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Home My WebLink About0216 SANDALWOOD DRIVE �, r ,. �� k APpli ... ...... umber.cation n .. BUILDING DEPT:s Date AN' U$'.2�2U slog. Building Inspectors Initials. TOWN OF BAR:NSTABLE ' t M ap/Parcel . S f da - Scl— TOWN OF B�STABLE EXPEDITED•PERMIT APPLICATION: ROOF/SIDINGI WINDO WS/DOORSI=..SISTOVES/WEATHERIZATION PROPERTY INFORMATION ' Y Address of Project: CCt.�1 �.�)D U STREET VILdAGE r , J Owner'sName � Phone Number w Email Address C � Pa � t Cell;Phone Number h Proi ect cost$ (3 3 Check one, Residential Commercial _,. .. +, �+ OR1ER':S AUTHORIZAZTON As owneryof the-above f property I hereby authorize /- Gfiemc eve,*� P P rtY Y to make application for a building peruut in accordance with 78 MR Owner Signature: Jt&a bt a.c, Date: TYPE OF'WO Siding " »Windows{no header.change)# . 4 . ,. Insulation/Weathenzation s u 0 Doors (no header change)# Commercial Doors:require an znspector's<Teview Roof not applying more than 1 lay er..of shin gles) Construction Debris will be going to CONTRACTOR'S INFORMATION m Contractor's name L f Home Improvement Contractors Registration(if applicable)# / 8 (attach copy) Construction Supervisor.'s License# /f (attach copy) Le Email of Conixactor QL�'Q/^hQ,�j � p7jx;: Phone number0701,4'°D. . ALL`PROP.ERTIES THAT;HAVE STRUCTURES;OVER75 YEARS:OLD OR-IF THE SUBJECT PROPERTY A HISTORIC:DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X -X - Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location (s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APP IC 'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. F SHE Tp ° Town of Barnstable I. BARN- SLABLE, ; Building Department Services MASS.9� Brian Florence CBO 0A 1639. N0R' , . TFo M' °" Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1, Carole Stasiowski , as Owner of the subject property hereby authorize)RI+0--A .-{TUC_ WWAO-I Z6.f7I1t—J-,' _to act on my behalf, in all matters relative to work authorized by this building permit application for: 216 Sandalwood Drive Cotuit (Address of Job) Signature of Owner Signature of . pplicant Print Name Print Name Date The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 �M yve,W www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC.' Address:2 LARK STREET City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 16 employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $, ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.M I am a homeowner doing all work myself[No workers'comp.in required.]t 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole l l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other INSULATION 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 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:LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#:XW058867158 Expiration Date:06/07/2020 Job Site Address: 4 4i1'L� U a Gl City/State/� � Attach a copy of the workers'compensation 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. I do hereby certify under e ' ` s and a�"s�ofeury that the information provided above ' true and correct Signature: Date: / vu Phone#:508-567-4240 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#: s, Commonwealth of Massachusetts Division of Professional Licensure lug Board of Building Regulations and Standards Cons`r ' r�Mrvisor CS-105454 fpires:05/08/2021 TIMOTHY CA 58 DICKINSO�fY;ASTREET+ f FALL RIVER'�3` 02721 �0 Commissioner Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvemg t Contractor Registration Type: Corporation s Registration: 175683 ALTERNATIVE WEATHERIZATION, INC.. A W Expiration: 05/28/2021 2 LARK ST FALL RIVER, MA 02721IV Update Address and Return Card. SCA 1 20M-05/17 - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYP�E:,Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation ^05/28/2021 1000 Washington Stre -Suite 710 ALTERNATIVE WEATHERIZATION,INC. ton,MA 02118 "'Aw. / T CABRAL.ti- f 2 LARK ST `L,-�w:yf' �/ �•� FALL RIVER,MA 02721'` Undersecretary of v � Withou Signature • c FDATE(MMIDDIYWY) 51 CERTIFICATE OF LIABILITY INSURANCE 0M24/19 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 have ADDITIONAL INSURED provisions or 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 GUNIAGI NAME: HOEAnthony F.Cordeiro Insurance Agency AICNNo E : 508-677-0407 Fn/c xt No): 508-677-0409 171 Pleasant Street E-MAIL Fall River,MA 02721 ADDRESS: HSouza@Cordeirolnsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Liberty Mutual INSURED INSURER B: Ohio$eCUt'Ity Alternative Weatherization INSURER C: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 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. INSR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDDIYYYY MMIDDIYYYY LIMITS x COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTE CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 300,000 MED EXP(Any oneperson) $ 15,000 A Y. Y BKS58867158 06/07/19 06/07/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $. 2,000,000 POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY O sBI EDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B OWNED Ix SCHEDULEDAUTOS ONLY AUTOS er )Y BAS58867158 06/07/19 06/07/20 BODILY INJURY(P accident $ HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ x UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/07/19 06/07/20 AGGREGATE $ 1,000,000 DED RETENTION$ ' $ WORKERS COMPENSATION - PER OTH- AND EMPLOYERS'LIABILITY •Y I N STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? nn N/A XW058867158 06/07/19 06/07/20 (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA,its direct and indirect parents,subsidiaries and affiliatesshall be named as Additional Insured on commercial General Liability and Automobile Liability polcies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESEN @ 19 -2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD . ,. Town of Barnstable BU11dlIl •e. �. .,`�-s, 3c �i ,.�4. .n. ,-. �?:.,,_ i'f,•.rr 'S1 ..e''�. .'a..�$% .r.:Y', ��%, f::: "?e, Post This Card So That rt rs Vrsrble;From the Str,.eet;=ApprovedTPla""Must be Retained o,n Job and this Card Must i , 'S' "� �,. mr Pose, Ins ection Has;Been iVlade° ' k ab34` C° ,. ...�,,,":% x� ''"p, •:i:a ."-.k• �, { 3'a` .s'a... ' ;'{� a za� taG�. ;',� "y -s` :, r ''• s. Permit , - • Wherea Certrficateof•Occu anc °s`Re uired�-such Burldrn .sh�all'Not bye Occu �ed'until:a:.Fnal Ins ection has,been madeF, < .�- .. . .. dp,.-...may, .q: !... .. ,: ,F g ... . :. . ... .p. ;.. -. ..:. ptr . .:,; . ,. . . . Permit No. B-18-1553 Applicant Name: todd leduc Approvals Date Issued: 06/07/2018 Current Use:, Structure Permit Type: Building-Insulation Residential Expiration Date: 12/07/2018 Foundation: Location: 216 SANDALWOOD DRIVE,COTUIT Map/Lot 025-045 Zoning District: RF Sheathing: 411,I'll Owner on Record: STASIOWSKI,CAROLE A Contractor Name ,,TODD LEDUC Framing: 1 a Address: 216 SANDALWOOD DR Contractor Licens �CSSL-106019 2 k COTUIT, MA 02635 � � � �..� �� , � Est Project Cost: $4,000.00 Chimney: Description: Air sealing and insulation of attic flat �� PerrnitFee $85.00 4 �R Insulation: Project Review Req: FeePaid $85.00 " Date 6/7/2018 Final: � Plumbing/Gas Tla Rough Plumbing: �Z s '�K - � s �' Building Official a Final Plumbing: : ' Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. g All work authorized by this permit shall conform to the approved appl ati n andtheTapproved construction documents for which this permit has been granted. g Final Gas: All construction,alterations and changes of use of any building and structures shalk in compliance with the local zoning by laws�and codes. This permit shall be displayed in a location clearly visible from access street or roadaand shall be maintained open forpublic inspection for the entire duration of the work until the completion of the same. A w Electrical The Certificate of Occupancy will not be issued until all applicable sign ture�s by the Building and Fire Officialsare provided onthis permit. Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or Footing "AN •21 r ,�k,•; s� 'A Rough: 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons cont ng with unregistered contractors do not have access to the guaranty fund" (asset forth in MGL c.142A). Fire Department Building plans are to be available on site Final: P rmit Cards are tAPPLICANT-I ECIPIENT All e he property of the ISSUED R Town of Barnstable Building • �I ' "d I '� - BARMNSATFAL • iPost This Card So That it is Visible From the Street Approved Pla u:Y 't be Retained on Job and this Card Must be Kept weuPostedUnt�il Final Inspection Has Beenr Matle " & .. ... .M M, Permit e» Where�Cert�ficate„NofOccupancyNis Regjuired,suc nspection hasybeen made z Permit No. B-18-134 Applicant Name: MICHAEL WOESSNER Approvals Date Issued: 01/16/2018 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 07/16/2018 Foundation: Residential Map/Lot 025 045 Zoning District: RF Sheathing: Location: 216 SANDALWOOD DRIVE,COTUIT �_- 5_ +Con#ractor�Name �,,MICHAEL WOESSNER Framing: 1 Owner on Record: STASIOWSKI,CAROLE A ' Contr ctorLicense CS-080957 2 .. .;. ;: Address: 216 SANDALWOOD DR Est Protect Cost: $ 15,750.00 Chimney: COTUIT, MA 02635 4 �Perrnit Fee: $ 130.33 Description: replace kitchen cabintry,flooring, replace section-of drywall & Insulation: Fee Paid:` $130.33 insulation. Install homeowner supplied appliances.all plans Final: provided Date ' 1/16/2018 Project Review Req: s g Plumbing/Gas � E Rough Plumbing: Building Official b Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and tFie!approved construction documents fo which this permit has been granted. All construction,alterations and changes of use of any building and structures',shall be incompliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street=oCroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. M F Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Bu ding arid' ire Offi als are;provid d on th s permit.30 Service: Minimum of Five Call Inspections Required for All Construction Work:, 1.Foundation or Footing ;; ' Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: S.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the.property of the APPLICANT-ISSUED RECIPIENT Appkahon Number.........4..'z F.'..� ..!................ i ust MASS. A *' Pennit Fee......�C..l.Y.d.... . Othec Fee............ 11559. Ec�" TotalFee Paid..................................................................... TOWN OF BARNSTABLE lPermit Approval by.. . ... ....................On.. ..... ... .... ...... BUILDING PERMIT — APPLICATION ......................... . .........Pa�e�......... . ........ ... Section 1 — Owners Information and Project Location Project Address/� t'� � O/�/� Village Owners Name Owners Legal Address City C-n¢L.,;c State, Zip 0-->6 3',r— Owners Cell#,5®u-- 912,,22 06 E-mail Section 2—Structural Use Single/Two Family Dwelling ❑ Commercial Structure over Y 000 iPT ❑ Commercial Structure under 35,000 cubic feet T 4161® 0 Section 3—Type of Permit eA�Nsr'��L ❑ New Construction ❑ . Move/Relocate ❑ Accessory Structure ❑ _Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar O'Renovation ❑ Pool ❑ Insulation Other—Specify Section 4—Detail Cost of Proposed Construction /s';2,=- Square Footage of Project Age of Structure _ 'Yo v4K,<-Y Dig Safe Number #Of Bedrooms Existing 3 Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design F Last updated.I1!l/LO17 Section 5 -Work Description e j Section 6—Project Specifics ning ❑ 'Oil Tank Storage . ❑ Smoke Detectors umbmg ❑ Gas ❑ Fire Suppression ❑-Heating System ❑ Masonry Chimney ❑Add/relocate bedroom , Water Supply Public ❑ Private Sewage Disposal ❑ Municipal �n Site { Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane C Yes ❑'l�o J 10, Section 7—Flood Zone I Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No I ' Section 8—Zoning Information 1 Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed j Side Yard Required Proposed i Has this property had relief from the Zoning Board in the past? ❑ Yes L'I No Last updatmd 11n12017 Town of Barnstable Building PostKThis Card So That rt isVisible From_the Street Approved PlansBASJUNMA Must be Retained on Job and this Card Must be�Kept Posted Until Final Inspection Has Been Made w h 163� rr Permit Where a Cert�ficateFof Occupancy is�Requred,su1chxBu�ldmg shall Not be Occupied unt�la Frnai Inspect�onhas bAeen made Permit NO. B-18-134 Applicant Name: MICHAEL WOESSNER Approvals Date Issued: 01/16/2018 Current Use: Structure Permit Type: Building Alteration INTERIOR Work Only- Expiration Date: 07/16/2018 Foundation: Residential Map/Lot 025-045 Zoning District: RF Sheathing: Location: 216 SANDALWOOD DRIVE,COTUIT Contractor Name. MICHAEL WOESSNER Framing: 1 Owner on Record: STASIOWSKI,CAROLE A Contractor License: CS7080957 2 s E Address: 216 SANDALWOOD DR =.. Est Protect Cost: $ 15,750.00 Chimney: COTUIT, MA 02635 Permit Fee: $130.33 _ Description: replace kitchen cabint flooring,replace se"ion of'd all& Insulation: p p rY, g, p N� Fee Pald: $130.33 insulation. Install_homeowner supplied appliances all plans Final: Date 1/16/2018 provided = ' Project Review Req: . . .. ... Plumbing/Gas s Rough Plumbing: Building Official I ; Final Plumbing: Js' This permit shall be deemed abandoned and invalid unless the work a thorizedby this permit is commenced within sixmonths after issuance. Rough Gas: r� M, All work authorized by this permit shall conform to the approved application and the;approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and strictures shall be incompliance with the local zoning bylaws,and codes. final Gas: This permit shall be displayed in a location clearly visible from access streefor road and shall be maintained open for public inspection for the entire duration of the �� .„ work until the completion of the same. Electrical- The Certificate of Occupancy will not be issued until all applicable signatures byAhe Building and Fire Officials are,provided on hi3 permit. Service: ' Minimum of Five Call Inspections Required for All Construction Work: " Rough: 1.Foundation or Footing1t 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT i The Commonwealth of Massachusetts Department of IndustrialAccidents _- - Office of Investigations 600 Washington-Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �Ji c`1 y�f!�/� aJ,S'!9•=/d Address: City/State/Zip:. _ Phone#: Sam•-29 z y�v Are.you an employer?Check the appropriate box: Type of project(required): 1.ElI 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 2.0'1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remd g ship and have no employees These sub-contractors have g_ ❑Demolition D�NG DepT workin for me in an capacity. employees and have workers' g Y P t3'• 9. ❑Buil ' on [No workers'comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.❑Electrical rep a .itions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Flits rhNg� additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs 'V`STABLE insurance required.]t c. 152,§1(4),and we have no employees.[No workers' 13.❑Other pomp,insurance required.] *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'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: �s.ly.�� Policy#or Self-ins.Lie.#: /'1i/'t' �2 �3 ems— Expiration Date: Job Site Address: ca -11*'11_____�1_e 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 pains and penalties of perjury that the information provided above is true and correct Signature: Date: A e/d" Phone#:.Sow 9�z •'i ';'s 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 id 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 along with their certificate(s)s of . necessary,supply sub-contractors)name(s),address(es)and phone number(s) g ate( ) insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the 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 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 (Le.a dog license or permit to burn 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 Massachusetts Department of Industrial Aecadents office of Investigafios 600 Washington Street Rosman,MA 02111 Tel.#617-727-4M ext 406 or. 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www,mass.gov/dia i ��£' [f'(+Q9f:79747t1OC',fl��/1 F�C:T'.-ZQJ,JC7Cftfl,JC'1�.7 •? OIHae:ofConsumerA4feirsi�f�HHsinessRegu�ation HOME IMPROVEMENT CONTRAGTOA BYRE.IndMdual:' ion Wiratloa L A—i05r25/20T9 AAICHAEG WOES'$t � NIICHAFiL.I� W O>rSSF e•' 3 ROWE ST f ,. $70NEHANI MA0218( Undersecretary;.' Massat:#tusetts Department of Public Safety j �s Board of Building Regulations and Standards License: CS-080957 Construction Supervisor MICHAEL.WOESSNER 170 NEW BOSTON ROADS°��b DENNIS MA 02638 '.hy§M , r� Expiration: Commissioner 0310412018 . g�1�o - ®V TOWN i y .......... / m_ � „ d su�ILDING ® 1 JAN 16 2010 • T OWN OF BpfqqSTP►BLE &,Kd"E vE4v V� p% {'Y '+W IY 3w 1 �,YF�r4;_N � � r q S � �a��fj��P��'� �� ko L�y�"y4J� „�'�' kf S�� d� ��iIJ •� �..a'� �"��`53� �g- s �RX ,�� • t��1 €r 1��'��_��' �i..�,`}� y .zg .� ki,� 3w3 di ,�' � �� ^�.�G��ts��`�� >�r Sy t`'� �� iA �aw"'��-�`'�>�'° a: ✓.5�s � �'�4'��' T +.�„ S' 45.> .` �S y'�+ • 'z,��.�?j�:o�^"6, t i� �'��3 ,.,-�� a -i .' s€� �^i+�"e�..��-ga Y K .� h *,� .. 7;5;e"''�'.,a ?.�''a.€.1#�"T f• • • • i• • 6 61i�iMIMMX;,?�... uW'4 y'&, s`' „z'e'y 3'.>�Mhj��, S.p..• a ky+..�s�,��,s 4NY•�a� "R!6rKF A' ,'�'F'�'�,nAA`'.'�,k�p � ' `L},,k"�W��»e': .'y x t r 41, s� aw+Ew .,' rim�SYr ~Tv;i 'F}"r`"u &v F',P t `,� c,.'N' L�4, W�,� , V, N��• "2 r8a�r.Gar t'rrsY" qMar.w? � ?l� e tv tx4"i%k't' .._ ; .i •r'C s $ 11M;,;i C''":�U ,r 5:'ir•' +' ,tt q 1, J '- " r�kyp. t� rKr i .7 k" Ea, 1i 'P '. .' T�1.'S z r .t �, :<t� tt.:: yy3 . ` .Ss.taw4 e, � '.__ .;i nzEasri',N'ha0 ,. '.�;' s?, „''� i � ,' >ea:i,kkx ry; } ?3;.,I.tt S.C. r t!."�E !t� r y ^S s,° '�' �" ` a. ve.- �.��.�,� d. .,;4,� r; c .w,, i a:x '•�,.��..�, ��7 �,a- :.i: tr r s::s 6's:rc,�. r..'>" :f, xy e. •s q�>�da.'"q r' ��°�5.� S:°'�ttr, 1, �`' k-.. ., ::•:< t, a x .ate. ,:.x »Y .r # + r Gf t fx .m !; t} a AX -", �.' x • ! s,-�.y_,�s� 1•r�pp'-!i%. ?' ;.', t It1 I:ar`�,. 4 r ':aY• �r!I . .},; tau �. w1 x ':a ti�'�.t.t, ,d '4 ' t kLn„`. 2b E , k fig.<..p:. ^•>v tx..E.. � # �';:� ,ta.'�;Pim��6,t€"•;;._, .F .,d,`�ri.,� , '°.'" '� �: � ;�,. $� r ,t �f 3x u,,,,a;I.4y �tlC��R�.. '.. 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CO C_Q_S p 0 o�-t (u CCy-, C 49 ; - #6 PSI Stasiowski, Carol _ All C Section 9—Construction Supervisor i Name A4 /moo e_ssln"C"Ne Telephone Number Q Y--2 S_?_ v Address 176 State Zip License Number-CS-c L>-o-,,5 7 License Type C,S Expiration Date 3 Contractors Email l.�o esyr,%-�,, /, �,�. Cell# b h - 7 y ' - �/�� I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date i Section 10—Home Improvement Contractor Name 4,4 L,>d<sss z Telephone Number T-, _ �,5el 2 Address Z& City s State I�Zip a2-- 9 Registration Number /G 9 i 4 Expiration Date s/yam-- I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature %_� Date Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature __ Date Print Name Telephone Number E-mail permit to: Last updated:I In2017 i E Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approvd Section 13— Owner's Authorization I, y as Owner of the subject property hereby authorize ,a. % to.act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature o Owner date Print Name i Last updated:-11n12017 THE Town of Barnstable *Permit*#. ,L- 5 Ex�gy�res 6 the rom is ue date �* Building Department Fee f— 6D WWST,mL : Brian Florence,CBO a639. ��' Building Commissioner � iOtEp Mpl a 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address :2/ 1YResidential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address CUga/ Contractor's Name.e,_f j� �� ,� Telephone Number t .2 i 2 •Z_ e Home Improvement Contractor License#(if applicable) Email: t' et=y, c Construction Supervisor's License#(if applicable) 5 ❑Workman's Compensation Insurance Che k one: [7I am a sole proprietor ❑ I am the Homeowner ^n ❑ I have Worker's Compensation Insurance JAW 11 K`0 Insurance Company Name wy_S/�h /,Joy{/a z; ., e-c1 TOWN N 0� W N S I AB LE 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)- - - --- -- - -- -- -- [❑ e-side - Replacement Windows/doors/sliders.U-Value: "b,_T (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does notexempt 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: .d' - :;ems QAWPFILESTORMSTMESS2017 The Cornmomveakh of Massadrusefts Degrartwent cif rarrius&iat Accidm& u - Office of Lwestigafims _ 600 Washington Mreet _ Boston,MA O2H1 wnn-v masLg v1dia NITiorrkers' CampensationInsurauceAffidavit:BugderslContractursMec€ricians/Plurabers A Ucan#InformatiQn PtewePrint Ilb�y I`rta>ae m6=ngsnQatioalFa a> &%o e.f-J:a Are you an employer?Checkthe appropriate box: ' Type of project(required): I.❑ I am a employer.v ith 4. ❑I am a general contractor and I 6- ❑New crosbmctim amp-loyees{full.andfor part--hme).* #lave lured the sub-contractors 2.91 am a sole proprietor or part ow- listed on the attached sheet 'f. ❑Remodeling ship and have no.emplogees. Mese lab-contactors have 8.,❑Demolition woddng far.rae in any capacity- eutployees andhave wodcas' 9. Buildsa addition s�-[No arioers' comp.+ns�*)ce comp.msuranmi ❑ g required-] 5. ❑ We are a corporatim and its l0_❑Electrical repairs or additions3.❑ I am homeowner doing&U wmk officers have exEmised ii�r 1 L❑Plumbingrepairs ar addititms. 1� � [No o • right of esemgiion per M(M epaim insunince required-]f c.152,§1(4haadwe have zYa ,,��❑.,,��Roafr employees-[No woA=e 13-910ther comp-inm anise requires.] ;Any app[i®4dat coeds cm I%I mast also fMoutthe swd=beZaw shuvdng theirwod me compenud ••periey iaformvaolL meoavners Who sah�t cots afiidat�d indxcadag tiney are dais s1F vrox�and ifiea hire antside rre nvren.c� submit a new affida&indicMCtino SiLCri fCaahscio�sth�cbecl�thiZboacsmmtaitachedaaaddili�alsfreeisboamgti+easmeofthe�andstate�rhethecarnvt�nseentitiesYlsve empkyees.if thesvb-ca�hareemptoyea%&ey=Lstpmvide&eir warkm'-=y.policynumbm I am an efnpIar Eliot is prouFdurg tvaficers'cottrperfsatiaft insrarancaaf•my'emPFal'ees: Seloty is fltepoiicy area joh site information, Insurance Company Name: C- Poficy AA or pelf-in,s.Lic. It1e2 s�.,z 44 4,7 2 7_ rpiratioaDate: -----Job Site Address:T=�'i ,�fda'a 6 C�1 w —-— -- --cifyl5tafeE.tp: Aftach a copy of the workers°coonpensationpolicp-dedara4ion page(showing the policy number and expiration date). Failure to secare coverage as.requireduuder Section 25A of MGL a 1M can lead to the imposition of criminal penalties of a fine up to$1,500:OU andror one-gearimpriso as we11 as civil penakies.in the fo=of a STOP WORK ORDER and a Rw of up to$250-00 a day aQaiflst the viDlator. Be advised that a copy of this stated may be forwarded to the Office of Investigations of the DIA for ins=nc+e coverage veriffcat o>L Ido hereby certify usuler the pains andpefabies of my 8fatilte iffforttrafims praF&W abm a is hiss and carrect Date- Phone it S aortal aril only. Do flat:fsrke in this Brea,to be completed by tarp artown officraL City or Town: Fermiff icense S Issng Antlrority(ride one]: L Board of Health ?..Building Department 3.Ck .Fi£own Clerk 4.Fteetrical Fnspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ormation and Ins ct ons. _ _-- _ _ -� ensation for Ioyees_ • Massw m c is Ge=-g Laws chaps M req=m all empIoyers'D WM&warkr�s comp a mp Pt this statute,an ernFloyes is deed as.',every person in&e,service of another under any corfract of hize, express or implied,oral or writ An Moyer is defined as"an in iduaI,partneashi�,asso®iion,corporation or other IegaI erOy,or any two or more of the inregoing engaged is a Joint ,and inclndmg the legal rpeseatatives of a deceased employer,or th e receives or trostes of an individual,parinrrsbip,associ dion or other legal entity,etoploymg employees. HowDver the owner of a dweIlmg house having Mt more tban three apar[meofs and who resides therein,or the occ t3pa of the dwelling house of another who employs pessans to do maiat�,conshucdon or repair woik on such dwelling house or on the grounds or building aj jr rL anttheretn shall not because of such employment be deemed to be an employer." 25 also states that state or lorai 11-0-9 agency shall withhold ffie issuance or MCrL iPr 1�Z,§ C{t7 �Y renewal of a Hcense.or permit to operate a business or to construct buildings ut the commonwealth for any applicant who has not produced.acceptable evidence of compliance with the insurance.coverage requxecL" Addition Ily,MGT.chapter 152,§25CC7)sus aldefther the cozamnawealth.nor auy of its political subdivisions shall ester into any cont:act for the pezfumianceofpabhowoikumtilacceptableevidenceofcompliaacevtiih the; sm7a„m. rez T7M3ie23ts of thi s chaptEr have been preseZIEd to the conL cting azohoiafy." Applicants ' Please fill o:c± the vv0t3eeas' compensation affidavit completely;by chug the boxes that apply to your situation.and,if nece�SSar3',S-UPPIy Sub--contr s)name(s), es)and phonemtmmber(s) along vitbL their=tEcate(s)of i n=ance. Limited Liability Compames(LLC)or Limited Liabi ityPaztaem1ups CLEF)withno employees other.than.the =nbers or partners,are not reed to catty workers'campensatlon nsuianm If an I-T C or LLP does have empIoy=s,apolicy is rcgaa-ed. Be advised that this affidayit may be sobmibb�dto the Department of lndusftial Accident mr confnmation of insurance coverage. Also be sore to sign and date the affidavit. The affidavit should beretnmed to the city or town that the application for the permit or license is being requested,not the Department of I-orinstdai AcQdesiS. Shouldyou have any rjuestiang regardmg the law or ifyou are required to obtain a workers' coazpensaiioa policy,please call the DepartmeEt at the nrnnber list d below. Self-insured companies should enter their srjf-finuiance license number on the line. Ci�or Town Officials . t - Please be sm-e;that the aidavit is completes and pritded legibly. The Deparlment has provided a space of the bottom of the affidavit for you to fi I out in the event the Office of Investigations has to contact you regmding tTie applicant Please be store to flI in the penmiYlicense number which will be used as a reference number. In addition,an applicant that must submit mub:iple pczmWlicense applications in any given year,need only submit one affidavit indicating current policy imbanation.(ifnwzssary)and tmder`Job Site Adffi7ess"the applicant should vnb--�a-U locati�.ms in (GfLy or town):' avit A copy of the-affid that has bey officially stmipe--d or mmaked by the city or t o a may be provided to the ' applicantas proof that a valid affidavit is on file for fatnre'pezinits or licenses_ A new affidavitmust be filled ovt Each year.Where ahome owner or citizen is obtaihffig alicenso or pennitnotielaiesdin bnsmess or conmercciia1 veatilm (Le- a dog licenseor permit to bum leaves etc.)said person is NOT rcgd=d to complete this affidavit ' The Office of Investigations would bIm t D thank you in actv-ance for your cooperation and should you have any questions, please do not hesitate to give us a call. The,Deparimenf's address,inlephone and;Ex ntnn =-- Tht CaMMIM'Wed- t OfllffaStaChnsetfs Department of Ii Aw9enta ice�7.�.�eafrg�tia� 6W washm. n �ostan= E�11F .. 'Tl�-1.4 617-727-4900 cxt 4€6 car Fax 617 727 7749 Revised4-24-07 .masS-gagIdia- -• E T Town of.Barnstable - * Building Department M,,SI �, $rian Florence,CBO ATE p a`� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.as Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This.Section If Using A Builder I, l Cc(r)+6 � Gi.S 1,D' 1. J K l ,as Owner of the subject property hereby authorize I`G 11L2oe Ss n Pr to act on my behalf, in all matters relative to work authorized by this building permit application for: (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 e Q;FORMS:OWNERPERMLSSIONPOOLS Rev:10/17 JL VVVU V1 1)Ql11Dl,auxv �oFIME A Building Department i Brian Florence CBO----- "` • Building Commissioner ' + aARNSTABLE v hUM 200 Main Street, Hyannis,MA 02601 'OrFo rat°i www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION, Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occnpied.dwellinirs 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 buildine Hermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection.procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 3 5,000 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 to amend and adopt such a form/certification for use in your community. t ♦ :,•,zuu..w .a»ra4. nr�.a:�. .,�. ,/ ;v.< E�!!f' RPJt YJ149Y./IJGKJ:�ll VIC�(�. jjd!.'kezw,�� OHi�e of Consumer Affairs&tlushiess Regylatian f'` HOME:IMMOVEM`ENT CONTpALTOA N E:IndMCual. MICHAEL WOE ST OWEST � .�•ONEHANI,MA 0218t ``' lJndersecf s Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS-080957 Construction Supervisor MICHAEL.WOESSNER 170 NEW BOSTON ROAD DENNIS MA 02638 CA— Expiration: Commissioner 03/04/2018 . " .f . P The Town of Barnstable '� ' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner SHED REGISTRATION r al(, S O-V\, a Wood -b r-i\J e. v '7� ..0 9 6.3 S Location of shed(address) Property owner's name Telephone number Size of Shed M arcel 1 J ignature Da Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? —] Conservation Commission(signature required) 0211 THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedmg I ULU Id '7b l l;deHI'I HLVHIY I Hlmt I'IUK I LiHIzL �. BUYER: Adinolfi 1 I t I 1 20 125�� I 2— 15 Jot s6� por, �l2 . I 1 I ANND I��nTr AIN s a MortRape Corp. MORTGAGE INSPECTION PLAN LOW0 IN i CERTIFY THAT M BUILDINGS SHOYN DO ( ►� To sETt3A0( REQUIROAENT'S I.E. (FRONt, SIDE, !REAR AGMf ONLY) OF Aarn�Wu F% 60-ram 1� WHEN GONSTRUOTFD, OR ARTS E?WT FROM, VICILATION OVORCEMENT ACTION UNDER MASS. G.L. l�AS�ACHU�ET� TITIZ Vile CHAPTER 40A. SEOTION 7, UTAM OTHERWISE NOTED. I FUSER TIFY TRAY THIS PROPERTY IB Not LOCATED IN THE E$1'AguswED FL00D AREA.COMMUNITY PANEL NO.: 250001 00210 DATO 8-3-9-85 DEED THIS COMPANY IS NOT RESPONSIBLE FOR ANY MNDENTURES MADE SUBSEQUENT TO THE RECORDED BOOK -- DATE OF THE LATEST OEM OF RECORD. PAGE WHENEVER BUILDINGS ARE SHOWN LESS THAN ONE FOOT FROM THE PROPERTY LINE IT 15 ADVISED CERT. NO. TT14ATT A MORE PRECISE SURVEY BE MADE TO VMFY THESE MEASUREMENT 1NiS CERTIFICATION IS BAST;D ON THE LOCATION OF SURVEY-MARKER OTHERS, AND DOES NOT PLAN BK, 2�1�PAGE 112 REP T A PROPF7tTY SURVEY. VERIFICATION OF SIJrtV>=11 M Ei j. AS SHOWN, PLAN + DATm MAY B2 ACCOMPLI� ONLY BY AN Aad1RAT INS'IhUMENT., m ARE NOT DEPICTED �I§L&RT1F10A'nON TO BE USED FOR MOM�i't3A.--1 �,4k w Y. OFFSETS AS SHOWN ARE R .T�'; BE ' ciY SCALEi i'« �r+ � USED FOR 7HE ESTABLISHMENT OM"P'jOPEfMf INES c:;I .„�.1,�ta.)111G•.fa ^, B R A D F O R D ENGINEERING CO. P.O. BOX 12" 4 V } • p I� � t i r vv 2G I t T 2 3 Ell" ; 00 90 Q 4 � A C 14, CoT'cr�T r8A)Zn%STAal-�C)q,+5'5' 3 0 ' F/2 o w i 4- Z:�Am .\704 z 2 &Aj /�L A iv ,U A 7 .t7 r C E R r/F-Y T,NA T rl-16 F00AZ>A 7"/��./ /5% ' NOV. 16 , /9 ,3 GaCAT60A!5 5A- 0U,9V0" Tel&V407"'0, .� &F-/AJG L-07- ?3 A-5; S140wav 1/ ` GEORGE ' G� -,t J Ley"' ? , f 0 V --5_ NOT._ �7"Y1A 7" t LOW,sR /tJ . rti�'ast�a ° i Assessor's map and lot number 8, • "s SEPTIC SYSTEM MUST BE yt t, r �� INSTALLED IN COMPLIANCE Sewage Permit number /� -................... .............. ............... 1�►ITH. ARTICLE II STATE SANITARY CODE AND TO\41N *THE � I A r : TOWN OF BAR"NSBLE I HASB9TADLE. f M�� ._ � '� DU-ILDING .. INSPECTOR �t Gp '"i639•/ 00 s r� _ .6 APPLICATION FOR PERMIT TO .°....................... �12T.^.u e. ...... .... .......... .................................. sLt TYPE OF CONSTRUCTION .. ................ .(,, -0.cr)... ... /. �. ...............:............:.................................. .....................19........ TO THE INSPECTOR OF;BUILDINGS: The undersigned hereby applies for a permit acco�rtdin��g�� tothe following information: Location ....A.t�.�........0�...C?(U...(.- ... .......... .................................. ProposedUse ........................6)40C°/i, . ............................................................:..............:.............I......................... Zoning District ...............�` ...............................................Fire District ............C. E?1.L ...................................................... Name of Owner .. . yC..Address ��2.. .. ............ ��.��. ✓:.�:.11t'............... Nameof Builder ..........4 ZAf .,e.7...................................Address .......................... !? ...........................:............... JJ Name of Architect ........... e.�1..4� 11..................................Address ...................k....��.ire............................................ Number of Rooms ..............................................................Foundation ..../Q........�ouned....... Exterior ......./ `/..... ..�..... ` . .� e1 R.!&hoofing ......QZ .....L.�7..........�� Dl /.. .............:..... Floors /t ... ......... �.:.!7.��..........................Interior ..... ..off / �7 �dC l� ............................ .. .. 5.......... ............. Heating ...f._.o.V,.bv.............. /./.....................................Plumbing .. . (/.c. ....... C.t'yrQi��r.................................. Fireplace .........4f,561- .... ..!f�? �`D!?. ...Approximate Cost ..... cam.. ......................... Definitive Plan Approved by Planning Board ________________________________19_______. Area .................... ........ ........... Diagram of Lot and Building with Dimensions Fee �'�� ..................................:.......... SUBJECT TO APPROVAL OF BOARD OF HEALTH 0.tidal CAJ'06� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Z% . ...... ....... ... Tellegen-Ferrone Associates, Inc® �s ti Now 19438... two story - + 1. Permit for,:.; ................................ single family dwelling = .i-?...�......:.-..i.. ................ .............. .. . ........... f /� Location... rSandalvo6d Road�..................... Cotuit �. ... ..... .................................... ................... Owner Tellegep-Ferrone Associates, Inc. ! .............................................. ......... r Type-of Construction .....game Plot ..:✓...................... Lot ......)t23 ......:........... Permit Granted' July 27 77 . Date of Inspection C.�..{� '/��-y -19 Date Completed . .1 /!��f..7../... ..: .... 19 PERMIT REFUSED - ................. ................................. 19 Y / ... ............... :.:................................ r/ !...........................:..........:..: r ` .....................................?. . . ................................. ry f ApproJed ........................................... 19 .. .................................................................. ' .... .................... ................. ,` w .1w_ l,� r .. � ay..w sr �F:.:.n.s,^ •.. - it..3-:e,;.�..:ti� ."+- r -^e' J4"' ;.:{�..� .'1.«�v... �.. Assessor's map and lot number ..............•.... Sewage' Permit number( .... ......................... ................ i TOWN OF BARNSTABLE y �fTHEtO� i BARNSTABLE, 9 s6}9• BUILDING , INSPECTOR Op \00 k APPLICATION FOR PERMIT TO .........................60..? 2�t ..................................................................... t TYPE OF CONSTRUCTION ...................... ! + rar ......... /;12.4.111 e............................................................... U ................................................19........ r TO THE INSPECTOR OFKBUILDINGS: �j The undersigned hereby applies for a/permit according to the following information: / Location ..... �� .� ..... ..R..n. i� , „!r/rid=?.......... .yt/1 :r.'!.............:...`. l!!.. ... ProposedUse ............................./ /IaP. !... !.... ....... .. ........ . .............................................................I......................... Zoning District ...............ZF. ...........................................Fire District t ..?.&.................................................. .............. ..... .......... Name of Owner . 7P, /kSaR....40<.��C..Address,118 ...3........... ................ Name of Builder ! `L�(lE .40'..7..........:........................Address :.........................: vl�/C ............... ..... 5q me Nameof Architect ..................../. .........................................Address ................................ ........................................ Number of Rooms ................. ?............................................Foundation .... .// �D /�✓`e� <�l�C✓`C?7� .... ...............................�... Exterior %�1 A /, S,r'ls'wo.`/v!Roofing ......,�.,�a . ,Z?.........�... .................... / L Floors 00/� ; '�� Interior /r� nac .......�..�..........�.. ...........` ../.................................... .. Heating ?�-�.. �.............. /...................s.... ... ........Plumbing ....,p� :......... �.a�XI�P('.................................. Fire lace .. (!.��0. .... / f�SC� r(!,�...........................Approximate Cost ....:Ifo . . ?p .... �r Definitive Plan Approved by Planning Board ________________________________19________ ° Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT .TO APPROVAL OF BOARD OF HEALTH ° 1 16 r � I hereby agree�49 conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name �/.......l.. r f . Tellegen-Ferrone Associates, Inca A=25-45 7- 19438 two story No ................. Permit for .................................... single family dwelling Location .Sanda.lwood. ...1 .... ..... .... ............. . ........... • s Cotuit ............................................................................... Owner ...............Telle. . .g.en-Ferrone. . ...Ass. ...ociates, Inc. .. . ...... . .......... ........ . .... . .... Type of Construction frame .......................................... ............................................................................... . Plot Lot #23 ✓ ................. July 27 77 Permit Granted ........................................19 Date of Inspection ........;...........................19 Date Completed .......................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ......................... ...................................... .............. .......................................:....:....... : 1..7....... .................... ................. .'.D ....................... 1 Approved .... ......................... 19 ............................................................................... ......................................................... ................. _r -f� w tA y � �(0s`•o� r r / _7- ex A . 16 Aj Kil ( 'Z� t`�� 9ka � 2�•�� io �`r` �,� .SU"/�c3l3lt.... R V IL //0 c 1 J3 U/LD/ArG S ETOACA-- ,2El(: 7U/R,--Me-Aj7z5 30' F20,,v 7- /S' S/tam / r )OF-1 TO P2aD0 5ED � BE.D/2ooMs SEPTIC SYSTEM C0NST2UC7-/0N . SHALL GOn/FQ2M TO "ASS . 0E5/G N FL O I-V 3 O GAL�I7A Y ENV/20/VMEn/TAG. CODS. T/TL.L ]z IeEViSE,?::) ?->- 77 6,4, l/S7-A6Z-L LEACAV RATE M/N../IAICAI �kLGSTi��' �/EALTH TZ�GIJLAT/OHS1-2 ?U/!� c /320' TOP OF P20ro05 E D L E.4C/-/ A.2EA ' . L�" �*c 20 4O MANHOLE Co✓E,� To E)cTEn!D 7-0 /MpE2✓/OUS COVET W/ 7W IA/ /' OF F// /SHED GraAOE: TO ,a2E VENT �Ml4 773 A5,,vD. .c20M /�/FlLT2AT/.tI6 �l I 5 72�ivE 4o Z � � 2 '¢~G4sr BOX Z/"w�DE ° n G"M AJ D/A. c q2 -�--- —�-3�ru'--�— �G r 4" o1A. /O LEAcA/ p/7�N F�Ow Li�vE iy1,v p _� _ �4'/FdOT /O"Min/ 14" 14 I T 2.. Mini /:irc�i �, p/7- �2 DIA. Y l 6- 0 Minl y /I"/•moor ^ �'t/ASHEO /.5', 3a, STO n/E CALL0&/ /A/VE.2T `�� ' p9 ALL liVVE..2T C-4 PAC/ TY .4fZ OunlO SE,oT/C TA VA-- /S• SO f S C F/ FV ll o� CWA TG lz 7/6 H 7•) / 8C�770M OF NVE2T /*-VEAzr /VO GA28A6E G,2INDE 2 20' M/n//MUA4 �LJ" ✓ `-Pj � l 6 L.00.A T/Oti/ (!:-'7cn 7Zof)Z � -ter�/sT j rvJ //U •FZ.A-;.j 66Zfs� / �✓� .SEDT/G TAN.L,� 0/S7-2/BU7-/ON 80X C6 An/D L. -AC.y/.vG .a/7- IcOr2 TO BE'OF .LE/�/F0�2CEZ7 COn/Gr2ET� _ CONC�2E TE 5 7 'E.VG7?� 5000 ps/ M/N. 20000 " H-10 LOADING S NO.tzT /NC. /4 TO,2Y LAAIF— a t� � D)21 VE WAY %/Or TO BE LOCATED , . MA S �� 4 0Vr- 5 YSTEM Un/LE55 f/- 20 S• YMo � G DES/GA/ L OA EVA./G /S USED. SNORT t No 27483 H i �rf`�St4'JVAL A D,4 T Al E EAL77-1 A .�tGF..�vT Z/)7 pPr�O✓,4 L 1 - F°