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EMEROY S430iumC s 2
378 Rout
Sandwich,MA 02563
PH:774-205-2001•844-90-AUDIT
Permit Affidavit
Permit#;� ��� , � C�
I,Craig Bishop,confirm that the weatherization and air sealing work completed at f UVf rn 1 Y1;S��f
has been completed in accordance with 780 CMR.
r.
Signature: Date: LI-2a
' ' ►. Town of BarnstableBuilding
t Post This Card-So That it is Visible From the Street-Approved Plans Must be Retained on lob and this.Card Must be Kept
RAMSTA
059 MAS& , Posted Until Final Inspection Has Been Made. i e�'n11�
Where a Certificate of Occupancy.is Required,such Building shall.Not be Occupied until a Final Inspection has been made.
Permit No. B-19-309 Applicant Name: Craig Bishop Approvals
Date Issued: 01/29/2019 Current Use: Structure
Permit Type: Building-Insulation-Residential Expiration Date: 07/29/2019 Foundation:
Location: 42 WESTMINSTER ROAD,CENTERVILLE Map/Lot 168-066 Zoning District: RC Sheathing:
Owner on Record: CHAPMAN,SHEILATR Contractor Name'`o Craig P Bishop Framing: 1
,Address: 375 YORKTOWNE CIRCLE Contractor Licenser CS-109777 2
ATLANTIS, FL 33462 � �" Est. Project Cost: $5,025.00 Chimney:
Description: Air Sealing and Weatherization Per mit Fee: $85.00
Insulation:
Fee Paid::! $85.00
Project Review Req: i Final:
( Date.�� ` 1/29/2019
Plumbing/Gas
way 7
Rough Plumbing:
n %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 inspection for the entire duration of the Final Gas:
work until the completion of the same. Electrical
S r <
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
Service:
Minimum of Five.Call Inspections Required for All Construction Work:
1.Foundation or Footing
Rough:
2.Sheathing Inspection
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 Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
at^Pi=— S EN T—
' Town of Barnstable Building
t 'b
PostT
.k.�his,.Card SogT.hat��ts V�s�ble From the Streets�A raved PlansMust be:Retamedon:`Jo and''this CardxMust be Kent=
est.s. • ... �`�,;: "`" ,�Y r� ..;ate t pp F"n 3 v T .p
Posted Until Flnal�lnspection
a .R Where a Certificate,off Occu anc.;;.�s Re, uired,auch Buildmvrshall Not be Occu ied until a"Final lnsrlect�o�n has been made ) Permit
Permit NO. B-18-3032 Applicant Name: CHAPMAN,SHEILA TR Approvals
Date Issued: 09/14/2018 Current Use: Structure
Permit Type: Building-Deck Expiration Date: 03/14/2019 Foundation:
Location: 42 WESTMINSTER ROAD,CENTERVILLE Map/Lot 168-066 Zoning District: RC Sheathing:
"r
Owner on Record: CHAPMAN,SHEILA TR x Contractor.Name Framing: 1 fi^
Address: 375 YORKTOWNE CIRCLE r License
A<- ��o t 2
Contracto
ATLANTIS, FL 33462 EstP�roj ct Cost: $5,519.04 Chimney:
r y:
� Permit Fee: $ 110.00
Description: replace existing 8 x8 deck with new 18 x18 decknew deck will be � '° Insulation:
the same height as existing deck. Fee paid for4underB 18 2550 Fee Paid $0.00
Date ``
Project Review Req: PROPER SUPPORT TO BE PROVIDED FORA FNG�LED PORTION 9/14/2018 Final:� , _ � �,� �a d
OF DECK. '
" - Plumbing/Gas
Rough Plumbing:
Building Official
Final Plumbing:
Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized bl this ermit is commenced within six months after issuance.
P Y P Final Gas:
All work authorized by this permit shall conform to the approved appl ci etion a d the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be incompliance with the local zoning by laws a"n'"d codes.
Electrical
This permit shall be displayed in a location clearly visible from access street oar road and shall be ma�ntamed open for publiccJnspectionfnr the entire duration of the
work until the completion of the same. I Service:
a G
The Certificate of Occupancy will not be issued until all applicable signatures by the euildmg and Fire Officials are provided`on this permit. Rough:
Minimum of Five Call Inspections Required for All Construction Work: ""' "
1.Foundation or Footing Final:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final:
Application NW3ber.. .... ..
MA33. ermit V�\ P Fee.......................................Other Fee.............
...........
03
Total Fee Paid....... .............:....: .....................................
TOWN OF BARNSTABLE PermitAm=valby-
BUILDING PERMIT Mv-----. ...................PaITC1........... .............
APPLICATION
Section I— Owner's Information and Project Location
Project Address
Owners Name C- n,P t`Ol
Owners Legal Address W 2 S� y�So�•�.
e' ���kab� state 1J1 Zip
owners Cell# E-mail
-'Section 2—Use of Structure
Use Group 1� ❑ Commercial Structure over 35,000 cubic feet
AUG 22 ZO ❑ Commercial Structure undei 35,000 cubic feet
-TO\NN OF 6AFINSTA"I .
❑ 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
❑ Addition Retaining wall ❑ Solar
❑ Renovation ❑ Pool ❑ Insulation
Other—Specify
Section 4 -Work Description
e, -
T s►et tmdata&219=1 8
Application Number.................................................
Section 5—Detail
Cost of Proposed Contra oA55 O° .C4 Square Footage of Project
Age of Structure %A0 Dig Safe Number
# Of Bedrooms Existing 3 Total#Of Bedrooms(proposed) 3
110 MPH Wind Zone Compliance Method MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
❑ Wiring ❑ Oil Tank Storage 0 Smoke Detectors
Plumbing ❑ Gas O'Fire Suppression
t
❑ Heating System ❑ Masonry rClumney� ' ❑Add/relocate bedroom
Water Supply Public ❑ Private
Sewage Disposal ❑ Municipal ® On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: I an using a crane ❑ Yes No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland,coastal bank? Yes ❑ No
Section S—Zoning Information
Zoning District Proposed Use Lot Area Sq.Ft. `
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yazd Required Proposed
Rear Yard Required aW Proposed' t'
Side Yard Required Proposed
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No
Last tmdated n2018
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 rr ```�'"` "'. a Date
S � j
Section-l0'—`Horne 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 IUC...
Signature Date
Section 11-Home Owners License Exemption
Home Owners Name: eA
k CleDymo.�q
Telephone Number '�5, Cell or Work Number �'"QS3—Z�
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 y 7 the Town of Barnstable. f
Signature =` Date ZZ
APPLICANT SIGNATURE
Signature �Date��22'� 1 g
Print Name ,S�c t.� 4 CA/La -nj 1 Telephone Number
E-mail permit to:
T.,..i.....i..a�.t.n mnnt o
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, as Owner of the-subject property hereby
authorize to act on my behalf, in all
matters relative o work authorizted b this boil ' g p rmit ap lication for:
Z
C Ails �sz�3 2
(Address of j ob)
Zz l
Si afore ZTOwner date
m-
Print Name
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Lest=dated:219r2018
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The Commonwealth of Massachusetts
fA Department of Industrial Accidents
-- Office of Investigations
600 Washington Street .
Boston,MA 02111 t
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual): )Aa 0
V 'hem
Address: � �' fY((1 �.�� �CK
S Co
City/State/Zip: 031 hone
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
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.M 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
comp. . ❑
P•insurance. Building addition
[No workers'comp.insurance
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 Other
employees. [No workers' 13.K c f
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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.# Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 c cnder tl p d penalties of perjury that the information provided above is true and correct
Si ature. Date: OL
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
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
4. + 'I 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 employmeiif be deemed Jto�be an eemf ployer."
MGL chapter 152,§25'C(6)also states'that
"every state or local licensing'a°gency'shall withhoid�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 inquired. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
din the law or if you are required to obtain a workers'
Industrial Accidents. Should you have any questions regarding y q�'
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 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'aild fax number:
The Commonwealth of Massachusetts f 1
O . .
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 0211.1
Tel,4 617-727-4400 ext 406 or 1-977-MASSAFE
Fax 4 617-727-7749
Revised 4-24-07
www.mass.gov/din
The Commonwealth of Massachusetts
Department of Industrial Accidents
......_._. Office of Investigations
' 600 Washington Street
- Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): d Q(i hO
Address: 1 -o C—Mrtn -49%a2g Q_oo,cl
City/State/Zip:E.Fo,1wpAk MA 025310 , Phone#: (at-7
Are you an employer?Check the appropriate box: Type of project(required):
L❑ 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.�4.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'
comp. insurance) 9. ❑Building addition
[No workers' comp. insurance P•
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
P 12.❑ Roofrepars
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.KLOther ��_ .k
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 is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 c ;fy unde :e ins and It' of perjury that the information provided above is true and correct
Signafore Date: 8 2.2 l
Phone#: [� S T -7191
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
r
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to,be an employer."
MGL chapter 152,'§25C(6)also.states that"every state or local licensing.agency shall withhold the.issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." .
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to cant'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.
The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call. `v „
The Department's address;telephone and fax number:
The Commonwealth.of Massachusetts t, , 1
Department of Industrial Accidents
office of Investigations
600 Washington.Street
Boston,MA 0211.1
Tel.. #617-727-4900 ext 406 or 1-977-MASSAFE
Fax#617-727-7749
Revised 4-24-07
www.mass.gav/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Shall,
Address: 42 oes+m I n
City/State/Zip: / d�' 9�34one#: q d 1^`I5 3—Z 7-6 10
Are you an employer?Check the appropriate bor. Type of project(required):
L❑ 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.❑ 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,#
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 13.❑Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
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 erh der h d penalties of perjury that the information provided72;
true and correct.
Si afar Date:
Phone# ^7 r� / ��f3
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#:
r
Information and Instructions y
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do:maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such,employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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-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.
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: t
The Gommanwealth of Massachusetts
Dgwtment of Industrial Accidents r
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFl,
Revised 4-24-07 Fax#617-727-7749
www.m=.gov/dia
Lauzon, Jeffrey
From: Colman Peppard <colmanpeppard@gmail.com>
Sent: Monday, September 10, 2018 9:29 AM
To: Lauzon,Jeffrey
Subject: Deck permit 42 Westminster road, Centerville
Jeff,
The bracket I will be using for the post to beam is the Simpson BCS post cap base bracket.The post to sonotube will be
secured by the Simpson ABA44Z bracket.
Thank you, Colman Peppard
Sent from my iPhone
Bowers, Edwin
From: Bowers, Edwin
Sent: Wednesday, September 05, 2018 9:45 AM
To: 'Sheila Chapman'
Subject: RE: Permit/Application:TB-18-2550 at 42 WESTMINSTER ROAD, CENTERVILLE for
Building - Deck
Hello Sheila Chapman
I would be glad to get your permit right out to you
Please Provide all Information as Requested on 08/17/2018 and on 08/2.1/2018
1) CSL for applicant and Home improvement contractor License or Homeowner License exemption form.
2) Code will require a workers comp affidavit for the applicant whomever that will be
3) Please provide detailed Plans of Your Deck demonstrating code compliance
4) Please provide Plot plan showing location of Work on property and distance to property lines
Your application will be at the front Desk waiting the additional information but cannot be approved as
submitted
This is required per 780 CMR 91h edition R105.1
Thank You Feel free to call with any questions
From: Sheila Chapman [ma I Ito:chapmansac@comcast.net]
Sent: Tuesday, September 04, 2018 11:20 AM
To: Bowers, Edwin
Subject: Re: Permit/Application: TB-18-2550 at 42 WESTMINSTER ROAD, CENTERVILLE for Building - Deck
Hello the permit for the deck has been pending since 8/7.Trying to get the deck built prior to the winter months.What
additional information is needed to acquire the permit?
Thank you
Sheila Chapman
Sent from my iPhone
On Aug 21, 2018, at 3:20 PM, Bowers, Edwin <Edwin.Bowers@town.barnstable.ma.us>wrote:
Thank you the permit will be at the front counter
From: Sheila Chapman [mai Ito:cha pmansac(5)comcast.net]
Sent: Tuesday, August 21, 2018 2:10 PM
To: Bowers, Edwin
Subject: Re: Permit/Application: TB-18-2550 at 42 WESTMINSTER ROAD, CENTERVILLE for Building -
Deck
The contractor is in the process of submitting information for the permit.
Sent from my iPhone
On Aug 21, 2018, at 1:02 PM, Bowers, Edwin <Edwin.Bowers@town.barnstable.ma.us>wrote:
Your permit can not be approved as submitted
Please provide information needed Per 780 CMR 9th edition R105.1
1
Town of Barnstable f REcEiP�
' HAS& 200 Main Street, Hyannis MA 02601 508-862-4038 5
4 Application for Building Permit
Application No: TB-18-2550 Date Recieved: 8/7/2018 1 LC,
L
Job Location: 42 WESTMINSTER ROAD,CENTERVILLE V SQ'� (D
Permit For: Building-Deck 0—
YNO
Contractor's Name: UPPER CAPE LANDSCAPE State Lic. No: 176510
CONSTRUCTION INC. �1J
Address: 238 JOHN PARKER RD, E. FALMOUTH, MA Applicant Phone: (781) 953-2766
02536
(Home)Owner's Name: CHAPMAN,SHEILA TR Phone: (781)953-2766
(Home)Owner's Address: 375 YORKTOWNE CIRCLE, ATLANTIS,FL 33462
Work Description: Replace existing deck and shingles �.V
C) k-
Total
ota Value Of Work To Be Performed: $7,500.00
Structure Size: 0.00 0.00 0.00
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker 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.
Signed: Sheila Chapman 8/7/2018 (781)953-2766
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost : $7,500.00 Date Paid Amount Paid ( Check#or CC# ? Pay Type
Total Permit Fee: $110.00 8/7/2018 $60.00 7CA�-X3COC-XXA�- Credit Card
5925
. .., �, m
Total Permit Fee Paid: $110.00 s..i7i. 2o1 b8 $50.00 XXXX-XXXX-XXXX-' Credit Card
5925
u
Application number ._
issued
Building Inspe rs In als
SEP 18 2010 �0� �.Map/Parcel ..
TOW
TOWN OF B SABLE �5• D (>
EXPEDITED PERK f APPLICATION:
ROOF/SIDING/W,MOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
-AddressofProject_ WC miag}tf Q CgAP(Vil�
NUMBER STREET V1LLwE
Owner's Name:i� +;�s UNAPM,, Phone Number
Email Address: racka^e}. Cell Phone Number
Project cost$_22,59: _ Check one.Residential ,/ Commercial
k OWNER'S AUTHORIZATION
As owner of the above property I:hereby:authorizey�
to make applicatio 't in accordance Ath 780 CMR
Owner Signat Date:
TYPE OF WORK
C Siding ❑Windows.(no header change)# Insulation/Weatherization
0 Doors(no header change)# Commerciad Doors require an inspector's review
Roof(not applying more than 1 layer of shingles)
Construction Debris will be goingoJu�ho
CONTRACTOR'S INFORMATION
Contractor's name
Home Improvement Contractors Registration(if applicable).# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor Phone number
ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS.OLD OR 1FTHE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT,YOU MUST OBTAIN HISTORICAPPROVAL BEFOREA PERMJT CAN BE ISSUED.
APPUCATION NUMBER
*For Tents Only*
Date Tent(s)will be erected Removed:o number of tents total
Does the tent have sides?Yes No (If yes Please attach floor plan:with exits marked)
Dimensions of each Tent X X_ JC
Additional tent dimensions can be attached on a separate piece of paper:
Check one:this event is a:for profit non-profit event
Check one:Food served Yes No
Flame Spread Sheet of each tent must.be attached:Provide a site plan with the location(s).of each'tent
Iffood is being served at your event please obtain a Health'Department approval between the hours
of 8;00am-9.30 am or 3;30 pm-4:30pnL Commercial events may require Fire Department approval.
*WOOD/COAL XLLET STOVES
Manufactures# Model/LD:
Fuel Type - Testing Lab
Offsets from combustibles:front back left side right side
Y — HOMEOWNER'$LICENSE EXEMPTION.
Homeowner's Name:
Telephone'Num Cell.or Work number.
I.understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor ifn accordance with 780 CMR the Massachusetts State Buildiag.Code. I understand
the coustructio ection pro aces,specific inspections and documentation required by 780
CMR and e T of B bl
S. Date
" ANT'S SIGNATURE .
Signature Date . l
All permit applications are subject to a building officw s approval prior to issuance
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."
i
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit 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 permitllicense 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 Massachusetts
Department of Industrial Accidents
Oilflce of Investigations
600 Washington Street
Boston,MA 42111
Tel. #617-727-4900 ext 406 or 1-877 iv1ASSA.FE
Fax#61.7-727-7749
Revised 4-24-07
www.mass.gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):S d`�p� tp�a.f I a`�C ?_-, y k UU V Lq n
t 1 C—rna Cie WI
Address:JL}- CAA\v'v%. I&e. F �-V&k"au
City/State/Zip: oA oVN. R 53G Phone#: 5 0`6 7\ �7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.2 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.
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 1 LE]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.
#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
e employees,the must provide their workers'comp.policy number.
employees. if the sub-contractors have y p p p Y
1 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.#: 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 unde Fenalties perjury that the information provided above is true and correct
Signafore: Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600-Washington Street
- Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):MpoCUB\ �G(t1rl�(,l�(\ ,�[rmqh pL�[, �Q�'1 6r 2dk4 �.
Address: ( U' '�
City/State/Zip: 6 M' (D Phone#:. 719 4 Q)a I(p 7(0
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
employees(full and/or part-time).* have hired the sub-contractors.. 6. El New construction
2.9 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑<Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
comp.insurance.
9. ❑Building addition
[No workers comp.insurance P•
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. 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ oof repairs
insurance required.]t c. 152, §](4),and we have no
employees. [No workers' 13. Other 5 lC��rl
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.
.lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.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
Si afore: Date:
Phone 9 N
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments.and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction'or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or.permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7):states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority." '
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit 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 fixture 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 Massachusetts „-
Department of Industrial Accidents
Office of fnvestigafons
600 Washington Street
Boston,MA 0211.1
Tel,4 617-7274900 ext 406 or 1-877-MASSAFF,
Fax#617-727-7749
Revised 4-24-07
www.mass..gav/dia
f Massachusetts
The Commonwealth o
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
yyww.mass.gov/dia ricians/Plumbers
Insurance Affidavit: Builders/Contractors/E lect
'bl �
Workers Compensation Please Print Le
A licant Information
Name(Business/Organization/Individual):_
Address: 41 Oe�l m 1
City/State/Zip:(�C/
one#:
Type of project(required):
J6V4h
Are you an employer?Check the appropriate bo eneral contractor and I
4. I am a g 6. New construction
1,❑ I am a employer with______ have hired the sub-contractors
employees(full and/or part-time).* Remodeling
listed on the attached sheet. 7. ❑
2.❑ I am a sole proprietor or partner- These sub-contractors have g, ❑Demolition
ship and have no employees employees and have workers' 9 ❑Building addition
working for me in any capacity. comp.insurance. Electrical repairs or additions
workers' comp.insurance and its 10.❑ P
[No work P 5, We are a corporation
required.] ❑
] officers have exercised their 11. Electrical
repairs or additions
q
3.❑ I am a homeowner doing all work right of exemption per MGL 12.❑Roof repairs
myself.[No workers' comp. c. 152,§1(4),and we have no 13.0 Other
insurance required.]t employees. [No workers'
COMP.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information-
*Any
Homeowners who submit this affidavit hid an additions doing show all ing the name k and then irthe tside cntractotrs and state whether or nOrs must submit a new ot those entities have
2 ors that check this box must 'com .sub-contractors
number.
Contract
employees. If the sub-contractors have employees,they must provide their workers p policy
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Expiration Date:
Policy#or Self-ins.Lic.#:
City/State/Zip-
Job Site Address:
Attach a copy of the workers' compensation policy declaration page
152(showing
lead to the imposition of cnriminal penalties of a
Failure to secure coverage as required under Section 25A of MGL c.
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
t1do
tigations of the DIA for insurance coverage verification.
hereby erh u der h ms d penalties of perjury that the information provided abov is true and correct.
r22,h
Date:
afar ' n ?_b1,o
Phone#:
official
nly. Do not write in this area,to be completed by city or town officiaL
Permit/License#
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Health 2.Building Department 3. Cityfrown Clerk 4.Electrical Inspector 5.Plumbing In
Phone#:
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Town of Barnstable
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KAS
s 200 Main Street, Hyannis MA 02601 508-862-4038
Application for Building Permit
Application No: TB-18-2550 Date Recieved: 8/7/2018
Job Location: 42 WESTMINSTER ROAD,CENTERVILLE /
Permit For: Building-Deck
Contractor's Name: UPPER CAPE LANDSCAPE State Lic: No: 176510
CONSTRUCTION INC.
Address: 238 JOHN PARKER RD, E. FALMOUTH, MA Applicant Phone: (781) 953-2766
02536
(Home)Owner's Name: CHAPMAN,SHEILA TR Phone: (781)953-2766
(Home)Owner's Address: 375 YORKTOWNE CIRCLE, ATLANTIS,FL 33462
Work Description: Replace existing deck and shingles
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Total Value Of Work To Be Performed: $7,500.00
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Structure Size: 0.00 0.00 0.00? �
LA
Width Depth Total Ar-4a M
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker 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.
Signed: Sheila Chapman 8/7/2018 (781)953-2766
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
k#Amount Paid Ch y Type
Date Paid ? ec or CC Pa T Total Project Cost : $7,500.00 i 1
Total Permit Fee: $110.00 8nl2018 $60.00 XXXX-XXXX-XXXX- Credit Card
5925
Total Permit Fee Paid: $110.00 � �
8nl2018 $50.00 XXXX-XXXX XXXX- Credit Card
1 5925
s� � THISISNOTPERMIT � z
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°FtNE' Town of Barnstable
O�
UMSTAB E, 200 Main Street Tel.(508)862-4038
!p \00p' .
TfOMA�a INSPECTION REPORT
Permit: Building - Deck
Use:
Date: .8/17/2018 9:47 AM Inspector: sheas Permit Number: TBA 8-2550
Name: CHAPMAN, SHEILA TR
Address: 42 WESTMINSTER ROAD, CENTERVILLE Unit No.
Inspection Type Inspection Item Status Comment
Building Admin - BA- Copy of Applicant's NIC No construction supervisor on project
Sheds, Decks, License
Porches, Gazebos,
Pools
Building Admin - BA- Decks, Porches, NIC We need plans on the deck's construction along with a plot
Sheds, Decks, Gazebos-Cross plan
Porches, Gazebos, Section, Framing, Detail
Pools on Plans
Building Admin- BA- Home Improvement PASS
Sheds, Decks, Contractors Registration
Porches,Gazebos, (If Residential and
Pools Applicant is Contractor
Building Admin - BA- Homeowner's NIC Homeowner must assume license requirements if no
Sheds, Decks, License Exemption construction supervisor is on the job
Porches, Gazebos, Form, if Homeowner is
Pools Applicant
Building Admin - BA- Property Owner PASS
Sheds, Decks, Authorization, if Builder
Porches, Gazebos, is Applicant
Pools
Building Admin - BA- Site Plan showing NIC Location of deck must be shown on a plot plan. Dimensions
Sheds, Decks, location of proposed of deck replacing old must be clear
Porches, Gazebos, work. (If required)
Pools
Building Admin - BA-Workman's Comp NIC Applicant must complete this form along with the
Sheds, Decks, Affidavit subcontractor
Porches, Gazebos,
Pools
Inspection Overall Comment: See notes above. Called applicant 8/17/18 left message asked her to return call to
obtain outstanding items listed above.
Overall Inspection Status: FAILED Re-Inspection Date:
Inspector Signature Owner Signature Total Score: 100
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Town of Barnstable *Permit# H. —, 2G. z
Expires 6 Mrs rom jssue date
Regulatory Services Fee
• swxrtsTn�ne C
9eb amass �` Richard V.Scali,Director
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
ExPREss PERMIT APPLICATION - RESIDENTIAL ONLY
_ Not Valid without Red X-Press Imprint
Map/parcel Number ""��/� D(Y/�—
Property Address yz IJes mi 4 j Pl !1 RX
YResidential Value of Work$ S 5 2 — Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address Sr-py k el SYi e i I A Cha 12 en a 1
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Contractor's Name E nJv,J A6/7 / //t;5p/( Telephone Number 0 I R S0 0
Home Improvement Contractor License#(if applicable) 73 Z 4157 Email:
Construction Supervisor's License#(if applicable)�Lj'S 7 Q 7
12Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ m the Homeowner
[have Worker's Compensation Insurance
Insurance Company Name (I yq f`aA I (l�Lel,_4 2a s �fz,
Workman's Comp. Policy# (dj�d R
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)- `
❑ Re-side
aReplacement Windows/doors/sliders.U-Value 3 a (maximum.32)#of windows_,-
#of doors:
❑ 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 kOwner must sign Property Owner Letter of Permission.
A copy cKtheHomelmprovement Contractors License&Constru&ion Supervisors License is
require
SIGNATURE:
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Bost-on, Mass achus'-_tts 0,2116
Home Improv-men.t Contractor Registlatio'll
Reqistration: 173245
Type: Supplement Card
Expiration: 90 9/2018
SOUTHERN NEW ENGLAND WINDOWS LL
BRIAN DENNISON
26 ALBION RD
LINCOLN, RI 02865
Update Address and return card.Mark reason for change.
7 Address Renewal L Employment Lost Card
Registration valid for individual use only before the
"Tairs&Business Regrifladon
-office qj Consumer.Ad
expirution date. 11 found return to:
rJME Tion
IMPIROVEMEMT CONTRACTOR Office of Consumer Affairs and Business Re.,lia"
Registration: 173'-2-15 Type: 10 Park Plaza-Suite 5170
Expiration: 9j1912013 Supplement Card Boston.NLA 02116
SOUTHERN NEW ENGLAND WINDOWS LLC.
RENEW:-'kL BY ANDEP'_E'OM
BRIAN DENNISON
26 ALBION RDA
Not vailid without signature
LINCOLN, RI 02365 ,—Undersecretary
P''u-blic, Safe,
IvIassac1huse'llfts 'Departirnen, 01 ty
i d
E3.oard ol Building Regulations ar�d tardar s
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'-_,0nSt, -uC't;,0n sucervisor
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7 LAMBS POND CIIRCLE� '
V
CHARLTON MA 0 15070'
t)(01 I'l r a t i 0 n
09!'0812018
...,cmmisstoner
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` The COrizYR0113vealth of l'1'rassachitsetts
_ Depaz tnzerrt of hzdzsstrial Accide;zts
r I Coftgl•ess Street, Szcite 100
Boston, M# 02114-2017
ivwly;Hass_J ov/dia
Workers'Compensation Insurance Affidavit:BuilderslContractorslElectricians/Flumbers.
TO BE FILED 1VTTH THE PERNUTTIIG AUTHORITY.
_D licant Information Please Print Leg-ibly
Ni Tame (Business/'Organization"lndividual): L If' I8) #J -S
Address: ;;ZP
City/State/Zip: $ -fL>f ��io �� Phope
Are vuu an employer'.'Check the appropriate box: Type of project(required):
1.�g i am a eiployer with 20 t p.mnloyees(full andior part-tune)." %- \Few construction
:.17 1 am a sole proprietor or partnership and have no cmployces working form in S. C Remodeling
any capacity.[No worker comp.insurance required-1
9. C Demolition
3.17 1 am a homeowner don__all work m=selE[No tt-ork:Rtl coma.insurance required.)'
l0 C Building addition
:1.7 t an a hamem:•ncr and:v41!h_Ftlnng contrac:ora to conduct nil work-on mi•propcm.•. 3 will
ensure that all contractors either have workers'compensation insurance or are sole 11.[�Electrical repairs or additions
proprietors with no cnmihyees.
12. Plumbing repairs or additions
d.❑!am a vherai contractor and 1 have hived the sub-conliactors listed on the aaachcd sheet. 13-C Roof repairs
These sup-contractors rave employees and have-,or.;ers-comp.insurance.- ,� r
6.�We are a corporation and its officers have exercised their right ofecemption per'OCIL c. 1—'••Cy Vtl12r
i 52,;1(-),and tee have no employees.[No workers-comp,insurance 14 Ct—
"Any applicant that checks box=1 must also;ill out the section bolo-.-shomn,thciracorkers'comp nsation policy information.
Finincowners who submit this affidavit indicatine they are doing all work and then!tire outside contractors must submit a new affidavit indicating such.
!Contractors flint check this hax 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 emploves,they must provide their v:orkers-Como-police number. 1;
1 anz air employer that is providing workers'compensation insurance for tzry eznplo}gees. Beloit,is the policy and joh situ �4
information. 9 f�
insurance Company Name: ,
a
Policv or Self-ins.Lic.t: r A a 13& ® S f Expiration Date: 7'/_Z /1:7
Job SileAddress: S-f y) I✓1 SJer tl Ot - City/State/Zip: /t-ter t ILAA
Attach a cop}'of the workers' compensation policy declaration page(showing the policy number and espirat on date).
77
ailure to secure coverage as required under NL IGL c. 152.§25A is a criminal violation punishable by a fine uD 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 S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLL for insurance
coverage verification.
i do hereby cer�inder the pkzs and penalties ofpezjuiy that the information provided above is true and correct
Signature: Date: 65
Phone
Official rise only. Do not write in this area,to be completed by city or town official_
City or Town: Permit/License
Issuing Nuthorihr(circle one):
1. Board of Fealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
SOUTNEW-01 UOLLINGER
ACORU' CERTIFICATE.OP LIABILITY INSURANCE DATE(MMIDDNYYY)
6/29/1016
THIS-.CERTIFICATE, IS,:ISSUED AS A MATTER;OF INFORMATION.ONLY:AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES.NOT AFFIRMATIVELY_;Ol NEGATIVELY AMEND, EXTEND Ott"ALTER THE.COVERAGE AFFORDED BY THE POLICIES
E
BELOW. THIS CERTIFICATE OF INSURANCE DOES NO CONSTITUTE;A CONTRACT BETWEEN`THE:ISSUINGINSURER(S),AUTHORRED
REPRESENTATIVE OR PRODUCER,:AND THE;CERTIFIGATE 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 porieies may r"ulre an_endorsement A statement on ih6 certlAcate does not Confer rights to the
certificate holder in=lieu of such endorsement(s):;
PRODUCER CONTACT
:NAME:
CoBiz Insurance,Inc.-CO PHONE_. FAX
821 17th SL AIC No.Era:(303)988-0446. N;:.(304)98841804.
Denver,CO 80202 ADDRESS:A CoBizlnsugan`. obizinsumnce.com
ADDRE
INSURER( AFFORDING COVERAGE NAIC#
INSURER A-: Western Insurance Company 10804
INSURED INSURER B:`
Southem New-England Windows LLC .. INSUREER'C; '
D/B/A Renewal by Andersen
26 Albion Road INSURER D
Lincoln,R)02866 wsuRER_E
INSURER-F.:
COVERAGES CERTIFICATE;NUMBERt 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 AEQUIREMENT,;TERM_;OR„':CONDITION:OF ANY'CONTRACT OR OTHER.D000MENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY:BE ISSUED OR,MAY:PERTAIN THE`INSURANCE AFFORDED BY.THE.ROLIC)ES'DESCRIBED,'HEREIN IS;SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF'SUCH.POLICIES LIMITStHO.WN MAY HAVE BEEN:REDUCED_BY PAID_CLAIMS.
LTR TYPE OF OrSURANCE. 1NSD"; CY EXP
WVD' POLICY NUMBER EFF MM� LIMITS
A . X. COMMERCIAL GENERAL LIABILITY EACH.000URRENCE $ 11000,000,
CLAIMSMADE 7, X OCCUR `CPA3136080, 07/01/2016 .0710112017;-PREMISES(Fa ocamence_�$ 10Q00
MED rEXP(Arty one person) $ 10,00
PERSONAL&ADV INJURY., $ 1,0001-00 .
GEN'L AGGREGATE LIMIT APPLIES PER: i GENERAL AGGREGATE $ 21000000
X POLICY❑JET ,�LOC PRODUCTS.-COMP/OP AGG $ 2,000,000
OTHER: EMPLOYEE-BENEFI $ 2,000,000
AUTOMOBILE LIABILITY i OMaBIIN SINGLE LIMB $ 1,000,000
A X ANY.AUTO .. CPA'3136080, 07/01/2016;;�0._7.101/2017. BODILY INURY
ALL OWNED ^SCHEDULED BODILY INJURY(Per accident) $
AUTOS NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOSdeid
i Is
X. UMBRELLA LIAB X_ OCCUR EACH:000URRENCE $ . S;000;OO
A EXCESS LIAB CLAIMS-MADE COA3136080 07/011.20.16 07/0112017 AGGREGATE $
DIED X. -RETENTION$ 0 ggregate $ Sim,000
WORKERS COMPENSATION H-
AND EMPLOYERS'LIABILITY STATLRE ER
A ANY PROPRIETOR/PARTNER/EXECUTIVE F7 WCA3136081 07/01`1201.6 07/01/2017 EL EACH ACCIDENT $ 1,000;000
OFFICERIMEMBER EXCLUDED? NIA _ .
(Mandatory In NH) E.L.DISEASE-.EA EMPLOYE $ 1 f000.000
if
DESCRI diiaO u OrPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1;000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,AddIdonal Remarks Schedule,maybe attached It space.ls,raquired)
CERTIFICATE MOLDER CANCELLATION'
SHOULD ANY OF THE;ABOVE DESCRIBED POLICIES BE CANCELLED:BEFORE
THE EXPIRATION .DATE :THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE'WITH THE POLidYPROVISWNS.
AUTHORIZED REPRESENTATIVE
01.988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered.marks of ACORD
Assessor's map and lot .number ,t�r�i'�...�,� ...: :? -:� su.
lit,zw e,G c/,
o�
Aza��lk /ta,u oGGe be �.fooas
Sewage Termit number .r....�:..°�.. 7:� :":..a:��. U�O� s �b/�y t✓/��TF¢t .
:j i
CNN r L TOWN s. OF BARNSTARLE
Z BARNSTODLE;
" 3 BrUIL'DING INSPECTOR:
APPLICATION FOR PERMIT TO ........ilQ.� .......... ................................
.. .
�r TYPE OF CONSTRUCTION ............... .................. ...............................................
............................... 1...�........197 .
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according, to the following information:
Location .......... ......� s%sZlf�%.S% ... ..��....` ..C� �e00 - /C ............................
Proposed Use .
Zoning District ...........................................:...........................,..Fire District ............ .....:....:..,
Name of Owner ......JP#,L/........4;...�� �-fL�.l`7- ,Address ...�. ......�i4.T��-....: �.l C-4.1-71r.-%47
Name of Builder .....Address
Name of Architect ./fF ��r �lT��' ����.....Addres3 �i3��c� 1 ..... . ......................
Number of Rooms .................Foundation. ............,/ ....................... ....................:.........
..... �ff' �G1. 9 l
Exterior ............ Roofing
Floors ..................t.'.e.�T- !6- . ............Interior ......-
Heating ..... T.� ......Plumbing ..............y
.................................................... l
Fireplace .............. f! .............:.......:........................Approximate Cost ......... ...:...........::......:.....:.::::.,
Definitive Plan Approved by Planning Board -------- _-----------19________. Area ....................
Diagram of Lot and Building with Dimensions �,/�lj, Fee ..... ....../.........................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
a
3
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
A
Name ... .... . ...............................
...... ...................
L
i Garrity, John P.
18140 remodel garage
No .................. Permit for ....................................
to ''1st- floor
............... ......................
`42 Westminister Street
Location
Centerville
......................................................... Al
....................
John P. Garrity.
Owper ..................................................................
Type of Construction frame
..........................................
. ........................................................................
I .Plot ............................ Lot ................................
41
k 1;9 76
Permit Granted ....j4AW!KYJ?.... ......��l
f94
Date of Inspection
n
E to Completed 9
' d ...31
lo,
A-w
14
PERMIT REFUSED
................ ....................................... ..... 19
ZIP
.......... ...............................................................
.....
......................................................................
IA
..................................................
........................................................... .........7
.T
Approved ................................................ 19
............................................................. /► +"'`,� }'; `,- ;
;3
. ................ ...............................................................
< .
Assessors map' and•lot ,numbers,?�? 'ft„F :'� {� t o h ;fG`'�
....�..D..:S••/1•.�G/�/6/!x� •L:-laULG� .11
Sewage%Permit number .....................
.....:..._...a..:...................... �� 1 c :ti U-i` rF rr
°fTHE.r TOWN OF BARNSTABLE
S
i E9HBSMULE, i
M639 0�.G11PY0'• BUILDING ' INSPECTOR.
O'Fe
APPLICATION FOR PERMIT TO ........ !'j�» E f_-..... r? �49{^
TYPE OF CONSTRUCTION ?..... w° r e.'JI ............. .........................................................
Y ........... '¢OJ .2'r, .......l 9:7f•
TO THE INSPECTOR,OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ........ �^1.........../lf. .. ...� •. O...✓./ ... .....'...........................(.....•'Tr'..... •.A. .....!..........................................
ProposedUse .............. ft�/� �'"...>2 Jr�.M..................................................
Zoning District .............................................................:..........Fire District ....... //c44"= ..�"'
Name of Owner ......,a!?!1,K i.. !' ;,, ' ✓'�° ��"t'' Address ...r?........ o'L S'�',/' a.�iTi?.1/,sp4J5.
Name of Builder ..........Address nL!'�... �. :+t-,.✓�. �r�t7?gI1.1�+clif
y ...... .: �.
Name of Architect .+' !���� .... �T?!-A`'�'! 'L!� Address ' ? c ?' c.-�.... /.......
Number of Rooms ....................... ........................................Foundation .............,....t......................
Exterior K' ........................Roofing ..............
Floors ..................r' /I,�'� .. 7.....................................Interior
Heating ..... .............%.... ... . ........ „ Plumbing ..............Z• tr..........................................................
Fireplace A� !!!""~~ .............Approximate Cost !. , "
Definitive Plan Approved by Planning Board _________19________ . Area ...... ........ ....................
Diagram of Lot and Building with Dimensions 41A, Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
t �
r
t -
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .....zlzt� � ��..........................
Garrity, John P. A=168-66
�l 6 -66
No .................18 1 40 Permit for ................ ....rem ode .gar.a.g.e
....
to1st floor. ........................ ......................... .... .......................
St
42 Westminis erStreet
Location
Centerville
............0..................................................................
Owner ............John..P. Garrity.....................
-
Type of Construction ....................frame,......................
......................................:...Lot
..............n.......................
Plot ........................ ...
............ ...... ...j/
............... ...........
Janua./ry 12 76
Permit Granted .........................................19
Date of Inspection .....................................19
Date Completed .......................... ...........19
PERMIT 'REFUSE
................................................./........... 19
........... ........
0"
............................................... ..................
............ ...... ............ ..........i..................................
........... ........ .... .. .........t............... ...................
Approved .............................................. 19
...............................................................................
...............................................................................
TO COVERS TO BE WATERTIGHT
P OF FOUND ER
ATION TIGHT AND
EL. 56.0' EL. 54.0
' BROUGHT TO WITHIN 6" OF FINAL GRADE SEPTIC SYSTEM PROFILE
not to scale
Flaherty Environmental
INSP, PORT �� Y Services
WI3 OF GR
ADE
2" Of o" to 1" DOUBLE WASHED CLEAN SAND P,O. BOX S�
4"CAST IRON or EQUIVALENT PEASTONE"OR GEOTEXTILE EL, 54,0' Yarmouth Port, MA 02675
MIN, PITCH 1/4" PER FOOT FILTER FABRIC
4"SCHEDULE 40 PVC PIPE . 4" SCHEDULE 40 PVC PIPE 774.994. 1166
FL0 V1 LILINE'
(first 2'tobeie!yl)37' 2.4% VENT REQUIRED
--► ;
L.EXISTING 0 14" 4 EL.51.11t
EL. EXISTING — —-�' tom " "' o000000c LOCAL UPGRADE APPROVAL:
EL.51.6' —r o 0 0 0 0 0 0 O: O O�p�p 000°o°o°c MAXIMUM FEASIBLE COMPLIANCE-
°o°°°°°° ODOLJOQ� �, 0 o°o°o°o°c ( )(b
EL. 50.53' o°o°o° ° ° 31b CMR 15.405 1 EL. o 0 0 0°0°0°0° �OQ °°°o°o°o° )
GAS BAFFLE a ��QQ® p 00000000e DECREASE IN SETBACK OF SAS
H=20 EL. 50.5' °o°o°o°o°o°o°o°o° 0 � CI�Q p�.(�r1a
D$OX �� �- o°o°o°o°c Z—U TO FOUNDATION-
o00000000° 000000 •oo°o°o°o° FROM 20'TO 16.5'
•g"•:.a+,:•.•''�'': STALL °°°o°o°oc EL.48.5' (3.5' REDUCTION)
_ 6' CRUSHED STONE OR 1"ABOVE OUTLET INVERT SOIL ABSORPTION SYSTEM (SEE T.O.B. COUNTER POLICY 41)
1500 GALLON SEPTIC TANK MECHANICALLY COMPACTED
(DATUM: ASSUMED) EXISTING (2) 500 GALLON H-20 CHAMBERS
3o t DOUBLE WASHED STONE WITH 4'STONE AROUND IN A 51
12,83'X 25'X 2' CONFIGURATION
ROUTE 28
52
BOTTOM OF TEST HOLE EL. 43.5' LOCATION MAP
52 L=100.03'
USGS ADJUSTMENT' N/A
R=5040.0 GROUNDWATER ELEV• N/A N TH
LOT 5 GARAGE Rt.28
15,114 SF± CD
MAP 168 LOT 66 _ OCUS
a
GRAVEL DRIVEWAY
AREA �— — I BUILDING DEh7 .
AUG
C�-�� I 2F+ 2018 NTS
ul
Ln 3 o
J(1
�a� DA
EXISTING (� (SLAB) 17
111 3BR F
BENCHMARK; H; f) R
I; N !
t
TOP OF FNDN DWELLING iy p O
EL. 56.0' TH-1 H-2 j 16. FGrSTEP�
'
54 -:,„ I ! 54 S�NITAR P�
CAUTIONI UNDERGROUND EXIST, S.T. ='
O O I DATE.•6/>5/20>7 EVISED:
ELECTRIC & GAS IN THIS AREAI ;�:,
APPROX. n '•"' I 10,
EXIST, SAs GARDEN AREA
SITE AND SEWAGE PLAN
100.00' VENT FOR
10, — _ B & B EXCAVATION, INC./
— WESTMINSTER ROAD SHEILA CHAPMAN
SCALE : 1 — 3 0' 42 WESTMINSTER ROAD
- CENTERVILLE, MA
'REF.•PS 235 PG 55
PAGE I OF2