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0884 MAIN STREET (COTUIT)
� V X��A/ sue: l NOTES �- I OG Town of Barnstable *Permit# d 0 f 306gpl Fxpi` 6 months from issue date Regulatory Services BARNSTABLK Mnss. $ Richard V.Scali,Interim Director 1639. ♦0 TFp MA'I� 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 Map/parcel Number C� Not Valid without Red X-Press Imprint r�� Property Address _(�13, 7/�/6�° ❑ Residential Value of Work$ V Minimum fee of$35.00 for work under$6000.00 i, _ , , Owner's Name&Address J. Jr Contractor's Name (i / l��f� Telephone Number Home Improvement Contractor License#(if applicable) a2C9-_ Email: 6eVjw,0 Ll bvileV - Construction Supervisor's License#(if applicable) X-PRE ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor NOV 14 2013 ❑ I am the Homeowner [P-I'lfve Worker's Compensation Insurance T01N9V OF BARNSTABLE Insurance Company Name dl/ Workman's Comp.Policy# ®0 _676V ,Copy of Insurance Compliance Certificate must accompany each permit. Permit Reques eck box) A � � e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to /V R ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #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 of the Home Improvement Contractors License&Construction Supervisors License is equired. ,,,SIGNATURE: QAIATFILES\FORMS\building p it forms\EXP .doc e Revised 061313 Elie �I e Commonwealth of Vassachusetts Department of l'uuastr trl Accidents Office of Investigations 600 Washington.SYreet Boston,MA 0211I wn mmassgoWdia Workers' Compensatioul snranceAffiidavit:Builders/Contractors/E ectricianMumhers Applicant Information J Please Print Leebly Name(PusmesglOWnizationdadividnat): 6f06Aejloss �Yo r Address: O f® ,S® /° l City/State/Zip: -o Ur , Phone� �`v��O�/`5 / Are you an employer?Check the appropriate bo T of project o'ect r 3'i� Pr' J (required): 1.❑ I am a employer with 4._ sin a general contractor and I 6 ❑Nevi ctmsfruat_ employees(full and/or part4ime)* havehir� the sub-contractors 2_❑ I am a sole proprietor or partner- listed on the attached sheet_ 7- ❑Remodeling slop and haze no employees Tbese sub-contractors have g- ❑Demolition worjcing f employees in any capacity. and have workers 9. ❑Building addition [No workers' comp.insurance comp-insurance- 1 required_] 5. ❑ -Are are a corporation and its 10_0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11..❑PI g repairs or additions, myself[No workers'comp- right.of exemption per MGL 12. of repairs insurance required.]3 c_152, �i(4),and we hatire no . employees_[No workers' 13.0 Other. comp.insurance requited-]. *�a "cog that checks boa#1 most also fill out the:section below shoving rhea wds oere'compen-d-polity iufarm=tion. Homeowners who submit this a$dwit mffcatiug they are doing all vradt and then hire outside conftwmrs must submit anew afd3rh mdusting such- TCJUntracmrs that check this box must sttached an additional sheet showing the name of the sob b cogractors ami state whether nrnot those entities have . employees. If the sobtontractnrs have employees,they must pmvide their workers'comp.policy number. I am an employer that isproviNag workers'compensation insurance for my employees Below is thepolicy and job site information Insurance Company Name- Policy 9 or Self-ins-Lic.4- Expiration Date: Job Site Address: 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 imprismmesit,as well as civil penalties in the fb=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 die DIA for insurance coverage verification_ I do hereby certify r the 'is and pe -ties of perjury thatthe information prmided above is here and correct & tune: Phone o facial use only. Der not write in this area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one).: 1.Board of Health 2.Building Department 3.Cityfrown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 t Information and Instructions Massachusetts,General Laws chapter 152 requires 0 employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,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 employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or.permitto operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance,coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any.contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to cant'workers' compensation insurance. If an LLC or LLP does have employees,a policy is required., Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Departrn.ent 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 (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would Ile 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 Industdal Accidents Office of 1nvestigatlons 600 Washington Street Boston,MA 02111 Tf,-I.#617-727-4900 at 406 or 1-977 Mf SS.AFE Revised 4-24-07 Fax# 617-727-7749 - www.mass�gov/dia Right£ax C1.-2 11/12/2013 5: 01 :29 AM PAGE 2/OOZ Fax Server DATE(MMfDDNYM CERTIMCA.TE OF LIABILITY INSURANCE . TWW IFICATE 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 O PROD CER AND C RTI C TE OLDER IMPORTANT:if the certificate haider'io an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED;subject to.the erms and conditions of the policy,certain policies may require and endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s PRODUCER CONTACT NAME: NORTHWOOD ESHBALJGH INS PHONE FAX 540 MAIN STREET (NC,No,Ext): (A/C,No): E-MAIL HYANNIS,MA 02601 ADDRESS: 27JDEi INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: RARTMRD UNDERWRITERS INSURANCE COMPANY SEAN E ANDERSON CONSTRUCTION LLC INSURER B:. INSURER C: INSURER D: 50 TROWBRIDGE PATH INSURER E. W Y_ARIVIOt1TH,MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: N ANY RMJ R AEW,TM OR amnGN Q ANYCO?MMCT OR aniER DO FT W TH REWECTTOW4CHWS CERTIRCATE MAY BE ISSUM OR MAY PERTAK,.THE INSURANCE AR'ORDEDBYMiEPOWESDMRB DHMMNISSJBJECT70ALLTHETkfiIJIS EX49U90t4SA1V@C tllC&OF9f1L1iPOL1QES LMM SHOMh7NYHAVEBEHJREDUCEgBY P'ND CLAIMS tNSR ADD SUB POLICY Eft=DATE POLICY SP DATE !TR TYPE OF INSURANCE: L R POLICYNIJAER (M.DDYYYY) (MWMYYYY) L ffm GENERAL LIABILITY i EACH OCCURRENCE COMMERCIAL GENERAL LUiBILITY AMAOE TO RENTED $ CLAIMS MADE -0 OCCUR. REMISES(Ea opcwenne) ED EXP(Any one person), ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: -'ENE AGGREGATE POLICY I3 PROJECT MIN ROQUCTS-COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $. ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per Person) SCHEDULE AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NONOWNEDAUTOS PROPERTY DAMAGE $ (Per accdent) UMBRELLA LIAB OCCUR EACH OCCURRENCE 1$ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ A WORKERS COMPENSATION AND X WC STAT rORY OTHEREMPLOYER'SLABILrTY YM -'UB-6B218513-13 09/ii/2013 OW4112014 LIMITS ANY PP00ER '0fWARTNEFVET:CL iVE y . N/A E.L EACHACCIDENT $ 5pp,ppp OFFICER EREXC4MED? ,(ftrdatay In NFL E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,deguibe urder E.L DISEASE-POLICY LIMIT $ 50p,OW DESCRIPTION OF OPERATIONS hdgw DESCRIPTION OF OPERA-IONS/LOCATIONS/VEHICLES/RESTFuc-n &spECIAL ITENr> THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO'I'HE CERTIFICATE HOLDER AFFECITNG WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLQTION � CAREY GROVER BUILDER SHOULD AW OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 55 S30WDOIN RD. BEFORE THE EXPIRATION DATE THEREOF,-NOTICE WILL BE DELIVERED . IN ACCORDANCE VATH THE POLICY PROVIS101�J ; AUTHORIZED REPRESENTATIVE MASHPEE MA 02,649 4 f{ ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1908-201 D ACORD COR %Tits re ived- Town of I�arnstable Regulatory Services gThomas F.Geiler,Director s6;g. 6 ?tea Building Division Tom Perry,Building Commissioner 200 Maim Sty H}mais,MA 02601 www.town-barnstabie.ma us• Office: 508-8624038 Fax 508-79U 62i0 Property Owner Must Complete and Sign This Section If Using A Builder Trusfte,as Owner of the subject p-toperty_ hereby authorize C,q r ft CWV VW to act on my behalf, in zu ummen relative to work authorized by this building permit M S'qe-�- (Address of Job) **Pool,fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are perfooned and accepted. Signature-of Owner Signature of Applicant �b 4 4 Id . 009 Print Name Print Natze _10 3. Date QFo-rrs-a es&zoiz \iassachusctts- Dclrirtmcnt t '.'Pui.',ic `:Jel.N l3wird of Building, Regulations anti Standartl< Cons; ruction Supervisor License One- and T 4vo-family LEA/eliinas License: CS 77754 CAREY C .GROVER• PO BOX 1080 COTUIT, MA 02635 cxuiraii; 11/2L2013 7083 �/r l�au,��rcirrccul(�r r•i!�ir ric.�rr,•!h License or registration valid for individut use only Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: , egistration: 144322 Type: Office of Consumer Affairs and Business Regulation = 10 Park Plaza-'Suite 5170 ,expiration: 9/23/2014 DBA 9.WMI . Boston,MA 02116 GROVER BUILDING+-REMODELING CAREY GROVER ' 56 BOWDOIN RC MASHPEE,MA 02649 Undersecretary Not v d without signature I °Fz l Town of Barnstable *Permit# 0 Expires 6 monthsfron:issue"date Regulatory Services Fee + snatvsTABLE, _ 9� MASS J Thomas F.Geiler,Director ATfD�,IA Building]Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us "^ Office: 508-862-4038 (Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY. - Not Valid without Red X-Press Imprint Map/parcel Number ©L?5- C-9FS7, Property Address esidential Value of Work `�� Minimum fee of$2S.00 for work under$6000.00 Owner's Name$c Address Contractor's Name Telephone Number --5'6 &�: �"�� � Home Improvement Contractor License#(if applicable) l 7 � Construction Supervisor's License#(if applicable) �7 S� '�� `;'l.�` 7 �� � � ❑Workman's Compensation Insurance 0 2009 Check one: ❑ I am a sole proprietor TOWN OF BARNS E ❑_Lzd the Homeowner I have Worker's Compensation Insurance Insurance Company Name Y LGIr/ ✓� /V L�'e I Workman's Comp.Policy# -T — '0 IC:774b t3/—( � Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ;�e�_roof(not stripping. Going over existing layers of roof) IeL Lr/e2lc,c 7 11 ,f If ❑ Re-side /X�`ty�- ,�QCr.�✓ ,#of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.44)#of windows *Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is re d, SIGNATURE: Q:\WPFILES\FORMS\building peg foims\EXPRESS.doC Revised 090809 The Commonwealth oflVlassachusetts Department of Industrial Accidents -;!' Office oflnvestigations 1 1 � 600 Washington Street Boston, MA 02111 Z3 >vrviv.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Po ,Joy 10,YpQ City/State/Z'p: Phone M Are you employer? Check the appropriate box: Type of project(required): 1. I am a employer with i 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. T ❑ 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 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ PILI pbiRg repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new,affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: f Policy# or Self-'ins. Lic.#: � �o Gl'�02 Expiration Date: 5�&, Job Site Address: �� Gui c 6,070-'ll City/State/Zip: zo:Ol Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against-the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify It r the pas and enalties of perjury that the information provided above is trice and correct. -7 4Z IIP- Si nature: - Date: 17 Phone#: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: �I Inf®rmatlon and Instructions tions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined.as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in'a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity,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-contractors) name(s), address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or 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 pen-nit 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. Office of Investi ations would like to thank you in advance for your cooperation and should you have any questions, The Offi g 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 t THE r Town of Barnstable � o Regulatory Services ♦ ♦ KAS&& Thomas F. Geiler,Director e039. 3 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, Tc-ewj, r -f MM-r f, , as Owner of the subject property hereby authorize. 6�--Qo U Vt2-. to act on my behalf; in all matters relative to work authorized by this building permit application for. A.) (Addre-ss of Job) / 7130'�/ Signature of Owner. Date Print Name If Propem Owner is applying for permit please complete the Homeowners License Exemption Form on the rever se side. Q:FORMS:OWN ERPERMIS SION �1 ram,, Town.of Barnstable of�t� o Regulatory Services * Thomas F. Geiler,Director IARNST"LE, 9�p 16 39 amp Building Division lED '� 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 4 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\homeex empt.DOC ®� Applied Underwriters 10/14/2009 8 : 07 : 56 'AM PAGE 1/001 Fax Server a■ IN ACORD CERTIFICATE OF LIABILITY INSURANCE DATE DD200 � 10/14/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Applied Risk Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 10825 old Mill Rd HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Omaha, NE 68154-0646 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (877)239-4420. INSURERS AFFORDING COVERAGE NA IC# INSURED INSURER A:Continental Indemnity Co. 28258 Grover, Carey dba Grover Building and Remodeling INSURER PO Box 1080 INSURER C: Cotui-t, MA 02 63 5-1 0 8 0 INSURER D:, ` CTL 1273 477184 INSURER E: COVERAGES 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 RESPECTTO 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADD'L POLICY EXPIRATION LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/V DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURANCE $ COMMERCIAL GENERAL LIABILITY - - PREMISES Ea occurence $ CLAIMS MADE ❑OCCUR ME EXP(any oneperson) $ PERSONAL S ADV INJURY $GENERAL AGGREGATE - $ GE GATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC JECT AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT ANY AUTO (Ea accident). $ ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS -(Per person) $ HIRED AUTOS BODILY INJURY NON-OWNEDAUTOS _ - (Peraccidenl) - $ PROPERTY DAMAGE $ (Per accidenl) - GAR AGE LIABILITY AUTOONLY-EAACCIDENT $ ANY AUTO - - - . . -OTHER THAN EA ACC $ - - AUTO ONLY: AGG $ - EXCESS/UMBRELLALIABILITY - EACHOGCURENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X WC STATU- OTH- EMPLOYERS'LIABILITY TORY S ER ANY PROP RIETOR/PARTNER/EXECUTIVE 46-805700-01-02 08/31/09 08/31/10 E.L.EACH ACCIDENT $ _ 500,000 A OFFICER/MEMBER EXCLUDED? It yes,describe under E.L.DISEASE EA EMPLOYEE $ 500,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS �[,c;r _. i _ - +4 _ - Da T - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE fM EXPIRATION Town of Barnstable 200 Main St. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3o DAYS WRITTEN NOTICE Hyanns, MA 02 601 TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Attn: Inspector - REPRESENTATIVES - AUTHORIZED REPRESENTATIV - �1"P'�— 1783118 ACORD 25(2001/081) 0 ACORD CORPORATION 1988 BA �/ Nlassachiisetts- Department of Public Saic' i. oYlSIInl7"5"abb i rs.n}Q�r � Q Board of Building Regulations and.$tand trds; HOME IMPROVEMENT CONTRACTOR 1 Construction Supervisor License Req!:,,; f}on [45322 License: CS 77754 Exp tPOb W23/2010 Trot 7 4090' }- x BA Restricted to: 1 G CAREY C GROVER GRi7VER E3UILDI�JGREMODELIhG. r r -- CAREY GROVER PO BOX 1080 1 56 BOWDOIN RD"' -- COTUIT, MA02635 ' -- MASHPEE,MA 02('49., =. Admini strator Expiration: 1 1/221201 1 l _ - Commissioner- t r '`�sA� Fla• ,�.E� r �r"zh'{^'� �:: ✓ >' gcr - h tr V � ^Y`E r s 4 0% NA 4 r— � y K r; ANY�T 4 �� y, IVl,issachusetts- Department of Puh�ic Sattt� License or registration valid for-individul use only- Board and Standai ds'' —_.,—valid Board of Buildin Re ervisor License beforethe ezpn ,tion date. tf found return to: Construction Sup [3riard of Buildm Regulations and Standards 1 t) License: CS 77754 n�.ashburon Place kr{ 1.301 - K: kM, Snstnn.Aia:"O�IQ Restricted.to �1G CAREY C GROVER, . u PO BOX 1080=, 5 _ __.._ . COTUIT, MA0263 ^� NoYvalid without signature. Expiration: 1312212011 {..: :j .. (•anon{psi{finer' �"�' ._� , n i I { S-�e s oy Town of Barnstable Barnstable Historical Commission 200 Main Street, Hyannis, Massachusetts 02601 BARNWASM mass. (508) 862-4787 Fax (508) 862-4725 i639• �� www.town.bamstable.mams p M1d October 3, 2007 Donald Cooper, J. Griffin, J. Jr Trs. c/o Hutchins,Wheeler and Ditmar 101 Federal Street Boston MA 02110 RE: Historic Building, the A. Lawrence Lowell Building 884 Main Street, Cotuit MA 02635 Gentlemen: The Barnstable Historical Commission wishes to express to you concern for the deteriorated condition of the historic Lowell House and temporary tarp covering on the roof. As you know, there is posted a stop work order from the Building Dept. dated 11/20 Dec. 2006 because of work being done without a permit. Nothing appears to have happened since then, except continued deterioration, and the building is Vulnerable to vandalism. This building is one of the notable historic buildings in Cotuit. The existing building was constructed in 1867 in the French Empire style. A 11/2 story cottage that was built on this site in 1807, may have been incorporated into the existing house. The present MJ structure appears to be largely unaltered and is one of three great post-bellum summer — houses in Cotuit. The house has long been associated with members of the Lowell C3 family, including A. Lawrence Lowell, President of Harvard from 1909 to 1933. 'F r 7' information on the architectural history and significance of the building, we hav enclosed a copy of the Historic Inventory Form B, on file with Massachusetts His-torical Commission. " ::M cf_ The building is listed on the National Register of Historic Places, as an individual lip ing, in recognition of both its historic architectural significance and its association with Teople significant in our past. As such, significant alteration of this building or demolition, is an automotive referral to the Cape Cod Commission. A The Historical Commission would like to meet with you to discuss the future of thec building. Please contact us at the office above to arrange a convenient time. Our next regular meeting is October 16. v y Sincerely Nancy Clark, Chairman Ruth Weil, Director, Growth Management Department, 367 Main Street, Hyannis, MA 02601 Town of Barnstable ✓Thomas Perry, Building Commissioner Town of Barnstable 200 Main Street, Hyannis, MA 02601 Sarah Korjeff, Historic Preservation Specialist Dorr Fox, Chief Regulatory Officer Cape Cod Commission 3226 Main St Barnstable Village, MA 02630 Joyce Ginouves, President Cotuit Historical Society 1148 Main Street, Cotuit, Massachusetts 02635 Brona Simon, Executive Director Massachusetts Historical Commission Massachusetts Historical Archives Building 220 Morrissey Boulevard Boston, MA 02125 THE. FOLLOWING IS/ARE THE BEST IMAGES. FROM POOR - QUALITY ORIGINAL (S) , I MF C. DATA AREA FORM NO. k RM B - BUILDING CTI3 20 .SSACHUSETTS HISTORICAL ,COMMISSION 14 WASHINGTON STREET, BOSTON, MA 02108 ' ` . �1. Barnstable (Cotuit-Cotuit Port) { ,•�' `� �ress off,;Main St. A: Lawrence Lowell House itoric Name k: Present _ dwelling Original dwelling bESCRIPTION: Le ( Y 1865 ma be 1806 core) Source Santuit-Cotuit Historical Societ SKETCH MAP Show property's location in relation 'Style mansard/C:oloniai Revival to nearest cross streets and/or geographical features. Indicate Architect George Lowell all .buildings between inventoried property and nearest intersection. Exterior wall fabric clapboard/shingle Indicate north. Outbuildings none Major alterations (•with dates) 4 ti - many see reverse p ' n Op } Moved no' . Date. , .• y - , cam` p r j Approx. acreage 4.56 i Recorded by Harriet R. Cabot Setting residential. village area Organization , Barnstable Historical Comm. Date 1980 revised 1985 Photo #80-2-B26* 80-1-B26 .(Staple additional sheets here) ARC2jITECMRkL SIGNIFI ANCE (Describe important architectural features and - evaluate in terms of other buildings within the communit y.) seems ]ikel• that n this site in 1807 by Capt. James Fish• it 'see y 11 story cottage was built o iat structure was incorporated into the present house due to its odd proportions and com- ination of stylistic elements. The present house consists of mansard and gambrel roof sec- ions which are tied together by a single cornice which proeets by about one root. Both actions are sheathed with. shingles and generally rhave -wisdlocatedtaining 6 e /6 sash. Anof round . the atry with 3/4 sidelights and transom and full su he two 'secti'ons. Since .gambrel roofs are very rare on early houses in Barnstable, it. is ikely that that feature is a Colonial Revival style addition. r HISTORICAL SIGNIFICANCE (Explain the role owners played in local or state. history and how the building relates, to the development of the commrnity.) :apt. James Fish (1785-1858) built a cottage.,%.on this site in..1807; Cap Fish was a deep Tater mariner who also acquired many acres of' woodland in Cotuit. In 1833 Capt. Fish'"sold illof his' property to his son James, Jr. for" .$200.00 :n 1865 the property was sold. to George Lowell .as a summer residence., At that time .i appears that a mansard roof 'was added to the cottage to give it a fashionable appearance leorge Gardner Lowell of Boston was the first of many 'ells to summ 11111,er. in Cotut, a trad ition that is-still -carried,on BIBLIOGRAPHY and/or" REFERENgES (name of publication, author,. date and publisher) Barnstable County Atlases;_ 1858, 1880, 1907. Santuit-Cotuit Historical Society;, Cotuit Library. F The Seven Villages" of Barnstable. 1976. Harriet Ropes Cabot; Family., history (daughter of James Hardy Ropes and Alice Lowell Ropes) 10M - 71 Massachusetts Historical Commission Community Property Address 80 Boylston Street BARNSTABLE; . Cotuit 882 Main St. Boston,Massachusetts 02116 Areas FormNo. _ CM 26 National Register of Historic Places Cnite -ia Statement Form Check all that apply: ER Individually eligible .❑ Eligible only in�a historic district 12 Contributing to a potential histon::district" Potential historic district t Criteria: O 'A [it B - 1z C D. Criteria Considerations:. ❑ `A ❑ ,C,. ❑ D ❑ E ❑ F ❑ G Statement of Significance .,y lamas �j Gould— The criteria that %-e checked in the above sectiawj� •ust be justified here. This .was -the summer home of A. Lwwrence Lowell, .during his entire Presidency of - . Harvard, 1909-33, where he wrote and revised many books on political science, biography and satire, and received eminent visitors like British cabinet minister Lord Bryce (photo of him here 1901), and Harvard faculty members and officers like Santayana, Yeomans, Taussig, Channing, Ropes, Homans and Henderson. Architecturally the house is impor.'-tant as having been kept in the original sty1he of French Empire as it was built in 1867. The present structure appears almost exactly as it appears in the west elevation in the hand of an architect of the period, described as "a lovely drawing" by Earl Shuttleworth. Of the three great post-bellum summer homes in the area (Perkins and Codman) this possesses the greatest integrity, having lost only the east verandah and the northecast kitchen. The building thus qualifies under criteria B and C: 7/92 - . �:.. �. � . ,- P -� w �.�.�Spa �a � _ � �.�-roe- . tl ��� i ^' � r ..... � - i. �� i z_ � _ �. ,22 - r e..�. •-' A Town of Barnstable Barnstable Historical Commission 200 Main Street, Hyannis, Massachusetts 02601 BAJUMABM MAM (508)862-4787 Fax (508) 862-4725 679. #�� www.town.bamstable.mams Mld October 3, 2007 Donald Cooper, J. Griffin, J. Jr Trs. C �V �`✓ c/o Hutchins, Wheeler and Ditmar p 101 Federal Street Boston MA 02110 RE: Historic Building, the A. Lawrence Lowell Building 884 Main Street, Cotuit MA 02635 Gentlemen: The Barnstable Historical Commission wishes to express to you concern for the deteriorated condition of the historic Lowell House and temporary tarp covering on the roof. As you know, there is posted a stop work order from the Building Dept. dated 11/20 Dec. 2006 because of work being done without a permit. Nothing appears to have happened since then, except continued deterioration, and the building is vulnerable to vandalism. This building is one of the notable historic buildings in Cotuit. The existing building was constructed in 1867 in the French Empire style. A 11/2 story cottage that was built on this site in 1807, may have been incorporated into the existing house. The present structure appears to be largely unaltered and is one of three great post-bellum summer houses in Cotuit. The house has long been associated with members of the Lowell family, including A. Lawrence Lowell,-President of Harvard from 1909 to 1933. For information on the architectural history and significance of the building, we have` enclosed a copy of the Historic Inventory Form B, on file with Massachusetts Historical Commission. The building is listed on the National Register of Historic Places, as an individual listing, in recognition of both its historic architectural significance and its association with people significant in our past. As such, significant alteration of this building.or demolition, is an automotive referral to the Cape Cod Commission. The Historical Commission would like.to meet with you to discuss the future of the building. Please contact us afthe office above to arrange.a convenient time. Our next regular meeting is October 16. S• ' Sincerely Nancy Clark, Chairman Ruth Weil, Director, Growth Management Department, 367 Main Street, Hyannis, MA 02601 Town of Barnstable Thomas Perry, Building Commissioner Town of Barnstable 200 Main Street, Hyannis, MA 02601 Sarah Korjeff, Historic Preservation Specialist Dorr Fox, Chief Regulatory Officer Cape Cod Commission 3225 Main St Barnstable Village, MA 02630 Joyce Ginouves, President Cotuit Historical Society 1148 Main Street, Cotuit, Massachusetts 02635 Brona Simon, Executive Director Massachusetts Historical Commission Massachusetts Historical Archives Building 220 Morrissey Boulevard Boston, MA 02125 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I Mr� DATA r ' AREA FORM NO. RM B - BUILDING CTB 26 ,SSACHUSETTS HISTORICAL COMMISSION 14 WASHINGTON STREET, BOSTON, MA 02108 L. Barnstable (Cotuit-Cotuit Port) 4 �ress off Main St. q' A. Lawrence Lowell House dfifiVd itoric Name - 1: Present dwelling Original dwelling bESCRIPTION: I o 1865 (may be 1806 core) . Source Santuit-Cotuit Historical Societ SKETCH MAP Show property's location in relation 'Style mansard/C-olonial Revival to nearest cross streets and/or geographical features. Indicate Architect George Lowell all .buildings between inventoried property and nearest intersection. Exterior wall fabric clapboard/shingle Indicate north. Outbuildings none . s . Major alterations (•with dates) many see- reverse, 0 O G ci � a o o v qi) Moved no' Date p�. Approx. acreage 4.56 Setting residential. village area Recorded by Harriet R. Cabot Organization Barnstable Historical Comm. Date 1980 revised 1985 Photo #80-2-B26* 80-1-826 (Staple additional sheets here) V' ARCHITECPURNL SIGNIFIG4NCE (Describe important architectural features and evaluate in terms of other buildings within the conm=ity.). 12 story cottage was built on this site in 1807 by Capt. James Fish; it seems likely that structure was incorporated into the present house due to its odd proportions and com- iat sinatitr of stylistic elements. The present house consists of mansard and gambrel roof sec- ions which are tied together by a single cornice which prodetFts by about one foot. Both actions are sheathed with shingle- s and generally have •windows containing 6/6 sash. An atry with 3/4 sidelights and transom and full surround is l8caf6d, at. the intersection of he two sections. Since gambrel roofs- are very rare on early houses in Barnstable, it' is ikely that that feature is a Colonial Revival style addition., ' HISTORICAL SIGNIFICANCE (Explain the roleowners played in local or state history and how the building relates to the development of. the community.) :ap_. James Fish (1785-1858) built a cottage,on this site in ,1807,, Capt: Fish was a deep Tat_r mariner who also acquired many acres of woodland in Cotuit. In �1833 Capt. Fish' sold. ill"of his' property to his son James, Jr. for, .$200:00 - =n 1865 the property was sold to George Lowell.,,as a summer residence At that . time.. it appears that a mansard roof was added' to the cottage to .give ;it; a fashionable appearance.; ?eorge Gardner Lowell of Boston was the first of, many Lowells to summer in Cotuita trad- ition that is still carried on. e BIBLIOGRAPHY and/or REFERENCES (name of publication, author, date and publisher) Barnstable County Atlases;" " 1858, 1880, 1907. Santuit-Cotuit Historical Society;, Cotuit Library, ; The Seven Seven Villages of Barfistableof Barnstable. 1976. r Harriet Ropes Cabot; Family, history (daughter of James Hardy Ropes and Alice l,owoll Ropes) 10M - 7i ,.F Massachusetts Historical Commission Community Property Address 80 Boylston Street BARNSTABLE; Cotuit 882 Main St. Boston,Massachusetts 02116 , ,. Areas FormNo. `- CM 26 National Register ,if 1 istonc:,laces C k�c -ia Statement Form. Check all that apply: .r -� Y r � R Individually eligible ❑ Eligible only ui a lustoricadistrict IZ Contributing to a potential histon::districts 1%, Potential historic district x Criteria: ❑ `A• IR B. C 7 D. Criteria Considerations: ❑. A 7 B O C ❑' D ❑ E ❑ F ❑ G Statement of Significance c,y Tamcc L•7 The criteria that r,.a checked in the above sectia�:: •ust be justified here. This .was -the summer home of A. Lawrence Lowell, during his entire Presidency of . Harvard, 1909-33, where he wrote and revised many books on political science, biography and satire, and received eminent visitors like British cabinet minister Lord Brgzce (photo of him here 1904), and Harvard faculty members and officers like Santayana, Yeomans, Taussig, Channing, Ropes, Homans and Henderson.- Architecturally the house is impor---tart as having been kept in the original sty1he of French Empire as it was built in 1867. The present structure appears almost exactly as it appears in the west elevation in the hand of an architect of the period, described as "a lovely drawing" by Earl Shuttleworth. Of the three great post-bellum summer homes in the area (Perkins and Codman) this possesses the greatest integrity, having lost only the east verandah and the norther least kitchen. The building thus qualifies under criteria B and C. 7/92 y ••sue' a"' `a �� �^� � '��-5. ��� � �-xt"�.:�./-2� . ow - -' I e.�,f.-' io""� St ",. _ "y`_ ' -� ,r 'fi r -..,�r•<, Yr G�. - :_ ro u -3 _s ��, .c�"y'�a,-gam°1�C�3�` .��''�'.r�c r.. � _�,�y' yl F•,yet x }} r t ,s r � t • a } x, dw 1 884 Main St. , Cotuit 12/11 /06 rv , y - e� � ,. ;#r, ,/ t � �"� $ �" „�*+}�,� A,r• s", jet �a -„✓ { Y;� �cs� d'tis �:,.,� rya. � .� .a � :k ��:.... .4v pl ,�. die`# .•�'p�_�S< ...,. '�4"- Isis A Mow 'LM: _ "wR �-ix+F. 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'a>. � .ns. �s.;:<: ..>�.9�M r:'8,',: ast� ''S o, a" 4`�,: —t: ✓Y: " n _!�s- .�`� a.. �� r �{,�� � �r '3-• 'yam �}� ' '' �'Ss'�'�� d �.�„,-� 4x.� . w Y, Ivy Poo A. j w � 41�71 StUILT.� Rim0 la i i sop x 6 �'��;� a o too ,r g .i. s .+a •.Tn S t' 884 Main St. . Cotuit 12/11 /06