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0057 EASTWOOD LANE
.s`I fas�WooD /emu . J i c fp Town of Barnstable *Permit Rqbw WMiL Regulatory Services 6S b- Ricbard V scali,Interim Director -PRESS Rya og I Building Division MAY 2 2 2014 Tom Perry,CBO,Building Commtnsioner 200 Main Stred,Hyannis,MA 02601 .. www.town.barnstable.ma us 1tl® Q �BLE Office: 508-862-4038 ax.50 ExPREss P,( w L N - ID M gWparcel Number W� U Not i�a d FAksmt Berl X-A+ays Ix�pAW Address ' C©Pmperiy . a Vesidwitial Value of Work S U/v (� Mime nm fee of M00 forwork"der S6000.00 Owner's Name&Address v 31 Conttac&s Name ) �F.tare1 �1� wS Telephone Number QOZ•2 z — Al Hones Lnprovement Contractor Uceme#(if applicable) l 73 245J Email: Construction Supervisor's Ikmse#(if applicable) OWorkmsn's Compensation Insurance Check one: ❑ I am a sole proptietar I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workmen's Comp.Policy# C.i o2 7Wt3ft0.-I Copp of Insurance Compffnft Certificate most accompany each permit. Permit Request(check box) ❑ Re-roof(horr[eane sailed)(stripping old shingles) All construction debris will be taken to R&roof(hurricane"Red)(not stripping. Going over existing layers of roof) Re-side Replacameut Windows/dooWslidtus.U-Value • 30 (max irm .35)#of wind o #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Eiectrkai&Fire Permits required. •Where requffa Immme of tins permit does cot=mpt oomphmw wBh odw town daps regandms,ie.Hntmw,CasrsavatM eta ***Note: Property Owner must sign Property Owner Letter of Permission. f AV, of the Home Improvement Contractors License&Construction supervisors Lie me is i'eq r SIGNATURE: T:II�VIId Iri&�igg Ct�estli7Q'RB� Revised 061313 r - Renewal EW REN1EIVAL BYANDERSEN MA linum fl!.AW, tAndersem Cy Wlttow rer►rnere.n -As14-p,�.,yy - 26-rllhii,i Roil • lane-alse,RI 02365 U.I.11 mm41 y? Phone 8,,i i 553.2235-Pax 401&13,[i4iqS K,uw,uA ir.R4r,•.mw,t Somtbera:iVet. H^sndows.LLUdfbto Rcoewd by Andersen of Boadicea'New Ea&glwd CUSTO?►€.WXtg0Ow ANI'O my oR teLbIODELING AG RI Er T Ba/ritxf i'bor,F�—r..�_r7• � IY' t}� l./fi�' Dxl:til:lier�e�::. '� /!.__:�. !l?N!s} -.ettMG2�.Iry Sc► and 27 Cede i R0.2rrt _UX4 ill rK4 p C604 (.r1��/�� s?= Fians:Y.,�INurUcv:J �f _ y�'•,rrtgMv:•rG.tiLeprr. BrryU41 ltrr.67jnicstlyaut WW4VA_ ly:tUctx.tc.(lHYdn'Se tht prcKtt NN aitd,oa Wnimx of 5ewr.Fsril New i ngkintd%Wndu 1A.0 d,bf:l3aea+.wi by Aril,-rseri. Suuilienn New INnglirtd 9`Canlrxtor'},in;'%=t&uiec.rlli die trims and mn6liimis aescriFAJ on tht fit:nb.;ind dic'2i rmz uf' lltiR IrcrT ant-.Brit on the alai dwd.%%Pcrilicalfom,hcci(s)fcolkclik-d.this A-- enroraii"i. N sxoric ❑'Condo ❑HDA7 Total Job Amount ti Eaictirrle�e 3 nya,�i:ur_ hit thud of pnymen_ rt Cheti< a �.r Cash fdnzn d Cm*Cards are zxepted for depsir a*-mnciet rn 12 of the Wance at Sint of Job(33 ti: pr•oje:s toss(Am a"fret Card lL ens hraii Bf sir r%this r Ea rand Ccnpl=aa oa:c Agrftft nt.you admawfedp due dr eab=as S=n of lob and dtC i l Obimcc on 5rbourvil i 9 1`.&L Dahnso on 5ubswium awspkeiaro at job eaax b=r.,aec by sr"n Ca,-ri0cslal of Job(33%):: card and twsr be mule py penoeal®ack bark dreck or cash. Buyer(s)agrees and uodersstands that this Agremment constaute s.Ih*entire'andersdaadiag betumon"p,xd4ps,and tlsat amm sir:no verbal understandlaq%x changing any of the terms of this;Agme mess.Buyer(s)nclmawledgrs tlaat 11-wolr(0 (1)has read 46-isi Agnomens,understands the terms of this Agreement,and has ve.cen a cirmpleted,signed,and dated copy of ti'tis Agrees eat,iodading the it**attached Notices;of Caiorel nsion,on the date first written above and(2)wrax arally informed of Ruyer'r;right to CauCel the.ASreemche.DO NOT SIGN THIS CO.NTltACT VP THERE ARE ANY BLAN%SPACMS. (RAodr Island SaW OxW Notice to Buyer.(1)bo not sign this Agreement if any of the spaces intended for Ow agaced terms to the Extent of then available information are lefeblanh (2)You axe entitled to a copy of tluSArreemrent as the time you sign it.(3)You may it any time pay off the full.unpaid balanee due under this;Agreement,and in so doing you may be eatid@4 to receive a partial r rlaate of.the finstrtce artcl insurance chzrgtxc (4)The seller has no right to unlawfully enter your premises or cuumn&any breaclb of the peace to mpossess gouda purchased antler this Agreement.(5)You way euaeel this Agreement. If it hag not:been signed.24L The train efrtce or a branch olrrce of the seller,rrovidCA you o olafy the seller at Ws or her main 01li4o or branc>n oflisae'dha%,=is the Apeemeat.63P eegis trod or oerti ll"mail,which shall be posted not later tbao Chid ht of ibe tb rd ealesadur day aherr the day on.which the druye,r signs dhe Ageeemen4 raelading Snaday red sayholcday oft-w-kick ' wa�ta�w�e7t/101�, Wrsisv[atvsecma.�a.Soo lLo aaaeoagsi�•u s-r±t9 ktpto owaeG.Ualava{'eem reraotK l;saatioo of bafve'-i 646e4o4 fiikp-11r1 Yrr it'ivi the rhwinrmr.rlxv asin 1 mmnr ore T.rru•iSi-d sus the B?ti do 1.1--3 Car i—i—�L»irirrr list �� tla.xr+:rt sLt Renews)b rJdct stir oi: u2lta Vey Bnaad Bur ri rs�' Batycr(s} f �P a1UF I'riDt Nmilc Or Pmdut:t Manager '[`"tint Mane Print Name YOU, THB BIJYI X(S), MAY CAANCEL THIS TRAN-SACMON AT ANY TYMI& 1,-R(OR TO L%UDh'IGHT OF THE THMD 13USINESSDAY AFTER THEAATEOFT SrRANSAt TION.SEE THE ATTACHED AO`3'iCft Or.CANcE.IIATIoNFORMS kOA AN YUPIT IINATIGN OF THIS RIGHT. ear NOTICE OF CANCELI.ATI9N - - - - _R - - - � - Ne nc-ry.�cpN EI.t..eTtnN Date oFTransactiot+ J*�' " You may cancel Date ofTrantacdon SLLAOU may cancel. this transaction,without arty penalty or obligation,within this transactWn,without any-perially,or obGgatiun,within three business days from the above date.If you cancel,any t three busiftss days from the above date.If you carted,arty property traded In,any payments made by you under the 1 property traded In,any payments trade by you under the Contract:or Sala;sad may nocetioblo instrument executed I Contract or t'n1r,,and any a w_.k4.at by you will be returned within ten business clays fpptrwing I by yuu will be returned within ten business days following e rcc*t:by the Seller of your cancellation ntice.Ind any I rnroiitt by the Wier of yaw cancellation nodca,and any security interest ari4hg out of the transaction will be security interest arising out of the trarlstiedon will be cancrled.If you cancef,you must make:available to the Seller I cant ered'.If you cancel,you tttust make available to the Seller at your mmiclan M, in substantially Osgood condition as when 1 at your residence,i it substantially ac good condition as when received,any goods delivered to you under this Contract or I received,any goods delivered to you under this Co ns mct or snit„or you may,if you swish,comply with the Instructions of I sale;or you may if you wish,eornply with the instructions of th6 Seller regarding the rennin shipment of tl're goods at the the Seller regarding the reWroi shipment-of the gow:s at tim Sel ier's expense and visit.If you do make the goods available Seder's expense and risk.If yotr do make the goods aysflahle to the Seller and the Seller does nit-pick them up within I to the Seller and the Seller does not pick them rip within tvmvty days of the data of cancellation,you may retain or I twenty days of the date of cancellation,yiaou-may attain or dispose of the gaoch without any further obligation.If you t dispose of the goads without any further obligation.if you: (dill to atakr the gvotb available to fire SLAW,or if yuu agrVe I fail to make the goods available to the seller,or If ylov agree to rew.rn the goods to the Seller arrd fail to do so,vhan you I to return the goods to tho Seller and fail to do scN then you remain liable for performance of all obligations under the remain liable for performance of all obkgaVoris under ft Gontract.To cancel this transactilon,mall or deliver a signed l Contraot.To cancel the transuLion,mar or deliver a signed and, dated copy of This cancellation notice or any outer 1 and dated copy of tbk cancellation notice or airy ath er ' written notice,or son d a telegram to Renewal byAr idersm of 1 written notice,o r send a telegram to lienewetl IbyAridorse-:n of Southern New England at;26 Allblon RoadJ inc i,R1.02S65, i Southern Now England at 6 Albion Road.Uncoln.RI 02865i S g NOT LATER THAN MIDNIGHT O P S 1 NOT LATER T14AN MIDNIGHT OF _ S-/t3 (Date) l (Dale) I HEREBY CANCEL THIS TRANSACTION, l f 14EREBY CANCEL THIS T RANSACTION. • B.!Yrr•rb�tuua '- rerntfCiine- lYam- � trvrrr's SlgnxrR Va1naN�aar cart. r%bA Copy:White Buyer Co,?r Yclln-, 6upr;r Copt..Pink '� e Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Oinsiruction Supcn isor License: CS-095707 ' BRUN D DENMSON it 7 LAMBS POND E1[1ltC Charlton MA 01507 i Expiration Commissioner 09/08/2014 ectmoomwa.Ll71' fa:(..�� uA, U�,ltOffof Consumer Ad BUSlness Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration TVW: Supplement Cord SOUTHERN NEW ENGLAND WINDOWS LL EmftNOt' SMOM14 DENNISON BRIAN 1137 PARK EAST DRIVE - WOONSOCKET.RI02885 Update Addressend intern card.Mark'reason for change. SOAt o was"r L:i Addraes ❑Beat"I r...,EmPloymem Leg Card .+��- men ofGoneter A166r f�lwhm 0ep4Uo. Unrest or rea4lntb re a valid for Indlvldol e only '" g-1�NE IMPROVEMENT tbNTRACfOR before the expiration date.11'Faced return to: Won of Coe T ..ARaies and Business Regahtiun- - gp 'S�Ratlktretbn:173240 lO Park Plan-Sane 3170 "'�-' Expiraeen:BM4r20U .Pp Ieman. :AM Berton,MA 03116 S011fHERN NEW ENGLAND WINDOWS I.I.C. RENEWAL BY ANDERSON DENNISON BRIAN 1137 PARK EAST DRIVE �✓�-, _ \'1-1 WOON90CKET,R102895 UWeronremry ai.—J.Not valid w116onl dgnat.e The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,ALL 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lecdbl Name(Business/organization/Individual) eed efl j Aa S LLL Address: (o loA/ Loa. City/State/Zip L I/�/CD AI , •4 1C, + 1.9' Phone#: y©/ o? g' ?YDO Are you an employer?Check the appropriate box: .Type of project(required): 1.1 I am a employer with 90 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' 4. Building addition [No workers' comp.insurance comp,insurance.$ g required.] 5. ❑ We are a corporation and its 1D.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their ll.❑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 aJ a c comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inlormation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp"policy number- I am an employer that isproviding workers'compensation insurance for my employees Below is thepolicy andjob site information. Insurance Company Name: ds!/ Policy#or Self-ins.Lie.#:��+/� ����/ 3�� Expiration Date: cZky Job Site Address_,�2 �S City/State/Zip: Mf 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification l do hereby certi under the pains and penalties of perjury that the information provided above is it and orrect c t 3icrnature: Date: 'hone#: /y I- a a g — �? — 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#: Client#:30124 SOUTNEW ACORD. CERTIFICATE OF LIABILITY INSURANCE FDATE(MMMDIYYYY) 8/06/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER WE:c`r Anita Little Willis of New Jersey,Inc. PHONE No 856-914-1881 (A/C.Ne Et:856 914.4660 1015 Briggs Road,PO Box 5005 EMAIL PO Box 5005 s: anita.little@willis.com Mount Laurel,NJ 08054 INSURERS AFFORDING COVERAGE NAIL ti INSURER A:Selective Insurance Co of the S 39926 INSURED INsuRER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 DB/A Renewal by Andersen 26 Albion Road INSURER D: Lincoln,RI 02865 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL UB LTR TYPE OF INSURANCE POLICY EFF POLICY EXP SR POLICY NUMBER M/DD MIDD .LIMITS A GENERAL LIABILITY S202945900 8/10/2013 08/10/201 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY RAMAG I NTEr Inca $100 000 occuCLAIMS-MADE �OCCUR MEEEED EEXXP(Any one person) $1 O 000 PERSONAL 6 ADV INJURY $1 00O 000 GENERAL AGGREGATE $3,000,000. GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $3 OOO,OOO POLICY ECTT Loc $ A AUTOMOBILE LIABILITY S202945900 8/10/2013 08/10/201 Co BtBBIINED SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) 1$ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NONX HIRED AUTOS X ED AUTOS PROPERTY DAMAGE AUTOS Peraccidenl $ $ A X UMBRELLA uae OCCUR S202945900 8/10/2013 08/10/201 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMS MADE AGGREGATE 1$5.000.000 DED I I RETENTION Is C WORKERS COMPENSAILITY TION 0000068028 RI 8/21/2013 08/21/201 XwC STATU- OTH. AND EMPLOYERS'LIAB B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN AIC927818352394 8/21/2013 08/21/201 E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? � N/A E1OOOOOO under(yes,describe u andMandatory In M E.L.DISEASE-EA EMPLOYEE $1 000 000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1 000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,N more apace Is required) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE.' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI 02865 AUTHORIZED REPRESENTATIVE 01988--2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S215109/M215088 AXL I i i. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Tt 1,IN OF 41P .` ti,P,t� Map �f?� Parcel # qQ Health Divisions `¢ }' � t Issued t Conservation Division Application Fee S� Planning Dept. t. -Permit Fee lP` Date Definitive Plan,Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address � La Village Owner Er-ari Is --n0/E 7t'_ Address S;' ��Zarc"e: � L%t �c� H,4 Telephoned Cj 5 � Permit Request Pe 12-kle i e ei T1'r6 r:1 eAn t '�� i tit + //�Cyal Y 4ck an 1,eh +�^s k_la I%OK u)P P iYr� e, J Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation %5:006, Construction Type tea' 04 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family hd Two Family ❑ Multi-Family (# units) Age of Existing Structure 3 3 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: iW Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing Z new Half: existing / new Number of Bedrooms: _ existing _new ` Total Room Count (not including baths): existing 55_ new First Floor Room Count S Heat Type and Fuel: ❑ Gas W'Oil ❑ Electric ❑ Other Central Air: ❑Yes ;'No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes X No If yes, site plan review# Current Use Proposed Use F APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �l�'c�2�r � t Telephone Number : 01 !219L�� Z/5�� Address l ,� �wc�r�r� Fdr, License # (f 1j 4 aS Home Improvement Contractor# Worker's Compensation # N ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO f� rrt31 kle LCc� l J SIGNATURE DATE -:� - FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED v- J MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION" 1 FRAME 'e'--xyt Ok INSULATION �&5 t FIREPLACE ELECTRICAL: ROUGH FINAL 1 PLUMBING: ROUGH FINAL 5 ROUGH .--' ,`- tv FINAL x r 'X R FINAL BUILDING_' .DATE`CLOSED OUT t ASSOCIATION PLAN NO., + F 4 TheCommonwealth of Massachctse.tts t ( Department of.Industrial Accidents'' 3 �9 t7ff ce of In vestigtrtonis " 600 Washington Street Boston, MA 02111 „v f 1 www.mass.gov/din Workers',Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A1plicant Information Please Print Legibly Nane'(Business/Organization/Indtvidual): —c4ael v � �Cf? a e• �a —��Q" - C i t/State/Zip: Phone 4. Are iou an.employer?Check,the appropriate box i' 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 l arn'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.=• workers'.comp, insurance. 9.,� Building addition [hio workers' comp, insurance 5. ❑ We are a corporation''and its officers have`exercised their 10,1 Electrical repairs or additions required.] ,- 3.❑ Iam a homeowner-doing all'work'r right of exemption per MGL 1 I.E] Plumbing repairs or additions myself. [No workers' comp. c. 152, §l(4), and we have no 12. Roof repairs , insurance`required.jt employees. [No workers' , t - comp. insurance required.) a]•,Other *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 in such. tcontractoa 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 iliat is providing-►vorkers'compensation insurance for my employees:,'Below is the policy and job site information. Insurance Company Name;. Policy # or Self-ins. Lic # °Ty Expiration Date... - Job Site Address: City/State/Zip;, Attach a copy of the workers.' compensation policy declaration page (showing the policy number grid expiration date). Failure to secure coverage as"required under Section 25A of MGL c.,d 52 ban 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.forrn 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.irisurance coverage verification,. {' w .I do hereby certify cinder the pams an penalties of perjury that the:information prov' d above is true and correct. St nature' - Date: Phone#: F e only. Do not write ill this dreg;to be completed by city_or town offccial.° n: Permit/L',icense# ' thority(circle one):a Health 2: Building C)epartment 3, City/Town Clerk" 4. Electrical inspector 5• Plumbing Inspector son: Phone#: Information and Instructions Kassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. lursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, ncpress 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 nceiver 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 of 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 L.LP 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 pertnit/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: . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia i of THE r Town of Barnstable Regulatory Services * MRNSTABLE, v KASS. Thomas F.Geiler,Director En59,�"�� Building Division Tom Perry;Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 1 6 as Owner of the subject property herebyaiitliorize L -eY .I e- to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature or CF6 bate Fravk v�.. Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. i Q:FORMS:O WNERPERMISSION SHE Tp�y Town of Barnstable �Of Regulatory Services * E, t Thomas F. Geiler,Director BARNSTAB[ S, MASS. 165q. ,0 Building Division JfD�aY a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: City/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town-of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages,a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would Aith a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, -that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fomi/certification for use in your community. 1 = � Massachusetts- Department of Public SafctN Board of.Building Regulations and Standards Construction Supervisor License One-and Two-Family Dwellings License CS 49205 MICHAEL'J AUPPERLEE 169 SANDALWOOD DR «. COTU IT, MA 02635 , Expiration: 7/14/2012 Commissioner Tr#: 29361 w✓fie V.viieaiu.ea o ✓G / iuOQtw - Board of uu uu a-Reoldatio s,aq] t�ndar HOME lmokOVEMENT CONTRACTOR Registration: 153440 E*iration' /1/2010 Tr# 278146 Type�lndividual rt r i� MICHAEL AUPPERLEE RENOUIONS ,1 _ €{: MICHAEL AUPPERLEE,P--_- 169 SANDALWOOR?QR t, COTUIT,MA(2635 t Admimstma pr i i I i a{ I �I I� i rr - I' If 11 I i ilk ! ®l11® - - ' I ! I I ! I I-! I I �� I ! _ I��'� I VIM I i f I I t I i I I -1 _ I i ! ' I ! i I I i ' ! i 1 j : -T- j _- - -- -- ;- - - ' ti i - 1 _ : I I ! � IYY ----- r ------- -i --t.- - --- - i ----�'i- ----i- ---- - i--�.__ I i I I i , V . pr L i .• �(�7- 1 � �A c- I 4 '. A4>rv1 ..4(/,,,, n - � c - TE L C C E rJ C E ov—>T!i-'7' 7-1—IA 7- 7-AXE FOOA DA T/OAj IS � Z- CAA TE 0 A 5 S/—/0 4UAJ 0 ! TAV E L Q 7-OF 6 rY of �A Aj--57-/4 C��'-��". 'w•..,16,=✓(;.�I�,/� iC..�` , �,+""" �"`��f :irt'r t Lr•C.+.�;� I�C.+•�rw'R..++"�A"�F1+�'(eqr� ��` 4 0 ✓ _ fir+f Y 'i..,✓ .Y, , l. '. t"�' _. �,_ _ ,. - i'9 f •:= a4." �i tLc �s£rPaA� �� » 2 y y � u� v AssessoQS map and loft:number .....M .......l:r•.14 �0'�' 1 2`7 7� SEPTIC;SYSTEM-IVI � gE :,�' 1271, ! INSTALLED IN COMA m ; ' Sevvage'Permit number ...,........�:......::. WITH AN 'TICLE II COMPLIANCE I SANITARY STATE 3 oFTNET� C3 =� �,� ,a�. CODE AfVp TOWN } TOWN: OF BARNSTABLE ' 1 BA"STLDLE, MABEL639. BUILDING , INSPECTOR ri67q. �90 NPY r.� APPLICATION FOR PERMIT;TO ..................b i.'I& ............................... ...................................... 3 : TYPE OF CONSTRUCTION ..............U_9J0"0(.... . .FM.MA. ........d.Q.&.V.1.1.!!LCJ�..............,..........:..........' s `" ........................ ..........19.?. 7 TO THE INSPECTOR OF;BUILDINGS: The undersigned hereby?appliieoes for a permit according to thPe-rfoll��rving information: �� A Location ......... 6.4............/2...................��S.f u?o(�...^,�J.........`�•�J�-IJ�U e.�.6�r e...............C/,.,� Ia. I N ProposedUse .1...gl ................................................................................................................................ Zoning District ............... .. ...............................................Fire District ...........4.... ......................: Name of Owner ...l.el4c elq... .�`t'C}ox...k4.0=..T�?CAddress ....!..P..6......... .........6.A�f�01.l.Q............... Nome of Builder ....r..��.1f , ��...........................................Address ................................�.......�.le................ Name of Architect ..•.1..e.u.egeh...........................:.............Address ..............................'S&.n?.e........ Number of Rooms .6 ���i.,, 4 ar e4 W�C wv ...........:...........................................Foundation .... ......... .............. ...................................... Exterior `��......... .....Q/L.. .�.....V.!?�Cw4a�G400fing ... ...........QS,t4?Ql. .......................... F • ' �...•.........LA. Y•T.f.. Floors ...... .n P................................Interior ...... Y....... .� . ...................... y--• Heafirig" .:...i� ......::. t .!../.....................................Plumbing ...... 0.� !'. ..�V.4,..................................... ��� 1 a5.0t r� Fireplace ........ .. .��(...................:..Approximate Cost .........r�� 00.U....... Definitive Plan Approved by Planning Board ___,____________________________19,________. Area ........ ./....�....S.. .`....... Diagram of Lot and Building with Dimensions Fee 9:14Q SUBJECT TO APPROVAL OF BOARD OF HEALTH eY s I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ' Name .........-.t5t... ........ Tellegen-Ferrone Associates, Inc® Not19495 1 1/2 story ................ Permit for .................................... single, family dwelling Locatioi°i'.. .Ea9twood MOO ....... - w • - r '1 ...................... ...................... _ ................. t ,t Telle en-Ferrone Associatesp Inc® Owner .................... ........................................... _ = 2Type of Construction frame ....................... ......... .'1......................`......................................:.... at .... .................... Lot ......... Z$................ 'August 12 77 - i Permit Granted '.Date of Inspection .. ..1. . , ........:19 .. 'Datd Completed 71-7 .........:19 PERMIT-REFUSED = -'• ......... .................................. 19 _- r .......................� .J. ............: .................................. - - - • •1 ......................... ...........•- .......................~. .. ............:.. .{........... ............... ........,....... .........................................................................:..f = `� -41 /•" 4pproved ................................................ 19 i ............................................................................... �� • . .................... ...................................................`..... - _ . .•,r .r`+'t ,� -_ � � 4,..! ..� #w a• ,, � C� t w„_54�....: ��-:'0 u � .- .+ ,.r. r r.• _ Assessor's map and lot. number .....�:...:....._,,:................. Sewage,Permit number TOWN OF BARNSTABLE i SARNSTADLE, • ! '°� pYp,��°� BUh`LDING INSPECTOR APPLICATIONFOR PERMIT TO ................ .......................................................................................... TYPE OF CONSTRUCTION �� � ' Ff�+C1.lMM. +� v) ``'-F I I Lia ......... ... .............19.Z.. -TO.THE.INSPECTOR OF: BUILDINGS: j' The undersigned] hereby applies for a permit according to the following information: � / 1/ Location ....... b.4...........19...................- -.�1 to �l? .. C ........ f;, �"' U r U? 1/ R'f�`f?.............. Proposed Use ............. L, )E? 1 !I/, .....................................................................................................I......................... .... .. . . .. • T ` Zoning District ............... ...................Fire District ............(ip....`.'.::.�................................................ Name of Owner ?..�� r ea... " 0+? •iP•• 5,5• ...`I�r7�Address ....!.. ........��.,3........6. .tt.�ear�st,��,P.............. Name of -Builder ......... ......... Address ..............................:.:� fl � v ............................ r-- 1. . Name of Architect ....1-fe ,le�-*F' ...................................... Address Srzwe Number of Rooms ..........................Foundation �� +�� Et/ �' �Ol?C ��P � y.•••.•..................................... Exterior `�/5ti TAl....���....f?�a��% SiCF,P U�/�rRoofing /X. /!� !....$•....!t,Q .......................... Floors ....:l.a.� �.......` .1./ :r11. ................................Interior ......// ....n � ........................ Heating �� ......... ?.!..�.................:..............:?...Plum'bing ......� 1 ?r f .......................`.............. Fireplace ........� .< � < . ......1/Ji�//53 .. �* .....................Approximate Cost ......`•'•�`t bC . '....................... �.. . .. ......... Definitive Plan Approved by Planning Board ________________________________19________ . Area ......................................... Diagram of Lot and Building with Dimensions .- 0 -'"'" .a?.S Fee ............................................. 1 SUBJECT TO APPROVAL OF BOARD OF HEALTH t)j� f rj , �o A/ ct wo o d ►`•Cl I hereby agree to" conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. a a Name t �►v , % +� ...... �L ....... .................. � � I T llegen-Ferrone Associates, Inca A=25-40 Jam` AIJ 19495 1 1/2 story No ................. Permit for r .................................... single family dwelling ............................................................................... Eastwood 4keed A-/2/kel-, Location ................................................................ Cotuit ............................................................................... Owner Tellegen-Ferrone Associates, Inc® ................................................................. • ame Type of Construction ..............fr....amI .................. ................................................................................ Plot ........................ Lot ..............#18........... Permit Granted Aupust 12 .....19 77 ........... . ................... Date of Inspection ....................................19 Date Completed ..............................:.......19 PERMIT REFUSED ..................... ....................................... 19 ............................................................................... ........................................ ..................................... Qz4" Approved ................................................ 19 ............................................................................... ...............................................................................