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1054 OLD POST ROAD
/a5'p ,O/d BsTX� _� _ � , 5 �+'� � �� ��-- ULIL " Town of Barnstable VA � ..Ulm, Z;Aa�1VlTPXH a`�r 200 Main Street;Hyannis MA 02601 508-862-4038 Application for Building Permit PP g Application No: TB-17-3017 Date Recieved: 8/31/2017 Job Location: 1054 OLD POST ROAD(CT&MM),COTUIT Permit For: Building-Insulation Residential Contractor's Name: Carl J Rebello State Lic. No: CS-084358 Address: Swansea, MA 02777 Applicant Phone:' (508) 567-4109 (Home)Owner's Name: FETTIG,,JAMES F&JOANNE M Phone: (508)982-5229 (Home)Owner's Address: 1054 OLD POST ROAD, COTUIT,MA 02635 Work Description: Insulation ,j .. -.s J . -. Total Value Of Work To Be Performed: $4,814.00 7 M3 Structure Size: 0.0.0 0.00 0.00-IJ Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office, Requests for inspections must be made.at least 24 hours in advance. Signed: Carl Rebello 8/31/2017 (508)567-4109 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $4,814.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $85.00 8/31/2017 $35.00 Paypal� Paypal Total Permit Fee Paid: $85.00 8/31/2017 M$50.00 __ Paypal Paypal mot , Town of Barnstable *Permit# F iT 6 monthsc issue date Regulatory Services MAC BAIUMABM Richard V.Scali,Interim Director 3b34• �� Building Division XAVESS Tom Perry,CBO,Building Commissioner POINT 200 Main Street,Hyannis,MA 02601 SEP 24 2014 rnstable:ma.us Office: 508-862-4038 www.town.ba TOWN OF B PTR ft-P230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number 1�5�Lo 2(p Property Address 10JTA Old PbS+ 903 t Residential Value of Work$__S,� �" Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Sam s F iaffiQ 10134 0A Pwt R rh�I i+ M ftT(a to3ri— l Contractor's Name r VAA11ndOULM10fTelephone Number!4h 1-6-0 g-of bo -- �• ' 1 i11S0Y1 Home Improvement Contractor License#(if applicable) �7 3a�J1' s Email: Construction Supervisor's License#(if applicable) OC1 KID:I_.. MWorktnan's Compensation Insurance " Check one: t ❑ I am a sole proprietor _} _ ❑ I am the Homeowner I have Worker's Compensation Insurance Insu'rance Company Name `RtOwn i a h ynn Ql;,(' - t Workman's Comp.Policy# W C,9271 Q 2 33 3��- 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 �xisting layers of roof) 'Re-side .•._..... -ReplacemeriC Windows/doors/sliders.U-Value ,3 a (maximum:35)#of windows #of doors: 0 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 towndepartment regulations,lations,i.e.Historic,Conservation etc. ~� ***Mote: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement.Contractors License&Construction Supervisors License is requ' , SIGNATURE: - TAKEVIN_D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313 *)M-re'llyoally and wmwavvtsca or so New E d 'A�rdet�ear:� OWtlIE tlrl 3��rie � , �" oeitracdoeF j;iar eves dllc tors spud eooelipnnpF drr dus egrormenr and on dlwe a �_v speciea(ioaro'sbCCgs) ocelle velgi 0i9`Wm. me!t"': e,, 931 COU6 ,0 HOA? 7drtal,J i4rmraar� IEaei�sd:?uer a :ll iod®d lr emt. I Cut Creat+Gavels:.me aowted for&T&At ordy-Impftum la of the 13alasrue az Stan- of �. men cast t as bed pbedM aarc :' b c s d &a aad F isa � ,lfi j,f .*Ira ft #�hrrtenra�itss�eeaal d.I *jaftambillir,e#aax ez bars e€jo'b and dra_ . ,-,� � i ..l3afanee•�Sufazt;�s�G�tn �ofi�o'b a�raet l�.e�e'tr�r�adh' CI €en of iJab 13y6�: ems' ' ' eard:arra i he B+�i.�crsel ,dam ar AS���.rO1049 Sao r(®�.agr�es eed. dau that' �¢s dl�e dine e d s� between the�.�cs.and Rid dMM %vey�no v$rba,t undeMbindiap c any of the ®of this e-MEnc, �l-cr d aelezw% �� etl this Ageje -�- eae g tQ�.M•a &ed:4�Udo"o C Yat1 date.firm wir a aim Ste, (1�1/ mad t eat �n'4crs air d s x�d has mod.a ids signed,anddued �a� infwr ed of 8111yees r4,U den cw=d was Agreffim—t-DO.141OT 91 .TMS CONTRA—Il,rk m i111E,1►NyE 5p.�10E5 (F o s leAiiae(Sade "j l�lo�ee �uyeee(1}a?o not s1� a,Jtgree �ot aif a►of the spas inoended for cbe,wed bft=> to e e extent of then aww'J able,Iufovr �n W left .M You nre eadi to s cogjr e1':t�+�4e� 'wt the e '. .:� 9 .'y r 1tadna IR Off the.fa01��betAd n=&r ithip A ,eas�a a�a�+49ia say bt enddicd to ail.'� �6ors anx .at' . . . �3� rsce a• M#ial ftbue of e c d Tim s SoE has no rigbria aalgwfuty;r�ter lro�p�me�e�,i or Vann-nit any biraaoch of&e'It to ve cd�goo as;�rechss6d eua�dew this-: �5)You'�y �tl�i6 lg i�t of it 1 not t iee�e,e a s office oe�i laa�c] +ate?of s el dnd eeo"y+-dLe,Seller,atitems or he .arsrias e�iTeemt*bedicesle etiaiar A � by:re ftried,tircrtifred w �fae.y stkxlnot�ertdeai gbt of the(bind s 0e1rtbe dnyqM &&e 1 mylr ems dhe: ut; .d �d3y"and=y 1" aWlfYI& �g;eaidoe of oaul�,paea��.�s3di _ _no.+af�yes;a5�gbts i#eayesm(s)Tseinid l the CombumiNr.education anu pnXided the Rl3ode-TA il'cSrtrsctous Rom a Re®ewalby` a oiheeNewunA Seersk,tMr L ,�� I' Pedn.t Naer e: _ �k_ GI iodact� 'e eel lYaettc T, `Ff4 ifiDYi3R�$�, M�►? #NC)T:TlH9*TR"8ACT1ON AT AW.TMM PWOR To.TM ? Oft!'. QF TTIR 'HOSIDI S'ED}►Y.li�'E�Timis OF=I;T UMION.SEE TM AI TTAC 4i�D N I=0,1? i LI1► 'Idm�►FO '►'1S FOR >L PL A.NMON Of T 'ls l�'Gltf OICS OF ceifw;C641AMO1 - - - - - - - - - NOTICE OF LA`IO Date gf action .You May cuecu i t 0 of Trrreaact3ion You may cancel diidt'tesartsa,ction,.oanitle64tt any nal ►'or.,obl %. vruthbM dais� acdon�Without ant' eeral% or a'bllgalb �vit$eEri dire t business doges from.tho Above date.l�# �carMI 2My ! thr+ec'busineas. (From tIe®.ad�re,dax�if dam rartcel,�edy pproperty triadesd:'in;any P �tr.ereauie - u order *.e•'l .F+�ercY ►'p+$yrrrerrt s amide bi'y�.under the Cor ^set�or Sjde-a e•ul►,rta�wtiabbe:Enst tsr�ad;cxen3ut !I_ Contract or sajej and acmdaMe J,mwum ,esaecut ky-you will.ba iretumed rrdinin.tee i is:dales following ;I by you will be mturnod mithitn:tom b�iaiu�a,days fio'llowirrg receipt by the'Seller of your cancellaI6-m nottk;D.-and aM l rcecip iboy the Seller of ydrur cl a n rssrteoe,seed eery t r:se�r : rrtDeres! ssrisi .,oiat 9 afae. on''�ar111 security, lrlterresk :WlUrlg Out of rdac. :�as pt� ties!! Ikte eaneele,L tf eorace' msrst rnalee aovailahl elks Rho Seller J .c2+ms�Od.!`you cancel, u must make-mr►alla to to -Seller' at your residence,in,sed ntialPy as Pod cdsasslitfonAs%wJ n A at your no*Wjneda�in su tiall',y as good condition as V41en r,vocevocis,any gar dz7 delivered to you Un&.r dais yCon&4ft or! u ueeeeived na'Y.l��defftwened to you under his Contract or Salk or you may,if ynu wish,comply rr�ulla the inr r�structio of:l ° e�or lrnu M* You Wistr d;*Mply�Wife the in4tru�ov�a of d aelltw regarding t he return, shipreerYt.of the goods at the . tlrg;�eJler'�ng tore retridrsa*hrgrsa cats of the garxd�ac ire. Se11es1-to anel rim.ilf yexse do die oda.aevala'bQh Salle,ws e�.fst`ra aged frisk:if'yddee do!renaJe goeielr stable the.Scllar and the .' If!or.does,not-pk dlfauarre vealdrere' dtdi.4 Seller atSre.5e�ller does:not po€Ic' er np.:witiri» twenty u a the ddvte:of-,eancdlaVo",.you may retain or 1. d�errerrty � of tihe die m#so�eollataon,ynae,etas mctain ar ells _ ee o stem go ►Strther obl9ga t Be. p .d fii try c u e�r3d➢rtoeat away rthe�yd q�.,�nn Q{yac�, rmalce the :" a►►aila6lg Seller,o'r H s W time tiller,oe'if. ere la ' man the goods ape tads 56dee and fail to eiid�so, you .,l to a+-WM#lec'gmods to the der and fail:�t{o�,#Teen you r rearin triaJde kr to se ell obl��ons tzhd e�.thc�. .l rem,able fear:perdurzrearace,of all olbl%gutioaes rcn it o Ctid t.T0 otratrl tieis traieorie rtoa��ae titJMer.a;shred ' ' OodttTa.sardoel thit tra rim c+�ion,mail tier dg9ire .a si eel oriel'dated,topgt of a rid:ellagot�: idcur r other J. mm#m tda ed coff s►uaeda< ��I�Rd; ots� our guar f ID &35, . o Renewal by� of Written ncrtieeaes or.send a ce r !?a.%wwwaJ And n of. I �ree Sr+othcrerpleerar d as'.� Albidrte hoed n. j Southem W&W nd at26All�'ion.�o . � !l to S NOT- ti(LATER T MIfl;DNIG14 OF _ �A ER N P°IIQNIGHT' OF { area f 1°I!ER Y CANCELTMSTiBANSA�1 . HIE ESYMANCEL' IUSTRA TIOy , D� IBihrr,�'�jR�' u'a�,t urn } { !' �� i. +.� • � �Yy i �.. _.� Southern New England Windows d.b.a Massachusetts-Department of Public Safety s Board of Building Regulations and Standards %� C:�rstroetion.5taprr� sor � t License: CS-095707 BRL4 N D DENNLSON _.. 7 LAMBS POND CHtt C'E F I w Chariton MA 01507Expiration r Commissioner 091=2016 am �� p � 12f/IPiU Office of Consumer Affairs 6nd Business Regulation. 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 173245 Type: Supplement Card SOUTHERN NEW ENGLAND WINDOWS LL Expiration: 9/19/2016 DENNISON BRIAN 26 ALBION RD - LINCOLN, RI 02865 Update Address and return.card.Mark reason for.change. scA1 Fl Address C Renewal (j Employment l-j Lost..Card ffice of Consumer Affairs B Business Regulation License or registration valid for individul use only rn f-�r�tOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: rrf Office of Consumer Affairs and Business Regulation r� yRegistration: 173245 Type 10 Park Plaza-Suite 5170 Expiration: g/jg/2016 Supplement•:ard Boston,MA �- SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BY ANDERSON DENNISON BRIAN 26 ALBION RD LINCOLN,R102865 Undersecretary _ lot Wa ithou' t signature __ The Commonwealth of Massachusetts t, n Department oflfadusttzalAccidents Office of Investigations :.> I Congress Street,Suite 100 F• =J ;T Boston,,MA 0211 4-2017 www.massgov/dig workers' Compensation InsuranceAffidavit.- Builders/Contractors/Electricians/Plumber�°s �w�lacant Information Please Print Legibly Name (Business/organization/Indlvldual). SOUTHERN NEW ENGLAND WINDOWS LLC Address: 26 ALBION ROAD City/State/Zip: LINCOLN, RI 02a65 Phone#: 401-228-9800 Are you an employer?Check the appropriate box: 1.0 I am a emplover Frith 20 4. ElI am a general contractor and I Type of project(required): 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 working for me in any capacity. employees and have workers' 8. ❑Demolition [No workers' comp. insurance comp. insurance.* 9. ❑Building addition required.] 5- ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11_ Plumbing re myself. ❑ g pairs or additions [No«corkers' comp. right of exemption per MGL 12 ❑Roof repairs insurance required.] 1 c. 152, §1(4),and we have no employees. [Now 13-n Other WINDOW REPLACEMENT Homeowners comp.insurance required j *-Any applileFS whoo submitthis h checks box l must also fill out the section below showing their workers'compensation policy information. affidavit indicating they are doing all-ork 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 iiz it formation. srirance for my employees. Below is ilae policy and job site Insurance Company Name: ARGONAUT INSURANCE COMPANY Policy T or Self-ins. Lic.4: WC927938352394 08/21/2015 Expiration Date: Job Site Address__ l0 /� 7) City/State/Zip: ;p //� , 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-vear imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine Of tip to$250.00 a day against the violator. Be advised that a co Investigations of the DIA for insurance coverage verification. p3 of this statement may be forwarded to the Office of 7 dm hereby certify under the pains and penalties of pej jury thattlze infonn IN aiion provided a 7ve;is ue and correct. /^ - Sianature: `' ate: /q Phone#: 401-228-9800 770fficialonly. Do not write in this areato be coinpieted by city or town official. n: Permit/License# Issuing Authority(circle one): 11 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: SOUTNEW-01 ANCHANNA CERTIFICATE OF LIABILITY INSURANCE DATE(M 8/27/2D/YYYY, 014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Willis of New Jersey,Inc. PHONE ($77)945-7378 FAX No: 888 467-2378 c/o 26 Century Blvd AIc No Ell: ( ) P.O.Box 305191 E-MAIL ADDRESS: Nashville,TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Selective Insurance Company of SE 39926 INSURED INSURER 13:The Beacon Mutual Insurance Company 24017 Southern New England Windows LLC INSURER C:Argonaut Insurance Company 19801 D/B/A Renewal by Andersen 26 Albion Road INSURER D: Lincoln,RI 2865 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. ILTR TYPE OF INSURANCE POLICY NUMBER ADDLSUBR MMILDDYM MM/DDT LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS MADE TOCCUR S 2029459 08/1012014 08/70/2015 •DAMAGE TO RENTE PREMISES Ea occurrence $ 100,00 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,00 GEHL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,00 POLICY JECOT a LOC ' PRODUCTS-COMP/OP AGG $ 3,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 Ea accident A X pANyAuTO S 2029459 08/10/2014 08110/2015 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS ) X HIRED AUTOS NON-OWNED PROPERTY DAMAGE X AUTOS Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS LIAB CLAIMS-MADE S 2029459 08/10/2014 08/10/2015 AGGREGATE $ 5,000,00 DED RETENTION$ $ WORKERS COMPENSATION X PER PER AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 0000068028 08/21/2014 08/21/2015 E.L.EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? N❑ N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,desaibe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 C Work Comp&Emp Liab WC927938352394 08/21/2014 08121/2015 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached H more space Is required) r CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Southern NE LLC �T�G/ 26 Albion Road Lincoln RI02865-0000 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS POLICY TYPE: Workers Compensation&Employers Liability WC: Statutory CARRIER:Argonaut Insurance Company EL Each Accident: $1,000,000 POLICY TERM: 08/21/2014—08/21/2015 EL Disease—Policy Limit: $1,000,000 POLICY NUMBER:WC927938352394 EL Disease-Each Employee: $1,000,000 ofl Town of Barnstable ` *Permit# P� p Erpires 6 monthsfroni issue date 'Regulatory Services Fee + BARNSPABLE, + v� 6 9 `�� Thomas F. Geiler,Director. .cl fD MPS p Building DivisionG . Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 r 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 �as ,+ba Prop Address. 0 pcis (.. V l/. 3 Residential Value of Work .� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address n� in Contractor's Name^ / �✓��,S �C�Gi�I✓ Telephone Number Home Improvement Contractor License#(if applicable) Con ction Supervisor's License#(if applicable) Y19 61 Workman's Compensation Insurance w PERMIT Check one: -XIPRESS Vame a sole proprietor . U 1 the Homeowner Worker's Compensation Insurance TOWN-OF QARNSTABL Insurance Company Name e �/%% � `d/✓�" ` Workman's Comp.Policy# 0 ( ' Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑.Re-roof(not stripping. Going over existing layers of roof) Re de > /� #of doors (/ Replacement i ows/ oors/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. P d tl _ t ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building pernut forms\EXPRESS.doC Revised 090809 I , The Commonwealth of Massachusetts . Department of Industrial Accidents w Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/diva Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant.Information Please Print Le ibl Name(Business/OrganizatiorAndividual): dV/U d Address: , V� 6 CitY/State/Zip: © Phone#: Are y an employer? eck the ppropriate box: Type of project(required): 1. I am a employer with 1 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* 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. ❑Demolition working for me in any capacity. employees and have workers' 9: �Building addition [No workers' comp.insurance; comp. insurance.$ 5. We area corporation and its 10.❑Electrical repairs or additions required officers have exercised their 11. Plumbing repairs-or additions 3.0 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 13.❑ Other employees. (No workers' 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 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 form employees Below is the policy and job site information. ,,�/ Insurance Company Name: e 4co ►� AVA- Policy#or Self-ins. Lic.#: Expiration Date: _ d City/State/Zip: o Job Site Address: � !'►'✓�� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152'can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be'advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and c/orrrect. Signature: Date• Phone# (� C-7T^��v V 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#: v.s-s % s ss sas►i--s s a yr■ s..si swas-ss s s ss-v—s ss ---- MOD'}'.`TA-1 05/07/10 46�PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Manville RI 02838-0001 Phone: 401-769-9500 Fax:401-769-9502 INSURERS AFFORDING COVERAGE NAICn INSURED Moon Associates Inc. INSL'RERA: National Grange Insurance Co 14788 DBA gutter Helmet - - - -�-�--- - ~- ~~ --- - DBA Renewal by Andersen Of RI NS'u?ER 6: Beacon Hutual insurance Co. DBA Clutter Helmet Roofing 1^ DBA Moon Works !NSLr.ER_----_----- --- _--,.—--- - 1137 Park East Drive INSURER Di Woonsocket RI 02895 iNSUREP.E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REOUIREN LENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT T 0`V'H1i H THIS CER?IFICATE MAY BE ISSUED OR MAY PERTAIN.THE iNSUPAr10E AFFORDED BY'HE POLICIES DESCRIBED HEREsN IS SUBJECTTO:ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGPEGA.TE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS. YEFFEUIIVE LTR PiSROI TYPE OF INSURANCE POLICY NUMBER 1DATE(MM/DDT))^N) DATE ST M�Q ) LIMITS GENERAL LIABILITY EACH OccURREtr-E $ 1000000 't' t�VEao n_:ccC A X COVMERCIAL GENERALLIA-BILITY MPS26619 09/16/09 ' 09/16/10 PREMISES urence) $500000 - CLA!hkS.DLALIE OCCUR WO E.X''r(Any one person) $10 U 0 0 PERSONAL s ADV INJURY $ 10 0 0 0 0 0 GENERALAGGREGATE s 2000000 GENT.AGGPEI,ATE LIMIT APPLIES PCP, � PRODUCTS-:-OMR10GA&, $2000000 POLICY PRC• LOC JECT AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIHIT A X ANYAlJTO B1526619 09/16/09 09/16/10 (Eaacclderd) $ 1000000 j ALL OVVNED AUTOS BODILY INJURY (Per person) $ SCHEDULED.ALITOS HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS 1 (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ---- !+NY AI-RO - OTHER THAN FA,ACC $ j ,AUTO?ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $1000000 AOCCUR CLAIMS MADE CUS26619 09/16/09 09/16/10 AGGREGATE --- $ — s i DEDUCTIBLE — $ — X RETENTION $10000 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY X TORY U;JiTS ER YrN B ANYPROPRIETOP./PAPTtJERIE.XECL.RIVE � 28586 10/01/09 1 10/01/10 E,L.EACH ACCIDENT $500000 OFFICEP✓MEMBEP EXCLUDED' - (Mandatoryi NH) E.L DISEASE-EA EMPLOYEE $500000 I It yes,describe unler SPECIAL PROVISIONS beipw E.L.DISEASE-POLICY L11-AIT $500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION REN wAL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$O SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Renewal By Anderson REPRESENTATIVES. 1137 Park East Drive AUTHORI DREPRESENTATIVE Woonsocket RI 02895 ACORD 25(2009101) O 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD or rep, �gWd bek" ft � tits z -_ F JAWS l OON s WOONSOCKE a [7ersecrgay pub #� W r,W .e si r 0 up ! t °„a' .� **� Lit— zsaw ad ' - � ' no � �. . 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W Wok Q its" Oj ed I I Z f7 5' Town ®f Barns table *Permit# S.,01. r, .y Expires 6 mo t!is from issue dates Regulatory Services Fee ; w M y Y ■ + BARN STAB r� 6 9: ���� �� Thomas F.Geiler,Director NO V ���uilding Division m �j 9 20olom Perry,CBO, Building Commissioner Y v �o�/�/� Q�B��NS T 200 Main Street,Hyannis,MA 02601 ABLEvww,town.barns table.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 �d Property Address lU 5— °`�/`— AV ' , Residential Value of Work Minimum fee of$2 00 for wprk under$6000.00 Owner's Name &Address a�1'�'� + Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side - #of doors Replacement Windows/doors/sliders.U-Value (maximum.44)#of windo 1.ws *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:: Property Owner must sign Property Owner Letter of Permission. A copy of the home Improvement Contractors License &Construction Supervisors Licen se is required. SIGNATURE: ci/r'"t' Q:\WPFILES\FO S\bui ing pennit forms EXPRESS.doa Revised 090809 R i The Commonwealth ofMassachusetts. Department of Industrial A ecidents Office of Investigations I' 1 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ih� City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. New construction ❑ • employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees . These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its l0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' t 13.�Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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. I do hereby certify under the pai and pe Ili f perjury that the information provided above is true and correct. Si Hato "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#: z Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an emplo},ee 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, constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.' MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) name(s), address(es) and phone numbers)along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to 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, I 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 atIthe number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City 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 allicense 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. I The Department's address, telephone and fax number: I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600!Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.inass.gov/dia Town of Barnstable Regulatory Services Thomas F. Geiler,Director • BARNSSTABLE, * - t+tass. qg, 039. ��� Building Division pIFD �a 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: 10B LOCATION: number street /y" village "HOMEOWNER": S �iAN,_ ►� 0 "► �' name II ho hone# r f work phone# CURRENT MAILING ADDRESS:�� � �1 gl! hAA G3IU 4 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 m 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.a d requirements and that he/she will comply with said procedures and requirements. Sig ture of Homeowner „ Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127..0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." ' Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section'2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that helshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC t 1 �1HE row Town of Barnstable i Regulatory Services hLA99. 8 Thomas F. Geiler,Director fo;A.c A,0 Building bivision Tom Perry,Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town..barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This S ction If Usina A Builde as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work thorized this building permit application for. ( dress Job) Signature of Owne Date Prin Name If PropeM Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. O:F0RMS:OWN ERPERMISSION �t The Commonwealth o Massachusetts -" Department of Indctstrial Accidents Office of Investigations 600 Washington Street t 1 Boston, MA 02111 Z i rvwmmass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information -Please Print Lep_ibly Name (Business/Organization/lndividual):_ /t,.e/rt.¢ Z OL,.vC':rJ Gut%�'^ /�y2'G✓Xi2f Address: /5V /dooe /6S-1 City/State/Zip: ,t4A Phone #: xws 2� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with. 4. I am a general contract6r and I have hired the sub-contractors employees (full and/or part-time).* 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 g. Demolition working.for me in any capacity. employees and have workers' Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LE] 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 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such, tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 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 th aim andpenalties ofperjury that.the information provided above is true and correct. Signature: Date: Phone 4: 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 S. Plumbing Inspector 6. Other Contact Person: Phone#: Informationand Instracti®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an einployee 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, of 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 p yment 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 for o any renewal of a license or permit to operate a business onto construct buildings in the commonwealth compliance with the insurance coverage required." evidence of com applicant who has not produced acceptable v p Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certificates) of - insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not-required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a.reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or r marked b the city or town may be provided to the town). A copy of the affidavit that has been officially stamped o y y Y P applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia f 'Lt , Town of Barnstable *Permit Jdo�' ��-�' Expires 6 monfhs from issue date Regulatory Services Fee nnrwti-TABLE, Thomas F.Geiler,Director .q MA,45- 4y, t639. �,� Building Division 'C� lf0 MAC 1 (� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Ov Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY g,/f Not valid without Red X-Press Imprint Map/parcel Number U✓✓�� � Property Address iC) 1 %75�- \ �, 0 CM CA. O� Residential Value of Work \ca. Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addresstzi , c �rJt�iN4Ct� f� 1n 7� � Kl \ZC� C��(�I liYaSZa tD '�,S Contractor's Name ���; tC iz��m�� Telephone Number3,-44`�-c{SN_7 Home Improvement Contractor License#(if applicable) \p 0-1�1 b ❑Workman's Compensation Insurance Check one: -PRESS PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner s` 1 have Worker's Compensation Insurance SEp 3 0 Z008 Insurance Company Name 0 C;M TOWN OF BARNSTABL Workman's Comp. Policy 41� 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 Windo door liders.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: Pro Zrty Owner must sign Property Owner Letter of Permission. A py of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:buildi ngpermits/express Revised 123107 The Commonwealth of Massachusetts 02' Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston,.,VA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(BusinessrOrganization/Individual): QV1 Z—Z Address:-boys City/State/Zip:��� _ , ��� Phone.#:!:Sc�- Are you an employer?Check the appropriate box: Type of project(required): 1.Q 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. 7.4�]Remodeling shipand 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.t required-] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' 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. tConbutors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:�r,i„ e � Expiration Date: Job Site Address: � O 5 LI c:)J� ���� City/State/Zip:&� . Clrl i i.c 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 tiue 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 again9t the violator. Be advised that a copy of this statement may be forwarded to the Office of Invcsti ations of the MAI insurance cove v'rif ation.. I do hereby certify under a pains and na ' of er.Ury that the information provided above is true and correct.Sj nnh � tre: _ Date: - A0 (, Phone Ujjicial use only. Do not write in this area,to be completed by city or town offlciaf 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 Ced)nt:1Ct Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employdrs to provide workers'compensation for their envi0yees. 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'Weither 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 incur ty mp ( ) ty p 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 returned to the city or town that the application for the permit or license is being requested,not the Department of be ty pp 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 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 burn leaves etc.)said person is NOT required to complete ethis 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-IVIASSAFE Fax # 617-727-7749 Rc�iscd 11-22-06 www-.mass.gov/dia f 71 Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: r Board of Building Regulations and Standards Registr}"tI.A�G, 100740 One Ashburton Place Rm 1301 pTt I =tr 3/2010 Boston,Ma.02108 o_ plement Card CAPIZZI HOME :jtTJI qy : r IaARY GUSTAFSm" .. _,L 1645 Newton Rd. Cotuit,MA02635 Administrator No vali itho ' nature Board of Building Regulations and Standards Construction Supervisor License License: CS 74640 Birthdate: 11/29/1975 Expiration: 11/29/2008 Tr# 6430 Restriction: 00 GARY GUSTAFSON 8 SHORT WAY SANDWICH,MA 02563 Commissioner I Client#: 47298 CAPIHOM ACORDTM CERTIFICATE OF LIABILITY INSURANCE 06/12/2008 Y' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Rogers&Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 434 Route 134 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.0.Box 1601 South Dennis, MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: NGM Insurance Company Capizzi Home Improvement, Inc. INSURER B: American Home Assurance Capizzi Enterprises, Inc. INSURER C: 1645 Newtown Road INSURER D: Cotuit,MA 02635 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION INbKLTR NSR TYPE OF INSURANCEU I POLICY NUMBER DATE MMIDD/YV DATE fMMIDD/YY _ —__ LIMITS A GENERAL LIABILITY MPB1075H - 06/08/08 06/08/09 EACH OCCURRENCE $1 000 000 �( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEU �?REMIS S cc rr $500 OOO CLAIMS MADE OCCUR I I ! MED EXP(Any one person) $1 O O00 ER�SO�NALL&&AADV INJURY $1 00O O00 GPI NeRALAGGREGATe s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I i PRODUCTS-COMP/OP AGG s2,000,000 POLICY PECOT- LOC AUTOMOBILE LIABILITY T v COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ALL OWNED AUTOS �BODILY INJURY SCHEDULED AUTOS I I _I(.Per pp, $ r HIRED AUTOS I I B(iUILY INJURY' $ NON-OWNED AUTOS j I (Per acclaeni) _ I i PROPERTY DAMAGF i (Per accident) $ GARAGE LIABILITY �— �ALJ1'U ONLY-EA ACCIDENT $ ANY AUTO I I > UTHER THAN EA ACC $ i AUTO ONLY AGG $ A EXCESS/UMBRELLA LIABILITY ICUB1076H 06/08/08 06/08/09 jtrEACH OCCURRENCE $5 000 000 X OCCUR CLAIMS MADE ! I AGGREGATE $5 000 000 $ DEDUCTIBLE i I ! ! $ X RETENTION $1 OOOO _ $ _ B WORKERS COMPENSATION AND I WC6716562 12/25/07 12I25IO8 X WC STATU, OER EMPLOYERS'LIABILITY - I 1 E.L.EACH ACCIDENT $SOO,000 ANY PROPRIETOR/PARTNER/EXECUTIVE i OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500,000 OTHER � I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable - DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN 200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPRESENTATIVE ACORD 25(2001/08)1 of 2 #S36540/M36539 KW © ACORD CORPORATION 1988 i • Y Page 7 of 7 CAPIZZI HOME IMPROVEMENT INC. SPECIFICATIONS AND ESTIMATES STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT J v p OWN THE PROPERTY LOCATED AT 6� f` 6 Q fd S/ �U{ IN % , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT CCORDANCE WITH 780 CMR,THE MASSAC SETTS STATE BUILDING CODE. - c SIGNATURE OF OWNER: a - . OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APPLICANT'S SIGNATURE: , APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: mom p1 PERMli PAYMENT RLCL IF. TOWN OF BARNSTABL.E BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: OBY1+/06 TIME: 14:02 -----TOTALS -------- ----------- Pj. MI1 $ PAID 25.00 AM' TENDERED: 25.00 AMT CHANGE: 25,00 00 APPLICATION NUMBER: 20062446 PAYMENT METH: CHECK PAYMENT REF: 727 Town of Barnstable Regulatory Services z # j Thomas F.Geiler,Director snaxsTnsLE. • �? 9.9� " ,®� Building Division to ArFp N►n�° Tom Perry,Building Commissioner � � 200 Main Street, Hyannis,MA 02601 � www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-623( PERMIT# , �l(/� FEE: $ �� SHED REGISTRATION 120 square feet or less /Ov ®L,o � Iic� - do /V// Location of shed(address) Village Property owner's name Telephone number � 12, Size of Shed Map/Parcel# Signa a Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. c� THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:042506 - TOWN OF BARNSTABLE Permit No. -- _ _27461------------------ • Building Inspector ICash ---------------:___-- A 1wP XOCCUPANCY PERMIT Bond -__-___-_--_ __ Issued to 'doy's Brook Realty Trust Address Lot #49, 1054 Old Post Road, Cotuit Wiring Inspector Inspection date r ' Plumbing Inspector, ry 'l z , ' Inspection date �'V f/ �-• Gas Inspector / Inspection date X Engineering Department ���.� r Inspection date Boafd of Health # y Inspection date 's 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. ........... .....: .. !...... . 1910 k�� i ,car l.c C Luilding Inspector T ��Q�o tl '°•°ew`a TOWN OF BARNSTABLE BUILDING DEPARTMENT ! lalk w r = TOWN OFFICE BUILDING rASa HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department f DATE: L An 'Occupancy Permit has been issued for the!liuilding authorized by BuildingPermit,#......................... ,.7....�... .................. .................................. ... ...............................».....:........... issued ... . ..... Please release the performance bond. a= n Assessor's ma and lot - "SS;MMS11N STE MUST 85 p o Q. `1 e;?.:-.a .6.....0 Qd B COMPLIANCE o*THE . Sewage PeL number ...............................................� �`qOIL—� WITH TITLE 5 ......... .. ENVIRONMENTAL COD' � � ^,,,, Z H9HBST4DLE, i S iEG hI 1C• M6& House number 1.0 `i1C �I F . ro i ou a. � 1 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .........................` 5i►` 1 c j. . �3!' ........� ... !...�L, TYPE OF CONSTRUCTION .�,a "Z: .. .�M: ....(..Gr ........................................................................ ............U. .y...................19 . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: .�. ...G..T...`..v � .Location .................C..�... ....P. `.......iZ :..Proposed Use .. i..h. � ...... �i\ .......��! ! .. Zoning District ...............................................Fire District ...0c-Tyr.'.Ak....................................................... Name of Owner .�C;: i .«'� �z� V.,ST Address Name of Builder �C%. , ....>.V.: 4.C ...1..VV�L................Address �........ G.: J!�►^C�`- Name of Architect ............... ........................�-�-r.v..�� Jam` 1 1.6.................................................... Number of Rooms 1� i �t> u�� 4ClNS -h�.Foundation . .... . ............... ExteriorC':3. �?Ca"C�n C�Ay� ci�v1 Roofing ..d: s �^I�L .... :F.......w iv,c� ........ T Floorsi.... �:. ,...- �e.................................Interior ....Yf��?1 � SILew� ZUA. ......................... 1 A S HeatingA...........w..........61.....0A.................................Plumbing ..............3............. .......................................... Fireplace .....2 . Approximate Cost'.....1z Oc ..................... t......................... ........................` Definitive Plan Approved by Planning Board ________________________________19________. Area .....S �.............. Diagram of Lot and Building with Dimensions Fee ©Zz .... SUBJECT TO APPROVAL OF BOARD OF HEALTH Te�T F �', 16 Z- OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of ?enef�.B ns able regarding the above construction. Name .`... ...... .. ..........................:............... Constrervisor's License `...�.3.! V g'* COY'S BROOK REALTY TRUST 1 .. No 27461 permit for 1 StO ............... .... .......�................ - ins�le..�am�.J ..JOa].i,rl ..............,, Location .Lot..4SL,...1D.54..DJd..Post..Poad..... COtuit ` Owner .!qy..'s...Brooks..ReaIty..Trus.t........... Y Type of Construction Frame............................... . ........................................................................... •a•Plot ............................. Lot ..................... ' Permit-Granted .....January 23.........;,,19 85 fG Date of Inspection 19 -Y Date mple d ... :(.... .............1 r . � G Assessor's map and lot number ..A........ ........� Sewage ,Permit number ..... Z EAEH9TAELE, i House number ...:.........................:...✓!�, y.'....................... 9� MALL .....0 r p t639. �Ep YP�Ar• TOWN OF BARN-STABLE o BUILDING INSPECTOR APPLICATION FOR PERMIT TO �v.„ J 4I� �,Q W���l� TYPE OF CONSTRUCTION ... t!` ........................................................................ ............�... � `�`-I .................19�. . 1. ;.. `�.TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: l Location �Cl ©Z, ...... ? �.... t� .......... v� ....� ..................................................... ............................. Proposed Use ..��1..�?-�� ..... !M4` . Zoning District ... .........................................................Fire District :.CCsfis?.�� ' .... ... ........................................................ roaK z�1 Tr s Nameof Owner .���,��'.'.............4-f'.........................�.....Address .............................�...................................................... Name of Builder �)y15....}.�,?�QG1`�... �.�-................Address Zq.?5;kfS` .. v ........e Name of Architect ..............0 .. ........................Address ............ .LG..................................................... Number of` Rooms ...... .......................................................Foundation ...V ,�! ..4?`uv�;�l.... 5 ....... .... ....... ............... Exterior .Ke��.�QCI�h C J�,�JJdl�vl(.I Roofing ( 1'�1�C Y ... A>F.......w�v�c�gL?��.5............................. .. ......`�. .... ..... .. ..... �+ Floors 1 1 ...................................lnterior � C A T ... Heating AAt ...................................Plumbing .............:3:..... ....A \ ; ...................................... Fireplace .... .............. ........`.................. Approximate. Cost'...., 5�60 ..... .&.. .. .... :... Definitive Plan Approved by Planning Board ____________ __ '________19________.�� Area :. Diagram of Lot and Building with Dimensions Fee /�' SUBJECT TO APPROVAL OF BOARD OF HEALTH { OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 5 I hereby agree-t6`66nform to all the Rules and Regulations of a-To n of B nsable regarding the above construction. ' " - r f Name t Constructi Supervisor's License .1.�.....'. ............ I - ' . . {%JY S BROOK IOUTY TRUST A=055-026-000 ' °y Aa 6,6~-^�� �^���� No -'Z7�l. Permit for .��. ................. � Single ----------...~--.---..-^------... ' Location -. .....I054.�ld.]���t.l���� _ Y` cotuit ........................................................... ' � Owner �ov`a --.~---.-'-.'===�=^..==°��--.. Type of Construction ....}�am.Q.......................... ' -`-------------------------' ` . Plot ............................ Lot ................................ Jan ~ - . . ~ Permit Granted -.. .2] '--1 � ` . Dote of Inspection ...........................�........lA Dote Completed ...................................... .` . _ ��,~ ���^ . � � T` � ' ` -^ ' - N | Assessor's offioe (1st floor): ` *THE Assessor's Assessor's map and lot number ....�.................................... . Board of Health (3rd floor): _ ro Sewage Permit. number r i 9Afld9TADLE, Engineering Department (3rd floor): � rasa - �p 1639. \e� House number ............................arle.Lid K1....:Y!?.!x.'A n........ 0 No APPLICATIONS PROCESSED 8:30.-9:30 A.M. and 1:00-2:00 P.M. only 1 TOWN OF BARNSTABLE 4 BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......... 1\ W1 1..4! ..... .............. TYPE OF CONSTRUCTION ...........5 "? d1AyK%—-K..�...............................................................................................4 ..�.` .......................19.- ... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby appliess for a permit according to the following information: Location ......U ...... ........ �.� .... dSC.... ................0 .... .U... ............................................................... ProposedUse ...........; ..:. .4N ......... �� .................................................................................... ........................... Zoning District ..............t r ' .............................. ...........................Fire District .......Grv- .),A.................................................... �o 515 l«I*,1 Name of Owner .. � ............ ...................... .... ......Address ...l .S. ...... G� °FCC C a �?-c�.>..... Name of Builder C(2� lS C,IZ.... .....�C.................Address Nameof Architect ..................................................................Address .................................................................................... Number of Rooms �—..................................Foundation `._' Exlerior ........ ...Roofing r— Floors ... ......................................Interior ............................................................. Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost ......411-� !/s Definitive Plan Approved by Planning Board ________________________________19____,___ . Area Jl ........................:..... Diagram of Lot and Building with Dimensions Fee f' SUBJECT TO APPROVAL OF BOARD OF, HEALTH 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 . ... .........!k:,. ........................... . Cons ruct.ion Supervisor's license ! d.0.3.t. ............. TSOTSIS, MIKE A=55-26 No ....295.14.. Permit for ..Build Swimmin. Pool Accessory to Dwelling . Location ....Lot #49, 1054 Old Post Road t ............................................................ Cotuit .....................................................................I......... Mike Tsotsis Owner ' Type of Construction ..,,Frame.... ... a . J ............................................................................... - Plot ............................ Lot ................................ y 1 Permit Granted June 17, .................................19 86 Date of Inspection ..........................r.........19 Date Completed 19 \ J 1 � Jt �I R Cp h/(� // �0 l Asse"ssor's offioe (lst floor): Cd-1 i`.k `tME T Assessor's map and lot number .....S f .... Q y ""�"���""' � SEPTIC SYSTEM MUSTS �& � Board of Health Ord floor): 6 o" Sewage Permit number ?....!,.-..., 6...1., kr ' INSTALLED IN COMPLIA .......... .... WITH TITLE 5 1 BARMTODLE. Engineering Department (3rd floor): /��� ®� S e ASIL I k ,�oa "6 9, 00� House number ........................r.. �. . ... L-......... ENTAL ' ! �• r,��= ''rE•oMara� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only, TOWN RECII) f TOWN OF BARNSTABLE BUILDING /IN SIP ECTOR APPLICATION 'FOR PERMIT TO .....( .......... -?w 1 .1.ld`�..... f�Z�..�................ TYPE OF CONSTRUCTION ...........tVY1h. -�,,...................................................................................:........... rr ...........�.�.��..... ................19. y. TO THE INSPECTOR OF BUILDINGS: b 1 The undersigned hereby applies for a permit according to the following information: Location ......L ......LA .......9....A .........�.d�.�......... ................�G.. .. .i...................................................................... Proposed Use ......... V. .�.N1 YNINK)N!).......... .............................................. ZoningDistrict ........................................................................Fire District ...... a-i1. .,A......................................'.............. Name of Owner ..1!' �� . ....�0.�...5.........C`<L�.��ddress ...`�5.�......��.����....... ..........�A�?-�. �. Name of Builder .... ..�5. �C.................Address �� �` ....kV.(�. IFsW Nameof Architect .......................................................:..........Address .................................................................................... Numberof Rooms ..................................................................Foundation •—.............................................................................. Exterior ........................ .—.-...............................................Roofin =. Floors ......................................................................................Interior .................................................................................... Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................................................Approximate Cost ....... �!/..l�ti.............. Definitive Plan Approved by Planning Board ____________________________19________ . Area ...... ...Gl Diagram of Lot and Building with Dimensions Fee 2 SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of arnstable regarding the above construction. Na ....... ...... ..... ....................................................... Cons ru tion Supervisor's License O.1.730............. TSOTSIS, MIKE No ....MIA— Permit for A411d...$.w.iMW!P9..F001 ...INP,11ing..................... Location ..Lot.J.4.9. .....105.4... . ...................cot.lur...................................... ......... Owner ...... .................................. Type of Construction ..Frame.............................. ................................................................................. Plot ............................ Lot ................................ Permit Granted .....June....1.7....................19 86 ...... . . . Date of Inspection ...................I.......:.......:19 Date' Completed ............ ...0. .............19 to lee 10 Iros TP - j - fly- . \\•�� ,e �.` . � _ � �' �,; _ 1 -. . .- � � ..\ . . t e;;.• � � •as ,� �. � w � . ` s , NN- o r j S t t I l �. , REVISIONS: TEST PIT DA TA DATE OF TES T/NG 4 e lL ga4._ - PERC. TEST DATA : SEPTIC TANK DETAIL : sfzE- _1 ...... _ :,'�� _-_ DIST. BOX DETAIL : LEACHING FACILITY DETAIL: NO DATE TEST BY., A :r+i_ ^� v_— _ _. DATE OF TEST/NG _-%`�_ �r�';3 ���__ TANK TO CONFORM TO TITLE 5 REQUIREMENTS. TO CONFORM TO TITL E 5 REOU(REMENrS � A[�L) IFX � �T"6Id.lC� � 4�uG, �n,��s �l-8� T P WITNESSED BY: _�_ .� cc r --------- .aa�► -7-,� �1 -�r-� -y��-- --- -- - -- NO. OF OUTLETS r 7W ,s WITNESSED BY �� - �, �ia,. \ � TEST BY.- �.�' � c:t1,C3,T �. , . 7 �/2„ .,. E OVE BLE COVER MANHOLE BROUGHT TO Si�s3: •;` ' f •'3 i. •� • . FINISH GRADE lL 2 PEASTOIIE LQ4M9F/LL S✓ iL i,'- A! CLEAR 3 CLEAR- r-T i --- - - Y - I. OUTLET PIPES fy,W ✓l�.r� -- - DEPTH OF TEST 6'• _�- 2' MIN 6'MlN I ' AS REQUIREDI I - - - ---- - - INLET ; ii t - RATE- Q .�,.� /nr� o M/N BOX --- - 18T --- --- ----- --- - -- --- --- -- -- IN L E T TEE - - —OUTLET TEE s i �� i �� _/ ¢., / B/S . . T. A' INLET AND OUTLET 4'0" MINIMUM OUTLET TEE DEPYH C• /000- GAL. 747 � TEES r0 BE CAST L IOU/D DEPTH I4"AT LIOUIO DEPTH OF 4' o 11 2" 6" �; SEPTIC TAMtC I . PRECAST OR BLOCK .�N. i `! 19" 5' I `` CONCRETE a� SEEPAGE PIT ---- _ / _ _ __ _ -. ._ _. ____ --- ____-- _--_ - -- ----- ---- -- /RON, SCHED 40 j DEPTH OF TEST _ _-_ . _- - -__-- -- PVc. oR casr;No . co/vsrRucric�v PL A CE CONCRETE :' 29„ MIN. RATE' CONCRETE , ,34 B' BOTTOM ON LEVEL 57ABLEBASECONSTRUCrI - --- - :.f�TJ '. - i (WATER� GH ON - F - -_- - -- - -- TANK TO HE ABLE TO W/THSTANL. T PROVIDED OUNDAT/ON -----_----- — • b. . .�. ,, ., e y I. t INLET TEE ROV DED WHERE SLOPE :-'-.•.•,.t.�,�.. ., .�,•, . •. .. - .. .. �. :. •.• OF INLET PIPE EXCEEDS 0.08 % OR BOTTOM OF TANK ON LEVEL STABLE BASE H-10LOADING UNLE55UNOER IN 4 PUMPED SYSTEM, 20'MIN. I I - -- -— { - --- ----- -- --- --- - - - - - - PA V EMEN T OR IN DRI VE. H-20 I4- ---- --- -- --- -- „I /�'WASHED STONE i L OA D I NG UNDER PAVEME NT OR DRIVE 1s----------- /0--- -o COr• o r�i r � � c NjAID WtIWR I I i i I NO TES PLAN V/E W __.- _ /N VER T EL E VA TONS. /. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OF THE SEWAGE 3� y��y� DISPOSAL FACIL I T Y ONL Y. SCALE : l = c_ � ' � i / ^G Bc<a.T OI�J J>/YG�E:�NT` 2. A L.L CONSTRUCT/ON METHODS AND IWA TER/AL S SHALL CONFORM TO . r odic INV. AT BUILDING /NV. AT SEPTIC TANK(/N) 'Ct►RIf r' �� �;; ';. MASS. G.E.Q-E. TITLE 5 AND THE N�>;�:rL.g BOARD OF ----- `s /NV. AT SEPT/C TANK(CUT) 101, a`' S� EFAF N >kA HEALTH REGULATIONS. I =i L : 7 is ti _. .•, !: '";� ALl vN w. 298G M to t i,C�T, t>1 WILSt7N -+ c> No. i9869 0 -- IN AT D/ST. BOX(/N) _emu-_ - _�— �,�s��sT- SI INV. AT D/ST, BOX(OUT) _� - •'� 7 -:�`'< ,-,�✓' sal'•• '" `' y✓ =o i Y�e4 ,� �► ,,�; AT LEACH/NG FAC/L/TY: 9•2_s BOSTON, MASS. WORCESTER, MASS. AT BOTTOM OFP/T- 14, HALIFAX, MASS. NORWELL, MASS. BEDFORD, MASS. LEXINGTON, MASS. 1 V HYANNIS, MASS. MANSFIELD, MASS. !�� IQ . �, CRANSTON, R.I. DERRY, N.H. N . e] �r r S Nj 101 DESIGN DA TA v Cr - . .b* ,.w -•' [�� `� T' DESIGN FLOW: - •\ '` \ \ •\ r • �/.^ t - leers.-irta =s.r x LJ.QSI P..IT L [2 li Cf C:LL-$-_�i' -_i.2L-1 p \ \\ ''••\ \�` ,fir / �---- ...,, F '., a� ` - _ -- .. —.. _. __._ _-_._ too q. REQUIRED SEPTIC TANK: ..�` � \ \ � �� \` �� � / �� 1' � •�` era � -�o, � 1 i : `:, --- — ', _ GAL. SEPTIC TANK PROVIDED _ LQs�_ GAL. CAPE COD SURVEY tx CONSULTANTS -� �, - ,� `\ — <,. REQUIRED SIZE LEACHING FACILITY: \ ` - -- - -_--- _ - - - - - -- P O. BOX 56 HYANNIS, MASS. 02601 617 775 —7155 \ M O ,n,. � ''• -..+1� .� \" - ,;i ," ._ `/,t� , iF9.c L..c�N ••��!-�1/C: ?"s•7Nit" (� e ' -._ .. _ -- -- - __-- ------ , � v �� `, : S+ is \. �•�� Y a � � t'1 —-- -- -- - - ._ ..._- _—_---- i - - --- - — DIVISION OF BOSTON SURVEY CONSULTANTS INC. SIZE OF LEACHING FACIL/T Y PROV/DED i ENGINEERING • SURVEYING • PLANNING ^� , '•� TYPE OF SYSTEM: ��kr�v� r TITLE: <' I.��PTN - LY --- r SEWAGE DISPOSAL SYSTEM �Qti :.� rl0� H�� �. DESIGN _'_>A,j _-A/U iJI=}trK'y /b' !�Q y v tI /• - - --- __ . l h/ L G T J� C'G 1� Al '� 6c-ref...[war./_ ti !,� tt ``-•W ,,q� IV-5 f�f LOCUS LA SCALE: AS SHOWN METERS f} ! J 1 ��./� //)^�\-7 !rr ^•}� �`....7 FEET 0 id •" � C 1.aC 4's \`��' DATE: �d"a�� c� '14 , o, V, t i COMP./DESIGN: c s v CHECK: DATUM' DRAWN: ,e• ',y �.S' r.�rr�,%�".� .,`•-,1=:s•-r•��' N,•�,�"`� FIELD: FILE NO: DWG. NO: JOB NO: O 3-- 1 3 a Y SHEET: I OF: I