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0106 GROVE STREET
c 4 i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map PP Parcel Application l(G (a P-2 Health Division Date Issued o��e �y Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board W/13 Historic - OKH Preservation/ Hyannis Project Street Address A Village _ ( y:A;1T WA Owner It Address M Telephone SB(P-- Permit Request dew©Ve4 't��aD��S �� � •4r,,ze - -5r Y i a 4/e � �e9 I s 7 �c,�. 3 r / wef -1'y Lv s! -{ tires LC ��� r� J-�o Il �v l � �� Usr s' AIJ �� �s�r r e1 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay' Project Valuation ? ll onstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family �I Two Family ❑ Multi-Family units) Age of Existing Structure Historic House: ❑Yes I No On Old Kin 's Highway: ❑Y g g ges 0'No Basement Type: Ga Full ❑ Crawl ❑Walkout ❑ Other ^� - Basement Finished Area (sq.ft.) Basement Unfinished Area (s cn c -cs C> Number of Baths: Full: existing new Half: existing ' —new "^ Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Ro lm Countn ;a Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other a-n 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 ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION / (BUILDER OR HOMEOWNER) Name !�l�T�i �� ��y� ��� Telephone Number Address 6,$ 4tic License # C 5 13o9g7s- gzti,Vs a2 G Home Improvement Contractor# 6 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE', f �t �`v DATE t 3 FOR OFFICIAL USE ONLY r f� APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER ti • DATE OF INSPECTION: �' ��FOUNDATI.ONar��-r;�:ara�=� �.�� v•�:�._ . _ FRAME -_`(bPadF�• ui —� , i3r �V�7�Oa� INSULATION.e swu -Il o J03 Iz/zo ll.; FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4 GAS: ROUGH FINAL !`. FINAL BUILDING IF o DATE CLOSED OUT i� 7 ASSOCIATION PLAN NO.. `l The Commonwealth of Massachusetts T Department of IndustrialAccidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // Please Print Legibly Name(Business/Organization/Individual): A 141 Address: City/State/Zip: ,,S C Phone#: re?- �"P0 Are "an employer. Check the appropriate box: Type of project(required): 1.1 I am a employer with t 4. ❑ I am a general contractor.and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑bTew construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling shipand have no employees These sub-contractors have g ❑Demolition working for me in any capacity. employees and have workers' insurance.* 9. ❑Building addition [No workers' comp.i comp.P required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself. o workers' comp. 1 right of exemption per MGL Y � P � 12. Roof reP ' 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 thesection below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ��k'!C!f-f� G� •co �tiSb Q� '�'GJ�U el Policy#or Self-ins.Lie.#: G X; Zr �/3�S"�?� /7— Expiration Date:_/O / / Job Site Address: /d�P a> (t l/GsS7 A1✓4 City/State/Zip:�PT�r'!l O 1'6 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the airs d penalties ofperjury that the information provided above is true and correct r Simafore: ! '�`�'�� Date: a l Phone#: Official use only. Do not write in this area,to be completed by city or town officiat City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: • I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express m oral or written. xr or implied, An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date.the.affidavit. .The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia NOTICE N NOTICE TO o TO EMPLOYEES EMPLOYEES O,�M SV♦ The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. 80X 1450 MIDDLEBORO MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GZZUB-4395P74-9-12) 10-01 -12 TO 10-01 -13 POLICY NUMBER EFFECTIVE DATES a� DOWLING & ONEIL INS AGCY PO BOX 1990 HYANNIS MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# m oO CAUTHEN, BILLY E 86 BETH LANE HYANNIS �— MA 02601 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE m— MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own-physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS ooseso W20PIG02 TO BE POSTED BY EMPLOYER ' Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super%isor License: CS-009975 BILLY E CAUTH" 86 BETH LN HYANNIS MA 02601: " "` Expiration Commissioner 08/13/2015 ��f e�aryr�rarrcaealt/r,ci�'�?�us�a�u.rEtt Office of Consumer Affairs&Busifiess Regulation { fME IMPROVEMENT CONTRACTOR gistration 116609 Typepiration: 6/29t2014 Individual BILLY E CAUTHEN BILLY CAUTHEN 86 BETH LANE 4 � HYANNIS;MA 02601 Undersecretary o �'T Town of Barnstable Regulatory Services MASS.g, Thomas F.Geiler,Director z6;q6 1m '6► 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 D as Owner of the subject property hereby authorize- f /li (74(#� ��� to act on my behalf, in all matters relative to work authorized by this building permit 1a .59 (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of et Signature of Applicant Print Name Print Name �"0'6 Y. Date QTORM&OWNERPERMISSIONPOOLS 6/2012 �,► , Town of Barnstable Regulatory Services A JL?,STU Thomas F.Geiler,Director 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 _. 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 Rerformed 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 EXEMPTTON \, 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.— this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor.�On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a'form/certification for use in your community. C:\Users\decolliklAppData\Local\MicrosoR\Windows\Temporary Internet Files\ContentOu[look\QRE6ZUBN\E}]PRESS.doc Revised 053012 ,� G1 3'x 6" Tub with Sho 5 x 6" 5• 3'x6" {jam Takt Strdc IR d Tm'FE: SeN� 3'x6" lam. new J�f/ ry w � J 77 lift Ar �, 106 Grove St. , Cotuit 7/17/13 106 Grove St. , Cotuit 7/17/13 n Z 0 - Town of Barnstable Permit: Regulatory Services Date: P�pFrtlE rO Thomas E. Geiler,Director Fee: ' °� wilding Division s,►wrsnaece• - Tom.terry, Building Commissioner Huss � 1� v� %639. ��� 200 Main Street, Hyannis,MA 02601 J)7 ' pTFDMP�a www.town.barnstable.ma.us Office: 508-862-4038 Fax`: 508-7.90-6230 TOWN OF BARNST'ABLE SOLID FUEL STOVE PERMIT Owner:�,1'll�lirm .Q- Phone: as- install at:_ -f-` P��' Village; e,r � Map/Parcel: Date Stove A. ! /Used { ' B. Type: adiant Circulating ; C. Manufacturer: { Lab. No D. Model No. "'�v(nb Chimney A. New Existin_ (If existing, please mote date of last cleaning) 3L I-- I B. Flue'Size 13�6 ► /� � `� 5�`.9t�'/ess S/ ��_. C. Are other appliances attached to Flue? rn rif0 D. Pre-fab Type and Ma ufacturer �/� E. Masonry: Line nlined Hearth A. Materials: � a B. Sub floor Construction, Coladt Name:_SftMiZAM�111ft1 C_ Address: Q,n . )L gO. i ,e . Phone: Location of Installation- Lj ci 24,►► C� H.I.0 Registration #, W2 ; Construction Supervisor# -C,3 OR check_,Homeowner,Installing, no license required APPLICANTS SIG UR)E APPROVED BY#sv Please make checable to the Town of Barnstable *.This constitutes an official stove permit after inspection, photographed, and approved by the Building inspector 5 Q:forms:stove 2cv 103107 From:William Keto<bilicape@comcast.net> To:Jeanne Cliff<jeannechimney@aol.com> Subject:Signed Permit Date: Fri,Mar 29,2013 1:08 pm Hi Jeanne, Attached you should find the signed permit. It came across fairly light although the signature is dark. Bill Keto See attached file(s) ..gin v ` " � ',ems°` _¢ts, ��-u`' ���.: s.b,., sw f • ' Y • t • , s , ry Town of ar°ntable regulatory Services Thomas F.Geiler,Director s6 a a � Building Didisibn. Tom Perry,Building Comnussioner !200 Main Street,Hyannis,MA 02601",s www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Propedy Owner Must. Complete and SignIhis Section If Using Builder I, �A`11 Ll as Owner of the:subject property hereby authorize clk tR`(1 to act on my behalf; in all matters relative to work authorized by this building permit application for. T (Adder s of Job) Signature of Owner Date ' _ ♦ ` Print Name + . Jf Property der is' applying for peit.please complete the Homeowne> L cense Exemption Form on the"reverse side. , Q:FORMS:OWN ERPERMISSION Massachu`sets -Department of Public Safety Office of Consumer Affairs&Business Regulation Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Construction Supervisor 1 &2 Family Registration: .. 920859 Type: ` License:.CSFA-058557 Expiration: -3%1122014 Private Corporatior KEITH A CLIFF -�• ;,.1: SAN WICH CHIMNEY SWEEP INC; 90 p0 BOX L k Y r SANDWICH MA 0256 , KEITH CLIFF ,0.4 28 EMERALD WAY �. FORESTDALE,MA 02644- Undersecretary J�,(a, �J '� =� Expiration C oni+Tais s i on er 02/27/2015 COMMONWEALTH OF.MASSACHUS.ETTChimney safety institute of America Certified Chimney SweepSHEET METAL WORKERS AS A MASTER-UNRESTRICTED ISSU +AB ES THEOVE LICENSE TO t 'CERTIFIED #2722 CHIMNE = 4 {'e .1 SWEEP Valid "l Thru KEITH A CLIFFt` June 28 EMERA:LD WAY r ORESTDALE A" ,MAr0 264`4 1F2013 530 1`1088'' 02/28/15 33D0`9�+ Sandwich Chimney Sweep Sandwich, MA r •L ' n ' o T . License or registration valid for individul use only Failure to possess a current edition of the before the expiration date. If found return to: Massachusetts State Building Code Office of Consumer Affairs and Business Regulation is cause for revocation of this license. I 10 Park Plaza-Suite 5170 Boston,MA 02116 Refer to: WWW.Mass.Gov/DPS Not vali thout signature " CONTROL# H 2 O 8 4 5 8 CSIA Code Of Ethics , IMPORTANT I fully acknowledge that certification by Chiuuiey Safety Institute ofAmerica(CSIA)carries with it certain responsibilities and obligations which may hold me - If this license is lost or destroyed, notify your Board at the: to a higher standard of performance and professional Division of Professional Lieensure, 1000 Washington St., behavior than applicable laws,rules or regulations Suite 710,Boston,MA 02118-6100. Y n To l regard,I pledge: g y 'I.To learn and utilize all chimneyand venting safety y - practices and techniques promoted by CSIA 2.To render my services in an honest and fair manner If your name or address shown is changed, notify your board and to retrain from engaging in unfair or deceptive practices or making any unfair or deceptive state- of correct name or address to insure proper mailing of next 'practices including but net limited to with regard to use Renewal Application. Always refer to your license number. of the CSIA logos This license is subject to the provisions of the General Laws 3.To comply with all applicable building codes iu the as amended. It is a personal privilege,and must not be loaned areas 1 onsser or with the products Iin ctur aid inwlanatiun instructions for the products I inslalt,'and with recognized chimney and venting practices. or assigned to any other person. Keep this license on your 4 To promete and educate consumers about-fa person or posted as required by law. chimney and venting practices , • 5.To strive to continually update my Iomwledge.ski16 - and techniques with'egard to cur-A accepted ., chimney and venting safety practices - 6.To conduct myself in a decent respectful,ajid "^•: - ,. professionatmanner when serving in n ypweity ! as a chimney sweep or when atte rdi g a hu cl on s or event of an organ nation in the chin i ey or Irea t - ��, _ products industry. 7.To comply with the proper usage of it,.CSIA . - Registerd Trademark as defined in the CSIA , Trademark Us.Guideline documents: ._ t • - www.csia.org/ethics' - Revised 516/11 MAR, 27. 2013 2: 19PM HART INSURANCE NO, 356 P. 1 A CER IFI4 ATE .VF LIABILITY INSURANCE . DA03127=1 THIS CERTIFICATE Is ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDEP, THIS CERTIFICATE DOES NOT ArriRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN YHE ISSUING tNSURER(S), AUTHORIZED REPRESENTATIVE OR,PRODUCER,AND THE CERTIFICATE HOLDER- IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pofty(ios)must uO endorseCL 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 endomem nt(s). N A Laura J Murphy IRODUM HART INSURANCE AGENCY,INC. PHONE (508)759-7326 Ax Na_(508)759-7366 243 MAIN STREET No PO BOX 700 InvrrphyhaRinslrranceagenOy.com oss BUZZARDS SAY,MA025320700 - INSURERS)AFFORDRIGCOVERAGE NA100 INsuxERA. MAX SPECIALTY IN$URANCE 20079 INSURED Sandwich Chimney Sweep IN$trrtfR6: ATLANTIC CHARTER INSURANCE COMPANY 44326 PO Box 90 INSURERC Sandwich,MA 02563 INSURER D INSURER' E INMW'R F COVERAGES CERTIFICATE NUMBER: REVISION NUMBEfL, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE @FEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT AM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUGiES DESCRIBED HEREIN IS SUBJECT TO ALL T'iE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, NT3LR YYPF or-INSURANCE AODL POLICY RUrMOM POLICY M II)o o - -- LIMBS A c-RaPAL umuJ1Y MAX013100005253 10/09/2012 10/09/2013 EACH OCCURRENCE 3 1,000,000 DAMAGE 100,000 COMMERCIAL GENERAL LIABILITY PREMISES E 3 CLAIMS-MADE V OCCUR MEDEXP Fv4 V,&Pa=R 3 5,()00 PER$M411.&ADV INJURY S 1,000,000 GENERAL AGGREdAVE $ 2,000,000 GEITLAGGRnATEUMIT APPLIES PER. PRODUCTS.COMPIOPAGO $ 11000,000 POLICY PRO. LOC S - AUTUftu BLLABlLrN ON ANY AUTO BODILY INJURY(Per pawn tl ALL OWNED SCHEDULED B0DI1YINJURY(ftr1WdonQ $ AUTOS AUTOS ` PROPERTY DAMAGE S HIREDAVTOS AUTOS i e UM I A LWB - HCLAWISNADE OCCUR EACH OCCURRENCE S EXCESS LIA13 AGGREGATE S DEC) RETENTION i S g WORKERS COMF rsAYtON WCVOI032500 08/2812012 0812=013 RTu; arH. AND EMPLOYERS'LIA841Tr ANY PROPRIETORIPARTNER/EKECU•rIVE Y J N Li.EACHACOIDENT S 5001000 OFFICERRMEMOVeXCLUop07 �. NIA' (Impoatwy in NH) E.I..DISEASE.EA EMPLOYEE S 500,000 H yYaess deSaiGe under OESCRIPnOM OF OPERATIONS bd*W E.L.DISEASE.POLICY uMiT s 500,000 y , ; 4 I. 09$CPJft0N OF OPERATIONS I LOCATIONS r VEHICLES IALtaeB ACORD 101,Add(Gonar Romarka SeryodPts,N more space Is F*Wdmd) )peralions as perfomied by Terms&Conditions in the policy, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCIELLEO BEFORE Town of Sarnstable THE EXPIRATION DATE THEREOF, MOMOE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REFRE$eaAYNE 01988-2010 ACORD CORPORATION. All tights reserved. ACORD 25(2010/05) The ACORD name and logo are registered ttMaft of ACORD i The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations -' 600 Washington Street Boston,MA 02111 T www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t l raw S' Address: Q:® &oo City/State/Zip: ' MPI ba�3 Phone Are you an employer?Check the appropriate box: Type of project(required): 1.9 I am a employer with -A ,_ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.El I am a sole proprietor or partner- These sub-contractors have listed on the attached sheet. 7. ❑ Remodeling ship and have no employees � 8. ❑ Demolition working for me in any capacity.' employees and have workers' 9.� Building'addition [No workers'comp. insurance comp. insurance.: ❑ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions myself o workers comp. right of exemption per MGL Y � ' p 12.❑ .00f repairs insurance required.] c. 152, §1(4),and we have no 13.L�Q Other employees. [No workers' comp.insurance required.] ny2 f "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. ` 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. Insurance Company Name: Wdf*LC_'y9A_tdnil MtE Policy#or Self-ins.Lic.#:. Expiration Date: Q�la�� 13 Job Site Address: City/State/Zip: �r� J Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine . of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cellr fy u r e pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 7— Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: rw TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Oa Parcel ©� ;application # Health Division Date Issued V" Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 3 Historic OKH _Preservation/ Hyannis Project Street Address �C(r G Ida rjL� �7 Village r 07U t % 1d'(A Owner /, /l/��G�� /���-rD Address Telephone 1-3 Permit Request vc-!` ��r S 5 (& ?712 c,e It C" <�•ti` -�- ��_- ��z,� rcr�ST V,4,'f TwW ru -;�"o A)LO") C-.:,tt 'I r fs W F 7L-45 (© CG'C/�/t�G�/�T J�() -7,4,44.6,/ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation b67,00 Construction Type cJty,-D i Lot Size Grandfathe'red ❑Yes ❑ No If yes, attach supporting documentation. / � N Dwelling Type: Single Family Pd . Two Family ❑ Multi-Family (# units) Age of Existing Struct e Sly Historic House: ❑Yes 01NIo On Old Kirfig;� Highway t��'.❑ ®`No w , Basement Type: Full ❑ Crawl ❑Walkout ❑ 0 Other a Basement Finished Area (sq.ft.) Basement Unfinished Area (sl Number of Baths: Full: existing new Half: existing / new Number of Bedrooms: existing _new Total Room Count (not including 21i s): existing new First Floor Room Count Type Heat T e and Fuel: ❑ Gas l ❑ Electric ❑ Other Central Air: ❑Yes_ ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: O existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes [-No If yes, site plan review# Current Use fral(� '�`2r I�j Proposed Use 57�-�- APPLICANYINFORMATION (BUILDER OR HOMEOWNER) y y Name �t �� �� Telephone Number 75 OcP-6""0 3� L Address �C ��7f! � � 446zz(T 1W License # C_5 i 7� Y Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -17U SIGNATURE`)Z< J-, DATE 2 FOR OFFICIAL USE ONLY APPLICATION# P f , DATE ISSUED `g MAP/PARCEL NO. y s c, ADDRESS VILLAGE OWNER DATE OF INSPECTION: N -FOUNDATION. FRAME 5114'> INSULATION 512-16 FIREPLACE ELECTRICAL: ROUGH FINAL ,r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING 7I�3 { DATE CLOSED OUT — ASSOCIATION PLAN NO. J.Q ' la tsttl rd ' _,•• 'A , 5 y ° � 1 °-t {f N • ' r�t i � + �� a+ 1d y i + 5� �f� + t� t i 3, 1 t �, ^Fr+.'. N a t s The 6mmoni`vealth of Mass chusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Auplicant Information / Please Print Legibly Name(Business/Organiz on/Individual): �l`/1 Address: City/State/Zip:.. ;g , ,_S' 1 ,4 Phone#: Are ou an employer. Check the appropriate box: Type of project(required): 1. I am a employer.with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance. # 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10:❑Electrical,repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required:]-t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other . comp.insurance required.] *Any applicant that checks box#1.must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Zto/C IC ff f� � Sys G;-feuy, P Policy#or Self-ins.Lic.#: �- t✓ ���5� �1-/-/Z Expiration Date: M / Job Site Address: l City/State/Zip: Zr fH (d .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$1,50.0.00 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 DLA for insurance coverage verification. I do hereby..certify u der the nsja enalties of perjury that the information provided above is true and correct -Si mature: Z � � 4__H_� Date: j 3 Phone Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: at e •� ' ! F Fft }� ft, t R �.1 . k 4 - �.. t, '1' •F , i* ., , Infosr�mation and 'Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this.statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more .. of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employ' 'employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house.' or on the grounds or.building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter.152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if. necessary,supply,sub-contractors)name(s),address(es)and phone numbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the' members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial . Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please.call the Department at the number listed below. Self insured.companies should entertheir self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you,to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current. policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or. town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the . applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled.out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us a call, - The Department's address,telephone and fax number: The.Commonwealth of Massachusetts Department artme t of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-774.9 Revised 4-24-07 www.mass.gov/dia 44'' WE Town•of Barnstable Regulatory Services t A�RNl.1'AAT.R • .. •• unss. g, Thomas F.Geiler,Director i6gq. 1m 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 16 L-1- c:�4u , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit aize _ I (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. 4 Signature of Owner Signature of Applicant LIA,g Print Name Print Name Date Q:F0RMS:0WNERPEFMISSI0NP00LS 62012 h 'Town of �j ., Baresable t Y HE Regulatory Services Thomas F. ile s�artsrwsi.E, : .Ge r,Director ,��a.�� 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 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 with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a form/certification for use in your community. Q:forms:homeezempt I 7 NOTICE M W 'NOTICE TO a TO EMPLOYEES EMPLOYEES O,yM C, The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-7274900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152,Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GZZUB-4395P74-9-12) 10-01 -12 TO 10-01-13 POLICY NUMBER EFFECTIVE DATES 0 DOWLING & ONEIL INS AGCY PO BOX 1990 HYANNIS MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# o� CAUTHEN, BILLY.E - 86 BETH LANE HYANNIS MA 02601 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS ooeaso W.20PIG02 TO BE POSTED BY EMPLOYER TOIVH OF SARNSTA CA 113 AT 28 Alkl 9: 15 0 — gp'V�,d wdlC f/� `_ � �u� � c� !,s � � �� 5� � � � � , � 2U � o � - � � � .�6d � , . { �4 1 � .__.. __ ;: `�� � i f ���t � . �� --__ __ •. �y, i ,��,�` � I acs cZ � �, � � �_ i- rr 111h3 X-PRESS pie AI Town of Barnstable Permit 'V xpires 6 momsuers", ° 116103 E Regulatory Services Fee s Thomas F.Geiler,Director 1659. 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 PE MT APPLICATION - RESIDENTIAL ONLY Not Viz id without Red X-Press Imprint Map/parcel Number Property.Address 1 Ulo (S7n A I/L_ �� •T V 0r ^4 Residential Value of Work qs-,0 ,OU Minimum fee of$35.00 for work under$600.0.00 Owner's Name&Address 0)1 l!lid' Ire 1-6 Contractor's Name 91//Cl � C =aL� �t/ Telephone Number. S-L���APO-5 P� � Home Improvement Contractor License#(if applicable) 116 6 U 9 Construction Supervisor's License#(if applicable) C'$ Cl 9 7,5- orkman's Compensation Insurance Check one: ❑ I am a sole proprietor Wam the Homeowner have Worker's Compensation Insurance ° Insurance Company Name Zf1,91Cf Awl,�iluv g lj-VV A,�Vee- 9/zr U P Workman's Comp.Policy# 0 Z z u 7y' l z Copy of Insurance Compliance Certificate must,accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value y, 3 _ (maximum.35)#of windows /3 ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. /J C_ -mow SIGNATURE. QAVVTFMES\FORMS\building permit forms\FMRESS.doc The Cammonwealth,o,f massach"Setfs 13e,parhnent,of Indusbial Acciden& 0fiSre of Investigadons 600 Washingion Street Boston,M4 672111 rt n,;V xtrrrs&gVV/dia Workers' Compensafian Insurance Affidavit- Bugders/Contractoi-s/ElecE ici-ans/Phimbers Applicant Information Phase Print Legi tlIy Dame(Busmess/orga tian&dMclaal): !fir, 6—, Address: City/State/Zip: s n Phone#: �c► - 2- Are you an employer"Check the app•Topriate box: Type of project(required): 1:L✓J I am a employer with 1 4- ❑ I am a general contractor and 1 6- [:]New vxshwtion employees(felt and/or pad-time * have hired the iub-contfactors listed an the attached shook y. Remodeling 7_❑ I am a sole proprietor of partner ❑ e stub-cttntrac#ors have g_ ❑Demolition ship and hate noemployees . employees and.have waake s' woticing for me in any capacity. 9'.• ❑Building addition (N0 LtlQrlCet3,Comp.in rtr�c a cam-m��nc-0 ❑ We are a corporation.and its�- l0.❑Electrical repairs or additions required] � 3_❑ I am a homeowner doing all work officers have exercised their 11_0 Plumbing repairs or additions of myself [No workers'comp- righttion M HfGL 12.❑R�vfrepairs c. 152,§1(4),and we have no insurance required.]T employees_[.No workers' 13.1.0 ether �4"C•�'l� ccmp.insurance r+equired.l *Any applicant that checks bone#1 mast also fal out the section below showing their woAere compensation policy infarction- I Homeowners who submit this af5dsvit indicstihg they ace doing sQ war$and then hire wtW&cantractars nmsi submit a new affidavit indicating such tContracmrs thst check this box most attached sn siiditianal sheet showing the Dame of the sub c tracfiocs and state whether ar noTfose entities have employees. if the suh-contracaaass have emplaymr.,they—ast.pmvide their Worke&camp.pollen number- lain an empioy,or tliatis prouWng workers'con gmusiWon.inmrance far nry enTloyem Below is fhepsiiicY avid jab site infotmra&m. Irts>zrance Company l`iame: If RCN �l lt��•r/ il��/f44"O"O^ov- (f U r — Policy or. iris_Lie_-9: Job site Address: fd� Gityfstate/zip: A€iacla 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. 1527 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 ike form of a STOP WORE ORDER and a fine of up to$250-00 a day against the violator. Be advised brat a copy of this statement may be for marled to the Office of Itrestipdons of the DIA for insn-ance co4tirage verifrcatic I dfl Hereby cej*fy ander tha pain s and pen alliws ofperjury Aat the informsdl Ta protPided abava is.true and correct Date- �Z Phone#: offidal=0 runty. Do not write in this area,as be cotnnpieted by city'or teimi official City ew own: Pera dtflAcense# Issuing Authority(circle one); 1.Board.of Health I Building Department ICity/Fown Cleric d.Electrical lnspertvr S.Plumbing Inspector 6.der a -= - Phone#: I • �0*THE tp + �P ti� • * 1ARNs'rABM buss. p Town of Barnstable i639• �� , pTED MAr . Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstabi.e.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder / Y --�C�i7"C ;as Owner of the subject property hereby authorizes l/ to act on my behalf, in all matters relative to work authorized by this building permit application for: �G (Address ofJo f 13 Signature of Owner• Date . Print Name , If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on,the reverse side. NOTICE N NOTICE TO a TO EMPLOYEES �= EMPLOYEES O,�M Svc The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 — http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH-AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.O. BOX 1450 MIDDLEBORO, MA 02344-1450 ADDRESS OF INSURANCE COMPANY (GZZUB-4395P74-9-12) 10-01 -12 TO 10-01 -1 3 POLICY NUMBER EFFECTIVE DATES o� DOWLING & ONEIL INS AGCY PO BOX 1990 ° HYANNIS MA 02601 NAME OF INSURANCE AGENT ADDRESS PHONE# 0 CAUTHEN, BILLY E 86 BETH LANE o� o = HYANNIS MA 02601 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE m MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably , connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS waggo W20PIG02 TO BE POSTED BY EMPLOYER ���assachusetts- Board ot,BuildinD'N't"M nt of public Sat-et,RcLrulations Supervis .end Standaruti Construction License: cS,,9975 or License BILLY E CqUTHEN 86 BETH LN h` HYANNIS � MA 02601 �'ununi>:�i„ner Expiration: &13/2013 Tr#: 1683 Sd(F/Aof)'ssey�• " h1dAAA :off aa�a� aaPOJ�ar��J0 II0r;¢30A0a aoj asnc�sr a9a�o uoprpa aaag g$as saaasngaesseyli ssassod oa 0artg3 ��ze�o'rnmro�zuse�e;��iTo��a�aac�iwseC� Office of Consumer Affairs&Busidess Regulation ME IMPROVEMENT CONTRACTOR egistration 116609 Type xpiration: 6/2912014_ Individual f - '' BILL CAUTHEN BILLY CAUTHEN 86 BETH LANE z..:= 1 Undersecretary HYAN NIS 02601 MA U Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Y �J o� ` Map Parcel G ` Permit# •� /� � .r , Health Division Co"J" +r 0, � _ Date Issued 7 . Conservation Division 77 0-2e. Fee !a Tax Collector ` " / c�:c�cr iP7 Treasur INSTALLED IN`C® PLIANj Planning Dept. ! a 'WITH TITLE 5 , ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS . Historic-OKH Preservation/Hyannis Project Street Address Village Oa 7U t i Owner W t I,kov. t`y-e` o Address 5dlp� Telephone Permit Request /0/ Z/ a S5. -�� �Uti7�c X::- st/ f 17(eel Square feet: 1st floor: existing - proposed 2nd floor: existing proposed Total new .Y Valuation b'. 0Z UCH Zoning District Flood Plain Groundwater Overlay Construction Type r.J Q a 2:2 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family �d' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes a o On Old King's Highway: ❑Yes Basement Type: bull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.)" Basement Unfinished Area(sq.ft) Number of Baths: ` Full: existing ;i new Half: existing 1 new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: E(Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes_�❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:6 existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed: ❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name �✓i - ��c�1f2�/ Telephone Number �?r4- OS-S// Address f' �P` A-y4. License# 66 99/� y�yyiS yz/w, 0a4 0 / Home Improvement Contractor# //6/&/,0,V Worker's Compensation# G,�f u` d 9-2 3- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE �� ( DATE ` FOR OFFICIAL'USE ONLY PERMIT NO. t a DATE ISSUED _ t MAP/PARCEL NO. ADDRESS VILLAGE - OWNER. DATE OF INSPECTION - r FOUNDATION "1U i '�/✓L t, <. FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL .- GAS: ROUGH . FINAL FINAL BUILDINGGOD wa P cc DATE CLOSED OUT ASSOCIATION PLAN NO. o C-4 _ _. 1. _ h' The Commonwealth o,f Massachusetts Department of industrial Accidents 1 � � -=�•� ��_ OlflCt o1l�Yestlgetloas -- 600 Washington Street f Boston,Mass. 02111 - Workers' Compensation Insurance Affidavit / ��//// � ///%//, locafiom city 4-44,111t)`5 ehone# ❑ I am a homeowner performing all work myself ffrI am a sole aronrietor and have no one wolkirw in=r capacity ❑ 1 am an employer providing workers'�=cation for my empiayees working oa this job.. M. 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Mtttp,1 wY1 •111 • 1• .1• • ✓.111 I �/ • 11 I• :li It It •�/•Ilil «w• 1111/1 • -• • 11 «1 I 1 / ��• �/1.n w t •• 11//11 •./ 1 •• • , as , • .I its w.y • ••-1 J•KU •Jw INw11•. 1✓. •Lw• I/✓. • , it • *01111 be 1 its talkIt k a • I 11 • • :I •• I.1 • 1 .'•••-/ .1• •U .11 • I• • • 1 . •11 • w•/l i 1 II 11 1 1 Ids KVjdkw4 I A � l •11 1 1 1 1 l � l 1 1 I 1 1 1 1 1 I I I l 1 11 • 1 / • �d 1 . 1 1 The Town of Barnstable - ;: - 6 ,,,►nrs : Regulatory Services '�Ec�►�` Thomas F. Geiler,Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c:142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: /jU �� s�til��C/� Estimated Cost Address of Work: /d� G�Ov�= Ste. �o-ro 7 Owner's Name: I `//,f Date of Application: ��/ I hereby certify that: Registration is not required for the following reason(s): QWork excluded by law OJob Under$1,000 []Building not owner-occupied ❑Owner pulling own permit y Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. { Date Contractor Name Registration No. OR ` Date Owner's Name gl6mis:Affidav • 0 Light 16'-0" 13'-6. 5'-0" 4'-0" 19'-0" 30'-6" Eli 4'-0" 10'-0" s 4 - 29'-6" 0 Light 19'-01, 30'-6" [Eli .4'-0" r f s ; LOT"Y41B' AS LOT 2B } Ws'.":r 6' / _\\: "a SUN -� '� •{ � {d LOT 142AA, �t PAF..CEL 2 a5 LOT 142;9 } ��,� PARCEL x. Lo IN • AS'LOT 30. - L, : FLOOD ZONE FO �TDA TIDIV�FsCE'RTIFICA�TIOIV ' RFS ZONE. �'RF". _ r TOWN COTUIT ': SCALE:'7 40'° :PL:`REF. 124 95ELE 'A I CE'RT.IF`Y THAT;THE ABO IVE, a YANh'EE SURVEY CONSULTANTS FOUNDATION>IS, LOCATED =ON .3�°" °i '�� P..O:r BODY 065 THE GROUND AS �HOVWN, ,:AND PA i UNIT I '� 03` INDUSTRYS ROAD y ITS POSI7'IOIVe-- QF _ " g M trl++ �v %� �I ARSTONS :Il1ILLS; eY1ASS� O964B COIVFORIVf; .TO: THE ZONING £LA L ` /,. :TEL28 rQ055 SEI'BACI RE'!�UIRE�IEIVTS OF ...., "�s "jcrs*tR ' 'r Fl t. ;. �4-=555�3> BARN — 7— x 77 JOB tt:. 'JUL �. EII 'RI:7HGlt` D.a k . . 07 r°omma�uuea/!/ o����aaacic/uael BOARD OF BUILDING REGULATION: License: CONSTRUCTION SUPERVISOR Number: CS 009975 Birthdate: 08/13/1942 Expires:08/13/2001 Tr.no: 4334 ---- - '"Restricted To: 00 BILLY E CAUTHEN 86 BETH LN ...p.r, HYANNIS, MA 02601 Administrator HOm: IMPROVEMENT CONTRACTOR Registration: 116609 Expiration: 06/29/2002 Type: Individual BILLY E CAUTHEN BILLY CAUTHEN &y-, 6'8ETH LANE ADMINISTRATOR HYANNIS MA 02601 - I . v. ,;. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map / y _ n Parcel �9 Permit# 4q I Health Division /�/L' �� Date Issued 9 Conservation Division _ Jo /�r' Fee Tax Collector Treasurer p b � � �� SEPTIC SYSTEM MUST BE Planning Dept. _ INSTALLED IN COMPANCE Date Definitive Plan_Approved by Planning Board 'M _ LI 5 ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address 146 e;_�ea t-l_rr' •5�,- Village ( W u 17- l�I1lS.S Owner &4//kow Address Telephone Permit Request CEO �.�> t�S7l�/ ,��s D,�'f{ --/0 pvi Square feet: 1st floor: existing ZyW proposed 2nd floor: existing .r/ proposed —n Total new c9v2 Valuation �;O?o AQ,o 0 Zoning District Flood Plain Groundwater Overlay Construction Type &,D0.0 Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 3' Two Family ❑ Multi-Family(#units) Age of Existing Structure y� ye5y,r Historic House: ❑Yes 2'6o On Old King's Highway: ❑Yes Basement Type: &"Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) D Basement Unfinished Area(sq.ft) Number of Baths: . Full: existing !� new Half:existing new Number of Bedrooms: existing 3 new Total Room Count(not including baths): existing 5- new First Floor Room Count Heat Type and Fuel: ❑Gas AI ❑ Electric ❑Other Central Air: ❑Yes ��2*�o Fireplaces: Existing New Existing wood/coal stove: El Yes &-N-o Detached garage:Wlexisting ❑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 ONo If yes; site plan review# Current Use S � lG e1ll�2- Proposed Use BUILDER INFORMATION Name Telephone Number 52V 7i0- U,PV/ Address License# 00 9z7s— liA�la- 1/�� �a10/ Home Improvement Contractor# //6tl09/ Worker's Compensation# WC J�— oaF 577.3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO U � /Gfi� �lf OAS ✓/ 1� % SIGNATURE � � DATE FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. "' F ADDRESS r ? VILLAGE { OWNER t. } DATE OF INSPECTION .. FOUNDATIOoN�r-7r FRAME a INSULATION lAof FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH a FINAL GAS: ROUGH Z„Z G FINAL FINAL BUILDING DATE CLOSED OUT M 7 w ASSOCIATION PLAN NO. 71 � �rzt i::+r 'yC^��y' r+.....+•. nor M'-:;.. +"'.p:^-•""""' ^^r` OFTHE Tp�� The Town of Barnstable • �ntuvsT,43M • 9MLAM ���' Department of Health Safety and Environmental Services t c►�u+" Building Division 367 Main Street,Hyannis MA 02601 r` Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner PLAN REVIEW Owner:Wt IIIAM 1l le l Map/Parcel: ON- Oar 7 1/ t0/ card-��h Project Address:.10( �rr(}U �'_ �l? Builder: �. The following items were noted on reviewing: 01 �91n QI�Y6 LAtIu V\ /n�ue. 9- 11 , Please call 508 862-4038 for re-inspection. {- Inspected by.. j ti - t V iLj 1t;� Date: 1 � q.building:formsseview t S oFtMME r asTAB . # The Town of Barnstable MASS. Regulatory Services 1639.ACED Ma+A Thomas F. Geiler, Director Building Division ` Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax! 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, - - - -- improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied •'�_, _. _ building containing at least one but not-more than four dwelling units or.to structures which are adjacent to - _ such residence or building be-done-by registered contractors;with certain exceptions,along with other requirements. Q Type of Work: Estimated Cost ig�BDD-d� Address of Work: 404 G41b/&r 5�77 dr0/,,` Owner's Name: L�/</ ! 1-E:1-it-U Date of Application: /ei'll"j-11�a I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. 5. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Da e Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav MAScheck COMPLIANCE REPORT Massachusetts Energy Code Permit # MAScheck Software Version 2 . 0 Checked by/Date CITY: Hyannis STATE: Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 10-9-2000 DATE OF PLANS : 10/10/00 TITLE: Porch Conversion PROJECT INFORMATION: William Keto 106 Grove St . Cotuit, Ma. COMPLIANCE: PASSES Required UA = 48 Your Home = 42 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS : Raised Truss 114 30 . 0 0 .0 4 WALLS: Stress-Skin Panels 224 15 . 0 15 GLAZING: Windows or Doors 11 0 .400 4 DOORS 3 0 . 350 1 FLOORS: Over Unconditioned Space 114 30 . 0 4 BSMT: 2 . 0 ' ht/2 . 0 ' bg/1 . 0 ' insul . 114 30 . 0 14 -----------=------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 ano J4 .4 . l<Builder/Designer / Date 730 C1M App=Wkj -. pre mripdre Fxdmga for One and Towfamidy Reaida dai BaiWlap Sated with Foal Fads INAMMUM Mama HUM Wail Eloae Baaemmt Slab ceiring Am)j Uwaluez tGvatu� R•valua� R.Vaines WAR � lftckaae lirvaisa� &-void 5101 to 6600 Heads;DeOeee Days' Q 12% 0.40 3E 13 19 10 6 Nomad R 12X 0.32 30 19 19 .10. 6 Normal S I20A 0.30 3E 13 19 10 . 6 95 AFUE T 13% 0.36 3E U 23 WA WA Namml U 13'� OA6 33 19 19 10 6 Nammi 1>7i iic �e t3 Fwis ' w !S AF[ W I3% 0.32 30 19 19 10 . 6 tS AFUE X IV/. 0.32 33 13 21 WA WA Nommi Y IVA 0.42 33 19 25 WA WA Namml Z IVA •0.42 3i 13 19 10 6 90 AFL1E AA ta'/. 0.30 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q--AA-see chart above): -NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. - BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f980303a e " 780 CMR Appendix J Footnotes to Table JS.7-lb: Glazing area is the ratio of the area of the glaring assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors) to the gross wall area,expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 fl of decorative glass may be excluded from a building design with 300 ft of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test proced�, or taken from Table JI.5.3a U-values are for whole units:center-of-glass U-values cannot be used. ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing(if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space auu we ventilated pw-don rf tha CGE 'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include trement could be met EITHER exterior siding,structural sheathing,and interior drywall. by an.R-19 re4u' by R-19 cavity insulation OR R-13 cavity insulationplus It-b�instalatiag sheathing. �Vau regNirements apply.to wood-flame or mass(concrete,masonry,log)wall constauctions_ but-do,not apply to_metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces-(suchas unconditioned craevlspaces,basements, or garages).Floors over outside air must meet-the ceiling requirements..: -w 'The entire opaque portion of any individual-base ment wall with an average depth less than 50%below grade must meet the same R value requirement as above-grade_walls. .Windows and .sliding .glass doors of conditioned basements must be included with the other glazing,. Basement doors must meet the door U-value requirement described in Note b. - ,,.. 'The R-value mquirements.are for unheated slabs..Add an additional R.2 for heated slabs.. ` If the building utilizes electric-r+esistance.heating ose approach pproach 3, 4, or,5. If you plan to-install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest cy- the selectedpackage,. efficienry must meet or exceed.the e._fficien required by. _ 'For Heating Degree Dayrequimments ofthe-closestcity or town see Table-J5.Z.la = -- „::, NOTES: a)Glazing areas and U-values am,max'rerun-acceptable.levels._Insulation_R:vaiues art minimum acceptable levels. R-value requirements are for insulation only and donot include structural components.--. b)Opaque doors in the building envelope must:have.a.U-value.no greater than 0.35. Door U-values must be tested the NF and documented by the manufacturer:in,accordance with RC test procedure or taken from the door U-value in Table J1.53b. If a door contains glass and an aggregate U-value rating for that door is notavailable,,include the-- glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 035). c) If a ceiling,wall,floor,basement wall,slab-edge,or-crawl space wall component includes two or more areas with different insulation levels, the componetiVe Tres if the`area=weighted average R value is,greater than or equalto - the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(035 for doors). 43 The Commonwealth of Massachusetts Department of Industrial Accidents t-=� Olficr ollaFestigauoos 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance davit %%% / ai , i ��������11111I' name: location: R hone# reP 7 D-os-ell ❑dam a omeowner performing all work myself. t[�I' t am a sole gro rietor and have no one working in any capacity ,,,,,.,,••• ❑ I am an emplover providing workers' compensation for my employees working.on this fob comnnnv name: address: # city: hone i olicv -insurance co: _. _ 1171# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the follo«zng workers' compensation polices: an v name: c :...... address: ....::... ... .::.....,.. .. hone..#. .> city: »:: ;>:> <;, insurance co. cornnanv name: address: ........... hone# city- insurance co // / Failure to secure coverage w required under Section 25A of MGL 152 can lead to the httposWon of criminal penalties of a fine . to understalsoo.00nd and/or one years'imprisonment-well as civil penalties in the form of a STOP WORK ORDER and a Me of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of theflIA for coverage verlflcation. 1 do hereby certify'un t e pains and penalties of perjury that the information provided above is truo and eorreat Date Signature Phone Print name �` !1> •G�-�/ official use only do not write in this area to be completed by city or town official " permit/license# ❑Building Department a city or town: QLicensing Board ❑Selectmen's Oilice h ❑check if immediate response is required 011ealth Department contact person: phone#; ❑Other ;` ;r vats:•9S NAJ Information and Instructions sachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their Mai to ee is defined as every person in the service of another under any co=,;-- employees. As quoted from the."law",an emP Y of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged'in a joint enterprise, and including the legal representatives of a deceased employer, or the re=ve: 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 construction or air work on such dwelling house or on the grounds c another who employs persons to do maintenance, rep building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renef of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h: not produced acceptable evidence of compliance with the insurance coverage required._ Additionally,neither the e of public work ur commonwealth nor any of its political subdivisions shall enter into any contract for ha been pres rented to the co =c=-Z acceptable evidence of compliance with:the insurance requft=ents of this chapter authority. Applicants letel the box that applies to your situation and rPlease fill in the workers' compensation affidavit comp y,by checking be...,..�.�..... h supplying company names,_address and phone-numbers along with a certificate of insurance as all affidavits may e Also be sure to sign and. submitted to the Department of Industrial Accidents for confamatioa of.insarance coverag __ :th, s , . ykk town that the apphcatron for the permit or license is date the affidavit. The affidavit should be returned to the city- . . . ons re �_"�w„or,if yc Accidents, Should you have any�quest? regarding not the Department of Industrial-- — at the member listed below. being' on oli lease call the Department are to obtain a workers' c,ompeasatr p c5'�P _- . City or Towns Tinted legbl The Department has provided a space at the bottom of t Please be sure that the affidavit is complete and p Y• the applicant. Please affidavit for you to fill out in the event the Office of . has to contact you regarding apP be sure to fill is the pe aiitlliceose number which will lie used as a reference number. The affidavits may be returned t^ the Department by mail or FAX unless other have been made. The Office of Investigations would like to thank you in advance for you,cooperation and should you have any questions. please do not hesitate to give us a call. ��/1 The D ailment's address;telephone and.fax number... _ The Commonwealth'Of Massachusetts t. Department-of Industrial Accidents Me of Inyesd0adons 600 Washington"street Boston;Ma. _02111 . fax#: (617) 727-7749 ,. phone#:-(617) 727-4900. eat. 406, 409 or 375 I ., .e. .'Ohl's�'Fr,.l�'.'�.t.'�i1'a,.�;:i•�. ,. { '; t. oil ^ { } a �S 4 j • Y -i E -. . 9 t �-;iAMkR Ile � � Sri w '� in zla fa iry E� .+ � {I. 'r •�: ♦ -4AIJ t.. .. -. .- -:�., ly, <`�' 1?P� Fi4.. ��' f � '�..� �� ',�'i }Y 'l�' v y ./ Cr .�.. .: ..•? r * .y Y1-r� �'k �M�r„S 1�J,�y��y",.. .� �'�. .v .�,,�• ;5�(r 0= '� 1/7 H0;!; IMPROVEMENT CONTRACTOR Registration: 116609 ° Expiration: 06/29/2002 Type- Individual s BILLY E CAUTHEN BILLY CAUTHEN �CD7j� �6-BETH LANE ADMINISTRATOR HYANNIS MA 02601 f BOARD OF BUILDING REGULATIONS . License: CONSTRUCTION SUPERVISOR Number. CS 009975 Birthdate 08/13%1942 t Expires 08/,13/2001 Tr.no: 4334 I ° Restricted To: 00 P' BILLY E CAUTHEN _ 86 BETH LN HYANNIS, MA 02601 Administrator IF s �. .. ..V^'1-..�i'.Mid`.'f.'..•.e."r'v""'}^'�'w•f'i'kwfn..^wFr�MT'.�'.^tH`V"F`t"�. ' 'YT "l��Y"w"'.'7•""'.gR!+i,.v+e.r'.r-Far^'"'•T?`°:^..�;T,.w ni"'e_'•4n='°r 't'• .'4•,-''.s. r .• f'. ` NP`oFtHe r �� The Town 0A Barnstable BAR Department of Health Safetyand Environmental Services "A ll: E. y MASS. 0 x prFD MPS Building Division. 367 Main Street,Hyannis, MA 02601 Office: 508-862-4038 `r Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection 14, .`F,,o Location Permit Number qq/c G Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: ��i i s ()A Ur Please call: 508-862-4038 for re-inspection. Inspected byT'" - j 1 v Date 1 ! 1 L1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map /9 Parcel Permit# ' q( � 37 Health Division Date Issued�c o f Conservation Division — Fee �' �/of.Z Tax Collector y Treasurer-' SEPTIC SYSTEM MUST BE Planning Dept. INSTALLED IN COMPLIANCE WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN rumUL MCNS Project Street Address /0�0 Village 1-1Ct?Ul Owner L✓i1l� 1 70 Address e*'10'V17 Telephone Permit Request �d�v� �/lye> ! a� y 941 6,?-%i,f_:2e .2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost v Zoning District Flood Plain Groundwater Overlay Construction Type a Lot Size Grandfathared: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family C( Two Family ❑ Multi-Family(#units) Age of Existing Structure Ifs Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric O Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing 2(new size aJ--0- Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# :4 Current Use Proposed Use BUILDER INFORMATION Name g"/& Telephone Number 731 01-Y� Address 69 &7f' k,4� License#— 00 17r 7S'__ /S, W.4, a?- 0 Home Improvement Contractor# /le�6 U 9 Worker's Compensation# Oef 3- a j�'rP 7 3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 9,,4il��mv/6 �41LI,V 61// SIGNATURE l c� DATE ti FOR OFFICIAL USE ONLY • + PERMIT NO. DATE ISSUED - MAP/PARCEL NO. t t .�4 i V, i ADDRESS l:P~ VILLAGE ' OWNERw ', :At DATE OF INSPECTION: FOUNDATION to °9, y FRAME i ' INSULATION FIREPLACE _t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH; Y:'� 11 INAL FINAL BUILDINGV ra DATE CLOSED OUT ASSOCIATION PLAN NO. , � r r LOT-141E AS LOT 28 ' \ �. HSE ti61• � \ �� :SUN PORCH LOT 142AA PARCEL 2 LOT142A - AS 'LOT 29 C� \ o AS LOT 30 ' \ A , FLOOD ZONE "c-"_ FO UNDA TION CE'RTIFICA TION REY ZONE-. "Rr"__- ,. TO WN' COTUIT x SCALE.'1 40' PL. REF'124 95 'ELE�N/A hiCERTIFY�THAT THE ABO VE., YANA= SUR t EY CONSUMNTS FOUNDA TION.IS, LOCATED""`ON °f P 0. BOX ?65 THE GROUND A'S. SHOWN, ;,AND � PAljt , N s ''. �. UNIT, L .40B -�INDUSTR f' RO-1D IT'S POSITIONS�OFS — -- a MEW MARSTONS MILLS, jV4S'S... 02648." ` CONFORM' TO . THE ZONING L�1 W ,��, �.' ' SETBACK REQ UIREIIIENTS;,OF �� "FGism .,`:' s. TEL' 428=005� BARNS74BLE '�. u os4 F.��l' 420=5�53r: PA UL A. �IIERITHETtj T 10 f 95l J9 ' ,vcrluQc 7 14b CI3 u 39'1 + 10' 22' v Existi ng tPus Mi i I I- i I T1 — 10' I CN I I o N j proposgd garage I i I N I ( I I So I I I Garage Door - 16' x 8' I I i I - •I I 22' 22' 90 --. 8" Poured concrete I I 20" x 8" Footing I I I I I I I LL - I I N I i Foundation Plan I I � I I I I cy I I I I I I L I Its 8" O.C. typ. i I. j I I I I I I Drop wall for garage door r i -71 � I 22' —� I', � _ � - _ � : � = p��� I '' __ _ � __ ��i�l - - _ - - - �T Ins Is' (, I+ n C. 40 ry�7c�c GG ....... a f k- y � � {z �' tit, � ��.• �} �� -�� �I�'!.��r e . -.. :' .. w � \ c � 1 c- r � 1 _ 4 a r L ; v 4 l �T r �:..- y ". � The Town of Barnstable f • snxtvsTABUM , 9� Department of Health Safety and Environmental Services iOrEo +" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: o7- TerWe vW/(t° Zf Estimated Cost �7 UUp d U Address of Work: Owner's Name: l/ / Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: 29 Daie Contractor Name Registration No.' OR Date Owner's Name q:forms:Affldav r --= '--- The Commonwealth of Massachusetts Department of Industrial Accidents - =o 600 Washington Street Vq- .Boston,Mass. 02111 Workers' Compensation Insuraanccee Affidavit name: 0/l// C:4 IWI-61 rO location: city hone# ❑ I am a homeowner performing all work myself. ❑ I am a sole vrovrietor and have no one working in a�capacity //�" 010/%%/%////////W/////%//%%///%�//%%///////%�%/////////%%// I am an employer providing workers compensation for my employees working on this job. comnnnv name: ow address: I,�� . . q... p- ... ..�.. : .:..:, city: 14iUYUl�. �"( phone#: /a` insurance co. ZeG)&400 nniicv# 4 ad'S ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have . the follo«ing workers' compensation polices: comnanv name: address: dtv phone#- .. ...... insurnnce cn. comnanv name: address ci ri— phone#i insurance co. — Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S 1.500.00 and/or ` one years'imptiaonment as well as civil penalties in the form of a SI°OP♦VORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Omce of Investigations of the DIA for coverage verification. I do herebv cerri vunder the pains and penalties of perjury that the information provided above is trn,-and correct t Signature L Date 9 _ Print name �/ %9 v7fl��t/ Phone official use only do not write in this area to be completed by city or town otndai city or town: permit/license tl ❑Building Department LILicensing Board ❑ check if immediate response is required ❑Selecmten's Office ❑Health Department contact person: phoned: ❑Other�� tevfseC 9i 9 S FIA I Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for th�.r employees. As quoted from the "law", an employee is defined as every person in the service of another under any cow=- of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more o: the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the:ec.:.i•e 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 an such dwelling house or on the grounds c. building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local Iicensing agency shall withhold the issuance or renewa' 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,neither.the . commonwealth nor any of its political subdivisions shall eater into any contract for the performance of public work mci? acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the comrac= authority. , Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or 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. --------------- City or Towns Please be sure that the affidavit is complete and printed legibly. The Deparaneat has provided a space at the bottom of the affidavit for you to fill out in the event.the Office of Investigations has to cm=zt you regarding the applicant. Please be sure to fill in the permidlictnse number which will be used as a reference number. The affidavits may be reaaaed Io the Department by mail or FAX unless other arrangements have bem made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of InVesdoadons . 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 ESTIMATED PROJECT COST WORKSHEET Value LIVING SPACE square feet X$55/sq. foot= (UNFINISHED) Sa d� square feet X$25/sq. foot GARAGE (UNF ) q PORCH square feet X $20/sq. foot= DECK square feet X $15/sq. foot= OTHER square feet X$??/sq. foot= Total Estimated Project Cost 3 r g990915b 1: 1: 11 i 1 .1 a g Fc.,�_ sue, ,WI", a p S,�`'`t�k a'r sy'r�#�4 r 9f �u' f �.' sgS,i+P+w+..•aw,.SrY."�``�� / d��-. �,��a„ i h�f i •.f.'`�'�"F.�� ox }f�'�vpi.�'6.t`�* .3u'�` � f F S � i 9'C ° 1�'� ;�•.�F g•'�`v. r�4R^ r,g""t`+r""+pf 6�r�.� 7S��� S b @,f:9/t� d 5l �,��eT1C i�� Y �• 1 : l i' ,ry, /C�4U J7.t-1/', /a"') �! �:-•-•-'---�—f- I_�aT � ''1 t .. ._ __ ._-___ -e-r—_ _ : - --___-. G;At t."fry LG : k , I I -n,r - NE,nt )cr;-.....i¢ A) -f L A-`I Gt?l' -Aj v,•L +� -fit. C`. 'r A A.Iti if l ri.v+l�7'yp jut, I f / i I i A In JJ - l , c�c,1 r. tj lit I 3 t 5X(�' ;tAK.Vtii V✓�4 FE 3l L. - I t;l, .PrY2.c it .'ll"p>P fl lL ilt�V -- . f -CiF T.17 �V"`" (�C t'- 4 x�7 .,.t.X(r f3.3 Y)L t t , T t.v If- 7✓.t.eZ - - ,) �15e)-)At,l Y+t'c1 07 iX 2 )rY PAfd n �j ���� ar .S:K>r�a,Ez'Z'�'"-. � - � /1✓_tht (.,:�t'r�Yi�+ -5!'�,.t+�� /i��.t:;,t tNa'r) ,pC I LJ 1x4't Csf'..PLA7r_.! ,'L, c�, Ex, _-- ' r.. � S .x to ✓G fd 1 r k�T1,,q t: r! r, .:�{,,�, $ NU!It3 f-;IY_ <j ;-e t �, l:r.� 51 c/ G q 3°x A^IA7"CPI £z --- - _- -� a X Y A.,r, 1 5 r '��;; 7 7Z` 7�rT .3. i. .Y't roi ta'1 N I)[E„r - - ..�__. ----...._ --}---- - ----r ni �i� ��' �. { e .>:. ,yeY�urrD;x - ------ t _—_---- ---� ,t �. -- f to A1ClU AA bLt \i` -t.� k)AI G �,/G1K: L{#L c r n ;i.v faUtt. f�; I C. 1 ^V t x It f,7, — - 47n/� 3xbF7 ettl f Kr57lrJ:. Lgh. r17CP ,a,:.L1A)A "NEB, j 1 S•-`.._ JJI so'Le1 •� r` `.,, A►IROVEO BY: ORAWN 4T r� DA'ry NlVISCD _DIGWING mumWiI SCALE: ,-�- ft� APPROVED BY: DRAWN®Y% l ws NUMBED