NGL UM I g mi 1,000,000 A I ANY AUTO 4 eODILY INJURY(Per Pmebn) IS ALL OWNED SCHEDULED AUTOS 8 AUTOS 12/1/2015 i2/1/2016 BO{DILYUtJURY(Per acIjdelm1 S NON-OWNED � � � PROPERTY DAMAGE -- 8 HIRED AUTOS S!AUTOS I j ` .FC !S i ! I { l Unnswad MoMst BI s0ft Ibi%I S 250,000 UMBRELLA LIAR _OCCUR I EACH OCCURRENCE Is EXCESS LIAR CLAIMSJNAD A . E I AGGREGATE S DED RETENTIONS t 4600050368 III/l/2015 11/1/2016 fb jg WORKERS COMPENSATION 1 STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE �Y-I^N- - !E.L.EACH ACCIDENT $ 1,000 000 iOFFICE"EMBEREXCLUDED? t `NIA $ (Mandatory In NH) ( W=50055 8 30120 15A 10/3/2015 10/312016 E.L.DISEASE-EA EMPLOYE S la 000 000 It yes,describe under I1 - _ t.__.a,19— DESCRIPTION OF OPERATIONS bebw 4 E.L.DISEASE-POLICY LIMIT g 1 D00 00 } OESCMPTON OF OPERATIONS I LOCA7=S I VENICLE4(ACORD tOl,AAdMonal RsmtaksScb ,m ybe anscded'arm m"ago w aPa is�u1nd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE. For informational purposes only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tupper Construction Co,.,LLC AC'CORDANCEIMITH THE Pt$JCY PROVISIONS. 546A Higgins Crowell Road - W Yarmouth, M 02673 AUINMED REPRESENTATIVE Lcra FitzGerald/MEK. ®1988-2014ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered mark$of ACORD INSD2G(�01a0A 1y V l (7—�/1.e �C11It?J2Q12U1C'«'1.�f2 (1�����Gf�',i�C�'C1�C�;�GfJ Office of Consumer Affairs and Business Regulation } 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Regisstrtration: 178434 Type: LLC Expiration: viwo1fl; Tr# 410291 TUPPER CONSTRUCTION CO, LLC, RICHARD TUPPER 546 A HIGGINS CROWALL RD W. YARMOUTH. MA 02673 Update Address and return card.Mark reason for change. sca, G xoraosri� Address Renewal (� Employment L" Lost Card Offiee of Consumer Aftsirs&Buses Reealsdon License or registration valid for Individual use only T HOME IMPROVEMENT CONTRACTOR. before the expiration date. If found return to: I Registration. 17,8434 Type. Office ofConsumer Affairs and Business Regulation Expiration: 4119MOIB LLC top -SOfte$170 1 TUPPER CONSTRUCTION CO,LLC: RICHARD TUPPER 546 A HIGGINS CROWELL RO ,., t• W.YARMOUTH,MA 02673 Undersrerenrr Not without signature BUILDING PERFORMANCE!NSTITUTE, INC 107 Hamm Road,Suite 210 Madle,W 12020 ( 77)274-1274 , www.toi.org ; Richard TUppe r }Y BPI IDP 6040M MEE R VM SIM FUR DF UTIONS AND EXPIRATION DATES) Massacfiuset a--Wp'artrneni of Public safety` Unrestricted-Buildings of 'any use Smp which 9'Board of Building Regulations and Standards; contain less than 35,000 cubic fee;(991m)of Curls[UCfi0n Supun i 1+r enclosed space. License:CS41118o88 , ' -�`i..-•i C pin. l•� P` Riciard S Tsar`` '- SU A Ads Crcfwell _ WestYarnouth ffiA Failure to possess a current edition of the MassaORLS tis State Building Code is cause for revoMlon of this license. Commmissroriei 12131*016 For 0PStwrWnglnformaponvisit: www.Mass.GOPOWS f Town of Barnstable *Permit# Expires 6 months from issue date )(.�� �a Regulatory Services - FeeA3 S ESS ��q�1�m Thomas F.Geiler,Director � T Building Division MAR 12 2013 Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 rQw� QFF www.town.barnstable.ma.us Office: 50$- �'iTggLEE Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY_ / Not Valid without Red X-Press Imprint Map/parcel Number �(� Property Address g Residential Value of Work Sboo.Of6 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 11 Contractor's Name W'OwtcA� �C'Fz Telephone Number Home Improvement Contractor License#(if applicable) 6 pz?:70 2 Construction Supervisor's License#(if applicable)_/,.,� y�� ❑Workman's Compensation Insurance Check one: [� I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction.debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Fj Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: o erty caner mus ign Property Owner Letter of Permission. op th o rovement Contractors License is required. SIGNATURE: Z:Forms:expmtrg tevise061306 ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston,MA 02111' www.mass.gov/dia ' Workers}Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organimtion&dividual). t {�O"Af 7 City/State/Zip. 6."2Ul��rAA Phone.#: L Are you an employer?Check the appropriate bog: :Type of project(required):, 1.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New construction . 'employees(full and/or part-time).*• have hired the sub contractors 2. I am a'sole proprietor or partner- �on the'attached sheet 7. ❑Remodeling shipand have no employees . `These sub-contractors have g• Demolition to ee and have workers' working for me in any capacity. Y 9..Q Butidmg addition [NO WOIkers' comp.insurance comp.insitranCe•$ required J 5. We are a corporation and its 10.❑Electrical repairs or additions '3.❑ I am a homeowner doing ill-work . officers have exercised their 11.❑Plumbing repairs or additions ' myselL[No workers'comp. right bf exemption per MGL 12.[]Roof repairs d t c. 152, §1(4),and we have no insurance.required.]j employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant @rat 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 tlien 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 subcontractors and state whether ornot those entities have employees, if the sub-contractors have employees,ffieymust providt their workers'comp.policy number. compensation insurance for my employees. Below is the policy and job site I am an employer that is providing workers' 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). Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a find of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the.Office of _ Investiaations of the bIA for insurance coverage verification I do hereby certi n r t aim nd p a1Nes of perjury that the information provided ab ve is rue and correct _ Si afore: Date• �a _ Phone Official use only. Do not write in this area, tb be completed by city or town:afficiaL ; City or Town: ' permit/License# Issuing Authority(circle one):' ' A.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 � r sn�MAE&i.E Thomas F.Geiler,Director` Mass. ' iOrE059. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstab l e.ina.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Et as Owner of the subject property hereby authorize owt to act onrmybehalf, in all matters relative to work.authorized by this building permit application for. CFJ5--( AV LU 0,3t G;�2 (Address of Job) Signature of Owner ate Print Name - If Property-Owner is applying for permit please,complete the Homeowners License Exemption Form on the reverse side. QTORMSiOWNERPERMISSION u zT. Town of Barnstable IKE Tp�� Regulatory Services saRtvsxAstt, ; Thomas F.Geiler,Director y MASS. g 1639• Building Division ArED s Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 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 homeowners to engage an individual for hire who does not possess a license,provided that-the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on-a form acceptable to-the Building Official,that he/she shall be responsible for all such work tierforined under the building pern it. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and_ equireme_nts and that he/she will comply with said procedures and requirements. ' Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrms:homeexempt License orreg►stratton valid for findmdul use only;' 'fore the ez gyration date. ff foundi return•to j, UlWee of Consumer Affairs and-Busmess.I e'g yob IWI'ark Plaza=Suite 5:170 x z-- l�or`vaii`d�thout-signature — -, =�`_= - os./�aaaac�u�aetta Office of Consumer Affairs&B._mess Regulation OME_IMP_BO��ENT_�QNTRACTQR% -- Registration �4 3702 TYPe Expiration; :3/2812013: DBA Tho as C White G�C3"ERTFE LC 415A Main St. � — Ile MXG:633 ` }�.= n erse_ere ry h Y T F CIL BoarUtthu.�etts scot) Buil�in.,c pa�7n).(nt license. CS ruction S(Jpe v' !)n.ti lndh/ic ets. 66582 SOr Cicens e t`��yrt/.4 Ty�MA S CENT Vitt iltE Co, over ExAiratio T 536� 13 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1Z:) Parcel ��. Permit# I !• - Health Division Z� � ,Date Issued >zoo Conservation Division S. 9 ,2 DD Fee Tax Collector e 9/,D 0 J D V Treasurer ��I o� SEPTIC SYSTEM MUST BE Planning Dept. f INSTALLED IN COMPLIANCE V=°f=6 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address 55 Su mme r Aw- Village Owner S Shee w Address Telephone Co 11 --48c 105 Ls ` .Permit Request�{�`�e hPq rPvrrxl�1 en 10 mQ i dfh Q rem y;-m Square feet: 1 st floor:existing proposed 2nd floor: existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type ko ' 4\Lot Size elm- Grandfathered: ❑Yes ❑,No If yes,attach supporting documentation. Dwelling Type: Single Family U/ Two Family ❑ Multi-Family(#units) Age of Existing Structure /� Historic House:.❑Yes v❑No On Old King's Highway: ❑Yes ❑No k Basement Type:- �ull Crawl ❑Walkout ❑Other i5� Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other _ Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove:, ❑Yes ❑No f Detached garage:❑existing 0 new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:O existing '❑new size Shed:❑existing ❑new size Other: i Zoning.Board of Appeals Authorization ❑ Appeal# Recorded❑ 'Commercial ❑Yes' ❑No, If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name t r lephone Number �50)?: 7 7 - 3 3 W Address 15 1 bl 2,f icense# 0410 a 3 T ��'l' a k k r �0�� 7 Home Improvement Contractor# ' 09 b3 Worker's Compensation# UX Op® 1031 r ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE '2�—�� s. FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. er ADDRESS r, ,, iVILL•AGE_ y i;. OWNER" DATE OF INSPECTION FOUNDATION FRAME M .INSULATION - s FIREPLACE ' Y` ELECTRICAL: ROUGH FINAL' a ' PLUMBING: ROUGHC2 ra -iz FINAL' GAS: s' fROUGH= cc FINAL - § M �-. FINAL BUILDING ENS r + y y s FEE "M i r i DATE CLOSED OUT C3 0 ASSOCIATION PLAN NO. s Q t � , - ✓1�e�oavrmeaiiu�ea� a�✓�aaaac%uae� `BOARD OF.BUILDING REGULATIONS j Liaemie:_CONSTRUCTION SUPERVISOR- Number CS=.. 046234 r hey r SITTM 1. 1-1959 s y 1 000 Tr.rsw: 4307 ed_To: I i _TiMOTFfX. GRAY 45 TOWS SET ST .,�, IWASHPEE; MA 02649 Administrator 94. HONE.INPROVENENT CONTRACTOR Registration: 102634 Expiration: 0710212002 1 Type: DBA. . TIMOTHY GRAY BUILDING I RE yTyiilothy Gray ADMINISTRATOR TOhi$Set. St Nashpee MA 01649 1 i . 11 1 1 11�• " 1 a 1-11 11 11 1 ' '1 1. 11 ' ■ 11 \ \ \ \ \ 1 . 1 1 1 1 1 1 "1 1.. 1 ' 1 1 ' W.11. ii n. 11 1 " 11 \ \ 'J 1 \ ' 1 1 ' '/ 1. a .\ 111\:.,/ \ . 1 / 11 �11111 \ • 1 1.. 111 1 1 11 "FOR•, 11 1 1 11 r ommmmsi mm, _2 Mon= ■ 11 1 1 \ /11 \ :il 1 1 1 1 \ 1 1 11 41 1 ✓ / .11 \ 1 1 �. 1 ►1 Ilt 1 �/ 1' \ •' 1\ Sl 17, I . 1 M tt .1 11 1 1 1 ' 1 1 I 1 1 1 1 11 - rl- r rli. Irr - -I. Ir _..li 1 1 1 �• I I I'I 11 1 J 11 LI 111 - /ice�✓ �A 1:1 �■ww�w■■ oincial use onlY do notwrke In thb am to be completed by city ortown oMdd .1or taim pffinwHemseo MBuUbMDepuftnmt OLkmxingBoard checkfflumiedlate response is required■ C3SelecbnmlsOflLm [3ffeaftDepartutent 3, ' Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contrac: 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 c 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renews 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,neitherthe commonwealth nor any of its political subdivisions shall eater 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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits 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 tows 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. City or Towns 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 applicanL Please be sure to fill in the pem /kioense number which will be used as a reference number. The affidavits may be retumcd in- the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would hike to thank you in advance for you 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 4 Department of Industrial Accidents 8mce of Investl0adons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 f ° The Town of Barnstable MM& Department of Health Safety and Environmental Services ram' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: KI=�ch e n Q YY�y Estimated Cost I , r 9 Address of Work: 5's SLl n na 'r be-1 I A w C i/1 Owner's Name: L"1 a Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law blob Under$1,000 Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: i rn Date tontractor N6de Registration No. OR Date Owner's Name q:forms:Affidav pfiG T"' 1 I ' I LAUNDRY SPACE RLA5G!/l� /Z.. V3(4) '` /t SPACE MDW • ----------0-v `—-------- f4) — —--------- — ._.._.. — -- — ----- i TKCV(2) -- T. I I i a v s8361Cftw T I W1536R 315R TOST I M r I RANGE r -.— SPA.CE - r l I +Y3018REP rt, - - PF-ANGE1 E. $PhGE ' - ---- _ IMW-GE ------- Iwya36R 'REF-STDi --- C$K15 \ 7 B9L FH0LN I1 33 ' s BD41 5sLS3F m ' 1 I N2f35 EFI 96C� i W 362418 t t ,. T W1830L f BASE WC24" /, - —-- w2 736 -- I � 32 ID S-1EEHY DESIGN PLAN 01 r1, t PLAN SUBJECT TO REVISIONS UPON t I FINAL FIELD NEASUREINAENTS T ' [