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HomeMy WebLinkAbout0804 MAIN STREET (COTUIT) e I I t N 1 pF11 rpw Town of Barnstable *Permit Expires 6 montlis from issue Regulatory Services Fee * atxxsrns�, v� ;6 9 ,0$ Richard V.Scali,Director �fD MA'1 A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL. ONLY `f _— - � ` / - '_t Valid without Red X-Press Imprint Map/parcel Number, ()?3 7 4.5!. Property Address Y0q xRlAi .Srl7 Er co%Ul'f— , L ' " i [Residential Value of Work$ ?Pn9 a 0 0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address :Pi+7rR iC A I4,e v l' h y Jae fi rT4 4U6rA) ►1r l 1- P NeLd Yogkl IVr Contractor's Name alr��`AA)E �Uilded5 (v I.I✓c. Telephone Number -5 Mf C h 4 e ! L?_j3 I&ij E: �c$ S Home Improvement Contractor License#(if applicable) (fr,4 U�7 331 Email: -4 2-bl 4,6t C U 6 /� Q Ca ix Construction Supervisor's License#(if applicable) /U A/3 4 5/ 14Workman's Compensation Insurance ®PRESS 'g; Check one: Nor ❑ I am a sole proprietor SEP 2 12015 I am the Homeowner I have Worker's Compensation Insurance TOWN OF p n DNST DLC Insurance Company Name 450t 4 ted k hoyl y elel . '41 VIUA/Ce `D D/1flIV /iD C Workman's Comp.Policy# LI) G G S 00 r 0 7�/� — 2 0/.$.,h 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) [j Re-side p eplacement Windows/doors/sliders.U-Value �_ '�.�11 (maximum.32)#of windows 'Z "Ovuoxe_ 64Je_ _AY #of doors: ❑ 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 he Home Improvement Contractors License&Construction Supervisors License is req . ed SIGNATURE: C:\Users\Decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Out]ook\2PIOIDHR\EXPRESS.doc Revised 040215 U Massachusetts-Department of Public Safety Board of Building Regulations and Standards CO i.Sti�Cii6ri�#j- -iSC�i License: CSFA057337 40CRAWF0RD . #142= COTUTT MA 02M .r Expiration �.�•�� '� 07/03/2017 commissioner `-y rc TCan ---------- Affairs a & i utation Office ofConsumerMNONTRpCTOR MEIMPROVE Type: egistration: 1.04364 private Corporatio, Xpiration: V..3/2Qt�i LEBLANC BUILDERS CQ:aG Michael.LeBlanc 40 Crawford Rd. �udersecretary Waquoh,MA 02536 X` License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 r , Not valid without signature Restricted-One-and two-family dwellings or any accessory building thereto,irrespective of size. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS 1 'WE r 0oiy ti • Bnstasrns[.E. '""SS. i639. Town of Barnstable ,0� �fD MA'I A Regulatory Services Richard V.Scali,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 as Owner of the subject property herebyauthorize �14.�1e < �dS - orze to act on my behalf, /Vi C/7 & tie 61a lit-P- in all matters relative to work authorized by this building pen-nit application for: (Address of Job) gnature of Owner Date 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 Intemet Files\Content.0utlook\2PIOIDHR\EXPRESS.doc Revised 040215 f The Coror+tonivealth'ofMassachuseffs Deparlttnent ofIrrdlrstraa!Accidents 00M of Incestigaidons 600 Washington Sheet Boston AAA 02111 *rmv.rna Lgov1dio Workers' Compensation Insurance Affidavit.BmIderslContracborgXle.Ctricians/Ptumhers. Applicant Information Please Print Leglt`bty Niue(Busineworgsnizationrtndividual}:. Al!C&e l 1 Z6/f dd,c e_3/Q 0c A &ess: f e 60,x A } . �U'4 oGr1- N City/State/Zig: 1 Phone 9 Are you an employer?Check the appropriate box: T of ro'ect 4, I am a eneral contractor and I P ] ( = 1.❑ I.am a employer with ❑ g 6 New construction_ loyees(full an pastime)* have hired the sub-contractors ❑ 2. i :I am a sole proprietor or partner listed on the attached sheet 7. ❑Remodeling and have no employees These sub-contractors have P . y _ 9"El Demolition wMiring for me in any capacity. employs and have Workers,, g Building addition. [No worloets'comp:insurance comp.msorance`I required] 5. El We are a corporation and its 10.❑Electrical repairs or additions 3.❑I am a homeowner doing all work officers hay a exercised their 11.❑Plumbing repairs or additions myself[No workers'cAmp- right of exemption per MGL insurance required]1 c.152,§1(4),and we have ao 12.0 Roof repairs employees.[No workers' 13.�Other a /tZ p�cU - camp.insurance required.] •Any applicsut that checks Ens#1 most also fill out the section below showing their workers'compensation police infar�teab t�H,omeowners who submit this affidavit ind`i g they are doing all wok and then hire outside contractors 1=submit anew affidavit indicating such*,� K.oIItraCtOPs that Check this box 141F3t attached an.additional SiLCet 6hti[S'iLC the name Of the sub-coutractor5 sad State whethiw or am those euntes have � -employees. If the sub-coatrattoas Lase eutpIuyee,they must provide their works rs'con .policy,number. P I agar all employer that is prws idiazg tvvrkers'compensation iti=rance for ut eng7lo?ee& Below is file policy and job site iaaformadwo Insurance Company Name: SfOC/ �t°GC l0 P/"f �r1 40.: ]Policy#or self-ins Lic #. '. Dipuatioa Date: Job site Address. : �' f R41i1,St- 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 requited under Section 25A of MGL c. 152 can lead to the imposition of '*n+nAi penalties of a fine up to S 1,500-00 and/or one=yrear imprisortmment,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. .16 Hereby cerh;fy�u �ns d penalties of pednry that Hte information provided abome is bite and correct Si tame. ! " .: 1. Date: Phone 9. official use Daily. Do not write in flais-area,to be c ampleted by city ar tort a,o clot. Citp`or Town PermitlL tense# Issuing Authority(circle one): 1.Board of Health.2.Building artment 3.aWrown Clerk 4.Electrical Inspector S.Plumbing Inspector P. - 6.4ther, Contact Person: Phone#: `WORKERS GUMHI=NSAI IUN ANU tMt'LUYtHZj LIAt511-1I Y INZWIIANUC. f-ULIUY - INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 800 876-2765 NCCI NO 40959 POLICY NO. WCC-500-5007818-2015A. PRIOR NO. WCC-500-5007818-2014A ITEM 1. The Insured: Leblanc Builders Co Inc DBA: Mailing address: Po Box 3414 FEIN: "--2044 Waquoit, MA 02536 Legal Entity Type: Corporation Ocher workplaces not shown above: See Location 2. The policy period is from 01/01/2015 to 01/01/2016 12:01 a.m. standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ _ 500,000 each accident Bodily Injury by Disease $ _^ 500,000 policy limit Bodily Injury by Disease $ __ _500,000 each employee C. Other States insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 37139 INTER SEE'CLASS CODE SCHEDULE Minimum Premium $550 Total Estimated Annual Premium $5,366 GOV GOV Deposit Premium $1,414 STATE CLASS MA 5606 State Assessments/Surcharges $4,934.00 x 5.8000% $286 This policy, including all endorsements,is hereby countersigned by _ __- 014 Authorized Signature Date Service Office: William F Borhek Ins Agency 54 Third Avenue 311 Plymouth Street Burlington MA 01803 Halifax,MA 02338 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800) 876-2765 NCCI NO 40959 POLICY NO. WGC 500 5007818 2015A: PRIOR NO. WCC-500 5007818-2014A. ITEM 1. The Insured: Leblanc Builders Cc Inc DBA: Mailing address: Po Box 3414 FEIN:"--2044 Waquoit, MA 02536 Legal Entity Type: Corporation Other workplaces not shown above: See Location 2. The policy period is from 01/01/2015 to 01/01/2016 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ _ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ __ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates _ Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTRA 37139 INTER SEECLASS CODE SCHEDULE Minimum Premium $550 Total Estimated Annual Premium $5,366 GOV GOV Deposit Premium $1,414 STATE CLASS State Assessments/Surcharges MA 5606 $286 $4,934.00 x 5.8000% This policy, including all endorsements,is hereby countersigned by — ___, __ ---- Autt,odze014 d Signature Date Service Office: William F Borhek Ins Agency 54 Third Avenue 311 Plymouth Street Burlington MA 01803 Halifax,MA 02338 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. TOWN OF BARNSTABLE BUILDING VERMIT,APPLICATION Map �J Parcel 617 "Permit# � Health Division Flo�� '� J Date Issued 30 L Conservation Division �- Fee Tax Collector �M �C /J3110 � Treasurer err? ZU SEPTIC SYSTEM MUSTZE , INSTALLED IN COMPLIANCE' Planning Dept. i, WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis ;a TOWN.REGULATIONS Project Street Address �O I . i 1"414-7 A_1' • s 7— Village /-2- �w�'s Owner � _�� � . Address Telephone �o l 7 `f— cl a 6 Permit Request i &i Square feet: 1st floor: existing proposed 2y 3c' 2nd floor:existing proposed ?YL.Total new Estimated Project Cost 201 °•a° Zoning District Flood Plain Groundwater Overlay Construction Type 4e-S - , Lot Size �7j �/� S.� Grandfathered: ❑Yes O No If yes,attach supporting documentation. O. . Dwelling Type' Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 9 w-� Historic House: ❑Yes *0 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 3 new Half: existing new .— Number of Bedrooms: existing 4,,Rew Total Room Count(not including baths): exis fing new ► First Floor Room-Count Heat Type and Fuel: XGas ❑Oil ❑Electric ❑Other Central Air: Yes ❑No Fireplaces: Existing 2 New -- Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size _ Pool:❑existing ❑new size Barn:❑existing ❑new size — Attached garage:Xexisting .O 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 12 Name �� � /�S C- Telephone.Numbers 7 = 3 9 S<<f Address License# ? 3 Home Improvement Contractor# Worker's Compensation# �S�GI 3 70 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 9� FOR OFFICIAL USE ONLY - PERMIT,N6. DATE ISSUED MAP/PARCEL NO. ADDRESS . `i VILLAGE OWNER ..,, RY; f+ , DATE OF INSPECTION: " • ' , FOUNDATION 1 ISl9 FRAME INSULATION FIREPLACE _ ELECTRICAL: ROUGHS '.',_r rfFINAL z PLUMBING• ROUGH Ni M. FINAL t GAS:_ ROUGH- iF- i 0 FINAL:-` FINAL BUILDING N 0.q _ ✓ / /y1 l Ivy • ti f" „ DATE CLOSED.OUT ! t ASSOCIATION PLAN NO. - / \ 0�1 oFIt Y►k,, Town of Barnstable *Permit# Expires 6 nronUis from issue dale EARNSTABL— • Regulatory Services` -Fee M & 1� Thomas F. Geiler, Director j A'fD �A Building Division Tom Perry, CBO, Building.Commissioner1" 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY (� Not Valid without Red X-Press Imprint Map/parcel Number 6 3 �J Property Address�0�1 Residential Value of Work S,OX` Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address ?04-6&UA&� Contractor's Name �( Q� il� C Telephone Number� ;rjqi 3 d --- Home Improvement Contractor License#(if applicable) U ?j�Q Construction Supervisor's License#(if applicable) (� ���j ,� _ � ❑Workman's Compensation Insurance Check one: ' SEP 2 4 2009 ❑ I am a sole proprietor � ' a�h HomeownerTOWN OF BARNSTABLE ave Worker's Compensation Insurance Insurance Company Name ftOate d &x p IUC a ef5 Jn,- 06 Y� Workman's Comp. Policy# w('C )oq Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box) . Re-roof(stripping old shingles) All construction debris will be taken to L7rr n &u rob r0 ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations, i.e.Historic,Conservation,etc. ***Note: Property Owner ign Property Owner Letter of Permission. Home I v Contractors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFIL;ES\FORMS\Express\EXPRESSPER DOC - Revi.se000409 i �R The Commonwealth of Massach usetts Department of Industrial Accidents �' Office of Investigations 600 Washington Street Boston, MA 02111 ►vww.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Business/Or anization/Individual bi-)c�TV 1 Ue ✓ Co>c— Address: City/State/Zip:. Wot M M5 MCC Phone #: Are yo an employer?Check the appropriate box: Type of project(required): 1. I am a employer with —3 4. ❑ I am a general contractor and I employees(fall and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 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' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.l 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 I.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. o repairs insurance required:].t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =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 andjob site information. /1 Insurance Company Name: QsxddW ' Policy#or Self:ins.Lic.#: LOT!-,D!]J 10U - Expiration Date: �J Job Site Address: lJt/l KAQAA1 S�• City/State/Zip:��� �( Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.60 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 insuran rage verification. I do hereby certify and a ains enalties of perjury that the information provided above is true and correct. Signature: Date: k Phone#: O 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical-Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: r Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employee 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,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 Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia .J Town of Barnstable Regulatory Services r s 9 B"MSTAB'E, Thomas F.Geiler,Director fp;g��,` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 12 L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building.permit application for. 'Wq i o 4UJ ffla - (Address of Job) i, Signature of er. Dat "T Print Name If Property Owner is applying for permit please complete the Homeowners- License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Town of Barnstable `3 {. "o Regulatory Services swteNSTast E Thomas F.Geiler,Director mass. 039. �� Building Division tEbMAIA 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, laws,rules and regulations. PP bylaws, 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\FORM S\homeexempt.DOC 1^ c �,, pomLrr�oouuecr� o�/lavculeuae%ta Bo✓ar/d of/Building Regulations and Standards ` HOME IMPROVEMENT CONTRACTOR Registration 104364 Expication 7%13/2010 Tr►k 271185 Te .Private Corporation .Yp i LEBLANC BUILDERS CO JNC Michael LeBlanc 1 40 Crawford Rd. I Waquoit,MA 02536 Administrator Massachusetts- Deportment of Public SACO Board'of Building Regulationwand Standards Construction Supervisor License License CS 57337 Restricted to 1'G M 1 C H A E b,UL LEBLANG ter: 4.0 CRAWFIOR'D RDMO BOX 14 t COTul M '02635 Expiration: 7/3/2011 C'ummistiioncr Tr#: 18036 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE i'OLICY INFORMATI DN PAGE Associated Employers Insurance Company Burlington, Massachusetts (800)876-2765 NCCI NO 4os59 POLICY NO. FWCC 5007813012009 —� PRIOR NO. NEW BUSINESS ITEM, 1. The lnsu,ed Leblanc Builders Co Inc Mailing Address: P O Box 3414 Waquoit MA 02536 (No. Street Town or City County State Zip Code ❑ Individual ❑ Partnership ® Cc-poration ❑ Other FEIN 04-2742044 Other workpla.:es not shown above: 2. The police period is fromOl/01/2009 t001/01/2010 12:01 a.m.standard time at the insured's railing address. 3. A. Workers Compensation Insurance: Part One of the policy;ipplies to the Workers Corpensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state lis,:ed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident$ 5 00,000 each accident Bodily Injury by Disease $ 5,0 0,0 0 0 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other3tates Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 Oo A D. This policy includes these endorsements and schedules: li;EE SCHEDULE . 4. The premium for this policy will be clotermined by our Manuals of Rules,Classifications, Ftates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated Total Annual of Annual No, Remuneration Remuneration Premium INTRA 037139 SEE EXTENSION OF INFORI 4ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium £ 14,204.00 As indicated,interim adjustments of prernium shall be made: Deposit Premium 3,724.00 ❑ Annually ❑ Semi Annually ❑ Quarterly ® Monthly MA Assessment Chg. $10,972.76 x 6.3000% $691.00 This policy,inc uding all endorsements,is hereby countersigned by 12/29l2008 _ Auhorized Signature Date GOV GOV KIND JPLACING CLAIM NAME ISAFETY1 STATE CL45S AUDIT OFFICE OFFICE CHECK GFIOUP I The Fairway Agency.Inc MA 564!i is 1504 305 Forest Street WC 00 00 01 A (11-88) Bridgewater,MA 02324 Includes copyrightec material of the National Council ou Compensation Insurance, used with its permis:cion. �'� �,, � � �� � s � � ���� . � ��� 2 e Town of Idarnstante Department of Health Safety and Environmental Services �t 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: � , ' � /� - Estimated Cost Address of Work: Owner's Name: "��� Date of Application: Z r S I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law Job Under SI,000 (ZBuilding not owner-occupied [30wner 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 Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav Department of Industrial Accidents Office 911fiYeSU189919S 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Afridavit name: C- location: 6,o �— . city Mone C] I am a homeowner performing all work myselL C3 I am a sole proprietor and have no one worldng m* any tv I am an employer providing workers compensation or my.employees working on this job. . ............................. wmaanv name .. ........ ...... . .... .......... ........... ........... ............ . .............. ..................... ...... Xlxxlx-� ........ . ......... .......... .: %.. , . ... .......... ........ ............................ .... ................. ......... . ..... . ......... ........ ............ ... ........... ... ......... ...... .... ..... ................... ........ W ............. ............. .......... ........ ..... ............. . ... ...... ............ ...... ..... ..... ...... -------------- am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following waters' compensation ... ... .........I....c...m-...p...e.....n..............s...�.........a...........................................o......................n...................................p............................o............................................c..................e...............s... ...: com .. .... .... ...... . . . .. . .. .... ......... asnv ... .... . ............................................ . ... .. ... .. ............. ............. . .......... .. .. . ........ ... .. ................................................ ... ...... .............. addre ............... .................. ....... . . ...... ..... @ .. ................. . ..... . . ............. ............. I."..'.. ......... . ... . ............ . ....... .... .. I ............... .. .... ... . ... ............. ....... .... .. ........ . .......... ...... .......... . ................ .................. ....... ......... .......... .. ........... . ... ...... .... .... . .................. 4.14- N ... ... ....... M M ................ ............................ i;V11111111.11111WIMA; ------------- -------- ---------------------- ................ X.�...... ...... gx .............. .. . ..... .......... . .................... ......... ................. ...... .......... ......... ... . ....... ......... OEM . . .... .... ...... .......dui res ..................... ....... .. ............ Xrtiid .............................. .... .............. gapure to I rl"A WA MA M WMEASIMIAM W"1111A Ma W""V110 - ------------------- -------------secure coverage as required—der Section 25A of MGL 152 can Ind to the imposition o(criultnal pauddes of Hueup to$1,500.00 and/or one years'Imprisonment as weR as civa penalties in the form of a STOP WORK ORDER and a fine of SIOLOO a day against me. I understaud tbat a copy of this statement may be forwarded to the Oflice of Investigations of the DIA for coverage verification. I do hereby certify under the pains and ffyUry that the information provided above is&up and corm t signature --Pate — Print name % 4*4 phase -------- ............ ------------------------------- - ---------- ------------- offlcial use only do not write in this area to be completed by city or town offlcial city or town: paumicause# OBuilding Department OLIcensing Board E3 checkif immediate response is required Mdectmen's Once C3HealthDepartment contact person: phone#-1 --:.C30ther_ ({eased 9195 Pi Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any cquutract 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, 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 OmL the grounds or 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 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,neither the political subdivisions enter into an contract for the performance of public work until commonwealth nor an of its bduvisions shall y Y P P acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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' campensatioa 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 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 P eiiitiliceose number which will be used as a reference number. The affidavits maybe rctuiaR in the Department by maid or FAX unless other arrangements 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. The Department's address,telephone and fax number- The Commonwealth Of Massachusetts Department of Industrial Accidents Omce of Invesduations 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 Aod(ions and Renovations to I LEWIS RESIDENC�J i 104 Main t. t Cotni k MA,02635'Scree i John R Tankard III.Archetect �✓� ?; 1452.Beacon Street; Wabat;MA,02468 ji Phone(617)§65-02.00 Fax(617)965-8067 iME 0[ QKRW�f#C J � t'� ncscw!nox� iq 3 mr,#T �r�ua.w.,=o nw I 3— Ws a7+u6 srriow .eetd r nK ne d= �r ow 1 ' J mw . ._. ..__ — o,noiawa•r o i I —rr+�oulos,pws SMOKE DETECTORS O.K. 6'--- �»�t �Fr rer.w ^•.RNSTABLE BU LpING zgal Er T. �. �rsbwa a. a a+rcerws d. .. l fW �ir� PLAD fic:TCA r °�. 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AUG-24-1999 13:15 FROM JOHN R TANKARD Architect TO 15084778342 P.02 MASCheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2, 0 _ Permit # Checke by Date CITY; Hyannis STATE: Massachusetts HDD; 5973 CONSTRUCTION TYPE; 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-ElectriC Resistance) ' DATE: 8-24-1999 DATE OF PLANS: 8/20/99 i TITLE: MAScheck Energy Calculations PROJECT INFORMATION: Addition to the Lewis Residence 804 Main Street COtuit, MA COMPANY INFORMATION: - John R. Tankard III - Architect 1452 Beacon Street Raban, MA 02468 617/965-0200 fax 617/965-8067 :OMPLIANCE: PASSES tequired UA = 496 tour Home = 490 Area- or Insul Sheath Glazing/Door ----- ----- ----- Perimeter R-Value R-value U=Value UA :FILINGS - ------ ---- ----- --=------ "FILINGS A 252' . 30 .0 �1.2 :EILINGS 570. 38 . 0 1.2 ----9- 17 'EILINGS '142 30 . 0 1.2: 5 IALLS: Wood Frame, 16" O.C, 280 30 . 0 1.2 9 IALLS: Wood Frame, 16" O.C. 1297 19 .0 1.2 77 rALLS: Wood Frame, 161, O:C. 573 13 .0 p.0 47 LAZING: Windows or'boors 1052 1g.0 1.2 62 LAZING: Windows or Doors 290 0 . 350 101 �_ - 407 LAZING,-Windows or Doors` 61 0 . 350 - 142 --------- _--- - ---- -- ----- 0 .35() 21 OMPLIANCE STATEMENT: The. .,.," .. --.---- --- .---R--- - -,`-_`------------- ocuments is consistent with 'theesbuildinglPlans, iPecificSented is these nd other al.culations submitted, with the permit application. The proposed abuilding as been designed to meet the requirements of the Massachusetts Energy Code . ne heating lomined us or this as been determine building, and the . cooling load 'if 'appropriate .ing the''applicable Standard Design Conditions found - .1 the Code. The HVAC equipment selected to heat or cool the building fall be no greater than 125* o ections 780CMR 1310 a d 14 design load= as specified in gilder/Designer Date V _� AUG-24-1999 13:16 FROM JOHN R TANKARD Architect TO 15084778342 P.03 MAScheCk INSPECTION CHECKLIST 7' Massachusetts Energy Code MASChech Software Version 2 .0' MAScheck Energy Calculations DATE: 8-17-1999 Bldg. _ . . • . Dept. , Use CEILINGS: c�P . .. . [ J 1. R-30 + R-1 Comments/Location ..�[��� G.E �::�.::.::..:__:.�- [ ] 2. R-38 + R-1 Comments/Location -� 1.r .6�✓ `" ! � .t.r7 (�( ��._:... [ J 3 . R-30 + R-1 Comments/Location [ J 4. R-30 + R-1 C [u(fJ Comments/Location WALLS: [ J I. Wood Frame, 16" O.C. , R-19 + R-1 -,; .• - CommentslLocation- _ I ] 2 . Wood Frame, 16" O.C. , R-13 -f Comments/Location MT.• LD CUT I J 3 . Wood Frame, 16" O.C. , R-19 + R•-2, Comments/Locationk.a► . ' WINDOWS AND GLASS DOORS [ ] 1 . U-value: 0.35 For windows without labeled U-values, describe features : # Panes Frame Tape Thermal. Break? [�(j Yes [ No Comments Location I J 2 . U-value: 0.35 For windows without labeled U-values, describe features: # Panes I Frame:Type Thermal Break? ( Yes [ J No Comments;LoeatiCsn- .. E I J 3 . U-value: 0 .35 -, For windows without labeled U-values, describe features : # Panes 1 ' Frame Type N<w The 1 1 Break) K Yes No , Comments/Location AIR LEAKAGE: [ ] Joints, penetration's, and all other such openings in the building envelope that are sources of air leakage must be sealed. Recessed lights must be type IC rated and .installed with no penetrations or installed inside an appropriate air-tight assembly with a 0.5" clearance from combustible materials and 3" clearance from insulation. VAPOR RETARDER': I l Required on -the Warm-in-winter side of all non-vented framed Ceilings, walls; and floors. MATERIALS-.IDENTIFICATION: ] Materials and equipment must be identified. so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be clearly marked. on the building plans or specifications . AUG-24-1999 1.3:17 FROM JOHN R TANKARD Architect TO 15084778342 P.04 DUCT INSULATION: [ ) Ducts in unconditioned spaces must be insulated to R-5 . ,Ducts outside the building must be insulatedto R-8:0 DUCT CONSTRUCTION: [ ] All ducts must be sealed with mastic and fibrous backing tape. Pressure-sensitive tape may be used for fibrous ducts. The HVAC system must provide a means for balancing air and water systems . TEMPERATURE CONTROLS I ] Thermostats are required for'each separate HVAC system. A :manual or automatic means to partially restrict or shut off, the heating and/or cooling input to each zone or floor shall be •provided. HVAC EQUIPMENT SIZING: ` I ] Rated output capacity .of the heating/,cooling system is not greater than 125� of the design load as specified in sections 780CMR 1310 and. J4.4: MISC REQUIREMENTS- Refer to 780 CMR, Appendix -J for requirements relating to swimming Pools, HVAC piping conveying fluids above 120 -F or- chilled fluids below 55 F, and circulating hot water systems: ----NOTES TO FIELD (Building Aepartment Use Only) ----- !`-- _-__ - _ „-- TOTAL P.04 BOARD OF BUILDI G REGULATIONS ' License: CONSTRUCTION SUPERVISOR y' Number CS 057337 a' Birtbdate d7/03/1954 Ezprres d7J03/2001 Tr.no: 11629 RestrlcLed To: 1 G MICHAEL L LEBLM 40 CRAWFORD RD.PCkBOXA4, 22 COTUIT, MA 02635 Administrator 77, M�. _ �NOME IMPROVEMENTg1�CONtRACTOR � . - AD4364 zP �Re9stratiP. �'s ' PRIVAYE CORPORATION ' ��1YPe 1$ C C0 INS€ LEBLANC ,t _ ,. " Le9lanc Michael E, x p Box 414 .:.. r awf or d Rd s? - � TOR �:aaquoit MA ,� � � x ppMINISTRA {, a.F t PUY �pFtNE TO Town of Barnstable *Permit# q`l P p Expiresf months from issue date N � BA ,,,STLE AB , : Regulatory Services Fee TO v nsass'i679' Thomas F.Geiler�Director �� AlEp�,ta t Building Division I Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 APR 1 c 2003 Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE EXPRESS PERI ET APPLICATION - RESIDENTIAL ONLY f � /Not Valid without Red X-Press Imprint Map/parcel Numberd 6 L�� Property Address ?� n ✓"I 7L X_�esidential Value of Work , Owner's Name&Address Contractor's Name 4,P �� � Telephone Number Home Improvement Contractor License#(if applicable) 16 Z4_3'& Construction Supervisor's License#(if applicable) 7 ❑Workman's Compensation Insurance . Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# ��C / Z57— 73 Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *where required: rssuanc es not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: roperty t si Proper er of Permission. Signature Q:Forms:expmtrg Revised121901 I ILA 'own of Barnstable Regulatory Services Thomas F.Gefler,Director o'� A Building Division Tom Perry, AuildingConmrWsdouer 200 Main Street Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authnrire A ' -47C , to act on'my behalf, in all matters relative to work authorized by this buzldirag pemit application for(address of job) §' o r ate GU Q print Name