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0394 OLD OYSTER ROAD
o3GI� o/d D s�� �aa -- � y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division nn _ Date Issued Conservation Division Application Fee •� r- r=. _Planning Dept. - � r:�..-��r,�- Permit Fee Date Definitive Plan Approved by Planning Board CIN Historic - OKH _ Preservation / Hyannis Project Street Address sivr Village ,gyp a,, q( p Owneriv \ �/ Lr' Address I`I Telephone :C ' ' Permit Request 1 `Sy 1 � ('1� Q /�,Q�� C� - '(1(� 4JMjQ_A r� S N SS 1 tt. C�X�iu-a o� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Aull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes No If yes, site plan review# Current Use �, (1 G� Proposed Use M A APPLICANT INFORMATION- - (BUILDER OR HOMEOWNER) Name -Z)lan� L4 aam n Telephone Number i5o& 0610 Address"l�l�j�= sffetT License #- M2& I RUAN Home Improvement Contractor# U � Email J �. Worker's Compensation # � ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO I VV S SIGNATURE /�- ���-- DATES/ FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER 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 Departnent of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciaas/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Pleasc Print Iibty Name(Business/Organization/Individual):Insulate 2 Save, Inc Address:410 Grove Street City/State/Zip:Fall River,MA 02720 Phone#:508-567-6706 i Are you an employer?Cheek the appropriate box: Type of project(required): I. ✓�I am a employer with 20 employees(full and/or part-time).' 7. []New construction 2.❑!am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp,insurance required.] 8. Q Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]i 4. El Demolition 4, 1 am a homeowner and will be hiring contractors to conduct all work on m 10 0 Building addition Y property. I will ensure that all contractors either have workers'compensation insurance or are sole 11 Electrical repairs or additions: proprietors with no employees. 12.Q Plumbing repairs or additions S.o 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. These subcontractors have employees and have workers'comp.insurance.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14:E:OtherInsulation 152,§1(4),and we have no employees..[No workers'comp.insurance required.] ' :*Any applicant that checks box#1 must also fill out the section below showing their.workers'compensation policy-iofotmation: a Homeowmers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .IContractors 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 enwtoyer that is providing workers'compensation insurance for my employees Below is the policy and job site in znsurance Company Name:Liberty Mutual Insurance . . 'Policy#or Self-ins. Lic.#:XWS 56418741 Expiration Date:.12/10/15 Job Site Address'.21'--I NA City/State/Zip: t3!1 Attach a copy of the workers'compensatibb policy declaration page(showing the policy number and expiration date). 'Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. t do hereby certify under the pains andpenaltces ofperjury that the information provided above is true ajed correct Si nature: Date: '1 Phone#:508-567-6706 Ofi7Ckd use only. Do not write in d W t;ea,to be completed by city or town offiriat 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#: RISE Engineering Federal ID#05-MS629 A division of Thielsch Engineering RI Contractor Registration No 8186 MA Contractor Registration No 12o979 CT Contractor Registration No 62012o S Dupont Avenue:South Yarmouth,MA 02664 i08-%&1926 X-6613 FAX 508-568-1933 CONTRACT R I S E Page 1'ROCjlli\A•1 ENGINEENING CLC_R('S THIS CONTRACT IS ENTERED INTO BETWEEN RISE CUSTOMER ENGINEERING AND THE CUSTOMER FOR WORK AS - DESCRIBED BELOW John E Culver PHONE DATE 8FRY,CE STREET 09IU8I2O I J(508)428-4130 CLIENT.e WORK ORDER - .... _ 198075 00003 394 Old Oyster Road BILLING STREET SERVICE CITY,STATE,D 394 Old P Oyster Road _ COtuit, MA 02635 BILLING CITY,St'Are.�,IP Cotuit, MA 02635 ,JOB DESCRIPTION AIR SEALING:in co Provide labor and materials to seal areas ofyour home against wasteful,excess air leakage. This work will he performed in Concen with the use of special tads and diagoostiC tests to assure that your home will be left with n healthful level of air exchange and indi�or air quality.Materials«,be used o seal your home can include caulks,teams.weatherstri in and other products. Primary areas for sealing include air leakage to attics,basements,attached o_araecs and other unheated areas(windows are not generally addressed.) ante working hours. A reduction in cubic feet per minute(cfm)ofair intiltruion will occur,but the actual number of cfm is not guaranteed_ AIR SEALING:Provide labor and materials to seal healing and/or cooling ducts within designated unhealed areas. 'this work will he: S 1,078.00 performed at the rate of S75 per man per hour,which includes materials. (2)working hours. AIR SEALING:Provide labor and materials to install Q ton wcatherstri S150.00 Aping and a doors-weep to(a)dcxx(s)to restrict air leakage. DAMMING:Provide labor and materials to install a 12"layer of'R-38 unlaced purposes. fihCr?lass baits to(3ul square feet for damm =in` S308.00 ATf1C hLAT:Provide labor and materiels to install a 6"layer olR-21 Class 1 Cellulose added to(h401 square feet Of open attic $6L50 space. -STORAGE 13ARRIf;R:Hotiteowner is responsible for the removal OfUte stored items blo king S768.00 work in the attic. Removal must Occur prior to the scheduled work start. the installation of eveatherization ATTIC ACCESS:Provide labor and materials to install(1) A easily moved,insulating cover lift the attic access flat surface of pl li,lding staiunr. small restrict air lea $O.UO ywood will he created around the opening within the attic. Phis will allow the Cover's integral weather-stripping a kage. VENTILATION:Provide labor and materials to install(1)insulated exhaust hose to existing bathrami ran(s). b237.G� VENT7LA'1 ION:Provide labor and materials to install(1 y insulated cxhnust hose with rtwl'mounted flapper $50.00 existing bathroom Ihn(s). pper vent to exhaust VENTILATION:Prov aborand materials to install ventilation chutes in(72)rafter bays to mainuiin air flow $1 16.10 BARRIER:Homeowner is responswle for the removal ofany Ceiling tiles blocking access 1()the sills. 5251.28 C'RAWISPACt provide labor and materials 171nstall (243)squ.Ire rl�t oTt2-10 rigjd'fhcrmax insulation to the crawls cc 50.00 Perimeter wall up to the sill and against the band joist. pa $1,006.02 - RISE Engineering Federal ID#05-0405629 A division nCThielseh Engineering, RI Contractor Fteglstrabon No 8186 gineering MA Contractor Registration No 120979 CT Contractor Regfstratlon No 620120 5 Dupont Avenue,South 1'aralouth.:�1A 02664 508-568 1926 X-66 13 93.3 CONTRACT R Y S E Page 2 ENGINEERING PRt)(iR.1ti1 C:LC-RC'S E}NOINEERING AND ENTERED CUSTOOMER�oRa'"�ivo"RK AS CUSTOMER/� .. DESCRIBED BELOW John Culvel PHONE l� DATE "CLIENT or .. . .. (�00)42�_4 130 WORK ORDER SERVICE STREET - 09�08/2O 15 198075 00003 394 Old Oyster Road BILLING STREET SERVICE CITY,STATE„LP ........ 394 Old Oyster Road CotUIt,,MA 02635 BILLING CITY,STATE.LP COtUit., MA 02635 .JOB DESCRIPTION Currently. I' RISFi En.inecring.will applyall applicable,eligible incentives t0 this contract. Yoll will be billed only the,yet mount: Currcnth,fOr eligible measures,the Cape I-ight Con act oftcrs 7i/D inuntive,not to cxcecd y,), incentive of 100%for the Air Sealing measures. p per calendar veal..and an For the safety and health ofyour homes indoor air quality:vve will be conducting a blower door diahnostic ofthe available air flow in Your hone both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of the avmhustion safety of your heating system and water heater.'This has a value 01190 and is ai no coSl to you. $90.00 Total: $4,116:55 Program Incentive: $3,493.91 r To WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FORIITH THE OOFFI' $6221.64 "'Six Hundred Twenty-Two&641100 Dollars UPON FINAL INSPECTION AND App - $622.64 UNPAID BALANCE AFTER 30 DA BY MSE END"NEERINO.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL,iVTEREST OF ty, .. ..' FOR IMPORTANT INFORMATION ON GUARANTEES .. ..._:................ WILL BE CHARGED R GNTS OF RECISION SCHEDULING ANO I. MONTHLY ON ANY - y'" "DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES REGISTRATION. anq AUTHORgED SIGNATURE.RLSEE ��f�rl .. CUSTOMER )"CE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF Nor"x UTCD MITHIN DATE OF ACCEPTANCE DAYS. ACCEPTANCE OF CONTRACT-THE ABO SATISFACTORY 70 US AND VE PR10E5,SPECIFICATIONS AND CONDITIONS ARE ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO 00 THE WORK y AS SPECIFIED.PAYMENT WILL Be MADE AS OUTLINED ABOVE To' -of Barn-stable �ry.f es o chstt9t.'P:StaTy Diveaor. Tom Perry, .. ft-Commwoaer 200 Mam Amet AY=ais;X+IA.O260I WWIWAO�b"table m us 0.00e: 508 862-039 �ar� .508-790.-62�p: propertyyOwner Must ,..as Cher.:p t te' b ecrpropa�y toaeroiimyb „� �•rei.kivt-to vmrl-,.authcizzee bp'6is.bu�pe-imit-applicatinn for: v.P ie - anal ads: ai o d a e s t lip` i ed..ari z d en'c is tat a l a nal iwPsMbotatepedomxd and.a cep c. r �. e 4t-Nauve Date. Aeon®. C ; ERTIFICATE OF LIABILITY INSURANCE TNU(B CI7iPICATE M AS A MATTLJR OF INFORMATION ONLY AND CONFERS NO RIG 12/9 14 CER{iFIGh7E DOES NOT A AtfVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE Pvt�pa . Tl�S FITS UPON THE CERTIFICATE BOLDER:TWS OM DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU ENFATNE OR PROM MID THE CMFICATE HOLDER. RER(S), AUITHOWED papsw h an ADD ,ffle olic les must be endorsed. ff S the hN and Conditions gftlle P A ) A O IS W subject 1b ,Ce�1 Policies my require an endorsement. A statern nt On this certificate does not confer CW1111 alli holder m lieu of such el 0*111I la s}, rights to the PRoouce+ CONTA T 1 AAt110A F. COrdeir0 Insurance NAME: — PHONE (5OH) 677-0407 171 Pl®asarit Street jFAX Ar N : (508) 677.-0a09 Fall Rtiver, MA 02721 X-D Miss: hsouza@cordeiroinsurance.com ----.. .. ;NSUFERIS)A>:FORDINCCOVERAGfl i+acx M13UR® INsuRERA:Liberty Mutual Insurance -- _ Insulate 2 Save, Inc, INSURER B 410 Grove St. Fall Rives,. M& 02720 INsuRetO:_ INSURER E — .� S INSURER F: - ... .-.-- '—-•-• W0AE CERTIFICATE NUMBER: REVISION NUMBER: THIS III CNOTW THAT THE POLICES R OF INSURANCE LIS ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERlOp INDICATED. NMAY BE ISSUED O M REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS CERT1FIQgTE.fW4Y 8E ISSUED OR MAY PERTAIN THE INSURANCE AFFORDED 6Y THE POLICIES DESCRIBED HEREIN IS SUBJECT 10 ALL THE (ERMS, I EXCLUSI"AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. • TYIE OF tNiYRMICE � Pp�y , A LJAfhJTY Y ' Y BKS 56418741BER aruoply I uNr ;--� ( 12/10/14: 12/10/15L EACH OCCURRENCE 5 1,,,000 000 1 I CihWERCU4.GENERALLMKJTY LAW r l CLAWAIADe J OCCUR ' ). 5-- 305 000. I NEO E*(Aryone Pawn) !S PERsoraLa Aov INJURY s 0 000 GENERAL AGGREGATE i S 2.00: ,000 ,j Qw;rL4GGREBATELMYTAPP�sPER i PRoouCrs-OOMPlOP AGG i s 2 000 O IPI.� LOC A /rlTot tLaLu LrrY j. IBAA 56418741 12/10/141 12/10/15; rt EL rr s 1,ow ANYAUTO I BODILY INJURY(Per•pemar.) ;S AI,LOWIED SCHED OS X ULED AUMS BODILY INJURY(Per accident)I S X HIRED AUTOS X NEON SWNED tPeraoddent) ' A X U 'LLAUAB �X OCCUR Y Y iUSO 56418741 12/lo/ia` i2/1o/15i S CLAdNBaAADE HOCCUR OCCURRENCE ss 2,000,000, EC6BLIAR 000i AGGREGATE I N S A AND UAWT, YIN :XWS 56418741 12/lo/1a; 12/10/15;X TWC STATU o Q �ARIICl1TNE _- In IPJLCLLOlD? NIA' E_L EAGNACpDENi..---, S 500,000 E.L D18EASE-Ea ENPLO_vFS 5 500,0070 M N' r RATtON$Uelew - I EL.DISEASE-P CYLMAfr S 500,000 i i OEOGUPi1 l OF OPERATIONS I L OCATICUS I V@ECLIS I Bch ACORD 101;Ao6tI Rener%s eche<Ue,if more space b regdnitd) Proof of Insurance. ` I TN;IbATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELL.EOI BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED LJ ACCORDANCE WITH THE POLICY PROVISIONS. AUTMOR¢EO REPRESENTATIVE ¢ j ©ISM-2010'ACORD CORPORATION. All right reserVod. ACORD•,25(2010/06) The ACORD name and logo are registered marks of ACORD PhrmP Fax: E-Maim 4wweald. .,'CAtj, - Office of Consumer Affairs and Business Regulation - 10 Park. Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Coat Vor Registration - Registration: 180747 'W Type: Corporation Expiration: 12/29/2016 Trtt 261507 INSULATE 2 SAVE , INC. ROLAND LANGEVIN a " - 410 GROVE ST - FALLRIVER, MA 02720 rff"� II`Update Address and return card.Mark reason for change. sCA, G 20M-05/17 Address Renewal " Employment_ Lost Card _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -flOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: iegistration: 180747 Type: Office of Consumer Affairs and Business Regulation ..Expiration: 12/2O/2016. Corporation 10 Park Plaza-Suite 5170 "' Boston,MA 02116 INSULATE 2 SAVE INC. ROLAND LANGEVIN.,;� _ _'.,>Y 410 GROVE ST FALLRIVER,MA 02720 ......_..:-...-..__..._._.-_..............__..•..... Undersecre tary _ __.. Not valid without signature Massachusetts Department of public Safety `® Board of Building Regulatio License: ns and Standards Construction Su0�1 pervisor ROLAND LANGEVIN 56 HIGHCREST ROAQ�- FALL RIVER MA 027 Co mmissioner =Xpi ration: 08/24/2017 r Town of Barnstable Expires 6 montha from issue date Regulatory Services Fee_ • ,nsrternU,s, • Richard V.Scab,Interim Director 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 ,,��• o d without Red X-Press Imprint Map/parcel Number Z ZJ . Property Address 3g3j 04A l/ow'1- I`/4 ��IC.t p o Residential Value of Work$ d �( Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name 4i7/� Zd✓3 Telephone Number Home Improvement Contractor License#(if applicable) /,;R/Q Email: Construction Supervisor's License#(if applicable) /0 0�'�j( Workman's Compensation Insurance MAY — 1 2W Check one: ❑ I am a sole proprietor ❑ I am the Homeowner TOWN OF BARNSTABLE 1 have Worker's Compensation_Innsurco �apn�pce Insurance Company Name kex) �1 rt/l��d ��� D�. ' Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value ' aO (maximum.35)#of windo Z #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 er sign Property Owner Letter of Permission. A copy of H Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: TAKEVIN D1Building Changes' SpaCdXPRESS.doc Revised 061313 r„ Department of Industrial Accidents Office of Ir:vestigcations 600 Washington Street Boston,MA 02111= www.mass.gov1dia —Workers'.Compensation Inshrance Affidavit: Builders/Coutractors(FFlect>ricians/Plumbers Applicant Information Please Print Legibiy Name(Business!organization/individual): � Address: i. L . r City/State/Zip: 6 303 Phone Are you an employer?Check the appropriate Irg: Type of project(required); 1.❑ I am a e to er-with 4.. lam a general contractor and I y 6. ❑New construction employees(full.and/or part lime). have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship.and have no employees These sub-contractors have g, ❑DemoLtion workingfor me in an capacity. employees and have workers' Y p tl'� # 9.-[]Building addition [No workers' comp. insurance comp.,insurance. 5. We are a corporation and its 10.0 Electrical repairs or additions iequtred.].. ❑ rP officers have exercised their 11.® bi Plutnn e 3.❑ I am a'homeowner doing all work f � g repairs or additions. p myself.[No workers'comp. right of exemption per MGL g 2 f] Roof repairs insurance required.]t c. 152, §1(4),:and.we have no l _ employees.[No workers' 13: Other WWI- comp.insurance required.] 1w °My 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'coImpensation insurance for nay employees. Below is the policy and"ob site information. Insurance.Company Narne:—Mew Policy#or Self-7ins.Lic.#: VV 7 / Expiration Date: �J® ,:.. , �' , A Job Site Address �TdL� `> Ctty/State/Zip: `�hl T D'T 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 a a' the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DI r brance coverage verification. I do hereby certify un r e pains nalties of perjury that the information provided a ave iZ ue and correct. Signature: Date: ,S'6 _ Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Pertnit/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#' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations IV 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): f t►[� .�(�n [}f I .. ( j ?/Ylef7 Address:-4(, 14nn Led Ro nj. City/State/Zip: tq&c&k •MA- Phone#: 62)9' Are you an employer?Check he appropria-box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors- 6. ❑New construction 2.( I am a sole proprietor or partner- listed on the attached sheet. - 7, ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' Building[No workers'comp.insurance comp.insurance.: 9. ❑ g addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF1 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152,§1(4),and we have no - employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I 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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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. Ida hereby certify, der the pains a eni ldaes of pci jury that the information provided above is true and correct Signature: Date: 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#: vn May 11, 2013 Barnstable Building Dept. . s The following is a list of our approved sub-contractors for The Home Depot: Ericsson Torres— CSSL # 100546 HIC # 163528 Michael Viola CSSL#-099403 HIC # 140993 Vincent Smith - CS # 106837 HIC # 165927 Timothy Thomas — CS # 51899 HIC # 152121 Ronaldo Solano — CSSL # 101027 HIC.# 152206 . Joseph Duarte - CS # 70077 HIC # 132349 Douglas Szynal — CSSL# 103950 HIC # 146142 Brian Laroche — CSSL # 100478 HIC # 152612 Joseph McKeon — CSSL# 98863 HIC # 132614 If you have any questions please contact Mike. Bedard our permit coordinator at 508-962-6942 or myself at 617-438-9017. S' erel -.-� uss one Bra Installation Manager THO At-Home Services,Inc. 908 Boston Turnpike- Unit 1 •Shrewsbury, MA 01545 Phone:774-275-2139 9 Fax:508-845-6076 9 Toll Free:800-657-5182 on da4nWa+g"Pafimes 4ce o'� o�ers 10 Park Plaza - Suite 5170 Boston, N sachusetts 02116 ►nm Improvontractor Registration i �Mt . :. .'• ! Ramon: 126693 j y y„f �' i•G ' F ?ylpa; Suppteln M Card .t Exiratb ; 6=014 The Home De t��At Home Se t3 ANDREW SWEET ;a • ' ' ,� �" 2690 CUMBERLAND PARKWAY` I•,°i .� ;:� ATLANTA, GA 30339 -: Vpdkte Addrm and return card.Mark reason for change. ` Address El nmeewaln Rmployment n Loaf Card pPBd".A1 O BON60V64•6101 MG tZ+fmiee or e a1 if a Lieeaae or reglratloa vM for ladwai user only PAE impiovEmmy COWTRACToR n before the expiration date. U fend return to: Office of Consumer A.#fairr and 8whion RePladen ibabLatbn:-'2 Type: 10 Park Yhm-Suite 3170 ' �tpl Su t Card 116 � I � )losto MA r ANDREW 8wj !�y�CtJ i-t. ioa CAA 3033$ t ."- • Uadeteecrabry i�atnre R M i Massachuseris Depar lent of Public Safety Board of Building Regulations and Standards �....4 a.� �.&$ti%ltpol ''s�i;.�sYa`f"i F�a�$°°f$45.°<:s:���'3 °x �tMa` •x,..";'�;uii:- License- CSSL-1005" • s4�r ER CSSUN TOR1ES tb HOOVER ROAD j 'VEST YARMOMM HOME ItlWMOYPdENT CONTRACT PLEASE READ TFUS y Sold,Furnished and Installed by: BrAmb Name:801toa.Norlh&south Date: /v�j THD At-Home Services,Inc. . d/Wa The Home;Depot At-lion-o,=Ac cls, Branch Number:31 and 33' 908 Boston Turnpike,Unit 1,Shrewsbury,'MA 01545 Toll Ree 877-903-3768 FeiWW TD of 75-269846(k METic 0 C 02439-R1 Cott l.ie#•1642'7 CT Lac#ffiC 0565522;MA lion-Improvement C<mi racrm Reg,#126891 Installation Address: 3 �t G i Rd C'�f,r'f /L4 0 :�%.633-• 3o 34� City State Zip Pprchaser(s): R, Phone: Rome Phone: God Phone: o?,- . 1 E l E l [ ] [ l • Koine Address: . .(If different from installation Address) City Stale Zip &mW1 Address(to receive project etxnmunJCeQons and Home l)epot updates)-- I DO NQT wish to receive arty marketing ernalts font The Horne Repot Protect Infitrmnation: Undersigned('Customer'),the owners of the property located at the above installation address,-agrees to buy, and TFW At-Home Services,Inc.("I'he Home Depot")agrees to furnish,&-liver;and aaange for the installation(IjustalMoVI)of all materiais described on the below and on the referenced Spec Sheet(s), all of which are incorpur,410d into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and arty Change Orders(collectively, "contract°r . Job# n ate. . p duetsSpec Sheet(s)# P `act Amount.. ' R-On g Offiding in&.s U Insotation 6 ❑Gatom I Covers❑Entry Dom ❑ _-- $ a2� Rboffug 0sidin. 0 Wwdows U Iasulatian $ ❑Gutters/Covers"Olen"Dcxres ❑ Roofing' Siding El Windows U bisulaion []Gutter/Covers❑Entry Doorp❑ $ . Rtutfing Siding El Windows 0 ksulation ❑Gutters/Covers 13EntryDocn'13 _ Mltttla�rtpi2$°Joxl2pasitoCCunttaelAmuuatdueupoaeaea�audtt6confratf. TolalContraetAmount $ . Maw PurrLawm may not dwo*muiethm owdiird of the Contract Amount Customer agrees that,imMadiately upon completion of the work for each Product,Customer wall execute a Completigh Cerfifcate (erne for each Product as defined by an individual Spa:Sheet)and pay'any Wlance'due. As rapplicable,-each Cma onderr W 'Contract agrees to be'jointly and sevemily obligated and liable hereunder. The Homc Depot reserves the right to issue a Change Ord or terminate this Conaaci or any individual PreSduct(s)included hcrcazt,at its discretion,•if Tyre Home Depot or its authorized service provider dctcrmincs tha(it cannot perform its obligations doe to.a sttitctund problem with the home,environmental bazards such as mold,asbestos or lead paint,other safety concerns,pricing c:rrnrs or because work required to complete the job was not included in th Contract. 1'avtttent Summary: The Payment Summary# included as part of this Contract, sets forth the total Contract:amount and payments required for the deposits and final payments by Product(as applicable). NOTICE TO.MU TOMER You are entitled to s completely filled-in copy of the Contract At We time you sign. Donut sign a Completiou.Certific ate(note: there is one Completing Certificate for each listed Product as defined by individual Spec Sheets)before work on that Product is complete. In the event of termination of this Contract,Cwtomer agrees to pay The Horne Repot the costs of tnaterials,labor,etgaernaac and services provided by The Home Deppoott Authorized Service Provider through the date of termination,Pius any other amounts set forth in this Agreement as alhwed under applicable law. THE HOME:DEPOT MAY WITHHOLD AMO[JNT5 OR HER LOWED To TjgF, ROME DFP(Yr OM THE DEPOSITIMITING THE HOME DEPOT'S OTHER REMEDIES FORYAYMXNT RECOVF Y OF SUCH AMOUNT5.1S MADE, WC7 Ht1UT A ran Authorv�tion: Customer agrees and cmderstands that this Agreement is the entire agreement between Customer and ire Home Depot with regard to the products and Installation services and supersedes all prior discussions and agnt=mentr,c lk" orral•or'writta,relating to said P-luets and Installation.This Agree mcnt cannot he assigned or ainendecl except by a writing signed -by Cwstor=and The Horne Depot,Customer ackctowledgcs and agrees that Customer has fc ad,understan(ls,volunt•erily accept`the terms of and has received a copy of this Agreement A P�by: Sub by .) )ao d �f 4t0V= QFpaLLxCe atur Date Sales sultant's Si arose Date Telephone No. 6 Date Sales Consultant Lic ease No. (as applicable) •.rM CANCELIrI DMER MAY CANCEL THIS AGN WTWIDT•PENALTY OR OBLIGATION liY DELIVICRING WRITTBN'.Ic10TICE TO THE SNFSS llVF�55 BUS DEPOT BY MIDMGHI' ON THE TADB DAY AFTER SIGNING THLS AGE- THE VALTE SLTMEMENT A-ITACHM FORM To USE IF ONE � SPECIFIGALI• ���✓5 CONTAINS Y PMCRiBldD BY LAw IN CUSTOMER'S S•TA'T E. Ns ARE SrATtLD ON THE REV6R!cE Mt.AND ARit PART OF THLS CONTRAC � NQTlt�:ArDrCIONAL TERMS AND We^6ranC11 HIS Yellow 'Ed Wtj0t7:9 010Z 9Z TLZZZ9£809: 'ON 7(tid PV6WVr: WD2id F I Town of Barnstable *Permit Expires 6 mi rVths from issuedmtp Regulatory Services Fee BMWSTesr e. • MASS.1639. Thomas F.Geiler,Director �0 Building Division o 7�do/i 3 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 Property Address `'E t�t Residential Value of Work$ H000, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address GC�Pyi n l., C!X— vL Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance L 2 9 2013 Check one: -� ❑�am a sole proprietor N OF:�� L`J 1 am the Homeowner 1 ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance.Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) []�Re-side ?aA1&q - ❑ 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 n required. {� SIGNATURE: QAWPFILESIFORMS\building permit forms0TRESS.doc Revised 061313 c` The Commonwealth ofMassachnselft Department of Industrial ccidenis Office of Investigations 600 Washington Street Bascom,MA 02111 wwm mass grn1dia Workers' Compensation Insurance Affi&vitr Builders/ContrackwsfF tricians/Plu nbers Applicant Information Please Print Lezibly Name(B tioafIndcv dnaD-, c:5j=- ` 1jor Address:_ _3Q W Okk— OusA- - 9,-& . City/State/Zip- - •`�" (� Phone# r Are you an employer?Check the appropriate box: Type of project(required):1.El ❑I am a employer with 4. I am.a general contractor and.I employees(full andtor part-time).* have hired the sub-contractors 6- ❑New,camattuctiun 2.❑ I am a sole proprietor orparbxT- listed on the attached sheet. 7- ❑Remod6ling ship and have no employees. These sub-contrac#ms have g_ ❑Demolition wodring for me in any capacity. employees and have workers'o 9.wor1ceis� comp.insurance comp.msuran l ❑Budding addition ] 5. ❑ We.are a corporation and its 10-E]Electrical repairs cr additions officers have their 3_ I am a homeowni�doing all work 11.❑Plumbing repairs or additions . myself-[No workers°camp- right of exemption per MGL 12-❑Roof repair insurance required.]t c-152, §1(41 and we haven ,--� employees.[No workers' 13.U�' tither , coimp.insurance required-] •Amy apptc�t that sheds boa f1 mast also fal out time section below shumng*&wadere compensation policy infcrmatian. Hamenarmecs Wba submit this affidscrit indicating they zm doing all work and then Lire outside coummn mmst submit a new afdavi3 indicating such. 1connactocs that check this bra in=attached am additional sheet showing the nme of the wb-caunwincs and state whedw oraat those entities base employees.If the sub-contractors have employees,dLey mrut provide their worker;'comp.policy number. I air an employwr that is prouikUng morkem'.conrpeetsaden insurance for my enrplayve& Blow is the policy rued job sfte information. Insurance Company Name: Policy#or Self-im.Uc.#: 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 Mtn.c- 152 can lead to the imposition of c*irninai penalties of a fine up to$1,500-00 andfor one-year imlttis�,as well as civil penalties in the foam of a STOP WORK ORDER and a Eme of up to$230.00 a day against the violator. Be advised that a copy of this statement may be hTwarded to the Office of Investigations of the DIA for insurance coverage verificatim I do hereby cerrh �ff y' under the pains andpenafties oj'perry ju that the informa�n prov Aid above fs true and correa Sigafft me: l>CV+�y1- �a ��u�A i Date: 1 Phone#: 0ja al uW only.. Do not two in this areri,to be completed by rat} or town o,,Y!c4at City or Town: PermitJLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City//own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town of Barnstable Regulatory Services i AAW&-PA7ifF. : Thomas F.Geller,Director 39- - Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: Please Print . �q �? n _I O,�, JOB LOCATION: "1 t I ��(� �+ � l l number n street village "HOMEOWNER": ya.2^ D S`-�'+2 8- W i�C`� name home phone# work phone# CURRENT MAIIMG 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 buildWg 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. c 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 F.XENIPTION 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. C:1Users\decolliklAppDaffiU..ocaAMicrosoft\Vrmdows\Temporuy Internet FueslContentoutlook\QRE6ZUBN\EXPRFSS.doc Revised 053012 oFTME Town of Barnstable Regulatory Services EARN t IMASS. � Thomas F. Geiler,Director A 1639. 16 n Mai' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b a rnsta b le.m a.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORM&OWNERPERNESIONPOOLS 62012 LOzCC� °� F Town of Barnstable *Permit# Expires ontks fro�sue date Regulatory Services Fee 1Z snxfvs-rAbLE 4 i6 9 �, Thomas F. Geiler,Director del Building Division 1 Tom Perry, CBO, Building Commissioner Yr 200 Main Street,Hyannis, MA 02601 www.toWn.barrikable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY � Nof Valid wit/rout Red X-Press Imprint Map/parcel Number o Z'Z. l/,dz- C t Property Address ( �h� [Residential Value of Work - J- O©o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A � A- A�b� C4 Q L)N.—.t.— µ ' Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) t , ❑Workman's Compensation Insurance Check one: WI am a sole proprietor. am the Homeowner k ❑ I have Worker.'s Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must'accompany'each permit. Pe rtni t— (—e he— t R nest cck box q ❑ Re-roof(stripping old shingles) All construction debris will betaken to. [ZrRe=roof(not stripping. Going over existing layers of roof) [2"Re-side. cat- z i #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 required. SIGNATURE: - (DGd :\W Q PFILESIFORMS\building permit formslEXPRESS.doc Revised 070110 n �4 r The Commonwealth of Massachusetts ^, 1 Department of Industrial Accidents Office of Investigations 600.Washington'Street ` U e U Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information .Please Print Legibly Name (Business/Organization/Individual): (L Address: S9 q ok Q- 6 4_c ,r' City/State/Zip: �� �t � �- �� �'— Phone #:P. 5P Lt 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 I -6. ❑ New construction employees(full and/or part-time).* ` have hired the sub-contractors 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. workers' comp. insurance. g ❑ Building addition [No workers' comp. insurance 5. ElWe are a corporation and its equired.] officers have exercised their 10.❑:Electrical repairs or additions 3.LJ I am a homeowner doing all_work right of exemption per MGL I].[IPlumbing repairs "or additions myself. [No workers' comp. c. 152, §](4), and we have no 12.["Roof repairs insurance required.] t employees.[No workers' 13.[ Other T-645V c 2 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 information. lam an employer that isproviding workers_'compensation 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: Attach a copy of the workers' compensationpolicy declaration page (showing the policy number and expiration date).: Failure to secure-coverage as required under Section 25A of MGL c. 152 can lead to the.imposition of criminal,penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of- Investigations of the.DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Signature• 1.A.Q� Date:� 1'� — •— a Phone#: r.1 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express 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 isTequired. 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The.Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston,.MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 ' www.mass.gov/dia THE Tf� Town of Barnstable Regulatory Services. Thomas F. Geiler,Director Eo ��� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis;Mk-02601. wwwrtown.b arnstable.ma.us Office: 508-862-4038 Fax:, 508-790-6230 Prop erty Ovine r Must Complete•and`Sign This Secfion If Using A Builder - as Owner of the subject..prnperty hereby authorize to act on my behalf, ' in all matters relative to work authorized•by this building perm.if applicatioh for.. (Address of Job) Signature of.Owner -Date Print Name If Propeil y Owner is applying for permit please ,comp - e Homeowners License Exemption, Fo=,on .th verse side.' •f�4 Town of Barnstable THE 1pyyy tiw o Regulatory Services Thomas F. Geiler,Director WLARS. Building Division �PrED Tom Perry, Building Commissioner 200 MZiT.Street,_Hyannis,MA_02601 Rfw Aourn-barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPT7ON c� f Please Print DATE: �_i JOB LOCATION: number (� street '1 �1 village "HOMEOWNER": S�1\t" C&� —e.! c ��I �4S' �C C7 name home phone# work phone# CUR-RENT MA-TLNG ADDRESS: Ol k CPS city/town state rip 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 HOMEOWI\'ER 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 constrgcts 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. Vo.- Signature of HomeownCr Approval ofBu�lding.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 F-xy-m bN The Code states that: "Any homeowner performing work for which a binIding permit is required shaD be exempt from the provisions of this section.(Scctian 1 D9.1.1 -Liceruing of c-mutruction Supervisors);provided that if the homeowner engages a pesco(s)for bin:to do such work,that such Home'"mcr sW act as supervisor." lvtany homeowners who use this exemption arc unaware that they art assunvng the responsibilities of a supervisor(set Appendix Q, Rulcs&Regulations for Licensing Construction Supcvisors,Section 2.15) This lack of awareness often rr_sults in serious problems,particu)ar)y when the homeowner hires unlicensed persons. In this case,our Board rannot procccd against the unlicensed person as it mould with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensur>;that the bomcowner is fully aware of his/hcr esponsibilitics,many communities rcquirt,as part of the permit application, that the homeowner certify that hdshe 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, ,a - Cl oFTHt:r�,, Town of Barnstable *Permit . Expires 6 trfyirths�ro tssue dale Regulatory Services Fee #� • BARNSTABLE, Thomas F. Geiler, Director �A i639. A�0 lFD MA't 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 C,e Map/parcel Number }_ Property Address ` Lf CDttQ Residential Value of'Work ,s000, Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address e�2k3cu 7 Contractor's Name Telephone Number I tome Improvement Contractor License#(if applicable) Construction Supervisor's License# (if applicable) - ❑Workman's Compensation Insurance Check one: MAY � � Z009 Pm a sole proprietor aIm the Homeowner TOWN ®F_�AR�S�'���.� El have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy # Copy of Insurance Compliance Certificate must.be on file. Permit Request(check box) ❑ Re-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/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: ).`\A PI-II:I-.S\FORMS\building permit forms\EXPRESS,doc Revised .100608 The Commonwealth of Massachusetts Department of Industrial Accidents Offtee of Investigations' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance AWidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationtindividual): •Address: 3R O (� s�r t '� ('�1� c 2 (� City/StatdZip: � t)� fi1(�— 02VS a'Phone.#: l a Are you an employer?"Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the stab-contractors 6. ❑New construction .2:0 I am.'a sole proprietor or partner-' listed on the attached sheet 7. ❑Remodeling. ship and have no employees These sub-contractors have 8.'❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'--comp.-insurance comp.insurance Tz'quir�] 5. ❑ We are a corporation and its 1Q❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their I LEI P umbing repairs or additions myself.[No workers' comp. right 6f exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-conbactors and state whether or not those entities have employees. If the sub-contractors have�r ployees,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: Policy#or Self-ins.Lic.#: 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 finq tip 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•Off ce of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct Simature• hD, l n s ue. Date: _ Phone M Official use only. Do not write in this,area,to be completed by city or town offu lal 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, corporation oration or other legal entit3,or an two or more "of the forego ing-engag in a Jom en rpns` eta -rncludd gthe leg represemilwk—of-ydemaseai-empivyzr,-orrthe-=--.-.- - - receiver or trustee of an individual,partnership,association or other legal entity,employing employees:However the t more than three ap artments and who resides therein,or the occupant of the owner of a dwelling house having no 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( )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 Rzth 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-contiactor(s)name(s),address(es)andphone 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 are to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense 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 lice 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 Ma=&useM Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 Tel. # 617-727-4900 ext•406 or 1-977-MASSAFE Fax# 617-727-7749 . Revised I1-22-06 www.rnassg.ov/dia Town of Barnstable Regulatory Services R.R,,e,.Rrr Tbornas F. Geiler,Director 39. ��� Building Division �rED Tom Perry,Building Commissioner . .200 Mairi�tree Hyannis;M*026D1 _...... .. - --- www.town.b arnstable-ma.us Office: 509-962-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE 5� I I P ` JOB LOCATION: ) N n I Q oU to=3(21 (t numberse�trletQ. village "H Y\OMEOWNER": 4 �sU `Q� c7 v O t 3 0 name l f" �^ home phone# work phone# CURRENT'MAILING ADDRESS: ��T L/ �(ii SAX v � - MIN- h2�- , cityhown state ap 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 HOM ROWNER 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 fain 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 Budding Official,that be/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 regaMons. The undersigned."homeowner"certifies that-he/she understands the Town of Barpstable,Buildm Deparpent 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 worts for which a building permit is rrquiTiA shall be exempt from the provisions of this section(Section 1D9.1.1 -Ucrnsimg of construction Supervisors);provided that if the homeowner engages a pm—son(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this rxcarption are unaware that they are assuming the responsibilities of a supervisor(set Appendix Q, Rules&Regulations for Licmuing Construction Supervism,Section 2.15) ibis lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons In this use,our Board caimot proceed against the unlicensed p==as it"would with a licensed Supervisor. The homeowner acting as Supervisor is uhimatrly responsible. To minim that the homeowner is fuDy aware of his/her responsilnli6ts,many communities require,as part of the permit application, that the bmnrowaer certify that hdshe understands the rtsponsibilities 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 fmTn1 'dfication.for use in your Community. Q:fomu:homw:cmpt ' Town of Barnstable of Regulatory Services vMAE& Thomas F.Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder 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. .(Address of Job) Signature of Owner Date Print Name . If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. O:FO RMS:O WNERPERMISSION Town of Barnstable *Permit# . cM7b L/ Expires 6 months from issue date Regulatory Services Fee 0 A Thomas F.Geiler,Director 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 - RESIDENTL LL ONLY Not.Valid without Red X-Press Imprint Map/parcel Number Property Address�� 01 y sacar-- y u [residential Value of Work �9-6 0, &0 Minimum fee of$25.00 for work under$6000.00 pp�p Owner's Name&Address C 1e'.s'1 (3, CA�1 A � D 02-6-SS , Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: X-PRESS PERMIT ❑ am a sole proprietor I am the Homeowner AUG — 1 2007 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) [��Re-side jJ r'?r ti ❑ 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. ''i'G A copy of the Home Improvement Contractors License is required. SIGNATURE: ' Q:Forms:expmtrg Revise061306 _ The Commonwealth of Massachusetts ' Department of Industrial Accidents Office of Investigations ' d 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): (�:_l n Address: City/State/Zip: ;Jr t)25o3 Phone { Are you an employer? Check the appropriate bog: Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I 6. El New construction . . employees (full and/or part-time).* have hired the stab-contractors 2.❑ I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in an capacity, employees and have workers' Y P ty $. 9. El Building addition [No workers'comp.insurance comp.insurance. t' 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 11. Plumbin repairs or additions '3: I am a homeowner doing all work ❑ • g P myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' . •13.❑ Other comp. insurance required.] . *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 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,SG0.00 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 certif1y1under the pains and penalties ofperjury that the information provided above is true and correct Signature �t \�t� , _--- Date: _ 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#: Iuformation and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two.or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity,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 bean employer." M GL 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 es and hone numbers along with their certificates of sub-contractors names address p ( ) g ( ) necessary,supply ( ) ( ), address(es) 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 burn leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:. Tho commonwealth of Massaohusetts Department of lndustrial Mcidonts Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-49Q4 ext 406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia Town of Barnstable "E Regulatory Services 4 '� 8A[iNSTABLE Thomas F.Geiler,Director y MASS jM, . *R t� 7 ) z, v. a.'$J 2e39. ��� Building Division Ec 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: O / JOB LOCATION: 3 O D s. �- ' oak Cz number.. (.� street village "HOMEOWNER": �_k`e, X JA �1JL�l'�)t /J�O g` 42��.�t-3© N 1. ` name t home phone# work phone# CURRENT MAILING ADDRESS: 3 1p 4 O)l_ © gye_r Poak G)A�, ►'"ll4 026S� 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 re uirements.QQ ��((��� J. F KQJ[, i Signature of Homeowner Approval of Building Official ` tT 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:forms:homeexempt �t;t;i�.wi�.t� , r,.v a�,''. .c�...:3`.h ,4 t;,'#t. ��, ,?,•-.�.f� ,:-t`x�.1: .' �'?�...,4. 4,�•' � s},;.e:6t�,`�tt'a-, ' �ti ...fi t 1,✓i„'�f�j�1 !Y `� , Lowe's Improving Home Improvement : Store Locator Page 1 of 1 Welcome! Driving Directions to LOWE'S OF KINGSTON, MA To help you get to your Lowe's store,we've outlined these easy-to-follow directions. , Advanced Store Search " {,, t ► Starting,.Address: �'ruOL•'[ c y t � - Street Address 394 Old Oyster Rd ' Cotuit,MA 02635 Al V 11S' fill A • t' r Ha..-bcr ^_ YM t - -_ — KINGSTON_MA#1663 `th ,> 32 WILWILLIAM C.GOULD WAY s° J �' 9 KINGSTON, MA 02364 S `�.r}r` '' (781)217-2000 tY (� {Itrti 4qr'?±; r. �_ �' x -r. "-�t' r. 5�11 !'Fl7!$SiOtE 3 tr7t!k (i •p Get directions back to Lowe's i fit,•, - d,. -v ' c;7., +�s Cy . ,fi RtJ. -. .. .2Az '$,• 3 7 •r 44 The following route can help guide you from your local Lowe's Store. 1. Depart 32 WILLIAM C.GOULD WAY on Local road(s)(north) 0 2. Turn left(west)onto William C Gould Ir Way 0.2 3. Turn right(northeast)onto Independence Mail Way,then immediately bear RIGHT(E)onto Ramp 0.3 4. Merge onto SR-3 16.4 5. At roundabout,take the second exit 4.2 6. At exit 2,keep onto Ramp towards RT-130/Sandwich/Mashpee 0.2 7. Keep STRAIGHT onto Local road(s) , ; 0 8. Bear right(south)onto SR-130 1.6 9. Turn left(southeast)onto Cotuit Rd 4.9 10. Turn left(southeast)onto SR-130[Main St] 1 11. Turn left(east)onto SR-28[Falmouth Rd],then immediately turn RIGHT(S)onto Main St 0.6 . r , 12. Keep right onto Old Oyster Rd • 0.2 13. Arrive 394 Old Oyster Rd 0.0 14. TOTAL 29.6 Locator service by,Know-Where Systems Locatpr service,by Know-Where$ysterns http://stores.lowes.com/lowes/cgi/directions?site=1663&address=%3A%3 A%3A%3AMA... 7/31/2007 t. o `Assessor's Office(1st floor) Map LotC.�` Permit# .57710 Conscrvaiion Office Oth floor 31 Date Issued Board of Health 3rd floor 4 �n+E Engineering Dept. Ord floor) House# � r PlanningDept. 1st floor/School Admin.Bldg.): SYS Definitive Plan Approved by Planning Board 19 T���®�� 1E A lications ssed 8: '9:30 a.m. & 1:00-2:00 .m. -WITH,T1TL ENVIRONMENTAL CODE AND TOWN OF BARNSTABLE Building Permit Application 1 L � Protect Street Address —T O kA Village A_ c Fire District fhvncr o N- zn�J 6J J-a_Z.. Address "�>9 q Q Q(4 6 Telephone Permit Re uest: S • Zoning District Flood Plain Water Protection Lot Size Grandfathered Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Tvpe Eaistin2 Information Dwelling Type: Single Family Two family Multi-family Age of structure Basement type Historic House Finished Old KinP s Highway Unfinished Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool }C Attached Barn None Sheds Other Builder Information Name IN�c�1�c tL 1����6w-3 1��O-d 1 (f&-r P Telephone number S��" 3�� I 1 cr Address upper- License# d Co2y i S Home Improvement Contractor# O Worker's Compensation # NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Pro'ect Cost O�L7 Fee .-p`d SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) BPERM T 4 ,! FOR OFFICE USE ONLY 5/4/95 der* 022.029 �• ADDRESS 394 Old Oyster Road VILLAGE Cotuit John & Ellen Culver ' OWNER l r> DATE OF INSPECTION: �- FOUNDATION FRAME 1 INSULATION Y- . 1 - I •,.. FIREPLACE ELECTRICAL: ROUGH FINAL W PLUMBING: ROUGH FINAL GAS: ROUGH. FINAL r , FINAL BUILDING: cj rr�• !>of `�. DATE CLOSED OUT,:-f, ZTA; ASSOCIATE PLAN IJO. r s 1 ' t k ��"��` � Syr •• _. , N ,TV 14>.. Y w d d ik 'L '` Akf:> rt�v K s ., �nr r ,g.:lY 4 'i:. _i. a +. r v._ r ;17 - p.�+•3 a : � h '`-... `COMMONWEALTHr, DEPARTMEN.T.OF PUBLIC,SAFETY 5 y �° z =_ . 151 ; OF 3'A,fit p'.. { Y ONE ASHBORTON PLACE. '•^ r MASSACHUSETTS BOSTON,MA.02108 a' CAUTION RATION DATE y L I C£NSE L 1 ` ►D4/2�I194)7 �OMSTR SUPERVISGR n '� ;t FOR PROTECTION AGAINST; RESTRICTIONS `tv EFFECTIVE DATE ,. LIC-NO F; THEFT,PUT RIGHT THUMB' uri >� Vs ;f _ , a PRINT IN APPROPRIATE Ol14/_.1. 9/► �71E, Y115 6F BOX ON LICENSE? rX-4 MARK T COLEMAN BLASTING OPERATORS� � ks . `' 4 L3 Q1 1/vc'x t m 24- C HEF�Gak CE: . RD m 1. MUST INCLUDE PHOTO k ' MONO(B6ASTINGOPRONLY) .'FEE :'fl r HARWICH OIA. 02645 '•„ " ; 3.:K ,. h ` ''- .,. NOT VALID UNTIL,SIGNED BY LICENSES+gNC OFFICI Yi ei •` fallsrl t0 potslas a Oarrosf •-+' !' :. j ' ''HEIGHT: STAMP�FpSOg1 7UREO�iFiEQj1�AlUSSIONER`ti� t YassaoAYaatt#StaNBe/fda�b x ` .kt +.'x".,' �` •Sf P,,,= (' M Cftis, ,. &;�`T,A937D1491iFA lei Code/sososo10rrsroOatloA DOB �• x ,ryiP14I,��.`,`+;,.s,°�',JY`�a�16' ..i8>xbelb a � � vi/PlilillL`oDod. ..THIS DOCUMENT:MUST, I • '«;SIGN NAME INLL ABOVE SIGNATURE LINE a w CARRIEDONTHEPERSONOF - _ SIGNATURE OF LICENSEE' _ THE HOLDER WHEN EN �xRIOHi THUMB PRINT GAGED INTHISOCCUPATION � � e} wu•� '1r a •"Qt ` yt - ... ��---...w.+.- .. � X--�a: LN•k ++v5'• ... — - .- r. ral.ew�. i� ZZ y Iry 1``'))4V•r`r ' �3 • 1151 �f t.t �I I n �r vt r' j (foinnwnwea&z, o f Way JacLietb 2eparlmenf 01 JndudfriaLJcciL,1J 'l 600 .V ..sL.►.91on �Ereef James J. Campbell 120J10n, MaiiacItuaeffi 02111 Commissioner Workers' Compensation Insurance Affidavit d� , J �-- (Gcaueelpermittee) with_a principal place of business at•,. , P 5 { M (Clry/sote/Zip) U do hereby certify under the pains and penalties of perjury;-that: 7 O I am an employer providing workers' compensation coverage for my employees working on this job. 7q Insurance Company Policy Number () 1 am a sole proprietor and have no one working for me in any capacity. () I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation policies: ►rn Contractor tilnsur nce Company/Policy Number i Contractor Insurance Company/Policy Number Contractor Insurance Company/Policy Number O I am a homeowner performing all the work myself. 1 understand that a copy of this statement will be forwarded to the Office of Investigations of.the DIA for coverage verification and that failure to secure coverage as required un r Section 25A of MGL 152 can lead to the imposition of criminai'penaldes consisting of a fine of up to S 1,500.00 and/or on years' imprisonment e I ivil penalties in the form of a STOP WORK ORDER and a fine of s 10o.0o a day against me. Signed this day of } f 19 S� Licensee/ ermittee Building Department "a i ,. Licensing Board Selecmens Office #' Health Department 37710 l' TO .VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 40S, 409, 375 - . : The 'Town of Barnstable NAB& �e� Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-775-3344 Building Commissioner For office use only pr_• 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: -D: rr 'Q� Est.Cost L-` O-Z 0 Address of Work: Owner Name: &p ,N Date of Permit Application: S f 3 c1S/ Iherebvcertifythat: Registration is not required for the following reason s Work excluded by law Job under S1,000 4. .. f Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING wrm UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO ,TBE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hcrcbv apply for a permit as the agent of the owner: —20 Date Contractor name Registration No. OR Date } y Owner's name Y i CONSTRUCTION SUPERVISOR FORM PLEASE PRINT: DATE JOB LOCATION 44 O (� S �-`c,(Z PROPERTY OWNER tfo c" CONSTRUCTION SUPERVISOR ✓�T-r +_ Cm LICENSE NUMBER 'Zo PHONE,t CQO ADDRESS " ` 1 LICENSED DESIGNEE (IF ;,ANY) 2 . 15 Responsibility of. each license holder: ' 2 . 15 . 1 The license holder shall be fully * and completely responsible for all work for which he .is "supervising. He shall be responsible for seeing that all work is done pursuant to the State Builciing Code and the drawings as approved by the Building -Official . 2 . 15 . 2 The license holder shall be responsible to supervise the construction, reconstruction, alteration, repair, removal or demolition involving ;the structural elements of buildings and structures only pursuant to the State Building Code and all other applicable Laws of the Commonwealth even though he, the license holder, is not the permit holder but :'only a subcontractor or contractor to the permit holder. 2 . 15 3 The license ?holder shall immediately notify the building official in writing of the discovery of ` any violations which are cove -ed by the building permit. 2 . 15 . 4 Any licensee who shall willfully violate Subsections 2 . 15 . 1 , 2 . 15 . 2 or 2 . 15 . 3 or any other sections of theses rules and regu.:_ations and any procedures as amended, shall be subject to revocation or suspension of the license by the Board. 2 . 16 All building permit applications shall contain the name, sian� ture and license number of the construction supervisor who is to supervise those Iengacred in construction, reconstruction, alteration, repair, removal or demolition as regulated by Section 109 . 1 . 1 of the Code an- these rules and regulations . In the event that such licensee is no longer supervising said persons, the work shall immediately cease until a successor license holder is substituted on the ree`ords of the building department. I have read and unders'fand my responsibilities under the rules and regulations for licensing construction supervisors in accordance with Section 109 . 1 . 1 of the State Building Code. I understand the construction inspection procedures and tle specific inspections as called for by the building official . LICENSED CONSTRUCTION SUPERVISOR I't J T X DATE(MM...................... . .... 03/03/95 ..... ..... UP C """R -.4 11.1, 07 tf W� PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowl i�g & 0' Neil Insurance ONLY AND ;CONFERS NO RIGHTS UPON THE CERTIFICATE C HOLDER. TIj S CERTIFICATE DOES NOT AMEND, EXTEND iOR Agenc�' , Inc . L ?'.COVERAGE AFFORDED BY THE POLICIES BELOW. y THIS THE 222 'Vest Main St. PO Box 1990 COMPANIES AFFORDING COVERAGE Hyanrv."is , MA 0.2601 COMPANY AInsurance Company of North America INSURED COMPANY Anchor Design & Pool Inc. B 143 Upper County Road COMPANY ` Dennisport, MA 02639 C COMPANY D . �W:777 -8 .. ........ .. .. 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 MAY TERM OR CONDITION-OF ANY CONTRAC-01.OR.OTHER.OTHER DOCUMENT WITH RESPECT TO-WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS! EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. J; Co POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICYNUMBER LIMITS LTR DATE(MM/DDIYY) DATE(MM/DDIYY) i. G ji EN:RAL LIABILITY GENERAL AGGREGATE $ 'A COMMERCIAL GENERAL LIABILITY PRODUCTS-COM P/OP AGG ijC LAIMS MADEF OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PRO T EACH OCCURRENCE $ FIRE DAMAGE An one fire j$ M ED EXP(Anyone person) $ AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILYINJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Peraccident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ A6YAUTO OTHER THAN AUTO ONLY: EACH ACCIDENT AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ U41BRELLA FORM g IliAGGREGATE $ OTHER THAN UMBRELLA FORM $ / 1 A WORMERS COMPENSATION AND C4081520A ` 04/15/94 04 15/95 STATUTORY LIMITS EMPLOYERS'LIABILITY EACH ACCIDENT $100,000t THE FAOPR'ETOR' INCL DISEASE-POLICY LIMIT $500,OOO PARTNERS/EXECUTIVE OFFICERSARE: EEXCL DISEASE-EACH EMPLOYEE $10 0 000 OTHER D ESCRIPTI1 iN OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Operations performed by the named insured as provided for by the policies and their conditions. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TOTH E CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLI TION OR LIAB ILITY I. OF ANY KIND UPON THE COMPANYAGENT Z-A7EPdESENTATIVES. AUTHORIZED REPRESENTATIVE .............. X P: ..... ..... FM.... . .... CERTIFICATE OF INSURANCE GENERAL AGENT ISSUE DATE(MM/DD/,YY) 0 4 At L: .v I n t e r"1 e d$ A f i C s THIS CERTIFICATE IS,ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS n C s i -v u r I'(:J a U NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND 14 A )I�6 j EXTEND OR ALTER.THE COVERAGE AFFORDED BY THE POLICIES BELOW. Pre . 1 ;a it a t i a i ins ;,,-#e€a C y COMPANY AFFORDING COVERAGE AGENCY NO. ?l3 2 t�auti'.iuy INSURED 54 �) arc t FSIDEN�A r (B.013)85 i �3outewY�4 as.UaniiisMassachusetfD ; COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EFFECTIVE TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DD/YY) ALL LIMITS IN THOUSANDS GENERAL LIABILITY GENERAL AGGREGATE E j e COMMERCIAL GENERAL LIABILITY ) (�4 Z 1 j/ ' !�4 J/ ()! .r PRODUCTS-COMP/OPS AGGREGATE E e j(C I PROFESSIONAL LIABILITY END. OTHER PERSONAL&ADVERTISING INJURY E Q`' —'4 EACH OCCURRENCE E p stFi FIRE DAMAGE(Any one Ore) E - J:. MEDICAL EXPENSE(Any one person) E EXCESS`LIABILITY EACH AGGREGATE H � OCCURRENCE , OTHER THAN UMBRELLA FORM E E OTHER ! - 14 V. DESCRIPTION OF OPERATIONS/LOCATIONS/RESTRICTIONS/SPECIAL ITEMS yi swimi, i n- pool installation ation ri CERTIFICATE HOLDER CANCELLATION 9 n !fa o r P SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA118N DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO V t• k o a d MAIL_ (� DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE 0 @ ii'a# s r//j Y: M A 6,r L i):v 5 LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. r AUTHORIZED REPRESENTATIVE 'i S 948 (1/92) ✓fie -Coop oono ol,Awadwe I HUME IMP!- C-VEMENT CONTRACTORS REGISTF;(-;T' [0N ' I E3oi rd �Df [,.,wilding Regulations and Standards) One %-.�hbur�ton Place -- F:oom 1301' Massachusetts 02108 HOi'•ii.: IMPRC?VE!vi[�NT i. ONTFkACTOR , Expiration 0 /22/97 I <L PP 1 VA-!L COi:PORATION HOME IMPROVEMENT CONTRk- a Registration 112070 ?NCHO1 DESIG1',1 & POOL C 0 R P � Type� i - PRIVATE CORPORA' EAk! !'1 . 0 C T-rP:CCH , Expiration 02/22/97 143 i. iPP11--lk C:OU1-�'rY R D DEN1,4 i `3POI0 MA 02639 ANCHOR DESIGN & POOL COS pEAN M. DITTRICH nDMINISTR+UOR 14 5 UPPER CnA I Y RD ' DENNISPORT [tit; 026 9 ......................... ......... ...... ............... ... ........................ .. ........................ ....... ............* ......... . ............**........ ... . ............*. ........ ............................. . ...................*................ ..... ........ .... . ...... ... .. ................*'***....... . ....................... .. ................... ....... . . .... ............. D/M' lin'' ISSUE DATE(MMID "EBT1.117.1999i "N U ............. . . . ................ F1 7/18/94:' PRODUCER THIS CERTIFICATE IS'ISSUED AS A MATTER OF INFORMATION ONLY'AND CONFERS NO RIGHTS!UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE PRESIDENTIAL INS11 ZANCE AGENCY DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 1368 ROUTE 134 POLICIES BELOW. DRAWER, K COMPANIES AFFORDING COVERAGE EAST DENNIS MA -)2641 COMPANY Al A LETTER ROYAL INSURANCE COMPANY OF AMERICA COMPANY B INSURED LETTER MARK X., COLEMAN COMPANY c 154 CE�TER STREET LETTER YARMOUTHPORT MA 02675 COMPANY D LETTER COMPANY E LETTER ............... ....... . ...................... ......................... ... ... ................... . ........................... ... ..... .... ...... . ..... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED PTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE.;'INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. it Co POLICY EFFECTIVE POLICY EXPIRATION LTR lj TYPE OF INf-URANCE POLICY NUMBER DATE(MM/DDfM DATE(MM/DD/YY) LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL( 'NERALLIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS V,ODE I OCCUR. PERSONAL&ADV.INJURY $ NER'S&CO!(TRACTOR'S PROT. EACH OCCURRENCE $ __ i FIRE DAMAGE(Any onefire) %J MED.EXPENSE(Anyoneperson) $ I AUTOMOBILE LIABILI Y COMBINED SINGLE Y AUTO LIMIT ALL OWNED AU OS BODILY INJURY $ SCHEDULED Ai ros (Per person) HIRED AUTOS N BODILY INJURY NON-OWNED A!JTOS (Per accident) GARAGE LIABILI FY PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE UMBRELLA FOF A AGGREGATE OTHER THAN UIABRELLA FORM .......... ...... ....... . .. .. . A F STATUTORY LIMITS WORKER'S COIAPENSATION BUREAU FILE #109577R 7/07/94 7/07/95 EACH ACCIDENT AN $ 1001000 DISEASE--POUCY LIMIT $ 500,000 EMPLOYERS LIABILITY DISEASE--EACH EMPLOYEE S 100,000 OTHER, DESCRIPTION OF OPERA' ')NSILOCATIONSNEHICLES/SPECIAL ITEMS": SWI14MING POOL ONSTRUCTION . .. ............................. ................... ........ ........................AR" V. ....... ....... ............. ....... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE'THE fi EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR !TO ANCHOR DESIGN 9 P( )L CORP. MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOr,THE 143 UPPER COUNTY I' AD T LEFT, BUT FAILURE0 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION FOR DENNISPORT MA 0; 39 .1Z LIABILITY OF ANY KIND,,UPON THE COMMY, ITS AGENTS OR REPRESENTATIVES. AUTOORIZED REPRESENTATIVE o .. ........�� .> ::/ 3n`7OWN OF BARNSTABLE LOCATION/ A O/e 60sMe SEWAGE # VILLAGE`> ;. ��Gi ASSESSOR'S MAP & LOT INSTALLER% NAME PHONE NO. AeIi14 , CMXI/L SEPTIC TANK CAPACITY LEACHING::FACILITY:(type) ,-.e- 09S-1 T'/;� (size) o2 )( . f� NO. OF BED:.ROOMS .3 PRIVATE WELL OR PUBLIC WATER f✓6/i ; BUILDER.:OR WNER 19R DATE PERMIT ISSUED: DATE -COL;iPLIANCE ISSUED: VARIANCE GRANTED: Yes No . \• sa,s..l xo,o,,.0,.eev,u,cl.s ;_ • t ♦ - .- . Y a.aww.rY r..o)!.W.wl•11w.r r ` ,: of • •-.. .., .. I I ,f ..l • • Iw1 AN pi • ! ., •l:.'I •4•JG'. ,I. - •' ...•• _ r � war•w.wb�wW�Md1r./Mlw+wx.w.� �Y �q � ••:re."nc S iCf• • - f.. �V . Jed Wes. ' l r.wwawe..••Y r)O F.A AN,•..t0 aa,.r�.O I•.w ? r•t. ` - I~ TYPICAL BAR LAP DETAIL ..�fir._.. ......r.._r..�... sTe.■[CT•Mau rWrr�e— /--),.S cvr.o u••a.•.0 ww r r,•l xrrr•w•r. — XSCTAM*Lt:20 v nr •+. y - ,mom_- ., •.).rw.wW.a..,-.4..C=r.r•,........ •.rr.� i1 o•w � . ' _ ----1-� i• .•l • Ifn.••w.•�w..x w•.rw w w ww.^r..0 w.W r I • O - ,_I I •t oo _ i 2O.b J�c �L�! ..s rwlw w v rr u.�w wxw.r•.�•w.. r [r ' r. s7o.c•ec).M TYPICAL WALL SECTION a.[Cur:20'..0' - CC ..3 z ' C - � \ e .ice - ,I.� � ����r; �I 'eel �- - .'� •p.� . . I ' Ste' �.j .•. . - x� -.. . PLAN SECTION ON - 1 _Ei TYPICAL PILASTER AT SKIMMER i CLIR f•JJ a•C 67.7all.,Z i6614 - / �I �r PLAN SECTION o7YP. LADDER�'DETaIL.: `'""• TYPICAL INTERNAL PILASTER wy nJ:r •y.• F VA '_ r—q •I WAG A i s e LL I h �CHAEMGEA _ N LL —V k cc N o. r Q? of W. co fr 9w Dtrrcmes rommsu I • � 'tA'.r' d•d •d - .t.A:. =f.a' .ye -6I a A a 87116 aArvow7r - _ CONDOR• IAAON S 2 n. 5 1 v J /R � yy�o stsa �l� 1�6v3� on 7.tf- � O Z3 SET �y '®®f e-C7 r li MIN`' Tw® 4•.� 2 45 y �3 GAL Ig to M-FT NIT Y._- 4�47- I � W ,C •,ffi;Jr.^"R"'�r�rSSr^te4"78,".i'^`.``>r+._"n.Y`r�lF"�;��' �^'.y�.�..,�,.�`.' .",'.'�"""'`a"{�'""*.'rs°T�S4Y'..`# �r',.��iR`i.�'"'Y-t`v.^� �.a_,�=. ., � c .. „-+r. ���A'�.-_i i TOWN OF BARNSTABLE Permit NoA. 8.07.. ....... BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash .a. ......... f 0 ` f65 9. / t ytnur�,, HYANNIS,MASS.02601 Bond ......... CERTIFICATE OF USE AND OCCUPANCY Issued to Gary & Ellen Souza Address Lot #29, 394 Old Oyster Road , Cotuit, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY-THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. November 17 87 .......................... 19................. ................... ............. Building Inspector TOWN OF BARNSTABLE BUILDING DEPARTMENT S asaae TOWN OFFICE BUILDING rua a. i639' HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Bui ding Department DATE: /7 An Occupancy Permit has been issued for the building authorized by f Building Permit #. . ©S"07....................n..........................................................................................»....................................... .. .......... issued to .... ..._.... ...... q.........................................._.............._......... _........._...._.... Please release the performance bond. .,a 7 P.. by� y"�':w r r' .n.,� .�...-.s.,i'rt.4'• .,s ia-�-: .+.fadh;• '- �"..'(:!,�^vv+is.�.ti'Fi:v tass,aaev ..`..rw,�. r +,. tiv3",:.ti°7-§��ry a{f t�`�a}s�t'�a:, :.. `' }+ I•:''"4 F+' � !d'i � i' °,.r y„ � _... y. >x T01NNOFBARNSTABLE, MASS.ACHUSETTS BU L INC. �PERMI ." _ - y�p = r i a DATE 3U;1C 3 19 h7 PERMIT l7lfflk i %"APPLICANT �Wi1�1 ADDRESS fit... 4 • e_ (NO.).•. '.(STREET) •, (OONTR'S `LICENSE) bu11d dwL'r11'�+:�'>, c >i:l, A NUMBER OF PERMIT7T0 to STORY r� _ rE.tl Iy,;dWelli.z2 i `DWELLING UNITS z lj y, i_ .r`'a' •'-!. (TYPE OF IMPROVEMENT): NO., - ,(PROPOSED U5E) • - k�'[ET x-a'€ 'E�`_n i'ut �.'l f�7 .,504• '..}itt {.3`' :f .t?s' %;.).�l t,� C<rit.tsit `,2'. ZONING x CATION) " f "' DISTRICT �L q' (STREET)EN' AND"(CROSS STREET) _ 1Y.(CROSS STREET) LOT /tSUBDIVI�SION ? LOT BLOCK_' SIZ:E.. t Y cer w sA b x.� a' - BUILDING IS TO BE FT"WIDE BY FT LONG.BY FT 'IN HEIGHT AND SHALL•CONFORM IN CONSTRUCTION . t, -5 TO TYPE Q USE GROUP BASEMENT''WALlS OR FOUNDATION ' . h P}++' �T7,C}.,.,a• (TYPE) REMARKS � t r� fJ5Vi3 �:fiY VOEA OF LUME yIca {a e s y1S6Q ry°q L t 3 r �F��wU 3 t iwi PERMIT 2 EFQt �l �" ESTIMATED COST ?'Icgft.` (CUB IC/dSQUARE FEET) Yy= Lx I i.Ld )I sb11 "i! OWNER t X_ s '4 ng`.z +Ll. >c.l.tlt,l�tlLl.7i.i lla.:!'a tt.ltl,LLD !Lel BUI'LDING.DERT. f{s, r ADDRESS BY r 'f: t ,(• -`,THISi-P.ERMITyCONVEY'S•NO RIGHT TO OCCUPY ANY STREET, ALLEY OR :SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR "PERMANENTLY:-`ENCROACHMENTS ON PUBLIC` PROPERTY, .NOT SPECIFICALLY PERMITTED UNDER THE,BUILDING C DE, MUST BE AP- '^ P,ROVEDrtBY. THE��JURISD(CTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LQCA'TION OF PUBLIC SEWERSJMAY,BE-OSTAINED r • fROMYTHE DEPARTMENT OF PUBLIC WORKS. TH-E ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT• FROM THE CONDITIONS QF ANY`APPLICABLE'SUBDIVISION RESTRICTIONS: 4s fi ..r )..:w a ,. . .' . '. . - 'w: � •' �'._•.. `MINIMUM OFa:THREE CALL-. APPROVED,PLANS'MUST BE.RETAINED ON JOB.AND THIS, WHERE.:APPLICABLE SEPARATE INSPE'OTIONS REQUIREDFORt CARD KEPT'POSTED UNTIL'FINAL INSPECTION. HAS'BEEN''PERMITS 'AREI,REQUIRED., FOR ' 1¢ ALC;.CO.NSTRUCTIO.N"WORK: - .'ELECTRICAL,'�s':PLU.MB.ING , AND ,. : - .a I ,FO'UNo'ArIoN5 0R:FOOTINGS. MADE. WHERE.�A' CERTIFICATt "O* F' OCCUPANCY>IS'RE MECHANiCAL.INSTALL"ATIONS f3 .<2.'PRIOR`T.O COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED`UNTIL .t� ' • '• ; f,MEMBERS(READY TO LATH)., 3"'FINA4INSPECTION.BEFORE ,L.. FINAL INSPECTION BEEN MADE. ..q !OCCUPANCY: POST THIS CARD SO IT IS VISIBLE FROM STREET '' + t '* BUILDING'INSPECTION APPROVALS Q�UMBING INSPECTION APPROVALSELECTRICAL INSPECTION APPROVAL o G � 7 d =} F i. y y.: 2 X • z HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT V,g ` }OTHER._` 2 9B0 LTH — 0 0 ti ..�„� Fef�T as ;. '. ..•. a •: .. r . p ,. ''� -- ` '` • WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W'L C B E COM E NULL AND VOID I F CONST R U CT ION INSPECTIONS INDICATED ON THIS CARD CAN BE WORK STARTED WITHIN SIX MONTHS OF DATE THE HASAPPROVEU-THE VARIODU$STAGES OF WOR . II ,'ARRANGED FOR BY TELEPHONE OR WRITTEN a l zCONSTR CTION�' F .R r t. PERMIT IS ISSUED AS NOTED ABOVE 4- NOTIFICATION. gv IS r7 x-u�fix,:,� shw`4a>,F� § - x y - - • - I l t � kJat r 1-4 r r I r i I f I i , d r ! I + { _7 7 t I� 7 7 t I i T , T 1 I t 1 [y -( ' �- - �, t i r--i .i 4 } -.I. I -i ' '. t I 1 L '�.,► F1t17�� v-S , rSl "�fig„y Y I T - -� t I I L1 T I l � , I i ! I • ' ' t � I Ti Eo I.o . f G '.2T/, y TNlaT E ,,�� �� ��aG.4T/O.V. C�TG�/T. !OATS ,_ ,r,��s/OE.�C/.cif A�!O SETBA.GK 1 !J .} . ;.a a a �, . , 7�12P F W ' rt I , r Tf.�/S,O.�G.4w/s�!/oT;B•4SEQ�G.v Ate!/ i ��6/ST E.�c'F_O 44A..4Z) 4;hI,::2."/4y St lo!/Ca oo(107-.gam I Assessor's .map and lot number ............................ SEPTIC SYSTEM MUST BE of YNE rot Sewage Permit.: number T....... ..�; q -,.t WSTALLED IN COMSLIAN WITH TITLE i`sAsa House number ............... Y.................. �91RONMENTAL CO® 90 MU& L$ 9.... E =•,� u C ��i�)�?�,`��N NEGoULATI®NS oe�s6}9. 'Fp YFY Ar TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .......(210 p. '� .�.�N!�� . ��.�..( TYPE OF CONSTRUCTION .h (. ............................................... ............... .. �........1M TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location L©—[ 29. �L ....(D' rz....P !o...,....c -rvLI...................................... Proposed Use ..... ..... .�1--` ..... � j.IJ�S....................................................................... Zoning District ........ .....................................................Fire District ......Cz U�'T.....:.................. Name of Owner .�?.t'?...... .. ...........s..................... ....Address ...�.��....s���.� ��n Name of Builder ��� ... t .........................Address ...).n..� r ........... ....... ZvI7 Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .................8...........................................Foundation .... .. .. .......w.JC�%-)1.M;�i;e............ Exterior ... ............................................................Roofing ....��? r. ................................................. Floors .....��.17-70 ..........................................................Interior ....... ............................................ rieating .. .. 4r..�.. Er............Plumbing ......... �r. 1"�:..�.. �� ......... ..... ........... Fireplace ........ .......................................................Approximate. Cost ............I ................. Definitive Plan Approved by Planning Board ---------------_---------------19________ . Area ZN „ 15.b0� .... ........... .......... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 40 P b roa GAL.'r It A r GqR, ^J r � ti f /�9 1 OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of t e Town of Barnstable regarding the above construction. Name ............ Construction Supervisor's License .. ................................ "SOUZA, GARY & ELLEN No ... -Permit for ...ZWP..Stgry......... .. ......... ............ Location ....Lot.............#29............... ....Q1.d...Q.y.;ater Road Cotuit ............................................................................... Owner ...... ...Ellen. . ....S.g.q.z.g................. .. .... Type of Construction .....F.r.am.e.......................... .. .... .. . ................................................................................ Plot ............................ Lot ................................ Permit Granted ....... .................ig 87 Date of Inspection .................19 ti Date Completed .........19 tu Ia tr Assessor's map and lot number .. 2 2q �' 'T• . ........................^�.. y�f THE TO Sewage Permit number ............. .............................. Z BARNSTABLE, i House number ......................................................................... 90oq,rb 9 t . j CEO NAj TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......L ����l UC��..... ?�W(9� 1-4P\)l�r.L �I C ! 3................ TYPE OF CONSTRUCTION � `�� �-" .... .................. .:481........1 94V TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies .for a permit according to the following information: Location ...... 0-(...�� ..........OL .... 5 � � �.... v�. ... Proposed Use ..... !\] I N� .................................... Zoning District ........'............................................................:..Fire District :....... Name of Owner � t .. ..�.`......... .`;. .....Address ...j � . ' . un Name of Builder ...�.............�..`.....��..Q:=...... ............................Address Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ................. ...........................................Foundation ... : r- .. ..GQ Exterior ... 1�4 �.............................................................Roofing .... \: Lx �.: (................................................. Floors .....� b.................................................:........Interior ........ ��T r2.. �^ .-�.....f... ............................................ Heating ..... ",-16s.. .Lr..............Plumbing ........� ...... ......... r-� ac Fireplace ........ ,� .......................................................Approximate. Cost ...........'. ),. ..DC........................ Definitive Plan Approved by Planning Board ---------------_---------------19________. Area 7 Nr> 1 SC�O� Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 18d. L03 W r . P. • S /2cl 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. Name .L. . ... ............. Construction Supervisor's License . .................................. SOUZA, GARY & ELLEN A=22-29' J No ....qj .§. . Permit for JX9...Story ............S i ng l e...Fami 1 y..Dwe l l.�,�?tg........ Location ........Lot...#2.P..........3.9..4...Q.jd...Q.y.S.ter Road .........................Cotu .t...................................... Owner ..... ar.Y....4... .............. Type of Construction ....F.r.aMe......................... ................................................................................ Plot ............................ Lot ................................ Permit Granted June 3 , .....19 87 Date of Inspection ....................................19 Date Completed ......................................19 Assessor's office(1st floor): Assessor's map and lot number .. .... .......... `C� you?NE tO� Board of Health (3rd floor): // .� 9� TM j env��" ♦" Sewage Permit number .:1l.... .... ,. .r 1�1.,1 • Engineering Department (3rd floor.): o NAM House number ................................ Q �0 Definitive Plan Approved by Planning Board ___"________"______""____"_""19_""_"__ . APPLICATIONS PROCESSED 8:30-9:30.A.M. and 1:00.2:00 P.M. only TOWN OF BARNSTABLE BUILDING . INSPECTOR APPLICATION FOR PERMIT TO ........?". .......�.'Q........ > � " ..! }— ................................... TYPE OF CONSTRUCTION ........... �f ......fi"'t��- ft....... � 5 ............................1.. .--..---.-19- J TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locationc A ...... .... `f ................................... � .,9...INN. ............................................... Proposed Use" ....... A....�� P.!.. -j.....�7��/�'�I L� ��A.� .. ...................................................................................... Zoning District yz Fire District ...� ............................. ................................. GA �21 Name of Owner ... � ��-�`Y'?`'�.... � �/�Address...�.....:............ 9 4..... -�............... .S....�........................ ��� , Name of Builder ...............:......................................................Address ..............:l................................................................... Name of Architect ..................................................................Address ..................`4 Number of Rooms ..................................................................Foundation .......... � 7 h..... Exterior ....... �Y'a ..................................................Roofing ..............eNS,- ..............'................... Floors . i....................................................Interior .................. �-! .1 .`C1Z.. Heating ..... /.7 .Y ......................................Plumbing .........................�Zi ......................................................... Fireplace #�0P. ................................................Approximate Cost .............................. ..., ® � Area ly, ......��.2 .... ........... Diagram of Lot and Building with Dimensions Fee ...�j...�! i ol 3 { • AC-tt,,s 1 �J��' it En 110 1- _ t '� x 15 A:rt>1�1C, 1 1 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. / Nam ll Construction Supervisor's License .................................... I SOUZA, GARY & ELLEN A=22-29 No ... Permit for ..Build Additon .......................... Single Family Dwelling Location ...,394 Old .OX.ster Road ............... _ Cotuit ............................................................................... Owner ....Gary & Ellen Souza ....... ............................... Type of Construction ...Frame .......................... ............................................................................... Plot ....................:....... Lot ................................ Permit Granted ..... ....19 88 Date of Inspection ....................................19 Date Completed ......................................19 e l Assessor's office (1st floor): Assessor's map and lot number .: ....22........ . .... � -- TNEto`♦ DIV Board of Health'(3rd floor): 9 INSTALLED IN CO Sewage Permit number. . ...f •.�. ... i • iR/jTH TITLE B6fld9T4DLE, Engineering Department (3rd floor): <� ENVIRONMENTAL C House numbei ..... .....:::............... �.. .�,l.�.............. y OWN r aY Definitive Plan Approved by Planning Board ________________________________19_:_-__-_ . T pEpYI,AT 4 ,• ,APPLICATIONS PROCESSED 8:30-9:30 A.M.- and 1:00.2:00 P.M., only: �d TOWN ' OF BARNSTABLE: BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..:............... :..... �........:Z.. �T/. ., ................................................ i TYPE OF CONSTRUCTION ...�'��.......� .�: �.���-.......:..., ...... TO THE INSPECTOR,OF BUILDINGS: The undersigned hereby applies for a permit according:Yo the following information: R 1 Location-... 4.:..:.�4-�.J. ��\ ��i. ::..��:��.e.��'—.�7........ ...MRS......................:.... Proposed Use ....... A.D. Zt.A�L.�...::�''"���.�-�...... U,� .............:...............................:....... Zoning. District .................... .........:.......... . ....1... .........::...Fire District' .... .......`? .. . 7...................................... t-D • P .fl.... c ..�.L.....:..... Name of Owner ..� ..... .� C ....�5 ` 1� Address ...... .J • Name of,Builder ........... ...... .................................Address .............. Name of Architect, .........Address ..........:... .... ...................... ............................ Number: of Rooms :.. ............�....... ................... .......: . ........Foundation ..... �C� . �i� ............................. Exterior .... 4� �. .......:......................:....:.........:..:..Roofing ........ . .G�4h.<�.......... ..... Floors O��O ..........Interior. ................; t� ................................. Heating ...... ... ... ;.... ..............:. ..:........... Plumbing .........................! v ...................................... Fireplace )44 ............................ ..................Approximate Cost .:.................. .......�... �. o...,�. Are 32 ...`�'........... Diagram of Lot and Building with Dimensions Fee � x l $ ,4b©IT�ow, . 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. d Name Construction Supervisor's License ............................. SOUZA,- GARY & ELLEN _ No 32248 ,Permit for ..ADD.ITION l 1 A Single Famil•Y Dwel•linq s Location .....39,4 Old••Oyste•r•• Road,•••••••„ , h Owner Gary...&+ _E ,..S za• �.......... ' Ellen Souza ' ka #► `• t ` Type of,Construction Frame ..... , . " ..... ........................................... Plot .... ...... Lot= ... a................... Perm it.'GroWed ..... Sep tember• 9.,,19 88 .Date of-Inspection ..:.. ............... .r......;1.9 ti \ 7� , e: Date Completed ....... ................19 r CO $• �j��� Aga»� i � 1 ' ••.0 1 :...., � � _ _.,f �, i s S � •.r r• f P �^+ i ,zin j *t r.