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0024 DANA COURT
P4AM ', c _ � . i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION MapO 5Cp Parcel O1 a Application # Health Division ` Date Issued Conservation.Division Application Fee Planning Dept. Permit Fee co Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address . T- Village � Owner;AA4._4f5 * q^1 L MAN nn,A;R A Address- Telephone 18'S-0 Permit Request 3=:, g t4 j'� 2- a Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation30,C5M Construction Type wzn'7 E0L^N-e w1C__0An As'T15-= Lot Size Grandfathered: ❑Yes IVNo If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing.St'ructure )q$4 Historic House: ❑Yes )(No On Old King's Highway: ❑YesNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing_ new Half: existing ne, Number of Bedrooms: existing new qL, o Total Room Count (not including baths): existing © new First Floor Rock Count`' _ C4 Heat Type and Fuel: ❑ Gas 4Oil ❑ Electric ❑Other c , Central Air: XYes ❑ No .Fireplaces: Existing New Existing wood/ oal stov:& ❑&es ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ xisting--U n size_ rn Attached garage: xisting ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use IggEE= ,„ -T-i A,_ Proposed Use i-!qEs gjE , T� 1 _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name M)L_1.`r=& Z3yc4c- Cofsj� Telephone Number 1) . 24-- �ddress P -it) . 21 »c, w.4, License# ff3 3 3 R' r.A 1 M n1r H , AAA 025_-$-J Home Improvement Contractor# Worker's Compensation # WG o?2.0 9r J ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO i ' v Ri , MA SIGNATURE DATE /O-- - x FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. t ADDRESS VILLAGE ` OWNER `. DATE OF INSPECTION: FOUNDATION ' FRAME .; INSULATION FIREPLACE ELECTRICAL: ROUGH , FINAL PLUMBING: ROUGH _`.FINAL GAS: ROUGH FINAL .� k ' FINAL BUILDING Y DATE CLOSED OUT � l Y ASSOCIATION PLAN NO. .i J �VE r Town of Barnstable y� Regulatory SerAces Thomas F. Geiler,Director ia,Ygt Building Division Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnst2ble.ma.us 'Office: 508-862-403 S Fax: 508-790-6230 PLAN REVIEW Owner: `�x�rn s2 A Map/Parcel: Project Address 2yD"3ti� dO4(Ar, C7 Builder: 141-e-A" -T?'� Bite-!` The following items were noted on reviewing: 'V �)E-C K I!o/S t'f I?ii R.X T �3e �m s 1'rl y 6-c_y 19�y ATC l-{�d 71 Reviewed by: Date: Q:Forms:Plnrvw ti The Cointnottwealth of!'1% ssacflusetts Departrnertt of Industrial Accidetzty Office of In-vestigations 600 TVashington Street Boston, Mai 02111 www.mass.gov/dia Workers' Compensation Tnslirance Af_fida,0t: Builders/Contractors/E]ec tricians[Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individuai): Address: City/State/Zip::P.ACt.a••tJe�al,4 . MA o26!tj Phone.#: Sa$ �� •l l2�{- Are you an employer? Check the appropriate boy: Type of project(required): 4. (] 1 am a general contractor and 1 1,'�1 am a employer with�G� 6..❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on 2.❑ 1 am a'sole proprietor or partner- the attached sheet, 7. ❑Remodeling ship and have no employees. These sub-contractors have 9. 0 Demolition working for me in any capacity. employees and have workers' 9., ]Building addition [No workers' comp.-insurauce Come. a corporation 10 Electrical repairs or additions required:] 5. [] We are a corporation.and its ❑ p 3.❑ I am a homeowner doing all work officers have exercised their I LF Plumbing repairs or additions Myself. [No workers' comp. right of exemption per 1v1GL 12.[]Roof repairs, insurance required.] t c. 152, §1(4), and we have no employees. PTo workers' 13.�OtheP.b�C1� comp.insurance required.] Any applicant that checksbox#1 must also fill out the scotion below shovring their workers'compensation polidyiriformation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet shoving the name of the sub-contractors and stato whither or not those entitics have employers. If'the sub-contrnctors have employees,they must providt their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for trey employees., Below is the policy and job site information. Insurance Company Name: {�•i1�y 1J'TCt�I� /.4t� `� � ��'E►,.A t'T`! Policy#or Self-ins.Lic.#: NVJ C— 220 1 Expiration Date: 03 —2�-- OQ]• Job Site Address: � City/State/Zips-ter. 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 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 tinder the ypains and penalties of perjury that the infarmadon provided above is true and correct.. S ature:--- i"ti Date: —O Phone# `56T 5 3ct I Official use only. Do not write in this area, to be completed by city or town officlal. City or Town: Pernut/License# Issuing Authority (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6; Other _. Contact Person: Phone#: Information and In S* tr,Uctiolis 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 biie, 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 housc.of another who employs persons to.do maintcnance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not bccausc of such employment be deemed to be an employer." r , 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 constructkbuildings.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)namc(s), address(cs) and phone nurnber(s) along with their certifrcate(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 confinnation`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 requited to obtain a workers' compensation policy,please call the Department at the nurnber listed below. Self insured companies should enter their self-insurance license number on the appropriate line. City or Towp Officials Please be sure that the affidavit is complete and printed legibly. The D epartrucat has provided a space at the bottom of the af£.davit.for'you to fill'ouf in:the event tlie'Officc of Investigations has,to contact you regarding the applicant. . Please-be sure to.;fill in the permit%lieensc number which Will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given yea)hied"only subrnit'one affidavit indicating current ,,policy.information(if necessary) and under"Job Sile Address" the applicant should write"all locations in (city or to :4 copy of the affidavit that has been officially stamped oz 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 (Le. 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: f _y The C6mmopwf,- lh of Nassau=M nt ofIl7.dust�a1 AGG1C1�nt5 Office Qf Inyestigatious 600 Washington Stroet BQstcn, I1'1A. 02111 Tel. # 617-727-490.0 ext 406 ar 1-M-MA.SSAFE Fax# 617-727-7749 Revised 11-22-06 www.rnasS-gov/dia o�zKEra,; Town of Barnstable Regulntory Services BAxNSTeBM Thomas F. Geiler,Director �4'pTFnMny"��� Building Division Tom Perry,, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnsta ble.m a ms Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section . If Using A Builder 'as Owner of the subject property ' hereby authorize ► — .� v to act on my behalf, �N-S-rRv cT'i o rj - in all.matters relative to work authorized by this building permit application for: 24 -D^r4 A L'w P-T Ccny tT,.MA (Address of Job). . gnatvre of Owner . Date dnt Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on th'e reverse side. DDRA , CERTIFICATE OF LIABILITY INSURANCE 06/06/2 8' PRODUCER (781)447-5531 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 458 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Whitman, MA 02382 Gwen Vosburgh INSURERS AFFORDING COVERAGE NAIC# INSURED Miller Starbuck Construction, Inc. INSURER A: MOUntain,Valley Indemnity Co. ' PO Box 726 INSURER B: Star Insurance 000204 Falmouth, MA 02S41 'INSURERC: INSURER D' INSURER E: ' COVERAGES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kDD`L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ELIM LIMITS GENERAL LIABILITY 328OOZ9156OZ 12/01�2007 12�01�2008 DON EACH OCCURRENCE $ 1,OOO,O0 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES(Ea $ 100,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS M - . BODILY INJURY $ N0 0 N WNEDAUTOS Per accident , PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WCO22091S 03/27/2008 03/27/2009 WCSTATU- OTH- EMPLOYERS'LIABILITY ER B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L:EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? OFFICER OF CORP ISIf E.L.DISEASE-EA EMPLOYE $ 100,000 SPECIAL PROVISIONS below yes,describe under INCLUDED E.L.DISEASE-POLICY LIMIT $ 500,000 S " OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS � 4 CERTIFICATE HOLDER CANCELLATION - s SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10, DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town Of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 Main Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE David H Mason ACORD 25(2001/08) ©ACORD CORPORATION 1988 PDF created with pdfFactory.trial version www.pdffactory.com License'or registration valid for individul use on before the expiration date. If found return I Board of Building - Y to: • One AshbuYton Place Rm t130 and.Standards . Boston Ma. 02108 Not valid without signa Joaea;slulwpV 9£ 20-1 IN 'Hl(lOWld iS`d3 M VM GNU IIIW M7 9JC 2i3IIIIN dIIIHd 'ONI'NO11'J aT,t Ji .f192id1S 1=13IIIW uoI}ejodjoo alLOAIM. adX�� 6VZ9LZ #jl 0LOVOZ/Ol= �uoii idx £L£011 up.l ��sl6aa N013"INO01N3W3AONdW1 3WON P1. 9 � ' Boar o Building RegulaVoi; and Standards One Ashburton Place* Room 1301 Boston. Massachusetts 02108 Construction Supervisor License ' License CS: 43338 Restriction: 00 Birthdate: 3/14/1653 PHILIP M `MILLER -- _.T s s Expiration 3/14/2009 r# 47 PO BOX 726 � ;;_, . . . . - _ __ --- . FALMOUTH, MA 02541 " Update Address and return card.Mark reason for change. -cni Co 50M-051o6-Pce490 i Address Renewal Lost Card f. C, l ,y. . o 1 ug Regulation and Standards Construction Supervisor Ucense r License: CS 43338 - Birthdate: '311411953 ExpiraU 14 3/1412009 Tr# 94�8`: Restnction:-,.00 ' PHILIP M MILLER ___'A ,. PO BOX 726 ' - FALMOUTH,MA 02541 Commissioner F O � 25 C l 0.'_�i�,:,.;:�..�._z.,.'.-..-,_,:'.�.I.��1 1:�:W'-:�...!.�i!.4f.:�.'�.��.F.�_.i:._.�.%..1�:��*ii l.i.�,.:..'�:.fi....i� ..�..:._��."�...--'.�.._.-_�_::,..�.._..,.:_�:4.,'.:�',".":_'2.;...�.....���:.�..�_*"!�,"�-'..:...:.,'I,�:.:4.%'�_..:w::..::._i..-.'�...,.*..�..�'._'�..,��,:"._.:..'..�.�,...,'_.:'�,...;,�-.:�..�.,'�--.p..::.:'��,,:...�'..::_:�0,.�,1.�.��"::.�..�:..'....:�.0-::.-_-.'�,.1�',,I:..,':::-:��,,-,:.����-.'.i.,�..-.,.�;'.:;e�.�,.':,...��:.::_.�f..� � 7F:.��:.+'�I_..�".�::.%..�..��...,_�.)��_.�:d;..F.���:+t�-:'':.._'�.:. u�c tit�Narnara Im, rvpery otult C , _::.'.:,.�:...'��.��.,;!..�.,�'.':�.::i'.,�,��9.l..:.��I;.-�..,.-.:�:�_�_..:�'��.._,.._:�,..:'�_,!'-'.� ."..J��._.'.'_..,.':�''..,.!,,�I,_�".._::.��.-`4...�'.:�.�,7..':I..,..�..:'.:_.1.'01..-:...,':M�'1!:...,...'...-_�-�.:.��......''.�.�-:....�..!:_::'..�.'�:'.��.���..,�..'.:I.-._�...:-�...�..�.�"._�.'I ....:.'-_I.:,���_.C'"...,.�-�....�1.'..�..�..::�_...._.�:�....:1-."i..'_:::'._.:.T...:.':.,-I_���'-:.'-_..�-.:,�.�_"'-.1,��i:�.�..'�,,_w.�..�.I,.%'%.�.�,;��1�.._ ..:,_�;..._..�i��b_'!�:..:.�_:.'._;...�:_..�:'�..,�-..%.:���Q.,.�.�.'z.::..%�.:....�,'-!:j�'.!�.+._,.. �:.;.N�...,�_:.,.��'..-I'�._.,.:...'�.'-_.._-I..�:.:,'I-.,..'��-:—�_..- :tr l ` 4p poi 3 �� R one stir bt o dwe'lCln N f24 64 N oro N der,�C .. � ool i GI D ' > ;73.81 X Cot G2 ..��. � I :... LL � . 2 t ....1.m_.,:-�.,.6.;11.:-*.-��'.._�—'..:::-�_:_��. �qr ` `F d'�A[Ytl�i 25 D�OI 0018 D 10oG� or1¢ _ �,�- .� �0 PAUI s1 .7 t12 CQ! tlfy 115 tttOC Q 1115 Ct 01L wars 'Dl~ o T 40 GROYER y : AJ EdmuV Grav►t &- .FirS�' Sarrcor a Ko 31311 �' . .9 9 the dueU rtg slhwn. het�eon, does not .in ci c o4 h . cm2a wi ti,ary¢{�ectwe da ee of 7 2 92 and:Mite hc&ur�ton� o F : th¢ 1 .' ' g G DeT corif ann rCo the local�orung 6y laws uti¢ atthe w o�cori.� vULth, Ces ec�to hor�i..j. t d dtrriertsiotia Seale t" I0 5¢Yba... i &: 1$ ¢ae l C!�'C t'Otri VtO�tWCL Q�1'Ce'I'I�1 ' Date: !I 20 0( dCfi .. , LiYlder A.5. C7^�LQCGIL �,�LWS � 1l Q"40 USCG LOYt�`7 Fite No ��P 235� PLEAS£ NOTE: The structures as shown on thn, plot plan are approximate pnly An actual survey is necessary for a precise determEnauon of the butld►ng locatgn and encroachments if any exist, either wav across property Lnes This plan must not_:be used for recording purpoties; or for<use in preparing deed descr:pttons and must not be used for .vanance or buiidmg plan purposes This plan must not he used to locate property lines Verification of huldmg locattonc;property lme dimensions fences or lot configyratton can only;.be accc�mpi�shei by a i accurate instrument surrey .which may reflect different mformauon':An ., what is shown hereon R.lease note,that: h►s is NOT 9 BOUNpARY SURVEY" and is FOR ;MORTGAGE PURPOSES'ONLY" .-, COLONIAL LAND SURVEYING COMPANY; INC i a 269 Hanover Street ;Hanover, Mass 02339 Phone 781-826 7186 Fax:781-826-4823 M�� rZA, rs . 2 X Ma 11-06 Ca 1 �X 5.t os l +✓ 5fb�+�A' l 1 xb��/ IG(o�c�xR t � �G�oStA►e, I.N AL N � -4j4AI.G �C i I i e , ty,It LAG ,f i 1 a 4a I } ` TOWN OF BARNSTABLE•BUILDING PERMIT.APPLICATION Map Parcel 04-1 Application# P06 053 J Health Division .?.`•b8 /b3-�-1 oc{ tf"'t p °I Q oteo o-q"10 ��' Date Issued "� Conservation Division Application Fee Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board lY" Historic-OKH Preservation/Hyannis Project Street Address )�`T Village , Owner 1 A►.Aes -t Q4 I- N &A Address Telephone is-0t . Permit Request AD: D AT 5�q�NZ22�W �L Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Z Flood Plain Groundwater Overlay Project Valuation Construction Type Vdco-p GAMY_ v(Ic-014 Crt �1�RS Grandfathered: ❑Yes ,(No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 19V4- Historic House: ❑Yes XNo On Old King's Highway: ❑Yes 4No Basement Type:)(I Full ❑Crawl ❑Walkout ❑Other i Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing 3 new Half:existing nfA Number of Bedrooms: existing _ new <: N Total Room Count(not including baths):existing - 0 new First Floor Roo unt Heat Type and Fuel: ❑Gas N I Oil ❑Electric ❑Other -- Ln rn Central Air: X Yes ❑No Fireplaces: Existing New Existing wood/coallove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage Aexisting ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use P- 4t`t a 9E.K�tw lam' Proposed Use BUILDER INFORMATION Name 1✓11 t L-cam C'roi*AS-r Telephone Number Address "b.,5?�-OJC —424d License# �'t• Home Improvement Contractor# I)C2 3 3 Eo L_4-_Ao-eT- ; C9.;:2_ Worker's Compensation# y4C-, ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ) FOR OFFICIAL USE ONLY ` \ APPLICATION* / DATE ISSUED - . UAPZP RCE O \ } 2 * ADDRESS ` VILLAGE OWNER` \ ' DATE OF INSPECTION: . { FOUNDATION FRAME . INSULATION \ / FIREPLACE ' ^ . . allELECTRICAL: ROUGH --FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL \ \ FINAL BUILDING 2 ' \ DATE CLOSED OUT / ASSOCIATION PLAN NO. % . ,, pep ar�rrzerxt of Industrial�ccidercts . Off ce of Xrx-pestigatzans 609 washilivon Street BOStOrz, AL4 02111 uz`t: Builders/Co�ntractors[E.Iectr cians/Tiuxnbers � Workars Coznpensatton Xnsura>a e AffiEla A Iica-at Information Please PrintD�F_ibly ` ai77 e (BusinesslOr nizationllndavidua[): �.J�t L.1_"S79— CJ1L C�fyST }ZV[`�1�N Address: Q o Bnx `�-2..C„ • City/State✓Zip;�.octMo�TH �� 025Ai�'hone.#: S'6B 53 1 12-$— Axe you an ero.ployer7 Check the appro'Driate box: Type of Projecf(req_=r-- : I I a a cruploycr with I b 4. I am a general contractor and I m E 7. R-cmodcling 0 Ncw consLI-mdon c:Mployces (full.and/or part fim- c).* have hired the stib-contractors 10 I am a sole proprietor or partrtcr-. listed oa the attached ebept ship and have np croployccs Thcsc sub-contractors bavc g, Dr-molition o k_ers o ecs and have w r working for me m a:y capacity. '1 y 9. ❑ Building addition [No workers' camp.-insurancc romp. insurance.$ rttrircd 5. c arc a corporation and its 10,F Electrical repairs or additions 3.❑ I am a Its) wnrr doing all work of havo cxeraiscd tLlcir 11.[]Plumbing repaiz� oz additions myself_ [No workers' cozup. right of exemption per MGL 12.[]Roof repairs c. 152, §1(4), and we haYt no int-=cr_reed.] t eLSlployCe5. [No wOLkGrS' 13.0.Othcr. Corop.InstIIi3S1cC rr_gvnrct±] *Any applicant that chccki bax#1 mut alto JM out the section below showing their WDT-},r_U' coropczisnJ?en policy in£arTMEDn- t HD=owners wbD submit thin af5davit indi�fmg tbcy arm doingall work and thEn hirr:outs de contrnetDTS must r•ubrmt anew aEdavitindca�g such. Tc=tmctarS that cbcmthi box must attacbcd an additimlal shcct showing the name of the sub tontrattars.and stun whether oTtrot thcs�Gntitits l�zvc amploy(-_cs. If the sub-conhactarT havo cznp)oyccs,they must pro-vi db fficir workers'comp,pob cy n=bcr. X ain an employer that[s providing workers' campensatzota Insurance for my emplarees. Below is the.policy and jab site • ircformaltatt. • Insurance Company Name: NAQ N`f'T'P,, eJ N/At.A-OX N- taJ tT`C Policy#orScLf--ins. Lic. #: (222o `�f Expo-adonDatc, 09 Job Sitc Address: 2-� -DrAei C,drJ}2_--[' City/StL_,ce/Z7P:5QP A) IT I"A Attach a copy of the workers' compensation policy declaration page (sbowin.g the policy numbcr and cxpLratiou date). Failusc to sccurc coverage as rcmrirr_r4undcr.Sccticn 25A of MGL c, 152 can lead to tho imposition of crimi�ial penalties of a 6nc vT to �1,500.00 and/or one-yeaz imprisonment, m well as civil penalties in the form of a,ST'OP WORK ORDER and a f e .of up to$250.00 a day against tho violator. Bc adyi.srd 11 a copy of this statement ma.y be forwarded to the Office of Znvcsti atzons of the DIA. for imu=ce coves c verif cation. I da (tereby certify under Che,pairts wxd perzulties ofpe7ur3 ghat the irformabon�rovida:d abvve is true a,-d correct. S-i atiu-c.:� Uat, 5 — Offtci_al use only. Do not wrRe 1n [his area,`tb be completed by ctly or tawtz officla� City or Town: Perrait`License# Issuing Authority (circle one); 1. Board-of Health 2,Building DepartrnenE 3, City/Towu CIerk 4. Electrical Lnspector S. Flutnbing Tnspecfor 6, Other Contact Persan: Phone #; Massachusetts General Laws chaptLr 152 rcgwres ali employers to provide workers' compensation for their cmpioyecs: pursuant to this statute, an emptcyee is dcfncd as "...every person in the service of another under any contract of hire, express or implied, Oral or wnttrn" An empLoyer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or mvrc Of the foregoing engaged in a joint cntcrprise, and including the Icgal representatives of a deceased employer, or tho. receivcx or trustee of an.individual.,partnership, association or otb.cr Icgal cnti.ty, employing cmployccs, Howcvcr the owner of a dwelling hDUSa having not more than three apartments and who resides therein or the occupant of the jwelling house of another who eraploys persons to do ro, -na.nce construction or repair work On such dwelling house or on the grounds or building appurtenant thereto shaU not because of such croploymcat be deemed to be an employer." viGL chapter 152, §25C(6) also states that "every stab! or Iocal licensing agency Rha-U withhold the issuance or •enewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not pro duced-acceptable evidence of compliance With the insurance coverage required." additionally, MC.M ohapter 152, §25C(7) states `Neither the commonwealth nor any of its pol.jgcal subdivisions shall Inter into any contract for,the performance of public work until acceptable cvidcace of corapliahee azth the ins-arance cquiremcnts of this chapter have bornprescated to the contracting authority." ,pplicants lease fill out the workers' compensation affidavit completely, by chocking the boxes that apply to.your situation and if ccessary, supply sub-contractor(s)name(s), address(cs) and phone number(s) along with their cerEficate(s) of isurancc. Limitr_d Liability Corcpanics(LLC) or Limitcd Liability Partnerships (LLP)with no employees other than the zrn'ocrs or partners, arc not required to carry workers' compensation inaa-ancc. If an LLC or LLP flocs have nployccs, a policy is roq C-d. Bc advised that this alhdavit may be submitted to the Dcpartmcnt of Industrial eeidents for confirmation of insurance coverage. Also be sure to sign and date the al�idavit The affidavit should returned to the city or town that the application for the permit or license is being rcqucstcd, not the DcPartment of iciustri.al Accidents. Should you have any questions regarding the law or if you arc required to obtain a workers' ,mpensat as ion policy,plee cell the Department at the number listed below. Sclf-insured companies should mtcr thcir If-insrtranGo EDCDSr,mmobct on the appropriate line. ity Or Towli Officials cast be sure that tho affidavit is cozoplctc and printed legibly, The D cp A=nt has provided a space at the bottom tbr affidavit for you to SIT out in the cvcnt the Off�cc of Investigations has to contact you regarding the applicant ease be sure to fill in the permitlliccnse number which will be used as a refczcncc number. Inaddition, an applicant it must submit multiple permi.tlliccnsc applications in any given year, nccd only submit onp affidavit indicating c=r-rLt �Gy information(if necessary) and undcr"Job Site Address" the applicant should write "all locations in (city or xai)."A copy of the aff davit that Has been officially stumped or marked by the city or town may be provided to the plicant as proof that a valid affidavit is on file for fuhu-c permits or licenses. A new affidavit,must be 511od out each ir.Where a home owner or citizen is obtain__ing a liccwr,or permif not related to any business or commercial vcaturc a dog liccnae orpersnit to busm loaves etc.) said person is NOT required to complctx this affidavit c Office oflnvos gations wound E -to thank you in advance for your cooperation and should you have any questions, a.se do not hesitate to give us a call Depa_TtMcnt's a-ddress, telcphone•and fax number. Tha C6ME0Dnwe9th of Ma.ssuhus�tts Delta cat of lade tial Accidents Offce of InvestigatlQus fiQf� Washinn Street Boston, MA 02111 Tel. # 617-727-4900 ext 4.06 ar 1-U7-MASS.AFB Fax # 6:17-727--7749- 11-22-06 ��,rw-�✓.m ass.go v�di a /vz Boar o ui ing eggu att ons an �nar s_. . - g � One Ashburton Place - Room 1301 " Boston, Massachusetts 02108 Home Improvemed 0ontractor Registration Registration: 110373 Type: Private Corporation Expiration, 1 W20/2008 Tr# 133422 MILLER STARBUCK CONSTRUQT-IQN INCsW PHILIP MILLER,JR. =_ _ P.O. BOX 726 EAST FALMOUTH, MA 02549 Update Address and return card.Mark reason for change. Address Renewal ❑ Employment Lost Card DPS-CAI a SOM-07107-PC8490 e lie'Pama�rearuaealfJ�o�✓�aaaacluc6P,ld - Board of Building Regalatio and Standards License or registration valid"for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registr46:.. 110373 Board of Building Regulattons and Standards One Ashburton Place Rm 1301 Ex t. n;=.Q/2012008 Tr# 133422 Boston,Ma.02108 -Type: Private Corporation MILLER S.TARBUGK CON$17 UCTION,INC. r PHILIP MILLER j A, �•+V 40 MILL POND WAX, EAST FALMOUTH.MA 03=6 Administrator - Hot valid-without-signature t Owe i Boar o t dil RZ e"gu I ations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Construction Supervisor License License C5: 43338 Restriction: 00 Birthdate: 3/14/1953 Expiration- 3/14/2009 - Tr# 9478 PHILIP M MILLER PO BOX 726 FALMOUTH, MA 02541 Update Address and return card.Mark reason for change. ,CAI 0 60M•05/06PC8490 Address Renewal ; Lost Card ..~. .... 01 u anono�andStandards i3oacd B i ag� 5 Construction supervisor License :i >k' Licerme: CS 43338 - Birfhd 53 fly ,tidn 311`412tx?9 Tr# 94�8 R 00 ";u PHILIP M MILLER GJ..�--�y -• _ PO BOX 726 02541 Commissioner FgLM01JTH•MA - i I - �ORD� CERTIFICATE OF LIABILITY-INSURANCE . . 06/06/200 PRODUCER (791)447-SS31 FAX (781)447-7230 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Mason & Mason Insurance Agency, 'Inc.; ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 4S8 South Ave. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Whitman, MA 02382 Gwen Vosburgh INSURERS AFFORDING COVERAGE NAIC# INSURED Ml er Star buck Construction, Inc. INSURER A: Mountain Valley Indemnity Co. PO Box 726 INSURER e: Star Insurance 000204 Falmouth, MA 02S41 INSURERC: INSURER D: INSURER E: s COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.: INSR ADWI TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY 32800291S602 .12/01/2007 12/01/2008 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ --" 100, CLAIMS MADE OCCUR; ¢y �; MED EXP(Arty one Person) $. S,0 A PERSONAL&ADV INJURY $ 1,000, GENERAL AGGREGATE $_. 2,000,0 GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ 2 000,O POLICY' PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMB ANY AUTO / (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY A :ONLY - AUTO ON EA ACCIDENT ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY. EACH OCCURRENCE $ OCCUR a CLAIMS MADE AGGREGATE $ DEDUCTIBLE w. RETENTION $ g WORKERS COMPENSATION AND WCO220915 03/27/2008 03/27/2009' WesrATu- onl- ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ lOO B ANY PROPRIETOR/PARTNER/EXECUTNE. _— = ,00 OFFICERIMEMBER EXCLUDED? OFFICER OF CORP IS E.L.DISEASE-EA EMPLOYE $. 100, If Yes,describe under SPECIAL PROVISIONS below INCLUDED E.L.DISEASE-POLICY LIMIT $ 500 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLD CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE $ EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE Tb THE CERTIFICATE HOLDER NAMED TO THE LEFT, Town of Barnstable BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 200 Main Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Hyannis, .MA 02601, AUTHORIZED REPRESENTATIVE [David H Mason ACORD 25(2001108) ©ACORD CORPORATION 1988 PDF created with pdfFactory trial version www.p.dffactory.corn ow1riEroY, Town of Bairnstable Regulatory Services f i �sAxxMesr Thomas F. Geiler,Director �p i63q. �a rEo. �a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-7.90-6230 Property Owner Must Comprete and Sign This Section If Using A BuRder �I�AM^i;r-A , as Owner of°the subject property. hereby authorize -4 I t-A--E f- �3'�',�K t3yC - ��SST to act on my behalf, in all.matters relative to work authorized by this building permit application for: •'z4 �ANA C��Sa.-T' - L-o'Ty t T . (Address of fob) .9 ignature of Owner,..; Date 9A L. P1)AV---^MA Print Name— If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. • �4 Town of Barnstable OF THE Tp " Regulatory Services 0 Thomas F.Geller,Director awxrtsrws ce MASS. ibsq. ��� Building Division Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 www.town.barnstabl e.rna.us - 0 Office: 508 862-4 38 Fax: 508-790-6230 HOIITEOWNER 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 possessa license,provided that the.owner acts as supervisor. 7—--`•'AEFINrTION OF.Fi0ME01'YNER- -;. ,,. 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 performed under the building permst. (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 requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner n Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or large; 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 lom,I-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 sit unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules &Regulations for Licensing Construction Supervisors,Scction 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 awarc of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that hdshe 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. - I -- - wow . �42ac� r T4 To, —FT—L--L— _I_: i - . TOPS FORM 33041- _ MA126 IN U.9.A. _ 1 {! I � , ' 1 1 I ( 1 i I O 4 _ I � � t � I Town of 13ar.nstable *PermitO- Expires 6 months from issue date r egulato ry Services Fee homas F.Geiler,Wrec¢or ` f / lV�v� 1�01•:. - .- tuilding Division x Tom Ppiwy,CBO, Building Commissioner ,��✓ AMN5T 'ain Street,Hyannis,MA 02601 U" ®� 8 www.tow.n.,barnstable.ma.us _ .. Office: .508-8J5 8 ': Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number � \,(i • �T Property Address J`T k 0_�t, �Z�U+ [Residential Value of Work 19, V u lJ• M Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address `-'"`' I1 c Nam as l _ J4 DCUW C � C huLf Contractor's Name L "`1_<' NAW Telephone Number -i 1 o - 4_R 10 Home Improvement Contractor License#(if ap, ic le) .3 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Che ne: 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 can 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 ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Horn rov ent ontractors License is required. SIGNATURE: Q:Forms:expmtrg Revise07I405 i_ i aptH�tOyy Town of Barnst llJle ti Regulatory. Services MASS. 'E Thomas F.� Geiler,Director 0'ppFo►�r•�°� Building D.ivisioll': Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 62601 ww�.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property OwnerMust !Complete.and sign_I lus Section If Using ABuilder as Owner of the subject J property hereby authorize \ -S &*-L' to act on my behalf, in all matters relative to work authorized building permit application for: (Address of Job) Signature of Owner Da e q Print Name Q:FORM&O WNERPERMISSION i ne lt-ommonweaun of iwassacnusetts Department of Industrial Accidents W Office of Investigations 600 Washua'gton Street Boston, M4 02111 www.mass.gov/dia Workers' Compensationklnsurance.Affidavit: Builders/Contractors/Electricians/Pivamers Applicant Information Please Print Ledbl� Name (Business/Organization/Individual): G�rVIQS Address: P o Q�o�_ 43 City/State/Zip: 1v 1� 02U,01 Phone#: Are you an employer heck the-appropriate box: :" 4 Type of project(required): 1.❑ I am a employer with 4•.❑ I am a general contractor and I , 6. ❑ New construction zmployees(full and/or part-time).* 4 have hired the�iub-contractois listed on the attached sheet $ Remodeling 2. I am a soli proprietor or partner-` .. r ship and have no employees These sub-contraciorshave 8,. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] - . officers have'exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work fight of exemption per MGL 11 P.❑ Bing repairs or additions myself.(No workers'comp.` c. 152, §1(4),.and we have no 12.[YRoof repairs insurance required.] t employees. (No workers' 13.0 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 lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 pokey declaration page(showing the policy Number and expirata®n date). Failure to secure coverage as required under Seetion'25A of MGL a. 152 can lead to the imposition of criminal penalties of a fine up to$1,50Q.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 un r t e qns d penalties of perjury that the information provided ab ve i true and corre Signafore: Date: I O Phone#: ' `O -Q0V Official use only. Igo not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one); r f 1.Board of Health 2.Buildlub Department 3 City/ Clerk 4.Electrical inspector 5.Plum in;Irasp-for 6. Other j Contact Person: Phone#: ps.• Y pp o i Board of Buildingeau Regulations and Standards ' HOME 1 PROVEMENT CONT License or registration valid for indivi Re istralloni RACTOR before the expiration date. -- 24310 du1 use only _ Board of BuildingIf found return to:h 007 � �� One A. Regulations and Standards TY Mdual Ashburton Place lim 1301 I Boston,Ma.02108 Ames Curley �� ==— -. , Imes Curl 9C11 1; = 17 Fuller Rd. mterville,M A 02632 Administrator Not valid without signs ure Town of Barnstable *Permit#C496 S ?S Expires 6 months from issue date PERMIT Regulatory Services Fee Z�,C2 0 X-P S Thomas F. Geiler,.Director, DEC 2 8 2006 Building Division Tom Perry,CBO, Building Commissioner . TOWN OF BARNSTABLE. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.nia.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint / Map/parcel Number - o 4 1 , Property Address d 4 [residential Value of Work I�t Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address y aj L 0C 'v' xak '64 Contractor's Name -T Telephone Number 0 ✓v V Home Improvement Contractor License#(if Qcable) W431 0 1 Construction Supervisor's License#(if applicable) ❑W, orkman's Compensation Insurance Che3k one: am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance ' Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) 2/Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Ho rlimapTove ent ontractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 r ± tMe roytio Town of Barnstable ` Regulat®ry Services BaxNsrast E Mass. Thomas R.Geiler,Director ; a ib39' ��� �ufl�(�lIfl��flV1Sfl®lfl. . Tom Perry, Building Commissioner , 200 Main Street, Hyannis,MA 02601 , wwwAown.barnstable.ma us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must �niple$e and oSign This Section If Using.A Builder as Owner of the property e J P riY , hereby authorize ' to act on my behalf, , in all matters relative to work authorized by this building permit application for. (Address of Job) , Wignatureot Owner Date e Print Name Q TORMS:OWNERPERMIS SION �� 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 Leg ibiy Name (Business/Organization/Individual): ( .:.5 Address: 0. 10 Y. 163 .1 a } City/State/Zip: LXu S k i�-0 2(D D I. r phone# Are you an employer? eck the`appropriate box:• Type of project(required): 1,❑ I am a employer with 4• ❑ I am a general contractor and I - 6. ❑ New construction loyees(full and/or part-time).T have hired the sub-contractors 2.ErAiam.a sole proprietor or partner- listed on the attached sheet 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8;. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' Comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 P Bing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12: oof repairs insurance required.] t 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 inforrnation.• t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit mdicating'such. �53'ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers,.comp.policy information. I am an employer that is providing workers compensation insurance for my employees. Below is the,policy aiael,y®b 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 ORDFER 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 un r the par d penalties of peryury that the inforenati®si provided rb®ve 's true and correct Signature:— Date: Phone#: 190 Official use only. Do not write in this area,to be completed by city or town official. j City or Town: Permit/License# Issuing Authority,(circle one): 1_Board of Health 2.Building Department 3.CityFfown Clerk 4.Electricai inspector 5.Plumbing laspector b. Other Contact Person: Phone#: f y - • .. Board of Building Regulations'and Standards HOME IMPROVEMENT CONTRACT License or registration valid for individu CONT R Re Istrdtiotna_ 24310 before the expiration date. If found re l use only t Est Board of Buildin Regulations and Sta dards -t r{}t2rn to: 007. g One Ashburton place Rm 1301 t�ibidual amen Curley i\ �- � i Boston,Ma.02108 Curley Ames y 17 Fuller Rd. �` -- mterville,MA 02632 Administrator Not valid without signa re r i Assessor's office(1st Floor): r' Assessor's map and lot nu. er ©� lv ` D`7 j moo*TM Conservation Board of Health(3rd or): INSTAL�p�,�>.��'�N�q(COMP i1 Sewage Permit number _ •�� E7 TITLE LE ' MASK i Engineering Department(3rd floor): � - NVIRONMENTAL Co °o aa�o. \d° House number OWN REGULATli , Definitive Plan Approved by Planning Board 19 • ONS APPLICATIONS PROCESSED 8:30-9:30 A.M.and,1:00-2:00 P.M.only, r TOWN OF . BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO <I-7� TYPE OF CONSTRUCTION ' r �1, °►2 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location �- �C-�c�S� C O-0 q--r C o—I -0 Z �� Proposed Use Q(Dp Zoning District Fire District Name of Owner Z,) C3 \Q y Q> Address Name of Builder�c�G�(1t�2 Stc,�-rQoeL COCK Address \u(� CO D� N Name of Architect Address Number of Rooms Foundation Cd\oC'4-0--ye Exterior ���e� Roofing Floors Interior Heating Plumbing Fireplace Approximate Cost _ 12 Oo d Area Diagram of Lot and Building with Dimensions Fee SDI , OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re rd?heve construction. Name f Construction Supervisor's License TAUB, VIRGINIA No 35287 - Permit For BUILD POOL Accessory to Dwellinq Location 24 Dana court 4 Cotuit Owner Virginia Taub Type of Construction Frame , Plot Lot j Permit Granted August 171 19 '2 Date of Inspection-1?0-2`--2' 19 Date Completed 19 s 4 i,. q. .Ir, T= / yr' 24 EL. " � �D•a n ?7f v � t i� . 37 In ,`, 412 -IN � •.g. y. 3. • _ ��.� :-'Z.{.•�' "•� SLO'PL CUM r.AO� o� l_ b SiG 3<.r- i) ( />�•:c,►�T �/� I` � �:' �' ,:: .. ! � t t :•� h .' 'Saris = �3.2 ET- T 35\T cs G.) T b cAstvvT EtZ-v.=.45,4 _ Asa .•o++w ,., i � t:� �l .✓'..m,.►' �_ ...�,�r+r, Assessor's map and lot number .........................:.................. ypi THE t0� SevSge Permit number v 3—�� . ! i BABd9TABLE, i House number —................. ...........................,...... rb 9 e� V ` TOWN OF BARNSTABLE BUILDING INSPECTOR �I /-/ u 0 X- APPLICATION FOR PERMIT TO .....C�C?. . 5.....1r G C...!....... �'�. ............................................................. '. TYPE OF CONSTRUCTION ............. ..................................................................................................................... ...............1...... 19. .� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for/a permit according to the following information: J�j Location .,Xat.....#.6..3.. ... C.�?.�-`�...... `�� . ............ .!..'%� �.....�.:.!. . f ..................................... ProposedUse ....... (.cJ /�l./.�"t. ...................................................................................................................................... ZoningDistrict ........R. ..................................................Fire District ... ....... ......................................................... Name of Owner ..f �?I!1. ./..�i.......... �t C!..4.................Address w ��c». .......... i cJ ,� c��l�t......!J q C0 f7�h� s Gf f T ��dtalit� Name of Builder .............. ............................................Address ................ ................ ...r;.................... ........... ..L. .... Nameof Architect ..................................................................Address .................................................................................... ._ Number of Rooms o Foundation �d r � e 7-� ................................ ..........................................................:. Exterior Ad.... C''A.V...... /c;,,✓6 .?..Of.. ............Roofing ......'.!. � fie.. ................................................ (� Floors ° `4--o G7 (-h,9 Interior ...:...14 '��-e'- f.�......�?.�.�:......... .�....�.�....................... ' .......................................................................... Heatingffh Plumbing �..� C- ......: ................................ Fireplace ...........`...... ...........................................Approximate. Cost ..... ` ................... ............................ Definitive Plan Approved by Planning Board -----------_------_-----------19________. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH r 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above , construction. Name ..... ....?!!......,/ ....................................................... Construction Supervisor's License .................................... � r r TAUB, DONALD A=56-41 No ,5346 Permit for ......................................tory Z Sirig le,,,Family. Dwelling ............. Location .Lot 63, 24 Dana Court ............................................................... Cotuit ............................................................................... Owner ....Donald:..Taub.... ....... ................................... Type of Construction ....Frame••••••••••••••••••••••••• .......................... ................................................. Plot ............................ Lot ................................ Permit Granted .............July 2 5 ' 83 ...... ................19 Date of Inspection 19 Date Completed ............... ...................19 Q I ' 150 :-T x � 5 1400 ' TOWN OF BARNSTABLE Permit No. --------------------------_----- Building Inspector : Cash - ------ -------� a .... d ,ego• OCCUPANCY PERMIT Bond Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of health Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ....................................................... ............ ............................................................................................................... Building Inspector I 71C SYS1 Eovl lot number ..................... ...............Assessor% map and & A INSTALLED IN COMPLIANC!" °F roe Sewage Permit nu ber ...... ....................... . WITH TITLE 5 VqViRdNIVIENTAL CODE AND 1 z 9 AZLE House number .............. ................................ MAB& .. ...... 'TOWN REGULATIONS 039. Ar. T N OF-. ,B ARN STABLE , BUILDING ' , INSPECTOR '0 /c,L" Sc 'APPLICATION FOR PERMIT TO ..... ..........(- ........... ............................................................. e7( J. TYPEOF CONSTRUCTION ...................................................................................................................................... (TI ..... ..... .............. ...... TO THE,INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... .....045 C .......... .................................. ...... Proposed Use ....... ................... ............. .. ..................................................................................................................... Zoning District ........R..........................a................................Fire* District ... ... CD .................................................................... Name of Owner Zo.ft.�K.d....... ..................Address ......... ........O.? ............................ Name of Builder ...J.Q.A.11.91. �rOl :................Address ........C,.-M.... ... .. .. ... ......... Nameof Architect ............................................................ ..Address .................................................................................... 'e Numberof Raoms ........................................... .......................Foundation ........ ... ............................. ........................... Roofi Exierior ...... ng ................................................ Floors Xe)'Vkj— w?, �Interior ... 4- ...I ............. .................... ................................................................................. ..................0.... ..... W............... ........ ....................... Heating ... ......... ....................Plumbing C) 0 a .1............................................Approximate Cost ..... ......... .................Fireplace .................. .... . ... Definitive Plan Approved by Planning Board ---------------------------------19--------- Area ....... Sf ..........Diagram of Lot and Building* with Dimensions Fee ........ ............I. SUBJECT TO APPROVAL OF BOARD OF HEALTHC��o- - 4 0 W6914110 ��o 0 ` ; (T/ OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the To )I Barnstable regarding the above the a construction. Name/.. ...... ....4................................................... Construction Supervisors License ................................ f TAUB, DONALD Now25346 Permit for ....................................tory :`... .S•ing•le••.aFR -1 •Dwe-l•]--in ............. - F J Location ..Lot...5.3......2 4...Dicer.a...GQu>;t...... ti ��, •�. { - o .4 ..................Dona Owner _ ...............................................................a `^' ,, •.= � f rr�. � �`� �. �,. Type of Construction ....F.rAme......................... ... ................ .................. . .......................... Plot .. ...................... Lot .. r n Permit Granted •• July 2..., ;, �� 19 83 Date of Inspection .....:..,•.. . ......:.' ..//....19 Date Comoleted :b;,'" �.:. :.,l......19 SY 117 G9' � d�,L 11 . r„y�{.v `'*.r•f ^'�,. .�Yc � -"" 1 4 ,.: .•..-r;A�" -rt�'::?-"* �rjt ""-`.., _r• tm». :•w',a-` .� `?�' - �'�".,..�. u .. a rio �• ^� A _ a `, o 6 "T/ At F � S7 C k T/ '! 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