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0024 HIGHLAND AVENUE
����/V I ,, �. i i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map dam— Parcel 634 - Application # Health Division Date Issued �. Conservation Division Application Fee 41 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis ,,^u Project Street Address I vlt: / Village (I'All If Owner 1( 1w L2,&eJ1 _ Address^ ) � Iwl r�I, Telephone (o0"l- (*- L4o 1.3b � Y \ C Permit Request i oc?r Square feet: 1 st floor: existing proposed 2nd floor: existing,55Zproposed Total new Zoning District Flood Plain Groundwater Overlay _NO Project Valuation 3.15, 019 Construction Type Lot Size Grandfathered: ❑Yes allo If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure ICA(— Historic House: $Yes ❑ No On Old King's Highway: ❑Yes )d No Basement-Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other. &Cj-a Basement Finished Area(sq.ft.)_ ( Basement Unfinished Area (sq.ft) o>2 J0 Number of Baths: Full: existing new Half: existing ( new Number of Bedrooms: existing —new Total Room Count (not including baths): existing tQnew First Floor Room Count Heat Type and Fuel: 4Gas ❑ Oil ❑ Electric ® Other C _ 2E Central Air: ❑Yes No Fireplaces: Existing _New Existing wood%coal stove: ❑ems U No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn:jOexisting never size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size Other: I =' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ D Commercial ❑Yes ❑ No If yes, site plan review# _ Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address M". License # GU�4A , MA C= ''> Home Improvement Contractor# 33�l1 Worker's Compensation # 00 5 y 3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE \ a - FOR OFFICIAL USE ONLY . / , . } APPLICATION# \ . \ - > ,,D A E7§U Dy«,-t� >y ( MAP/PARCEL NO..- . w. . 3 } k ADDRESS VILLAGE \ OWNER , ) DATE OF INSPECTION [ -FOUNDATION- FRAME 6.10 } . { INSULATION G.J. \ « / FIREPLACE ( ELECTRICAL: ROUGH FINAL » IT . 7 PLUMBING: ROUGH FINAL GAS: g®a ROUGH,*a=� ,, . FINAL �K . |NAL( BUILDING f r. . . . 4 { . / DATE CLOSED OUT } ' ` . ƒ ASSOCIATION PLAN NO. ' ® \ ' The Carrzmbnweakh ofAfarsachusetts >;t ' Department of IndizstrW.4cddez%tY Y- Office ofJrgvestigadons !10, 600-Washington S&eef ; j Boston, M4.0211I C www.r aSS.gav/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Flumbers tipplicant Information Please Print Leeibly kTaine (Business/Organizomvindivi.duan: Address: �.� (�t/11►/YI�Ar'['q�i� �f(Op - City/Mate/Zip: Phone#:--S(O' 477 _ .gr Z 7. Are you an employer? Check the appropriate box: Type of protect(required): I.� Tam a employer with �� 4. ❑ I am a general contractor and I 6, �New constructior. employ=s.(fu1I and/or part-time).* have hired the subcontractors 2. ❑ I am a sole proprietor or partner- Iisted on the attached sheet I. ._ � .p Remodeling ship and have no employees These sub-contractors have S: Demolition working for,me in any capacity, workers' comp. insurance: 9 Building addition [No workers' comp. insurance 5. [] We are a corporation and its required] officers have exercised their 10.0 Electrical repairs oradditions 3. ❑ I am a hcrneowner doing aII work right of exemption per 1vIGL` 1 1:D Plumbing.repairs or additions myself. [No workers' comp. c. 152, §I.(4), and we have no j2•Q Roof repairs insurance required.J t employees,.[No workers' 13 0 Other comp. insurance required.) 1.. *Any Applicant that checks box#1 most also fip ouf the section below showing their workers'compensation policy information. t Homeowners why submit this affidavit"indieating they am doing all work and then hirr outside contractors must submit a new.affidavit indieatingsuch, ICorrt nators that check this box must attached an additional sheat showing.the name of the sub-contractors and their workers'comp:policy information. I am an employer thaf is providing workers camp=Padon'kurcrance for my ernp[nyee& Below is fire poficy'and Job,site , information Insurance Company Name ` Ir IQt Policy#or Self-ins. Lic. #:_00—,5 418 n4 I Expiration Date: ' Job Site Address: t 6A9 city/State/zip: , �� - Attach a copy of the worke ' compensation policy declaratiDh page.(showing the policy num ber 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/oione-year imprisonment;as weII as civil:penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the-violat6r.. Be advised that a copy of this statement may be forwarded to the Office of Investigations I e DIA for insurance coverage verification. I do hereb c u de the a' d anaidp-s o e 'y p p f p rJury flzat the urforrratcorr provided above is Prue and correct Si ature: Date: f Phone#: `J O.• 77 U 7 4fficicl us anly.,.Do not w,rrte.in this area; to be comp[eied by city or town official City or Town: Perm'it/Licease# Lssuitig,Agthority(circle one): 1. Board of Health 2: Building Department 3.City/Town Clerk 4. Electrical Inspector S, Plumbing Inspector 6. Other •. Client#:51439 CAPEENT DATE(MMIDDlYYYI� ACORD.. CERTIFICATE OF LIABILITY INSURANCE 04/16/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in Ileu of such endomement(s). PRODUCER WCT Linda Taddla FAX Rogers&Gray Ins. Kingston P ", ;508-746-3311 a No):877-816-2156 63 Smiths Lane ADDRESS: Itaddia@rogersgray.com Kingston,.MA 02364-3700 INSURE S AFFORDING COVERAGE NAICN 508 746-0055 INSURER A:Arbella Protection Co 17000 INSURED INSURER 8: Capewide Enterprises LLC INSURER C J.P.Macomber&Sons INSURER D PO Box 763 INSURERE: Centerville,MA 02632 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN pRpELDDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE I OL V POLICY NUMBER MMID W MOMIUDC � LIMITS A GENERAL LIABILITY CPP8500050813 4/30/2012 0413012013 EEAACCHp�EOCCCURRRENCE $1 OOO OOO X COMMERCIAL GENERAL LIABILITY PREMISES EaE oa rrence s250,000 CLAIMS-MADE Q OCCUR MED EXP(Anyone Awn $5 000 PERSONAL d,ADV INJURY $1 00O 000 GENERAL AGGREGATE s2,000,000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000,000 POLICY PRO LOC $ A AUTOMOBILE LIABILITY 589" 00004 4120/2012 04/20/201 Mee accidentSiNOLE LIMIT 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) s AUTOS X AUTOS NON-OWNEDPROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per socid nt S A X UMBRELLA LIAB OCCUR 4600050814 4/30/2012 04/30/2013 EACH OCCURRENCE $5 000 000 EXCESS LIAB HCLAIMS-MADE AGGREGATE $5 000 000 DED I X RETENTION 10000 $ A WORKERS COMPENSATION 0054370411 4114/2012 04/14/201 we TORY LIMIT E04W AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER�EXECUTIVE� E.L.EACH ACCIDENT $500 000 OFFICEWMEMBEREXCLUOZ N NIA (Mandatory In NH) NO EXCLUSIONS E.L.DISEASE-EA EMPLOYEE $500 000 Ir yes descr®e under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E500 000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) 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. AUTHORIZED REPRESENTATIVE ®198 -2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S803691M80368 CJF NE i * BABNSTABLE, `"639.A. Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 :1)2 1(�/I I ,as Owner of the subject property hereby authorize Nto act on my behalf, in all matters relative to work authorized by this building permit application for: a4 4'�a� I (A dress of Job) S nature of Owner D(Y Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 Massachusetts - Department of Public Safety Board of Building Regulations and Standards oin%tructirm Super\isor License: CS-089273 RICHARD M O PEN ' 122 WHTTMAR RD�9 rr COTUIT M 02635 �,�w•+� IS\ `` Expiration Commissioner 11/27/2013 Officeot(`oncumcr \II'airx`.Bnsinr,: t2r=ul+tinn HOME IMPROVEMENT CONTRACTOR Registration: ,43358 Type: Expiration: 7/8/2012 Ltd Liability Corpo CAPEWIDE ENTERPRISES L L C RICHARD CAPEN 4507 R RTE 28 COTUIT, MA 02635 lhdcrsccrct�r� Restricted to: 00 00- Unrestricted 1G - 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business.Regulation r 10 Park Plaza-Suite 5170 Boston,MA 02116 �alid with t signature s i � 1 i ......:. _ { i E � r iin f ' t�' ter 5 1 _........................._.......,...... .. _._.._....._......_... �. .._ 7-44 ® ttsthiaS�n ^� T EQ= I Clai%kpber-. 1171��? Policv Number: az'T I 0� i-4— i "" ..ti,rt..�... T" toad (I N � N f�✓ t 7' s' y f In Ul Open E4$ s .. .. , r r # j f � Nlamer8e&oam T w.w:t,..... L.S' >5" 12'E" � } ate•: E. 13.2: � — am q llli b r: 1171952 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION. Map Parcel :Map_t6Application Health Division "`Date Issued Conservation Division ,.Application Fee (60 Planning;Dept, Permit Fee e -U Date Definitive Plan Approved by Planning Board Historic = OKH Preservation/ Hyannis e Project Street Address 01"7 h49-n e Y' Village Owner r / o Address PP, 69 Ra � gc,:, V R Telephone - = Permit Request �je r 1'e & 04 G �0,-c sl eAyc.k —-1-oJ�c� �G�`�1 �v, JJoo s -e Cti1-0 i e:4-s ,yam. ' VJ et-,,,;a 0_c ? bv o l d ' Square uare feet: 1 st floor: existin ro osed ©"2 d floor: existing J q g p p n g prbposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation t5__0_-0d - Construction Type t Lot Size _T"7 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ' Two Family ❑ Multi-Family (# units)- Age of Existing Structure g Highway:Historic House: ❑Yes N No On Old Kin 's Hi hwa ❑Yes CCNo Basement Type: 'A Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.)' Basement Unfinished Area (sq.ft) r ' R Number of Baths: Full: existing_ new ® Half: existing .µme newer' Number of Bedrooms: existing Qnew Total Room Count (not including baths): existing new First Floor Rooml Count " Heat Type and Fuel: Gas ❑Oil ❑ Electric ❑ Other_F�_/Yq o. rn Central Air: ❑Yes 10 No Fireplaces: Existing-1—Nvew Existing wood/coal sst ve: ❑Yes ❑ No Detached garage: ❑ existinV L new size_Pool: ❑ existyin new size _ Barn: ❑ existing0 new size_ o Attached garage: ❑ existing ❑new size _Shed: existing ❑ new siz070;Ahl"r� " r Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# n 0�- Current Use ��C' Q a 0 Proposed Use QS1dLtkP,9J _ —APPLICANT INFORMATION ,-- (BUILDER OR HOMEOWNER) Name :Obtedo A, ,'?�►'Y�C'A Telephone Number erP Address CQ License # /40�,Q e5_� 1 Home Improvement Contractor# n��/_9' Worker's Compensation # 'T/()C� /D ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO DATE SIGNATURE �D/ s 4 = ; FOR OFFICIAL USE ONLY APPLICATION# IS DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER T a DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts e Department of Industrial Accidents Office of Investigations ' 600 Washington Street `Boston,MA 02111g ry. www mass gov/dia Workers' Compensation Insurance Affidavit: B_uilders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizatiott/Individual): � �y �� Address: City/State/Zip: {,��^ Phone Are you an employer?Check the appropriate box: Type of project(required): 1.DQ I am a employer with 10 4..❑ I am a general contractor and I , . have hired the sub-contractors 6 ❑New construction employees(full and/or part-time).*. _ 2.❑ I am a sole proprietor or partner-' listed on the attached sheet. . ;.7. ❑ Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for me in any capacity. employees and have workers' 9: ❑ Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its . I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised'their 1Jw 1:❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12:❑ R f repairs insurance required.] t 6.152,§1(4),and we have n `employees. [No workers' 13. Othe/r1 .0 comp.insurance r Hired. '7t/--�. P eq ] Any applicant that checks bo%#1 must also fill out'the section below showing their,workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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. _ h Insurance Company Name; Z r Policy#or Self-ins.Lic.#: p 7600 Expiration Date: Job Site Address: ��1"�"/P City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.=152 can4ead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well ascivil penalties in the form of a STOP WORK ORDER and a fine= of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of.' Investigations of the.DIA for insurance coverage verification. , I do hereby cer if un a the pains and penalties of perjury that the informatihn provided above is true nd correct. a r , ��) Si ature: Date: ' �, tC�/ Phone#: Official use only...Do not write in this area, to be completed by city or town official i w City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: RightFax 141-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server IS5UEDATE ;;"'$ f •v.`Ri 1 ,3.SI! ylt I� t r{ - e F x!' £� 'ir -.r,e .,i..,." .r i,. e'R'., �a z: �,....;.• Mir'ra•:v ,F.:: 12J2212011 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION ONLY•AND CONFERS NO BIGHTS VPONrTHE CERTIFICA HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICIES' BELOW.TIUS C11Z11 CATE OF RiSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),)1ATHORIY W AEPRESENTAIIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT;N the certNicate holder Is an ADDITIONAL INSURED,the pollcoas)must be endorsed,if SUBROG TION IS WANTED,subject to the terms and condNlonsbf the policy,certain policies may require an endorsement.A statement on this certificate d es not confer rights to the certificate holder In Neu of such endorsements. PRODUCER CONTACT OCEANSIDE INS GROUP NAME: 52 WEST MAIN STREET PNONe FAx ac No,Est; HYANNIS,MA 02601 E•01L ADDRESS: PRODUCER , CUSTOMER ID Y. INSURED INSURE S AFFORDING COVERA& NAIC It' BENABBY INC DBA INSURER A ZURICH DISASTER SPECIALISTS INSURER g P O BOX 480 WsuRER C SANDWICH,MA 02563 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUCIP.S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To IT HE INSURED NAND ABOVE P R THE POLICY PERIOD INDICATED. NOT'WITIISTANDRIG ANY REQUIREdENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC%43NT WA8 RESPECT TO WHICH THIS CERTIFICATE MAY BE- ISSUED OR MAY PERTAIN,THE INSURANCE AFPORDED BY THE POLICIES DESCRIBED BFREW I$SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SLICE POUCE3.UMrTS SHOWN MAY HAVE 9EYA1 AFDUCPD BV PA[D ClA¢.dS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EX LIMITS LTR INSR WVO I GENERAL LIABILITY , EACROCCURRENCE I 000MMERCLILGENERALIIABILITY DAFAAOETORENIFD S PREMISES(FACIE ' occmence a CIATMS MADE 0 OCCUR. - M®.E)oPENSE unr mrt I ! Qsw - PERSONAL&ADV S INJURY OENERALAOORWATE S GEN'L AGOREUATE L blI T APPLIES DER PRODUCTS-COMPlOP i 0 POIICY OPROJECT 0 LOC AQG AUTOMOBILE I.IARILTTY COMBINED SINOIE S LIMIT fCEach accident)' 0 ANY AUTO i BODILY QIIURY S ar Pers j 0 ALL OWNED AUTOS y' I BODILYIHJURY I. !. i er Accident) 0 ScmmuLED AUTOS PROPERTY DAMAOE S ! er amsdenE i 0 HMAUTOS S 0 NON•OWNF.DAUTOS S 0 0 UMBMA ALIAS 0 OCCUR - EACH OCCURRENCE t . 0 EXCESS LIAR 0 CLAIMS-MADE - AOGREOAIT S 0 DEDUCTIBLE S 0 REIEMTON S _ WORKERS'COMPENSATION ! WC - A AND EMPLOYERS LIABILITY NIA STATUTORY Y/N ANY PROPRIETOR/PARTIdER! , EXECUTIVE OFFICt ER N ! LEACH ACCIDENT S500,000 LDc UDEm Nu 67ZlJH 4102P700 01/01112 Ol/01/13 (MANDATORY IN NHI EL DISEASE-EACH S500,000 LOYEE IT yes,describewdorDESCRWRONOF _ DISEASE-POLICY S500,000 OPERATIOM belm r U¢SCRIPTIONOFOPERATIONSILOCAttONRIVFIIICLSS(AlUch ACORD 101,Additiml Remarks Schedule,ifmore spice is required) ' THEWgURED'S MAWORYJM COWENSATION POLICY AND ITS LR&W OTHER STATES INSURANCEENDORSE14ENT AUMORIZFS THE PAYMUTT'OF BENEFITS FOR C1.ADM MADE DY THEINSURED' ! EMPLOYEES IN STATES OTHER THAN MA NO AUTHORISATION IS OVEN TO PAY CLAIMS FOR BENEFITS IN ANY STATE MI-MR THAN MA IF M IISURI'D HIRES,OR HAS HIRED,EhIPIAYEES OUTSIDE �. MA T.TUS POLICY DOES NOT PROVIDE COVERAGE FOR ANY STATE OTHEIT14AW MA THIS REPLACES ANY PRIOR CERTIFICATE ISSUED 70 TIM CE UI FICATE HOLDER AFFECTING WORKERS COVERAGE F,�i.L1S� !'.i�... .�1NAh�;6q,.d•4.,',PiI•A 3R4ikk'.��+ i "N.\�.i',,.'.'�'I•i'!.'v dl Alsa" EM �.A 'n-;.:-.4-� n#"., :'Y.^c5 -�h,r - + ... 6NOULD ANY OP THE ABOVE DEBC CO POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE HALL BE DELIVERED IN ACCORDANCE VdTH THE POLICY P V1610NS. ._.-. AuntoRm RPPREsmAnvE 8rtaiv MacLecu'v i�aeaii ?':t:�COR`Df2.'I 0091d �3=Ir.�'Si�',L':arM•' .r i.:,,.t;�sa .. <�_:....'"'r,...�.�>,+YC,�+.::.: .�a����t? ��'� r. i - '�, - F �.: .. �''�.. _ .T t. a - • x a- wem `' Off e o onsumer air��, and Tuasi4esse anon g 10 Park Plaza - Suite 5170 r Boston, lV assachusetts 02,116 ,. r . - Home Improver U' Registration ' #I CS 864- egis#ra n• 10 2 Type: Supplement Card 3 Expiration: 8/20/2012 R BENABBY INC/DISASTER SPEC R JOSEPH MARMAI' I i y i 9 Jan-Sebastian Wa 7 . Sandwich MA 02563 -A Update Address and return card.Mark reason for change. Address Renewal Q Employment_ Lost Card , DPS-CA1 Q SOM-04/04 G101216 s n < v TM L Office of Consumer Affairs&Business Regulation - j License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to: �r ., Office of Consumer Affairs and Business Regulation on�1, Registrati 8642 -'TYp e: _ 10 Park Plaza-Suite 5170 ExPiraUo1 a8120/2012 Supplement Card Boston'MA 02116 a - , r ` BENABBY INC/DilrS,Tgr, FLGl#AfJST ' JOSEPH MARMAf Box 480 Sandwich,MA 02563 .. ' '° '- - Undersecretary ,� > .'� Not valid without signature 1 _ .. _ ... •fir ,.n. .. - ... .. v v - .] . , •>, rye/ u _ ., i .. .. ' r AL Ma„ss.,01usetts- Department of Public Sat'etl - Board of Buildioy Relauiations and Standards r` 4 •d Construction,Supervisor License ense: CS 104053 ' , Restricted to: 00 ;► JOSEPH MARMAI 93 PARTING WAYS RD s KINGSTON, MA 02364 . . � _. e - Expiration: 3/1512014 � .. �'mIII)Ii5siuOel' Tr .104053 j'• , - ., h•. r - _ Tom° .. , .. .. , r , .v P r • a ... .r • '4' y� .. a Q I e .. £e •- v � i • .•n. . `' E Ali 6 r. - • .. r 3 � .i Town of Barnstable Regulatory Services HARNBTADLE, Thomas F. Geiler,Dfrector 1639. Building Division Tom Perry,building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma,us Office: 508-862-4038 Fax: 508-790-623 Property Owner Must Complete and Sign This Section zf U ing ABwilder . 1 as Owner of the subject property hereby authorize /, ;CYm" %- /S/}�y ;to act on my behalf, in all matters relative to'work authorized bythis building permit application for, (Address 04 ob) • t:. Signature of Owner D to - Print Name If Propei-: Owner is applying for permit please-complete the Homeowners Licerise Exemption Form on the reverse side. Q:FOWS:OWNERPERMIS SION Town of Barnstable T Regulatory Services Thomas F. Geiler,Director 019. Division =bss� .�� prfD '�a Building 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 ------ - _._.!HOMEOWN work hone# name home phone#. p 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 care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC r I �t Town of Barnstable *Permit#���THE M. u1' �•Qn Expires 6 month o issue e Regulatory Services Fee * BABMSTABLE, Thomas F.Geiler,Director p�FD MAT A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 2-4 141(,14tAnyb A.r • ,C° 01 T Residential Value of Work "4( 00 m Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 2-1 q� 11 1 t✓L(r 2 4 A it _ , Co ) i r Contractor's Name 90,4tboAe j C-4pt-wlori, Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) CS 29 2�-3 Workman's Compensation Insurance .PRE 5 S PERMIT Check one: ❑ I am a sole proprietorI I(� q3 (11 ❑ I am the Homeowner I have Worker's/Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# 00 5-134 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) �f 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 (maximum.35)#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 wired. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 I ` Hof Er y Town of'Ba)rnstabze o� Regulatory Services It A • xiar:srtar.� ; Thomas)t. Geller,Director i6sp. ATEo �a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rnsta ble_ma.us Office: 508-862-4038 Fax: 508-790-623 0 Property Owner Must Complete and Sign-This'Section If Using A Builder as Owner of the'subject prop J p?xly hereby authorize to act on mp behalf; in all matters relative to work authorized by this building pen-nit application for.. (Addxess of Job) c S atute of Owner . ate Print Name If Property Owner is applying for permit please complete the Horfteo:wners License Exemption Form on the reverse side. Ae Corf mornivalth of arssa dimsetts - r tmerat qfIn&sftia1AcciderLtv:' Office r�,f`Ir est g, s 60t1 Washington Street B'ostb# 4 02111 it iti:rrras& a vIdiaa Workers'Compensation Insurant:e Affidavit. Bri e l nntr"actor-./E ectriciau 'I bees Applicant Inf€armution Please Print LegibIy Naraae Oxg on&dimduai): C14"115vJitc— 9vTf7 ea_)Sr_S Address: S; a CitylStatejz* Mft4pte VO.4 4`1 Ph. _ S-C9 1• • -q- Are you an employer"Cberk the appropriate boa: Type of project(required)- LV I am a employer uwith 4. ❑ I am a general contractor and I employees(full anchor pat#.-time).* ha-=e hiredthe sub-conffittrrs 6. 0 New construction 2.❑ I am a sole:giopsietor or partner- listed on the attached sheet- 7. ❑Remodeling ship and have.no employees These sub-contractms have g- ❑Demolitim worms for me m any capacity. employees.and have workers' o tvarkers"comp.i re conjP-insurginm� 9. ❑Building addition El We.are a corporation and its 10.❑Electrical reps or additions 3.❑ officers exercised o 11_❑Plumbing repay or additions m1 1f[No>,worl ' p right of exemption per GL 12_X Roof repairs 152, 1 4 insurance required]`s c. � and a have no ' 1 . f tithes �16 1t.�,T employ.06 workers' 3 comp-in required:] •t�uy-applustit that decks box#1 roast also fill out the section below sbowing their makers'compensation policy information. fl�ianeovtners wbo submit this affidavit indicating they are doing all work and then hire outside contractors artist submit a new affidavit indicating Sikhs oairactors'that cbe€t.finis box must attach an additions&sheet showing the name of the sub-contractors aad state whether or not arose entities,bane employees. If the sub-contractors have employees,they must provide their workers'comp,policy number:: I ami an employer that is providing n arkers'coirrensationjnsiironee for qv enrpLVj e s. Beloti,is the pol' and j[ b site information. Insurance Company Name: 4 aLq Policy#Or Self-ins-Lic_)) : 00J-43 T+ Expiration Date- � 1 4 1 L Job:Site Address: Z4 14'1&t f�i 4 v',> .44 C 9 f.itya StatedZip_ c7 V:i r Y'14 ®2,&-3 AtE cla a ci►py of the workers'rompe�atio polite declaration page(showing the policy fiumber and tspiration date). Failure to secure coirerage as required uncles Section.25A of Nf GL c. 152 can lead to the imposition of criminal:penalties of a fate tap to 1,513o_tla and'or tine-year:iiuprisaitii nt, 6ue11 a ci-t it p aialties in flit form of a STOP ARK ORDEFLand a fine of:up to V50.IDD a day against the violator. Be advised that a copy of dais statement may be forwarded to the Office of In�,stigaoom of the DIA for_ cov,�e age vitrification. I dot herabt^certr t aiiider thh prrfrts aairt;paltr hies�f per iu mat flt,�frifaarulation pt^tat�rl arhiiA�e is to and cdrrect Signature-, Date- Phone Official use out v. Do not write in this area,to be completed by cittv o town officifil, City o.r"Toys€►: PermitflAcense Issuing Authority(circle one): 1.Board of Health 3.Building Department 3.Citvfl`own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.other ContactlPerson: Fhaire#;I _ 6 Client#:51439 CAPEENT DATti ti�iicavrrn ACORDn CERTIFICATE OF LI Bf'LITY-I'NSU � 04115J2011 THIS CERTIFICATE IS ISSUED AS A M4 R'0 IR?65 AT18N OKY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER:%THIS CERTIFICATE DOES.NOT AFFIRMATIVELY OR NEGATIVELY AMEND,:EXTEND OR ALTER THE COVERAGE AFFORDED SY THE POLICIES t sow.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITtiI•'E A CONTRACT BETWEEN THE ISSUING INSURE R(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE:CERTIFICATE HOLDER. NIM TANT:If the.ce 1 Ica Mfibidar:Is:an ADDITIONAL NSURra cyoos:must be ondoraed.If SUBR .B&(S WAI.YED;subjectto. p01! the.tsrms and condltlons of the pgllcyr ceitajn:policies may:roqulro ai endorsement A:statement on this tiMcate do"net confer iights:to:the caslflcate holdor In Ilou of such endorseme+nt(s) PRODUCER' _..._.. - ..:... _... 'BANE _. Rogers B.Gray.lns. Plynwud+ Q:�c,S08-74E-3311 nrc,uo. 341 Coutt Street _. P.0.Box 370.0 Plymouth,MA 023614700 INSUMS1 AMORDttN COVERAGE NAIe a wsuaco' txsuReaA;Arbel a rotecttNsn Co 17000 Capewide Enterprises LLC . - INSUREINIB: J.P.Macomber B Sons PO:BOX 763 INSUR¢RC Contervillo,MA 02032 tR3URei€4!_. CtkV. !{I(G $ CERTIflQgTE NUMBER: REVISION NUMBER:` THIS IS TG CERTIFY THAT THE"POLICIES.OF INSURANCE LISTC.O.DELOW HAVE BEEN 13$UM TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT:TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH:RE$PECT T.0 WHICH THIS CER.TIRC47E MAY BE ISSUED OR MAY.PCR'rAIN,THE INSURANCE:AFFCRDED BY THE POLICIES DESCRIBED,J9EREIN IS SUBJECT TO:ALL:THE TERMS, EXCLUSIONS AND.CONt.rnoNS CF SUCH POLICIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CINMS. WWI:TYtE9 1?taUP c ARM. P6ctav:NU CGtttTS aetN�u Lu1 tttrr CPPOSOODS0813 3012011:0d/301��11 FA�3{EiGG�1R}tENCC st 00ti' 00 d itl . X c�utiBRcuV.:CaNtSuu. CLAIMS4AADE FX OCCUR 't lYchiP nail: S 00t1 t;FctEtltrl#t9Pt canttCrs.0010 ID�Ac s OQft . 7,7LIMMOGILELULeam' d834iCt00t 4#20120fi1:t#+iC,>t {f1 cOIINEoNl1<t : I . .AN'�Auro tEaasdoj OdD t) .: BODILY, :ALL OWNED AUTOS _ .. .. .... Booky .uwky.{Per 4660chi l S +$CHMULLD AUTOS X HfR50AVTOS PR#PE ?1?AjfASeG:' _.. X;NON-OWNED AUTOS S. A vaal;Llnta tjC<jvl; ASti05t181401041 04/301 (y1 ;r�rItle. 6 araoa M x AC REO T ncoveThatc X wx I 10000 s ,A. YltO>sit OD?kPEtN3ATFOtd O.DSd37 4/14#2011.04114201 A ATt aND FNPwYExa L4Lett rTY Y I N OPFICEWMEMo6R EXC UO� WA lase Maty.16 N►n cSOA`t100.... .. ... .. .. ................ :. bE8CR1PTI0N OF OPERA114Nb 1 LACATIONb I VEHI4LE5(AtwcA ACORD:tOi,ACAdOriad RatfeAte 9eMBVM,N mcrr.�pwa h npulro0j: Proprietors/PartneriUExecutive:OfflcerstM*6ibom,Excluded: Richard.Capen (Saa Attached OesCrip.tions) GAt1n HOLD _ CANIC"', ,.:ON SHOULD ANY:OF THE ABOVE 0E3CRISED POLI.C158 BE CANCBI 1:W BEFORE TME:EXPIRATION GATE IMEREO:F,:NOTICE WILL BE DELWERED:IN ACCORDANCE WITH THE POLICY PROVISIONS. AVP(ORM REPREbE<1/TATNH. 01988.2009 ACORD CORPORATION:All rights:rosprved. ACORD.25(2009109) 1 of 2 The ACORD name and logo are registarod marks of ACORD #S65874/M65871 LAT 4 •. � `3,r.::.. .. ii iir i.:. _ r.C_i: :. .t l:Ii 1i.11if l,t s.�i. �rrers� CS 89273 RByl:rt:trr;(u. 00 RICHARD M CAPEN 122 WHITMAR RD COTUIT, MA 02635 11/27/2011 9638 6 Office of Congomer \rrair•c& Ruxinc.: RceulAfinn HOME IMPROVEMENT CONTRACTOR r; f Registration: 143358 Type: Expiration: 7/8/2012 Ltd Liability Corpo CAPEWIDE ENTERPRISES L L C. RICHARD CAPEN 4507 R RTE 28 _s - COTUIT, MA 02635 l'ndcrsccretan Restricted to: 00 -- -- 00- Unrestricted 1G- 1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Refer to: WWW.Mass.Gov/DPS License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation +r r 10 Park Plaza-Suite 5170 Boston,MA 02116 i aIi d with t signature TOWN OF BARNSTABLE BUILDING} DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print, DATE Hoat- (6 3 JOB LOCATION Z / L yl T nNumber Street Add ress/� Section Of Town "HOMEOWNER" /�L f4k) dl�( Z(2o Z� �I Name Home Phone Work Phone PRE MAILING ADDRESS �. $�( �� Qj 2- City/Town State b Zip Code The current exemption for •"homeowners" was .extended to include owner-oocuDied dwellings of six units or less and to allow such 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 to six 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 Hermit. (Section ?n9 : 1, 1 ) ` The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-'-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Depart nt minimu ' nspection procedures and requirements r HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, .will be required to comply with State Building Code Section 127 .0, Construction Control. > MIUC5 1 HOME .OWNER'S EXEMPTION The code states that: "Any Home -Owner 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 Home Owner engages a person( s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor ( see Appendix nd for Licensing Construction Supervisors, Section 2 . 155) .Ru This les alackeoflations awareness often results in serious problems, particularly when. the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the unlicensed person. as it would with licensed oupervisor. The Home Owner acting as supesrv,isor is ultimately responsible. To ensure that the Home Ow ,er is fully aware of his/her responsibilities, many communities require, part of the permit application, that the Home Owner 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 to amend and "adopt such a form/certification for use in your community. r Assessor's office(1st Floor): D A An �" P 6y�.3�EOW ���UST EE Assessor's map and'lot number U 1t ,LED IN COMPLIANCE Pyo* +nnservation / f3 WITH TITLE 5 Board•of Health(3r fbor): ENVIRONMENTAL CODE AND = DA13T'LELE Sewage Permit number I rua Q�N REGULATIONS Engineering Department(3rd floor): '630' House number. Ito Y1ir Definitive Plan Approved by Planning Board qg APPLICATIONS PROCESSED 8:36-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF . BARNSTABLE E BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 7 /`ti�0leia 19 -. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ZY i!hYk Mb Ayc, Grvlr Proposed Use 5TofV,E Zoning District (1 Fire District Name of Owner ?ilew �. 141ji>-L-I Address 211 11166LAO-2 Aft �a/j Name of Builder Address Name of Architect Address Number of Rooms ] Foundation1l) Lf�G�� Exterior Roofing Floors W 06 D Interior Heating �' Plumbing Fireplace Approximate Cost �� Area 1 L1 5Q Diagram of Lot and Building with Dimensions Fee 1_040j LD I107 v1 csP�. ❑ AIL, ��� a I 2� . 4k( s _ U)1 a��� 1 Z 6 J I F--- t Z -----( OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. C / Name Construction Supervisor's License DANIELL, BRIAN R. 4 64 No 35708 Permit For PLACE STORAGE SHED j . +.,;. Accessory to Dwelling ? Location 24 _Highland Avenue Cotuit Owner Brian R.,'Daniell - Type of Construction Frame Plot "Lot ! Per�rit Grted March 184, t g 93 Date of I ion ' - 19 Date, &Ie))�d 19 CC"' U6in- 3 �� 1 w�.`1nJ�D M 4. ...,} • � i ., ' s � - 1. { ' • { p .. A f � i j t Town of Barnstable *Permit v V D9- Expir ion s fronT�Ssue date Regulatory Services . Fe Thomas F.Geiler,Director n Building Division f�— Tom Perry,.CBO, Building Commissioner 200 Main Street,Hyannis,MA 01601 www.town.barnstable,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 Q o 3 U l nY y 3s Cd � Property Address l�c.c-6 /d �GL. 6 residential ValueofWork �,,� S Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address (t lLt a O(,t.4n.x-c� Contractor's Name Telephone Number-50 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Oworkman's Compensation Insurance PERMIT Cheep one: - P e ❑ I am a sole proprietor L G 2 ❑ I am the Homeowner 0,I have Worker's Compensation InsuranceTOWN OF BARNS TABLE Insurance Company Name # A=6- OIL Workman's Comp.Policy# c 5 5 O L 3 s Copy of Insurance Compliance Certificate must be on.file. Permit Request(check box) aRe-roof(stripping old shix les) All construction debris will betaken to ❑Re-roof(not stripping. Going over existing layers'of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. _A copy of the Home Improvement Contractors License is required. SIGNATURE: ir Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): FR f-}S ft Address: Q y- 5 City/State/Zip:__C 6-G C,t_1'-� PM- 6Z3,_5Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.X,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 workingfor me in an capacity. employees and have workers' � y p tY comp. insurance.t 9. ❑ Building addition [No workers comp. insurance p required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.KRoof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 1311 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. N 1 ll IIn Insurance Company Name: Policy#or Self-ins.Lic.#: . D 25 0 L w 550� Expiration Date: � ' oC(0 ' Q Job Site Address: t A 9t�-�V J City/State/Zip: �ZGc1( �Qo�6 Attach a copy of the workers' col6ensation 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi �Iheains and lties of perjury that the information provided above is true and correct~ Si ature: Date: Phone Official use only. Do not write in this area, to be completed by city or town offkiaL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other , t Contact Person: Phone#: ardOf 06 Ids venlenvcoior act®ron y �7"F2[JC7'I® Re�pcn: 7TZ a 12782a boardVpdRf � --- _ _ _ C7 Ads �� 9 - _ Clones. HOUR 1M � ��dMILaurk raw wIr ,' 4zmp License or Loft Cord Valfd for �{1, 813 nee: bob Tf#Y 927s2n ® � 8'� �.�� coTWr,MA a2WS - I�1®t g Iid adB out ' i - i i y_r -rl- ((�i�,, I13 ® 'YJ:':}:;$'.'r-s•-;:..,•-:r,,:.:y:".:,`•,'<'-f.•}:C, ."'tt�;;^,�i''�2.'•%�,4`irrY+:+i:}..,:},.y,+•x+'-••}x{$+, .. ®®�� }�ty- ' - .:.h' ;$?; #ram,$ s., •.v';{�::;:: :;::vct•' f•.l:r.•$si{,i 'f m�®® .I:. �,•' J i i?; •.'f-v, ryry }f ;J+,-.'•'i:>$`iZ;} J..::•f.•-�$'iti{ $:ti�$' nv{:::,�%•..{r••.v. •- :\• r- ,•:::,Fi':.r:-{.}v..;.;.. .•J.v{{ -•`••:n-:..:.a}-:..-' rx;- Y } ' •-. ' .,x_ _ .pty: •:x,Y$::$fc';:;-,:tr}::•:ah,.; ',:},�,-'S.., .Y,:.:: p �..Nic't•.. ,..-.:. .r:.r.{n4rY.+ri•'f.+iif•..:h:?�:�$:-.-i.'J o i.$n-'::i-.'s d',c:}??s:s� �-s.�'�t{x:��::;.:.r 1?.?�.:,.C�'� +n.�9,. w`',}��•r}J*., �Ys �n.-V- �''• �'_ ' '::i£?v:::.fi:f f{�r.${,-nxx1-.y�.:,qx•,:,:�-k;;$�+*.•G''�.:.?.:{}G'}�',`':.�v-=%.++'4..,.},-�.v.i-C}$`�,.c-{ DATE n(:fi:N?•BYDD;C•I�::.. k:+.:�.axR.}: i:�?�x;�i•- :d}$5s�:-Jr}:%uJ:;.-'%,eft'-:fG".vk}$:}t-: - ' 'nt'�4,"w�n}' E+ i%3"::' 'r`'-b },f:+`. }'n-?'�,--��`,"J,Y.-}J'�':�:S,{t�-a.�r}'• 10-15-07 FffB6s CERT/EF9 gE IS ISSUED AS A MINTER OF RNFORMAT ON WISE & QUINN INS AGCY ONLY s��D COINFEIRS BNO RICaId'1'S UPOIRi�, TI'IE CERTIFICATE 449 PLEASANT ST aIOLDER. T�IIS CE�BTIFIC�TE DOES IdOY �4MEIND MENDTE I4LTER TBNE COVERAGE�+FFORDED BY THE POLICIE>�3 BELOW, OR BROC B COMPANY 24WC MA 02301 COMPANIES AFFORDING COVERAGE 24 , IPoSURED A HARTFORD UNDERWRITERS INSURANCE COMPANY COMPANY FRASER CONSTRUCTION LLC ® " PO BOX 1845 COTUIT MA 02635 COMPANY C COMPANY D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE n OD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT -P-O { I h: CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ATo LLOTHE TERMS, IXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. WHICH THIS CO TYPE OF INSURANCE LTR POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION " GENERAL LIABILITY DATE(M.MI)JA N) DATE(MM UDjVV) LIMITS COMMERCIAL GENERAL LIABILITY GENERAL AGGREGATE CLAIMS MADE 0 OCCUR. PRODUCTS-COMP/OP A(3G. OWNER'S&CONTRACTOR'S PROr. PERSONAL ADV.INJURY EACH OCCURRENCE FIRE DAMAGE(Any one fire) . AUTOMOBILE LIABILITY MED.EXPENSE(Any one person) g - ANY AUTO COMBINED SINGLE ALL OWNED AUTOS LIMIT SCHEDULED AUTOS BODILY INJURY HIRED AUTOS (Per Person) E NON-OWNED AUTOS BODILY INJURY x (Per Accident) IiARAE LIABILITY PROPERTY DAMAGE E ANY AUTO AUTO ONLY-EA ACCIDENT S OTHER THAN AUTO ONLY: EACH ACCIDENT $ EXCESS LIABILITY AGGREGATE E UMBRELLA FORM EACH OCCURRENCE 1 OTHER THAN UMBRELLA FORM AGGREGATE $ A WORKER'S COMPENSATION AND 18111PLOVER's LIABILITY (GS60UB-085011_35-5-07 j THE PROPRIETOR/ 09-26- Og STATUTORY LIMITS ,>}��J•':,:n�.i';'�:�`,,, �;v.•'-;„•``:nt. PARTNERS/EXECUTIVE INCL EACH ACCIDENT $ OFFICERS ARE: X EXCL DISEASE-POLICY LIMIT- i OTHER $ DISEASE-EACH EMPLOYEE E 500 000 DE8CRIPTIOPo OF OPERATIOWS/LOr-A IONS/VENICIEWRESTFUCTIOPoS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED` TO THE CERTIFI I ;n.. .:f::{--'.'.F'+:.,n::�• f...z:•.rfk>s;:}<fit •x%::�$i:'$9-v><:�:3:•i{::_;•.}1'x::�::'.:• - HOLDER AFF -::f'^:::::}:;::}•:-,'::-Cr}•{{.:f..nn-::::.-::Yr.f.;•}..{?..'v" %%$;:::^it::.}oy.,�.J:N�}Y{...r:.•:.;;:r::•:.J:{ n,r--. ..-..-. ...f: :. � �,r.Yr?•:n ,L•, �,.-,.:,'.�;.$:, -•: CTING WORKERS CO MP -i{. i-• f.f..,.;;+:.:� ',�:�^:y..<.}Y.x�•r} ':'xY'�$:• €�` ..,/.?:..:..:::::::::xv' f.. .,•.-'F v$""$f$ffiG}'nA?x { ••err:�h,.-•.:--- rv-.: n^}}}:w:xi•::vJ..:rJ.•x.?i.}:ii:::::}:iYfv:'v{•}}:�riiii'{'.'_+�.$. .:WP16b '-'�: ' `•.',ri?:}�:r?l`"}}ri-,::::{j{:i:::i i._�:?$$:::�r.•.::{?v- $:f+4„rr'my:., ,..,COVERAGE. I ' . .:tits}}r$:.^.v}::{-} :?•:{.:3 ,}YJ }J �$,' :s,l(•ti:•'- '� :n bf •'xr} y,'ii:}�:1:4}:}'{.• I + -- 'v}fil'.-...-.v$:-:v}}}$:ti!i?4:$ J >n-..-- f• }' r�}}ry,:}''i:}?$+.'vj: 8 SHOULD :n,r" :::}:::r:".f..:: AINY OF THE AB01►E DESCRIBED POLICIES BE.CAPNCELLED BEFORE THE EMPNRATNDIN DATE 7TNEREOF,'T3IE ISSUIPoS COMPAPoY WILL ENDEAVOR TO MAIL' FRASER ENTERPRISES LLC 10 Dgy3 WRITTEN R1oTICETOTgNECERiNFNCATEFpOL•DER NAMED YOTHE PO BOX 1845 y,, t LEF'B; BUT FAILURE To MAIL SUCH NOTICE S"L IMPOSE Pao C OTU I T UABILITV OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. DR MA 02635 � AUTHORIZED REPRESE9TA I. i6}':`---':::i_:il�si�..vr-.:}.::{ i}r•:Yf:}:;:{:�$?v?i:}:y}:i�:ti i .-::.:.r. , 'i:.{nYr.:{y'�f}�?.r'r':$'::{•i r;ti} $'-•:-}?'}-i::}•'':•:i'•Y}}}.r??{{•�}}: :v i:{:ti•{:.f}Yr3 r:}Y.:i:.:r:.::•-•---• ' nr� '}{+?✓O..•{;•::,Y-''v 1:fn.,,:J:::,•+•!.•'ii}: {, n{x:}: n;J.:y::;�}' {n •- c _ n?•..-nn ""`';:,::.: f uY�if•;:n$•:!?:?:}$::$:$•,}1$:r{f???r;}}};u?.}'+Y.}•.}:Y::..: ..........:.•r-- •c;...'•...r{.;1.:t•`.?i::�»}>}5,.:}:$rf{.-$,-l.•. ,�•i:::'2Y-f-:c:.- x. f-J::::n•. ;•}Y:o-fn:•_�-: •n.,r-.,n•.4••;•,.'`.::� ;4>2%r:?.xrx:!rY,,.:•.::•. :f: �y .�,y - - vnry:•iin{•1.•.v:,•f.•::+x•{.:nkq:i:::?i$i$:�:�r�.r•:_:1::-.:r,'::. -.vi:!N};;NR9i�i:V:} q>,92AM-2 Fraser Construction, LLC CONSTRUCTION P.O. Box 1845, Cotuit MA. 02635 ROOFING ' Email: fraser constructionnverizon.net SPECIALISTS www.fraserroofing.com . FAX 1-508-428-0123 508-428-2292 HICL#112536 CS#97668 RE-ROOFING PROPOSAL, PARTIAL DATE: August 12, 2008 PHONE: 609-896-4213 NAME: Brian Daniell MAIL ADDRESS: Off Cape JOB ADDRESS: 24 Highland Ave Cotuit, MA 02635 FRASER CONSTRUCTION hereby proposes to perform the following services in a neat and professional like manner and in accordance with the manufacturer's specifications and local building code. -Remove and Haul away all of the old roofing material -Re-nail all plywood sheathing as needed. Supply and Install - CERTAINTEED LANDMARK /WOODSCAPE AR 30: 30 -Year Warranty, 5 year Sure Start Protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi- Layered, Architectural Style, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10 Year Warranty against ALGAE Containment. 5 year 110 mph wind- resistance warranty with six nails in common bond area, Fraser construction includes six nails in common bond area at NO additional cost. See actual warranty for specific details and limitations. Color: v PRICE- $5,075 Initial Supply and Install - CERTAINTEED LANDMARK /WOODSCAPE PREMIUM: Limited Lifetime Warranty, 10 year sure start protection, CLASS A FIRE RATED, ALGAE Resistant, Extra Heavy Weight, Self Sealing, Multi-Layered, Laminated Architectural Style, Fiberglass Based Asphalt Shingle with New England's Exclusive COPPER/CERAMIC Stones with a Full 10-year Warranty against ALGAE Containment. 10 year 110 mph wind-resistance warranty Wind warranty upgrade to 130 mph when CertainTeed starter & CertainTeed hip 8s ridge are used. See actual warranty for specific details and limitations. Fraser construction includes six nails in common bond area at NO additional cost. Color: PRICE- $5,575 Initial • Price includes building permit • Re-do upper main roof • Includes South side shirt on dormer Supply 8a Install - CertainTeed Winter.- Guard: (ice & water shield) Waterproof Underlayment System(3ft. on eves and valleys, 18" on rakes, walls, and skylights) Supply & Install - Roofer's Select Underlayment Paper (as recommended by CertainTeed) Supply & Install - Hick's Ventilated Drip Edge or 8 Aluminum Drip Edge Supply & Install - Aluminum & Neoprene Soil Pipe Flashing •Supply & Install-Air Vent Midge Vent (as recommended by CertainTeed) Clean & Remove - Debris from work area daily. X4 Star Warranty Upgrade will be applied if proposal is signed and returned within 10 days. (see enclosed brochure) 2% Discount if paid by check immediately upon completion NO MONEY DOWN - NO Payment at the. start or part way thru Payments accepted are: CASH- CHECK- MASTERCARD -VISA-AMERICAN EXPRESS ` *Any payments not made within 30 days of completion will be charged'1.5%for every 30 days the payment is late. Possible Extra -After the shingles are removed,from the roof, we will lift one sheet of plywood to make sure that the insulation is not up against the plywood sheathing preventing ventilation from the eaves to the ridge. If it is, ventilation panels will be , installed by; removing the plywood sheathing, installing the panels, turning the plywood over and then re-installing the plywood. If needed, this would be charged for as an extra at the rate of$6.00 per panel including Materials & Labor. •There are 6 Panels per sheet of plywood. Possible Extra -Any rotted or otherwise deteriorated trim boards,plywood sheathing,` lead flashing, or other carpentry needing replacement will be done and charged for as an extra at the rate of$55.00-per hour, plus materials, plus 15% overhead mark-up on total extras. " FRASER CONSTRUCTION Warranties the"labor for 12 years ` E ti FRASER CONSTRUCTION Warranties the shingles against Blow-Offs for 10 years.. .CAINTEED Warranties the shingles and labor 100% through the Sure Start ,xarranty duration. CERTAINTEED Warranties the shingles to'be'ALGAE resistant for the duration of the Sure Start*Warranty depending on the shingle that was purchased. Any deviation or alteration from above specification will be executed upon written orders and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays are beyond our control. Owner should carry fire, tornado and other necessary insurance upon the above work. We, if not ' accepted within thirty days may withdraw this proposal. FRASER CONSTRUCTION, LLC: Carries Workman's Compensation and Public Liability Insurance on the above work, certificate available upon request. DATE OF ACCEPTANCE: 0 If'tlo i Homeowner Fra o t6nj LLC 5 a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION • Map' Parcel Permit# ��0�o Health Division Date Issued Conservation Division Z) Fee 35 Q u Tax Collector 0L 7/��P�4c5� P ��®� 00 Treasurer ore / c Planning Dept. �Ch p T°If UEPTIC SYSTEM Date Definitive Plan Approved by Planning Board ai A'ppav2�$ — OF BEDROOMS Historic-OKH Preservation/Hyannis Project Street Address gt�ja, iub Ave: Village r T U a- i Owner 3 et Ao I� ti to LL Address bhqK7_ib1D Aue (ClU tr Telephone 6M Olt, !t z-13 Permit Request �. Square feet: 1st floor: existing proposed 2nd floor.: existing proposed Total new, � Valuation �6Z00 Zoning District Flood Plain Groundwater Overlay f Construction Type Lot Size 40'4$ Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 5d Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes C(No On Old King's Highway: ❑Yes ❑No Basement Type: O�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 f ram, Heat Type and Fuel: O Gas Cl Oil ❑ Electric ❑Other �' e? c Central Air: ❑Yes . I(No Fireplaces: Existing New Existing wood%oaI stover]Yes Cl No G) 6-s s, Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:4 xisting ❑new,;size Attached garage:❑existing ❑new size Shed:C(existing ❑new size f2x 12 Other: 'X Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ W r Commercial ❑Yes Cl No If yes, site plan review# Current Use T _____ '.__` Proposed Use .. BUILDER INFORMATION Name &14A) D606)IL Telephone Number j Address License# ( i NIT R® 02 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS�RESJG FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO. t z DATE ISSUED MAP/PARCEL!NO. ADDRESS - VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - 0 +y GAS: ROUGH FINAL ' FINAL BUILDING ,. co DATE CLOSED OUT ►•. ASSOCIATION PLAN NO. �., rf� I ;j u 'The Commonwealth oj'Massachusens Department of Industrial Accidents Office of Investigations a 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/O pnization/Individual): )AA) ---�)A iu 19 L-t Address: -Eh4wr ma A City/State/Zip: f�t_1 - 6 5'. . Phone#: 6M .d t L r¢Z1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and T- 6. [ New construction loyees(full and/or part-time).* have hired the sub-contractors emP 7. Remodelin 2.❑ I am a sole proprietor or partner- listed on the attached sheet*• ❑ g ship and have no employees These sub-contractors have 8. ❑ Demolition F workingfor me in an capacity. workers' comp. insurance. y Y P t}'• ❑ Building addition [No workers'comp. insurance 5. ❑ We area corporation and its required.] officers have exercised their 10.❑ Electrical repairs'or additions 3. I am a homeowner.doing all work' : right of exemption per MGL 11:❑ Plumbing repairs or additions myself [No workers' comp. c:152,- §1(4),and we have no 12.[:1 Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill_out the section below showing their workers'compensation policy 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 their workers'comp-.policy-inforrriation. I am an employer that is providing workers'Sompensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:' Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: 8 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. 15.2 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. Ldo hereby rt y and he pains an enalties of perjury that the information provided bove is true and correct t Si ature: Date: 0 Phone#• h C4 B 96 L(z) 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 - d Contact Person: Phone#: .Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers, eerof another underon for any their'ctmofhire Pursuant to this statute, an employee is defined as ...every person in the service express or implied,oral or written." *or any two An employer is defined as"an individual,Partnership, e corporation representatives of a deceaer legal sed�employer,ortheore of the foregoing engage in a joint enterprise, and including g employees. However the receiver or trustee of an individual,partnership, association or other legal entity,employing o-avner 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 dent be oy 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. insurance coverage required.'- coin compliance with the g rice:of . . . evidence applicant who has not produced acceptable ey P ter 152, 25C 7 states"Neither the commonwealth nor'any of its political subdivisions shall Additionally,MGL chap § ( ) 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 1 sub-contractors)names), addresses)and phone number(s)along with their certificate(s) of necessary, supply Liability Companies(LLC)_or Limited Liability Partnerships(L,LP)with.no employees other than the insurance. LimitedtY members or partners; are not required to carry workers' compensation insurance: If an I:LC or UP does have employees;a.policy is required. Be advised that this affidavit may be submitted to the Department of Industriauld Accidents for..confirmation of insurance coverage. Also be sure to sign and date the affidavit: The affidavit sho 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 appl icant Please be sure to fill in the permit/license number which will be use as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (citY or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fixture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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. e Department's address,telephone and fax number: The The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Town of Barnstable Regulatory Services It ak?Mas1 ' Thomas F.Getler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us 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. ` Estimated Cost 'Type of Work: Address of Work: Owner's Name: I1,14, Jl l��Films Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 wilding 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: Date actor Name Registration No. OR I te wner's Name QATms:homeaffidav , Town of Barnstable oFt� "o Regulatory Services ` Thomas F.Geiler,Director BARNSTABL& + ' AM 1639. ,�� Building Division rfc �p 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:JV L'i lib JOB LOCATION: Z T VL�jl`IL� l�f�� �I� number street village "HOMEOWNER'°:�f�lA P� 3 bf 6 name ,,LL home phone# work phone# CURRENT MAnJNNGADDRESS: 2- 6 OZZ1 35 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 uermit. (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 minim . WInocedures and requirements and that he/she will comply with said procedures and req eme Si tune o Ho 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 pemvt 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 care t amend and adopt such a fomm/certification for use in your community. Q:fon-mhomeexempt ,;. } d . (FFRAMING•PINE IIA"ORThe CAPE CODDER " ull Dimension Pine 2"x 6 WOOD PRODUCTS ATALLER POST and BEAM SHED • Rafters C 2'on centers • 2"x 6"Lo t Joists C 4'on centers It all abortt the Mood ` • 4"x 6"Top Plate Beams • 4"x 4"Center Support Posts • 4"x S"Corner Posts are 7'0"tall • 4"x 4"Corner Braces • 2"x 4"Wall Purlins • 2"x 4"Door and Window frames • 0"CDX plywood flooring (Prey 'sure-Treated is optional) • 2"X 8"PT Floor Joists @ 16"O.C. • Rough Pine Trim(primed pine or red cedar is optional) ¢; • Ix4 Corner Trim • Ix8 +Ix3 Roof Trim • 12"x 14"Red Cedar Louver Vents • Standard Board and Batten Siding • Clapboards or white cedar shingles are optional <; s ROOFING: 5/8"CDX roof sheathing iL� ' Choice of shingles and colors �a s NOTES: , -•`s. Ens'/, .. Stock and Custom doors and windows are available • Concret e Block or optional Sonotube footings available (12'x 1 with optional transom window shown) FREE Pressure Treated Ramp For the ultimate in storage. This building offers 7'6"high walls, 30"roof overhang for outside, covered storage, a steep roof pitch (ro/I2), two inside storage lofts, substantially upgraded construction features and much more. This building is much more than just a shed. / ■■■■ r ■■■ ■------ MINIS ■�-.-�■i!�t will I � i r r JOB 1 Zx 1 G' CA PE C_UID VCl2 ADDRESS PINE HA"OR Ha Queen Anne Harwich,MA 0264545 WOOD PRODUCTS (508)430-2800 PHONE# DATE FAX(508)430-1115 It's all about the wood' E-iMail:harwich@pineharbor.com YIN= INN € i I J - € � s.If o) .w. ...... i f f if --# s } € 1 € - f f ' JOB ADDRESS OR Ha Queen Anne Rd. Harwich,MA 02645 PINE f WOOD PRODUCTS (508)430-2800 FAX(508) PHONE# DATE 430-1115 It's all about the wood' E-Mail:harwich@pineharbor.com xC s —�— —�—�— —` �/ W�►.r a oD I s { �uTb , 41--;- X _ f sI , f i 1 i I � I f 11 le Tder From NEaS CUST*'M"`Mtifinn crrvirp lAr.).aaa.aarT RIFPC o .. ASSESSORS LOT 33 N83 30'�' 200' (BY DEED) ASSESSORS ¢5 LOT 34 c•� �' N85 30"!Y (Bj r DEED) �VAy RE.S: ZONE.- "RF" This MORTGAGE INSPECTION Plan is For FLOOD ZONE:' "C" Bank Use-Only___ TOWN: c00U,T —_ -._ — REGISTRY OWNER: _LL7SLLC CAREW DEED REF: 64ZZ/1_ '6 — BUYER: .BRZ4A �MX I194 DATE: __ZZ23192 _^ _ PLAN REF: NO PLAN SCALE:1'== 40_ F'T. I HEREBY CERTIFY TO M CHA,EL A._DUN.N.I.tYii-------- -----------------THAT THE BUILDING YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN AND THAT ITS POSITION DOES ____ CONFORM pgDL �y CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE � A. 143 ROUTE 149 __ _ S mE ITHEW TOWN OF _BA,&NSTABLE _—___—__—_AND THAT t r\o y209. MARSTONS MILLS, MA. 02648 IT DOES__1V_OT LIE WITHIN THE SPECIAL FLOOD HAZARD -;,. .` o TEL: 428-0055 AREA AS SHOWN ON THE H.U.D. MAP DATED.,7% � :�'�'^;cTcr:��i�J`` 25000.1 0021 D =o FAX r20-5553 C munit --P --:•.n - G� THIS PLAN NOT MADE FROM MENT L 'PAUL A m W.E PLS- —'___ SURVEY NOT TO BE USED FOR FENCES, ETC. 9086 DPG