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0001 ELMWOOD CIRCLE
1 � ____ .� � � ,. 1 i z�. n A � r 1 ll � G , �. ' �`� =3 S. 90 • � 2q9 A 63 ld LoT h� zo,j 2 5268'Q� P2o pos Gn . 00 - 07 CCU -7-Oe.1^1 o r= a M 1 40 ' ZJ)A7-,=— 6- 22 -77 I �'��'T'i� - T,�•/��" Tr/� �'�U lt,.�,4 T•C��v !� �., L_0 CA 7E V A :5 S f-ta 0&/ L 0?-OF /S S! bE ���1�Z x=» ;% .-~ AnJc� , S � r7cf•�'�7"� r-y ?�.�:� �oAJ- " ,'�'C.?,�'�`.'� i•V!77,�•f �_-�,PJ J i'�.l� 7s-�''�Gs��`.,t!`;�F:. f�:,r�;/tJ T„�' �t�, 7'AI,41 7` `4,14E Z c :'7-A T TA4 !VD!/, 16 , Y✓14L-AJ TW& PGAN � r LO R. A J A 4f-- Z;)EA,>A G. Z�>,E 5 !G;AJ Tom. 7 L 3 d SVRV� L. .Ai ! C /<! Assessors map and lot number ..... SEPTIC SYSTEM MUST BE Sewage: Permit number ..............v�'.............................. INSTALLED IN COMPLIANCE ,. WITH ARTICLE II STATE EK TOWN OF BARIS, r ; @_ TOWN. 4{ i BAUSTA&E, -INSPECTOR INSPECTOR 9 (� 0MPYa` .7' .T(.... f f� APPLICATION FOR PERMIT TO ............... �... ........... uj. TYPE OF CONSTRUCTION ...:........................p_ C, C' . rrL/ .Q........�l:�IJC,X!.I ........ ,I. ' �. .... . r= F, ..................... ,5...:.......19 .� TO THE INSPECTOR OF. BUILDINGS: The undersigned hereby applies for a permit according to the foll owing information: / / Q Location ......../10. ........ ........(.r� Cyt.�Gl. f...... ....... R. .n(��ii.1R�( G�..1\FL.......... ProposedUse .............f).Wje_t]..(-n ......................................................................................................................................... ZoningDistrict ..................R .:...............................................Fire District .......... Q.�Ih�.�.............................................. nn Name of Owner ..1. �epevy2a1�141Q...17 .,.. 124'.....Address . .......... // �O�v....., 7�...........C '.�t:�l�........... Name of Builder. ..:....1. �.�1'��.�I..........:..................:..........Address ......:.....................r�'�G� {......................................... Nameof Architect ... 1.4a..!.q` s:.,l.......................................Address ........................... . ......................................... Number of Rooms ................ ................................................Foundation ../.8.......�l�.K.!`.�.�........co.n. ;. ...... Exlerior .... ... �.�' fir.. pty... .IC4 �e ..Raafing ... ....... 1..!........'L�.`?�L..r.............................. �.. .... ......... /�` sue? ' Floors ....X .10.1�. Interior .../............... ............................................... .. .. ..... . ... Heatin9 ....� ....../.... ...b.l..I.........................................Plumbing- .. �yP.... . ... Fireplace (.�.5.�.. ...... .... Approximate Cost ............ 8®C) Definitive Plan Approved by Planning Board ________________________________19________. Area ......s,.J....7. ..................... Diagram of Lot and Building with Dimensions Fee /.7 ........... SUBJECT TO APPROVAL OF BOARD OF HEALTH l 7 5 - 11 V) I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . G .. ..... :y Tellegen-Ferrone Assoc. , Inc. j193Z8 11�2sto ' No ............ Permit for ... ... ... single family dwelling - �- •tuit Owner .....Tellegen. Fe.rrone Assoc. , -Inc. ti ............................. ............................... Type/`of Construction rame ..: . . ............................... .....�1 .I............ , •` Plot ............... .. Lot ................................ Permit Granted a........ .June...23..........19 77 Date of•Inspection .. �..... ........ .19 ` J J,•_ r 'Date Completed .. 3d ........ .19 PERMIT REFUSED r ....... .: ..... .. , �..........:...... ,,19 f . ........... .................................. .......................... yA.ry.. ............ ..... ......................................... ..... . ...... ................................................... . ....... ..............y'. . .. .............. 'Approved ... ................ ....... ... 19 /........................................................ ........:...... .. !r �'� +"�v.r..�r/ .... ✓.' .{. __ h „ . VX`.... .i.�.""✓"f..jh, ti:y,+`5. .- . vr':'h�.. entl4i '' .l%rY .{`..r�.w�rY.n'!'" -F ... �+ a . z Y ,t sse is map and lot. number Q,(v — �"' 2-�'... ,.... . 1.. q 7 y l k� •Ji �: .vim � V1� Sewage Permit number 012 TOWN OF BARNSTABLE {i ypFTHETO SS r i 211 STLELE, i G o Y_a�e� r: RILDING INSPECTOR _ APPLICATIONFOR PERMIT .TO ............... lt i ........................................................................................... TYPE OF CONSTRUCTION .......................... jt 11!a)CI.... ........jlbi.&16I mo................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit accordingto the following information: r ! / Location ...... ��. ........! ......................... 1 ..!..! .�� 1 � «CT/!p ...... 1n (Gl /t1l)", f. ��........... /r S ......... J , ProposedUse ............. a�a�?.�� ,��. ..................................... ................................................................................................. ZoningDistrict .................. .. ......................................Fire District .......... 4'.1...�.............................................. Name of Owner fA ��rrevi £?ttnnA.. ../ ,.. ya ......Address RQ!: ......: 7 ..........`... .st f',/11 --6ZP,........... �.. 2�� ........................................Address .........:...................S71?. ?a ?......................................... Name of Builder .... Name of Architect ......Pl� .!�.....................:.................Address ............................. .......................... SQ2......................................... v 6 ``'' Number of Rooms ..................................................................Foundation .. .......V ....,!.... .......0 ,�.,/` `,P Exterior ..5�.....T. . I ....�?r..�'g-41 .. RuCui��PG...Roofing ..�+���5.....��? �? .r.?...... .......! �... �? T /a 1� !� rock Floors �✓ ,O .� / J 4 i i7.V............................Interior ...�............�...�.t°.,.........,........................................................................ Heating.. �W. ...... � ?.!...�............................ Plumbing ..��? ?� .�`.... ��"UC... ...............................�.. : �. y. Fireplace IJ5?e.d k' 1..�. ........................Approximate. Cost ............;?.0. nc>C')............................... Definitive Plan Approved by Planning Board ________________________________19________. Area ......< .../ ...........:......... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I � u�Qt� 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name T...�. ........... . � 'fir Tellegen-Ferrone Assoc. , Inc. lk=10-29 19328 - 1 1/2 story No ..'.............. Permit for .................................... single' family- dwelling ............................................................................... k Location ....... ........................................................ c �45Imu otuit ............................................................................... Tellegen-Ferrone Assoc. , Inc. Owner .................................................................I frame Type of Construction .......................................... ................................................................................ Plot ......................... .. Lot ........#�................... June 23 77 Permit Granted ........ .........................19 Date of Inspection ....................................19 Date Completed ......... ............................19 PERMIT REFUSED ............................................................... 19 ............................................................................... ............................................................ �..:... - ................... ........ �.�. ............. .................. ... .. ...... f0.�........................ Approved ................................................ 19 ; ....................................................................... ....... oktr�, Town of Barnstable Pernutl# Expires 6 mor t r iss to date RegulatoryServices Fee snxtvsrna�.e. � " 9. Thomas F.Geiler,Director AtEC AAAr A r f . Building Division Tom Perry,CBO, Building Commissioner A 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red.X--Press Imprint Map/parcel Number Property Address / 61 in wem C i ?cIt 1�rul FVR/esidential Value of Work /l Od Minimum fee of$35.00 for work under.$6000.00 Owner's Name&Address I / z�savf� C�iZG/� C 071Vd v. 6 Y/_1 Contractor's Name , Telephone Number Home Improv ment Contractor License#(if pplicable) �0 d C 5 SS PE Wit I Zc . �� X-PtionSupervisor's License#(if applicable) RE ��man's Compensation Insurance JUL 2 4 202 Check one: I.am a sole proprietor Yam the Homeowner have Worker's.Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# "- C' C �d 1 G b a. U Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box)- Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to El Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ R -side - �tt� � f/JG'l d_ '. • #of doors / [ Replaceme Window door slide .U-Value �� maximum.35 #of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.ffistoric,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improyeme ontractors License&Construction Supervisors License is r quired� SIGNATURE: d 3 C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 THE COMMONWEALTH OF MASSACHUSETTS A Department of Public Safety One Ashburton Place, Room 1301 Boston, NIA 02108-161$ APPLICATION FOR RENEWAL OF CONSTRUCTION SUPERVISOR LICENSE �AY�w► NAM ` �p ADDRESS 1�� i �4C� CITY m. OLD ADDRESS ' co 0�20_6A E-Mail Address Licenses not.renewed by .the expiration date become void, and shall after a two-year period, be reinstated only by examination of the licensee (780.CUR 110.R5.2.4). All future.renewal notices will be sent by e-mail communication only unless an applicant certifies, under pains and penalties of perjury, that he\she is unable to be notified via electronic message. (Please refer to the certification line at the bottom ' of this form.) AUTHORIZATION FOR RELEASE OF RMV INTORMATIO-K �K, , C�� My signature .. ow,authorizes the Department of Public;Saftty to electronically � � q� access tny; �t graph from the Massachusetts. istry�ofMotor Vehicles databases 1 - or u5'etfl`i n e/registra N,. N r:� MA-IUV photo release signature 'Qtherwis6'lease>submit a 66lor Passport Photo 2x2 inches in size taken within the past 6 months showing current appearance.Tape photo on edges to the box ficiach photo on the left with ciear.tape. 4 Tapc photo edges to tbcs box. .. Please enclose a check or money order made payable to the Commonwealth of Massachusetts for the required renewal fee of$100.00. DO NOT MAIL CASH::Please include your license number on the front of the check or money order. Mail the completed renewal form with payment and photograph to: Department of Public Safety-CSL Renewal P.O.Box 414376-Boston,MA 02241-4376 Also, please refer to the Department of Public Safety website.@ www.mass.gov/dps for newly enacted continuing education requirements for construction supervisor licensees. I hereby certify under the pains and penalties of perjury that to the best of my knowledge and belief the information above Likorrect and that I have filed all state tax returns and paid all state taxes required by law and complied with all law of mmonwealth r�e t the withholding and payment of child support. gn tore of Applic 't Date ` I hereby certify,under the pains and penalties of perjury,that I Signature am unable to access a-mail notifications and therefore request U.S.mail notifications of renewals. Date s:\admin\current'fonms\bbrs\appl_csL renewal_8 2011.docx 7/17/12 :Details iYtc =t5ial Wetsite of the Executive Office of Pablic Safety and Security(E)PSS) Mas&Gov Home State agencies State Online Services ' ensee Details uemographic Information Full Name: JOHN T STRUMSKI Gender: Omer Name: LiCenseAaaress inTorm,ation Address: PO BOX 861 Address 2: City: BUZZARDS BAY State: MA ipcode: 02532 o ntr : Un' ed tates License n orma ion License No: CS-064817 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 6/28/2012 Issue Date: 1/10/2011 Expiration Date: 6/18/2014 License Status: Active Today's Date: 7/17/2012 Secondary License: Doing Business As: atus Chan e: 18 Prerequisite inTormation No Prerequisite Information iscip ine No Discipline Information ocumen um �C�lo� e 1lVindow ©2011 Commonwealth of Massachusetts Site Policies Contact Us Site Map elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&license_id=253767& 1/1. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ' OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulatio s Registration" Type:Type: 10 Park Plaza-Suite 5170 Expiration,;"� 37A 14 Supplement Card Boston,MA 02116 CAPIZZI HOME 1MPR0VEMENT•`:INC. JOHN STRUMSKF.' 1645 Newton Rd. Cotuit,MA 02635 = Undersecretary Not out signature t � . � � ✓he T�o7n2nti�z�eaGCh ay'✓(/(,aaaact},uaeCl6 + Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration;; 06740 Type: 10 Park Plaza-Suite 5170 Expiration"._fi123_2014 Supplement Card Boston,MAD2116 CAPIZZI HOME'IMPROVEMENT C. JOHN -�- 1645 N&Alon Rd. Cotuit,MA 02635 r Undersecretary. Not va id wi out signature Nzsachu,setts- De lraran:'nt of%' blic Safe#i. _ $ozird of Building ' Regula#ians ar^id Standards .. . . Coi s#ru-cti�on SUpervisor License 1:acesise CS 64817 ..,:QO BOX 861 BUZZARDS BA tMA 1t72532 Yn Expiration: 611'spot Z C nnhni�sipnei-' .A 10573 The Comrnonwealth.of Vassachusetts Department of Industrial Accidents Office of Investigations 600-Washington Street Boston,MA 0211.1 www.dtass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I Please Print Legibly Name(Business/Organization/Individual): lIf;;?2t• �r l� _71n PO8/V EyV- _ZN� Address: /4 eW-1VAA0 City/State/Zip: bo a / *>� Phone.#: Jr11 M4 9 A;re an employer?Check the appropriate box: Type of project(required): 1• am a employer with 4. 0 I am a general contractor and i 6,, New construction employees(full and/or part-tune).* have hired the sub-contractors 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 workin for me in an capacity. employees and have workers' g Y P tY• 9. Building addition . [No workers' comp.insurance comp.instuance.# required.] 5..0 We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp.. right exemption per MGL 12.❑Poof repairs insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13. Other , A comp.insurance required,] "Any.applicantlhat checks box#.1 must also fill out the section below showing their workers'compensation policy information. y,• t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new 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'coin',policy number.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /7•�/OG`, � ���� '�.l �/l�� i�i�/t1t" �d Policy#or Self ins;Lic.#: W C. C-so `.0 A 0 l® Expiration Date: � � �/ 612 Sob Site Address: ] e/ ®® C, � 0��3rpClT 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 Investi ations f the MA for insurance coverage verification. I do hereby ce u er the pains and peg aloes o jury that the information provided above is true and correct. Si nature: / Date: Phone#: ® Ird Official use only. Do not write in this area,to be completed by city or town officiaL s 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#:47298 CAPIHOM ACORD,. CERTIFICATE OF LIABILITY INSURANCE . DATE(MM/DDIYYYY) 6/08/2012 THIS CERVICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms.and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER i - - CONTACT Karen Walther - - NAME: Rogers 8r Gray Ins.-So.Dennis PHONE Fnx 877-816-2156 A/c No Ext: Alc,No 434 Route 134 EMAIL ADDRESS: - - South Dennis,MA 02 6 6 0-1 601 INSURERS AFFORDING COVERAGE NAIC# 508 398-7980 INSURER A:National Grange Insurance Co. INSURED_ - INSURER B:Associated Employers Insurance Capizzi Home Improvement, Inc. Capizzi Enterprises,Inc. INSURER c: INSURER D 1645 Newtown Road 'INSURER E Cotuit,MA 02635 INSURERF: - 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MMIDD MM/DD A GENERAL LIABILITY MPB1075H 6/08/2012 0,6/08/2013 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED nce $500 000 CLAIMS-MADE OCCUR - MED EXP(Any one person) $1 O 000 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- JECT LOC - $ A AUTOMOBILE LIABILITY. M1 M28044 6/08/2012 06/08/201 (CEOace den SINGLE LIMIT 500,000 ANY AUTO BODILY INJURY(Per person) .$ ALL OWNED X AUTOS SCHEDULED AUTOS - - .BODILY INJURY(Per accident) .$ X HIRED AUTOS X 'NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X rive Oth Car $ A X UMBRELLA LIAB OCCUR CUB1076H 6/08/2012 06/08/2013 EACH OCCURRENCE $5 OOO OOO EXCESS LIAB .CLAIMS-MADE - AGGREGATE - $5 00O 000 DED I X RETENTION$10000 $ B WORKERS COMPENSATION WCC5010547012011 12/25/2011 12/25/201 X `O Y LIMIT oTH- AND EMPLOYERS'LIABILITY - YIN ANY PROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $1 000 000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE $1 000 000 If yes,describe under - 'DESCRIPTION OF OPERATIONS below. E.L.DISEASE-POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included.Officers or Proprietors CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE . THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE r" ©198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S82889/M82857 TLH _:. Page 7 of 7:. Capizzi_Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS = LETTER:OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT �- b:L,4X OWN THE PROPERTY LOCATED AT .W06 0 Cr 46c-e' IN . 1 ;MASSACHUSETTS.• _:: I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A.BUILDING PERMIT IN ACCORDANCE WITH 780 CMR. THE MASSACHUSETTS STATE BUILD G COD .. - - SIGNATURE OF OWNER. � IrT - OWNER'S ADDRESS: ' OWNER'S TELEPHONE:- LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S:SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd.; Cotuit, NIA 02635 APPLICANT'S TELEPHONE: 508=428-9518 RESPONSIBLE OFFICER: -RESPONSIBLE OFFICER`ADDRESS: RESPONSIBLE OFFICER TELEPHONE: c � �oFzHE Teti Town of Barnstable *Permit# Expires 6 month' o issue IT Regulatory Services Fee aARNSTABLE Thomas F. Geiler,Director , i639 VUW OF SARa.^,0' TFD N1p'tcA �`t NSTABLE Building Division Tom Perry;CBO, Building Commissioner 200 Main Street,'Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL-ONLY Not Valid with oui Red X-Press Imprint Map/parcel Number Property Address L ' ""� esidential Value of Work Minimum_fee of S25.00 for work under 56000.00 Owner's Name& Address-JSA/y , CeV.111; Contractor's Name Telephone Number lf0-; / Home Improvement Contractor Li ense# (if applicable) Construction Supervisor's License# (if applicable) - [�Workman's Compensation Insurance S U ` Check one: . Q�'I � G P^-•I-am . • []-�-atrr-t-1}e•-I�I-erxee-v�rer- ('d� Q-Lhave Worker's Coinpensation1nsurance, Insurance Company Name Workman's Comp.Policy# � M3 d Q Copy of Insurance Compliance must.accompany each permit. Permit Request(check box) Ut"`Re-roof(stripping old shingles) All.construction debris will be taken to ❑ Re-roof(not stripping. Going over'existing layers.of roof) ❑ Re.-side 4 # of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License &Construction Supervisors License is., re d.. `. SIGNATURE: . Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC - Revised 090809 The Commonwealth of Massachusetts Y— Department of Industrial Accidents 14 Office of Investigations .600 Washington Street t 'Boston, MA 02111 �� Sy WWYV.Inass.g ov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): 1 �r Address: G � (� I`Q'�� CitWState/Zip. Phone # d-37- -1 Are u an employer2*•Check the appropriate box: Type of project. (required): j, 4. I am a general contractor and I 1. I am a employer with 6. ❑ New construction -- * have hired the sub=contractors employees;(fu11 and/or part time): - - - -- 2:0.I am asole pro or partner-,; listed:on the attached sheet 7. 0 Remodeling ship and have no employees These sub.-eon tractors have g Demolition.- " working.,for ine in any capacity. employees and have workers' 9. .E] Building addition [No workers' comp. insurance comp.insurance.1 required.] 5. We are a corporation and its, 10.0.Electrical repairs or additions 3. L am a homeowner doing all work officers have exercised their 11,E] Phimbing epairs'or additions right of exemption er MGL myself. [No workers' comp. p 12:0 Roof repairs insurance required.]t C. 152, §1(4),`.and we have no-',', ' employees. [No workers'' 13.�Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the sectionbelow showing their workers'compensation policy infomiation. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new,af-iidavit 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 is providing workers' compensation insurance for my employees. -Below is the policy and job site information ll Insurance Company,Name: 55o�k ' Policy# or Self-ins Lic:#*' �0 © 20 Expiration Date: l} P�C�0/0 ( city/State/Zi Q�(o. /� ?L Job Site Address: � l/ P 35 Attach a copy of the workers' compensation policy declaration page (showing th'e policy number and expiration.date). Failure to secure coverage as required-under Section 25A of MOL c. 152 can lead to:the imposition of criminal penalties of a `fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 i ranee coverage verification. I do hereby certify and e nc% enalties.ofperjury that the information provide above is true and correct. Si nature: �J Date: � Phone#: Official rise only. Do not write in this area, to.be completed by_cityor town offcieLL ; f .. l City or Town:. PermiULicense.# Issuing Authority (circle'on'e): ' 1.Board of Bealtli 2-Building Department 3, City/Town Clerk 4; Electrical,Inspector S: Plumbing Inspector 6: Other Contact Person: ` Phone#: InformatioD and fnsfructiODS s to provide `Yorkers' sachLISetts General Laws chapter 152 requires,all employerceOf anotheru compensation nderany contra I opflhire, Pursuant to this statute, an e1pployee is defined as ".,.every person in the service express or implied, oral or written:" An ern to er is defined as "an individual,partnership, association, corporation or other of legal deceased employer, oo feore py of the foregoing engaged in a joinl ente1pnse, and including the legal representatives receiver or trustee of an individual, partnership, association oieols er legal entity,and who resides ther oein, or hpeloccupant of then the owner of a dwelling house having not more than three apartmsuch dwelling house of another Who employs persons to do ma`because of sucth employmenpt be de mconsrilcLion or reir Workoed to bedaneelmploy r.' or on the grounds or building appurtenant thereto shall no withhold the issuance or MGL chapter 152, §25C(6)also slates that"every state o.r local licensing agency shall renewal of a license or permit to operaeb sinesseorPoo con mpliance wstruct ith t'he insurance e coverage gs in the requ rely' applicant who has not produced acceptable Additionally, MGL chapter 152, §25C(7) states"Neither the{�nacCen abletevidence of co plih nor any of]its po I lance with d the]m'sr�a shall enterinto any contract for the performance of public work Lint] p requirements of this chapter have been presented to the contracting authority!" Applicants '. . e workers' compensation affidavit completely,by checking the boxes that apple r�ifiocate sh,of on and, if Please fill out the w ( ) necessary,supply sub-contractors)name(s), address(es)and phone numbers)along with then insurance, Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)wit h no employees other than the._ members or artners, are not.mquies have red to carry workers' compensation ins.uranc to the De a�if an LLC DlmEnt off r LLP Indust ial P employees, a policy is-required. Be advisee Thal this affidavit may be submittedP Accidents for confirmation of insurance coveragc. Also be sure tolsignsanabeing requesteddate the Yntot the Dep1artment of ld be returned to the city or town that the application for the penntt or Industrial Accidents. Should you have any questions regarding the law,listed below.ySelf insou.are u ed compaquircd to nies should enter their ber compensation policy,please call the Department at the n self-insurance license number on the appropriate line. City or Town Officials at the Please be sure that the affidavit is complete and printed legibly, The Department has t provided a space. aiding the applotantn of the affidavit for you to fill out in the event the Office of Investigations has Y an Please be sure to fi11 in thc.permA./license,number which will be,usedneed only submibone affidavit er, In ndicatpng,c�ient that musisubrrut in permit/license applications in any y ion3 in_(city policy information (if necessary) ai3dunder"Job Site Address" theraaprk d by should city OrOr wr,ttown may beprovided of the or town)."-A copy of the affidavit that has been officially stamped o Ytit Each applicant as proof that a valid affidavit is on file for future permits o[noier laced loses. A new any busdavit must be iness or commercial venture year. Where a home owner or citizen is obtaining a license or p Jett this affidavit. (i,e, a dog license or permit to bum leaves etc.) said person is NOT required to comp tion and should you have any questions, The Office of Investigalioas would like to thank you in advance for your coopera please d'o not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of IndustTial Accidents Office of Investigations t 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 •, w ir Town of Barnstable O Regulatory Services' W_RNSTkBLF_ Thomas F. CkEar, Director 77`b b 9 Building Division RFD µAS p rom'Perry, Building Commissioner 200 Main Street,Hyannis,MA 02601 �vmv.t Own.:b ar astable,ma.us paz: 508-790-6230 Office:'_508-862-4038 Property OW-her Muu t r C_ o rr plete and Sig T s section P. f Using A Builder w . I as Owner of the subject property:' to act on m behalf, - hereb aut orize y. y . in all matters relative to wo k authorized by this b.uMng permit.,application f or: , Cn �3S `r ° Z . . . . . (Address of job Signa `e of Owner . Da h Part Name' f f:Pro e Oyrier is applying foremt please cromplete tie .T Homeosvne s License Exemption Form on the.reverse side. s Town of Barnstable Regulatory Services Thomas F. Gei]er,Director i HARTtSTklnx, 7 7r 39- Building Division ` A�FD �a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 wtvw,town.barnstable.ma,:Tas / Fax: 508-790-6230 Office: 508-862-4038 , HOMEOWNER LICENSE EXE1vlYTION Please Print E. DATE: JOB LOCATIO village number street� "HOMEOWNER":' `' Z name home phone# work phone#1 CURRENT'MAILING ADDRESS: ` } state zip code city/sown 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 a / supervisor. „ 1)E3IN?TIC:`' OFHCT-AEO`vtiNER a 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_(SCC6011 109.1.1) CO liance with the Stale Building Code and other The undersigned homeowner assumes responsibility for p 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 requirem • Signature of Homeowner s • Approval of Building OfEcial 5,000 cubic feet or larger will be required to comply with the Note: Three family dwellings containing 3 State Building Code Section 12TO..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 Hoincowncr shall act as supervisor." Many homeowners who use this exemption are unaware that they arc assum ng the responsibilities of a supervisor(sec Appendix Q r y Rules&Regulations for licensing Construction Supervisors,Scr-'On 2.15) This lack of awareness often resutts in serious problcins,.part.culad 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 homcovrner is fully aware of his/her responsibilities,many com issue is a form currently used by munilies require, part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this several towns: You may care t amend and adopt such a form/certification for use in your community. n-turDT71T F.C\FCIRMS\homccxcmnLDOC Massachusetts - Department of Public Safet-, Office of Consumer Affairs&Business Regulation r Boad of Buildin- Reaulations and Standar('Is HOME IMPROVEMENT CONTRACTOR Construction Supervisor License Registrationtio . � �"!:- 125630 License: CS 70225 '. Expiran, '�* ti10/2012 Tr# 291636 Restricted to: 00 Type; An..,. GREGORY A HARTSON GREG HARTSO,N:,�:-�,�:.,:!':...-'!*�:'�'::-i��,- 14 MAIN ST GREGORY HARTSON ORLEANS, MA 02653 14 MAIN ST ORLEANS,MA 02663:'.—' Undersecretary Expiration: 517/2011 Tr,: : 10564 Restricted to: 00 License or registration valid for individul use only before the expiration date. If found return to: 00- Unrestricted Office of Consumer Affairs and Business Regulation I G-1 2 Family Homes 10 Park Plaza-Suite 5170 Boston,MA 02116 Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Not valid without signa" re Refer to: WWW.Mass.Gov/DpS co/R CERTIFICATE OF LIABILITY INSURANCE OP ID KC DATE(MMIDDIYYYY) v 1 07 06 10 .THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Kerry Insurance Agency, Inc. PHONE AX Scott Kerry A/C,No,Ext: (A/c,No): PO Box 1945 ADDRESS: North Eastham MA 02651 PKUUUUtK CUSTOMERID#. HARTS-1 Phone:508-255-8000 Fax:508-240-1860 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Harleysville Worcester Ins.,Cc Hartson Inc. INSURERB: Associated Employers Insurance Gregory Hartson 14 Plain Street INSURERC: Orleans MA 02653 INsuRERo: INSURER E': INSURER F: COVERAGES CERTIFICATE NUMBER: _ REVISION NUA_4BFR:-•--. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVDbutst' POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A COMMERCIAL GENERAL LIABILITY CB 7GIO95 08/25/09 08/25/10 PREMISES(Eaoccurrence) $ 100000 CLAIMS-MADE F_x1 OCCUR MED EXP(Any one person) $ 5000 X Business Owners PERSONAL&ADV INJURY $ 1000000 _ GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER* PRODUCTS-COMP/OPAGG $2000000 X-I POLICY PECOT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR. CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERSCOMPENSATInr.L..._ `7CC 50.nne? 012nnn,_. U ..,.,,,_,_,. -"^ '- •�.�. V VJ.Js icvv.� -vu/25i 05 Oo/25/ G - X- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS 1 OTH ER ANY PROPRIEfOR/PARTNER/EXECUTIV� E.L.EACHACCIDENT $ lOOOOO OFFICER/MEMBEREXCLUDED? ! — I, /A (Mandatory in NH) • E.L.DISEASE-EA EMPLOYE $ 100000 If yes,describe under ' DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Residential Carpentry Greg Hartson does not elect coverage under the current workers compensation policy term. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable AUTHORIZED REPRESENTATIVE Building Department 200 Main Street Hyannis MA 02601 . © 988-2009 A ORD CORPORATION. All rights reserved. .. ACORD 25 (2009/09) The ACORD name and logo.are registered marks of ACORD oFZHE r Town of Barnstable ' ' Regulatory Services w saxxsrABLE. + MASS. �* Thomas F. Geiler, Director 1639. ATf°""AAA Public Health Division Thomas McKean, Director 200 Main.Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Certified Mail: 7008 3230 0002 5177 8360 October 13,2009 Ms. Elizabeth Powers 1 Elmwood Circle Cotuit, MA 02635 .EMERGENCY CONDEMNATION- AND ORDER TO VACATE Finding of Unfitness for Human Habitation and Determination of immediate Danger In accordance with M.G.L. c.l 11, sec. 127A'and 127B, 105 CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and.105 CMR 410.000: State Sanitary Code,,Chapter'H: Minimum Standards of Fitness for Human Habitation;Donna Z. Miorandi, R.S., Health Inspector for the Town ofil Barnstable, on October 10, 2009, conducted an inspection of the dwelling located at, 1 Elmwood Circle, Cotuit, Massachusetts. The owner's name of this dwelling is Elizabeth Powers. Based on the results of that inspection, the Barnstable Health Department finds that the dwelling is unfit for human habitation. Pursuant to M.G.L..c. 127B and 105 CMR 410.831 (D), the Health Department further finds that the conditions within the,dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay may be permitted in making this finding. Conditions found within the dwelling, which give rise to the emergency finding of unfitness and determination of immediate danger, include: T 410. 750: Conditions Deemed to Endanger or Impair Health or Safety 410.750 (I) Failure to comply with any provisions of 105 CMR 410.600, 410.601, or 410.602 which results in any-accumulation of garbage, rubbish, filth or other QAOrder Letters\Condemnations\l Elmwood Circle,Cotuit,MA.doc I causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. The occupants, Elizabeth Powers, and two minor children ages six (6) and twelve (12). had much garbage, rubbish present in the dwelling, and a lot of clutter. Much garbage and rubbish on.all the interior stairways thereby not providing for safe passage. Debris piled high on floors and furniture. This occupant has a condition known as "hoarding" and needs social and, sychological assistance. 410.600: Storage of Garbage and Rubbish The occupant of any dwelling shall provide as many receptacles for the storage of garbage and rubbish as are sufficien t nt to contain the accumulation before final collection and locate them so-that no objectionable odors enter any dwelling. The occupant has caused objectionable odors both inside her dwelling and emanating to the outside. There is much debris on the exterior of this property throughout the yard. In addition there are also many chickens and chicken feathers. Inside the dwelling are two separate birdcages with cockatiels. 410.750: Conditions Deemed to EndanLyer or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well- being of a person or persons occupying the premises. (B) Failure to provide heat as required by 105 CMR 410.200 (A). The furnace of this dwelling was shut down and thereby inoperable. (G)Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. This dwelling has no clear passageway due to the accumulation of rubbish and trash. (1)Failure to comply with any provisions of 105 CMR 410.600, or 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (N) Failure.to provide a smoke detector or carbon monoxide alarm required by 105 CMR 410.482. This dwelling has oil heat and had no carbon monoxide detector and had inoperable smoke detectors. Chief Olsen was on site on Saturday, October 10, 2009 and was taking measures to correct this matter. (0) Failure to maintain a safe handrail or protective railing for every stairway. The stairs to the cellar had no safe handrail in this dwelling. Q:\Order Letters\Condemnations\1 Elmwood Circle,Cotuit,MA.doc Based upon these findings any and all occupants are hereby ordered to vacate and the landlord/owner is ordered to secure the subject dwelling immediately as of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated she may be forcibly removed by the local Board of Health (Massachusetts General Laws C. 127B), or by local police authorities at request of the Board of Health: Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from $10-$500. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this unit may not be occupied without the written approval of the Board of Health. Any person needing access to the inside of the dwelling must get permission from the Board of Health prior to entry. Note: This is an important legal document It may affect your rights PER ORDER OF HE BOARD OF HEALTH Thomas A. McKean, CHOIRS Director of Public Health Town of-Barnstable Cc: /Elizabeth Powers, Owner */ Mr. Tom Perry,Building Commissioner. Chief Christopher Olsen, Cotuit Fire Department Ruth Well,Town Attorney' Chief Paul MacDonald, Barnstable Police Chief Kathy Eccleston,.Department of Family&Children Q;\Order.Letters\Condemnations\1 Elmwood Circle,Cotuit,MA.doc Town of Ba rnstable Regulatory Services Thomas F.Geiler,Director 9 MUM. -- Building Division .s6gg �0 ACED 39 a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 'o,�°3 PERMIT# D FEE: $ , SHED REGISTRATION 120 square feet or less(�, 4 � 06 Location of shed(address) Village. 2 2 8 W Jr y roperty owner's name Telephone number �R k�o -e-'/i Q l P C C (O Size of Shed Map/Parcel# Si Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? � Conservation Commission(signature required) PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg' u REV:121901 9 A=35. 90 yy -14 °4r ` . A= 5/. 63 L 07 25 _ � �-.•L ,....+r ,,_ Imo- i f'� �/ M/N/M.tJ�.rl 40 ' 6- 22-77 � E To c/� S .3o Tr�Ot✓ 7` 1` C E le 77/r� ?",d-lA7' 7A/& �'0ZJ .4.Ttt3�/ /.5 Tom: U 7A xj .7 kv E Z F— !n! F ''A% ,.`7-A 7- 4. `ram k :; A TV 71E� {fly`` I AJ A ; 'Rs4L,. VOO h..r _ tee,9/ �'.