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1519 SANTUIT-NEWTOWN ROAD
65 J f Efficient Buildings, LLC N ire. f i_i.. February 2, 2012 r Town of Barnstable Attn: Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 ' re: 1519 Santuit-Newtown Road,'Cotuit, MA 02635 (Rose Medeiros) Dear Mr. Perry: This affidavit is to certify that all work completed at 1519 Santuit-Newtown Rd., Cotuit, has been inspected by a certified Building Performance Institute (BPI) inspector. Work included air sealing, and installation of 496 sq. ft. cellulose (9") in open attic floor, 132 sq. ft. FGB on rim joists, 39 sq. ft. damming, installation of two Therma-domes, and vents.All work performed meets or exceeds Federal and State requirements. Sincerely, a Atevehite.. Owner/Managing Member Efficient Buildings, LLC ) .:F .. t q $vw ry r. a }..{� Y.J ...�.1:.�.N �3». t C� ' ° y ... ... ��.` ^'i.- 1'.„r, a f r`•� ��'Is rQ .... n-'r �:,�-l�'.�i IMi.,i{LL'.1 •a{.Y ..al �0 _ 8 Jan Sebastian Drive, Unit 10, Sandwich, MA 02563 Tel: 508-888-1110 Fax: 508-888-1109 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION {b TTV '�, r . p A . Map � Parcel : _ Application # Health Division 2(3`7 ,(t;4` 210 ti' j: Date Issued a� l Conservation Division Application Fe Planning Dept. Permit Fee b i2'' `ti C. Date Definitive Plan Approved by Planning Board � J Historic - OKH _ Preservation/ Hyannis Project Street Address 1 5/ 9 SA1V T0-iT-h-16 LJ TocJ/\1 /2,0 Village o 'Ty/ -r , Ae /Z1),COTu/Owner Telephone 5d�. -q-a.F - 5 3`7 rya Permit Req uest �4/,- 5C,4 /JG- 1 r SuLA To�J; A P PW Vf. /ry Gj'�N �� LDolt, )37- Sod FT (�.,Z> -PP3 R/10 JO/ST5, 1-EIvTS T/465-ieml�- -b6r,& S 3�1 7t--T 7- (�MI�rN Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation aO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) 1 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas . ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name S�60E V C G "17ii Telephone Number 66a- - ��U Address � 1 Cl(5N'7LT) S C License# / Home Improvement Contractor# k' _ ��Nrx�-ICF 04- &3 Worker's Compensation # W 9 y y ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO mjf:�a S7O Ns fo ) L_ L-S X-FLsl S7R77 v SIGNATURE DATE J/ 1 l/2 r t FOR OFFICIAL USE ONLY APPLICATION# 4 DATE ISSUED "C MAP/PARCEL NO. : 4 3 . ADDRESS VILLAGE fi ' OWNER DATE OF INSPECTION: r !: FOUNDATIOW' FRAME `* INSULATION- FIREPLACE ELECTRICAL: ROUGH FINAL, - E� l PLUMBING: ROUGH FINAL , t .. GAS .r€ ." ROUGHC't`K =' FINAL E FINAL BUILDING+<.'Z { ;itl' !RIN F ,. .DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts ' Department.of Industrial Accidents Office of Invesdgadons ' 600 Washington Street z Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E FF 101 1 E/V T O U l lz>l wc,S L C C Address: 9 JAN -SE t3 A S7'1 R►y' r:b2l V97, 0,U17" #/O City/State/Zip: JA>JDo1Cf4' M"gOaS&3.phone#: •5'p$ S8g -/f /C� Are you an employer? Check the appropriate box: Type of project(required): L. I am a employer with 4• ❑ I am a general contractor and I employees (full and/or_part-time). * have lured the sub-contractors 6• New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.' 7. ❑Remodeling shipand have no employees These sub-contractors have' - 8. []Demolition working for me in any capacity, employees and have workers' 9. n [No workers' comp. insurance comp:insurance.# �Building addition ; required.] 5. ❑,We area corporation and its l0.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12:Q Roofrepairs insurance required.] t a 152,'§1(4), and we have no - employees. [No workers' 13.[ 'Other =NSUL-ATt a N 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 showingthe 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 insurancefor;my employees. Below is thepolicy and job"site information Insurance Company Name: '�� GAD U Policy#or Self-ins.Lic.#: 9 g Expiration Date: 3.`C>?-I:p Q/ 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 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 andpenaldes ofpe fury that the informationprovided,above is true andcorrect Signature: z.,. Date: Phone#: d Official use only. Do not write in this area,to be completed by city or town official Cityor 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: a Phone#: .- A� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 9/14/2011 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 Co CT Crawford Eldredge & Lumpkin Insurance Agency, Inc. PHONE FAX (508)945-0393 A/c o:(508)945-4048 697 Main Street E-MAIL david@elinsurance.com _ADDRE S: INSURERS AFFORDING COVERAGE NAIC# Chatham MA 02633 INSURERANational Grange Mutual Ins Co 14788 INSURED INSURERB:Commerce Group IG001 Caliber Building and Remodeling LLC, INSURERCAce American Ins. Co. - ARWC 22667 Efficient Buildings, LLC. INSURERD: 8 Jan Sebastian Drive #10 INSURERE: Sandwich MA 02563 INSURERF: COVERAGES CERTIFICATE NUMBER:Housing Assistance Corp 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 TYPE OF INSURANCE - POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYYI JMMIDD/YYYYJ LIMITS GENERAL LIABILITY - EACH OCCURRENCE $ 11000,000 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTEU PREMISES(Ea occurrence) $ 500,000 A CLAIMS-MADE a OCCUR mpo27360 9/15/2011 9/15/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,060,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY in F7 PRO- LOC _ $ AUTOMOBILE LIABILITY ..,CO aCBINetDSINGLE LIMIT E 11000,000 B ANY AUTO BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED BNVCS 2/16/2011 /16/2012. BODILY Per accident $ AUTOS AUTOS ( ) NON-OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE k - Per accident - $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE - AGGREGATE $ 1,000,000 DIED RETENTIONS 027360 9/15/2011 9/15/2012 $ C WORKERS COMPENSATION WCRY I IOTH- AND EMPLOYERS'LIABILITY YIN - TO LIMITS I I ER - ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT $ OFFICERRA.EMBER EXCLUDED? ❑ NIA OOO - - + - - 5OO (Mandatory in NMI �4941P844 /2/2011 /2/2012 If yes aescrbe under E.L.DISEASE-EA EMPLOYEE $ 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE.-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - Carpentry. In conjunction with the Weatherization Assistance Program, the following entities are named as Additional Insureds for Liability coverage under Pol #MP027360: National Grid Corporate Services LLC DBA ?rational Grid, Action Inc. , Colonial Gas Co. & NSTAR`Electric. CERTIFICATE HOLDER CANCELLATION .�:.:. •�. . a .; s s SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THEI EXPIRATION DATE THEREOF,'-NOTICE'WILL BE DELIVERED IN Housing Assistance Corporation ACCORDANCE WITH THE POLICY PROVISIONS. , `, Att: Ruth Bechtold ,w.� - 460 West Main St. rw AUifrORMREPRESENTATIVE Hyannis; MA 02601 b y74 avid Crawford/ELDDCI "'"� ACORD`25(2010/05) ©1988-2010 ACORD CORPORATION' All rights reserved. J09SMfx,annsi m Tho A(.npn n2mo=nA Irwin nro roniefnrxt m2rite of Ar:r1Rrl _. - ... 'lassactiusetts- Depart'mcnt of Public Sufch Board-.of Building Rc ulutions u"Fl, t:►nddr(ls Construction Supervisor License License: CS 96038 ' Restricted to: 00 STEVEN WHITE �r 147 RIDGEWOOD AVENUE HYANNIS, MA 02601 �--G- -Expiration: 2/28J2012 ('aumiv:i•.�ner Tr#: 19311 /le �om.,ro,us�all� ✓ aaac�uaelta License or re tration valid for individul use only Offece of Consumer Affairs&Bdsioess Regulation" . HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _. Registration: 169944 Type: Office of Con�mer Affairs and Business Regulation ,. 10 Park Plaza-`Suite 5170 Exp?ration: &1912013 LLC " Boston,MA'a2116' ErFtC —=.ILDhN,S,LLC. STEM ; 1:,jl:c SANDYAIC' V.= =—0 Undersecretary Not valid without signature 1 � oev .y !k i pyw.l�i»< g � R,+^"���MJ �'. e^'M� VRMn,�*at*nM .r •" _ ,"1' � a t"be +Il^a +a.•. "p' 'Yys g+o +a�,y. ..ir-�, ,{j+�'• ", 9�C''as *��n •dry s'9#,.,�s•k`Y**"3' � �i�7i:'t � :, atlL.° a � 'i."w 0�, r a v iH j �xxsresr�, + a auss �, Thomas F.Geiler,Director i63q •` 1 ► Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 , www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A-Builder I, T O s E M L D E I IZO.S ,as Owner of the subject property hereby authorize I C I �( 3 to act on my behalf, in all'matters relative to work authorized by this building permit. I�1 J A NTUI-T T.T�) CQ I U I T (Address of job) Pool fences and alarms are the responsibility of the applicant. Pools. are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. Signature of Owner Signiature of Applicant S7G v t N C W H I Tr E Print Name Print Name aA1a � rt� Date Q:FORM&OWNERPERMISSIONPOOLS C:) oF�xF r Town of Barnstable 'Permit# t Expires 6 rrionths froi.n issue date �P Regulatory Services Fee CQ -� i BARNSTABLE, v MAC $ homas F. Geiler,Director. 1639• �0 �rFD MA 1 A f M1 - ESS Building Division 7 2010 Tom Perry, CBO, Building Commissioner JUN 200 Main Street, Hyannis,MA 02601 UU �� gARNSTABLE www.town.barnstable.ma.us Office: 508 �2-4038 Fax: 508-790=b230 EXPRESS PERMIT APPLICATION = RESIDENTIAL ONLY Not Valid withoirl,;2ed X-Press Imprint Map/parcel Number Property Address S l shin-rUi-r Meky-F-L"Vl 2d �Tui W1 1'C Residential Value of Work '3 t Minimum fee of s25.00 for ,York under$6000.00 Owner's Name&Address 1 S 19 Nei)-f& AI kd C�rui1 �'a Contractor's Name 3-ameS 6Z` Aerge i rv5 itJt �de� Telephone Number SUfJ 39S 86�Z Home Improvement Contractor License#(if applicable) Construction Supervisor's License# (if applicable) &6 50 — ❑Workman's Compensation Insurance Chef am a sole proprietor ro P P �'PRESS PERM-IT I am the Homeowner ❑ I have Worker's Compensation Insurance JUN d 7 20.10 Insurance Company NameTOWN-OFBARNSTABLE Workman's Comp.Policy# r 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) 1['RRe-side #of.doors Replacement Windows/doors/sliders.U-Value (maximum .44)# of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property'Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License &Construction Supervisdrs License is required. SIGNATURE: ✓2 el Office of Consumer Affairs&Business u ati,,HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only Re'9istratron RACTOR , before the expiration date: If found return to: Ex pi �140157 Office.ofU!p Consumer Affairs and Business Regulation P �9/19/2011 TYPe'' IncJi dua, {' Tr# 288734 10 Park Plaza-Suite 5170. y Boston,MA 02116 JAMES R MEDEIROS 'd . JAMES MEDEIR 696 ROUTE 6A YARMOUTHPORT MA 02675 —; Undersecretary —9�"Not valid without signature iNl issachusctts- Depar-tment of Public Safct� Board of Buildin!r Rc(yulutions and Standards . Construction Supervisor License License: CS 66658 Restricted to: 00 JAMES R MEDEIROS z - ;� . 696 RT 6A YARMOUTHPORT, MA 02675 Expiration: 4/16/2011 <'unnnfsiuner Tr#: 5104 � e e r m The Cornrnonwealth of Massachusetts —� Department of Indcrstrial Accidents d' r�t Office of Investigations, 600 Washington Street l Boston, NIA 02111 'J wivw.mass.gov/dia . Workers' Compensation;Insurance°Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individtial): 'Mmeg e- Medc'Cms Bui her Address: toq Co (LT A City/State/Zip: o S Phone #: .SUB- Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.El am a employer with 6.,[j New construction �Iamp'a loyees (full and/or part-time).* have hued the sub-contractors2. sole proprietor or partner- listed on the attached sheet.. 7.. ❑Remodeling ship and have no employees These sub-contractors have g- E] Demolition working for me in any capacity,, employees and have workers' 9 Building addition. [No workers' comp. insurance comp. insurance.t 5. We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.❑ I required.] a homeowner doing all work officers have exercised their 11:❑Plumbing repairs or additions right of exemption'per MGL myself,..[No_workeis cozpp, .. _......,-.._. . ....-. .... 12 j:jAoof.repairs , insurance required.] t C. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the'name.of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. -lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t'„ 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 pains and penalties ofperjury that the information provided above is true and correct. Si-nahtre: Date: x- Phone# 50� 3°I S ���,Q12 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 Ini®rmati®n and Instructions f Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for.their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair.work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.' MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into anv contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members of partners,are not regiiired to carry workers'compensation insurance: If air LLC or I LP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain.a.workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been,officially stamped or marked by the city or town may'be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. ' The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: l 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 wwtiv.mass.gov/dia THE T Town of Barnstable Fp� O Regulatory Services BARNS'^B t Thomas R Geiler,_Director ED;9.�a`� Building Division Tom Perry;Building Commissioner 200.Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790=6230 propexty Owner lYMust Complete and Sign This Section ifUSing ABuilder" I, k9oSe twet`r�S as. Owner of the subject property hereby authorize ITCCMeS e, M e cl eAw5 "to act on my behalf, - in all matters relative to work authorized by this building permit application f or: SanTv l-r "Alew fawn <�Ls1 (Address of Job) Cy► U dv t b Signature of Owner Date QAQ, r Print Name' if Property Owner is applying for permit please complete the Homeowners License Exemption Form on the. reverse side. Q:FOR1vIS:OWNERPERMISSION. 1 Town of Barnstable P�OV IHE Regulatory Services ' Thomas F. Geiler,Director * BMINSTABLE, ' - MASS 1639. a, Building Division TE �( D MP 'n Tom Perry,Building Commissioner. 200 Main Street, Hyannis,MA 02601 wtivw.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 _ -- —_ ---HOMEOWNER LICENSE EXEMPTION Please Print DATE: 10B LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT•MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as t supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner, Such "homeowner shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is,ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner.certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fora/certification for use in your community. Q:\wPFILES\FORM S\homeexempt.DOC 1 ' a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION �s Y r , Map Parcel zD�I L Application# ' Health Division �' ��® Date IssuedCo 7-A Conservation Division Application Fee Planning'Dept Permit Fee �► Date Definitive Plan Approved by Planning Board . Historic - OKR _ Preservation / Hyannis Project Street Address lS l9 Ow f 70J/7 Village Owner Ko-se ej ro Address ° 1515 %llgihou/n �d u/R Telephone Sag - 4 Z9 fi- :63179 Permit Request £'x Lfi J deel< Whi?11 Measm /9 L0 )r 6 e n/a ce f .A2 a New C�'i`- 6 yC U.'-z( T)ccg- uit+�i, a mmp t6ndi 4p access Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District: Flood Plain Groundwater Overlay Project Valuation Sib 66 Construction Type Lot`Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ".0 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes 0 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type.and Fuel: ❑ Gas ❑Oil 0 Electric ❑Other Central Air: ❑Yes 0 No Fireplaces: Existing New Existing o 'es ❑ No Detached garage: ❑ existing 0 new size Pool: ❑ existing ❑ new size _ Barn: ❑ ex�s` rlg L4n�X9 size_ Attached garage: ❑existing ❑,new size _Shed: ❑ existing ❑ new size _ Other: -TOW Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial 0.Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ernes Mer-le'aig Telephone Number 608-395--RUN- `_ Address 06 Ravfe 6 A License # Gofo55 `lArLmovN Part M4 Home Improvement Contractor# H6 t51 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (3(15Ah 10wtnWh4 r SIGNATURE DATE 5 It �� r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL°N0. ..ADDRESS VILLAGE .L 'i OWNER DATE OF INSPECTION: FOUNDATION 6P0 ®k -q ® R FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL FINAL BUILDING f DATE CLOSED OUT ASSOCIATION PLAN NO. r r Town of Barnstable Regulatory Services Miss Thomas F.Geiler,Director 'Ara :",�� Building Division Thomas ferry, CBO,Building Cor'amissioner 200 Main Street, Hyannis,MA 02601 www.town.banist2ble.ma.us Office: 508-862-403 8. Fax: 508-790-6230 FLAN REVIEW , , It�,o9ozz®9. Owner: IA��E/rZO 5 Map/Parcel: a Z S 00 1 Project Address /-V1I NE-QUmWAl P . Builder: The following items were noted on reviewing: �N�EtZ"o/LS �YdFt.g- j2CuSr TE ff So No TGt/3� A.3 L.E 2-F M wD 51L L (/ira R g �s"> No�. C—Q CA_�i Z-is_ 40 C-U-r-n,✓ CIO—(-s o /S'gQu rleC-� oNE t Reviewed by: iz Date: 6 Os 09 Q:Fonns:Plnrvw i Vie Commonwealth of Massachusetts Department of lndustr•ial Accidenty Office of Investigations 600 Washington Street Boston, MA 02111 www.rnass.gov/dia Workers' Compensation ingnrance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant lnformatioli Please Print LeLyiblY Name (Business/Organization/Individual): I°-'o',w-S Address: (,%2 Ro f•e b A City/State/Zip: IIA"10A Port- Phone-4: Are you an employer? Check the appropriate boy: Type of project(required): 1.❑ I am a employer with 4. .I am a general contractor and I 6. ❑New construction e *oyees (full and/or part-time).* have hired the sub-contractors 2, am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me employees and have workers'in any capacity. 9, E]Building addition [No workers,.comp.•insurance comp• insurance.$ required-] 5. We are a corporation and its 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I l_❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per Iv1GL 12.❑Roof repairs in.c=ce required.]t c. 152, §1(4), and we have no employees. [No workers' 13.®'Other l �fen�n� 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 it ust submit a new affidavit indicating such. tContractors that check this box must attached m 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 provi dt their workers'comp.policy number.' lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: . Policy 4 or Self-ins.Lic.t#: 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 tine 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 bIA for insurance coverage verification. I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct. Si ature: Date: LO7 _ Phone#: ��- Offrcial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License-4 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 Misr'u&IODS Massachusetts General Laws chapter 152 requires all employers to provide workers',compensation for their.employees: Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or wntten" 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." ., all withhold the issuance ar MGL chapter 152, §25C(6) also states that every state or local licensing agency shall commonwealth for any renewal of a license or permit to operate a business or to construct buildings in the co m 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 RZth the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affrdavit completely,by checking the boxes that apply to your situation and, i.f necessary, supply sub-contractors)name(s), addresses) and phone number(s) along with their certificates) of insurance. Limited Liability Companies'(LLC) or Limited Liability Partnerships (LI2)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LIT 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, mot 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 nurrtber listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Towp 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 oup 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 liccns e 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 like to than 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,telepbone•and fax number: Thy C61amonwe4th of Massarhuse�tts Dep.zt=,nt of Jud-u 4 AC-cid�-,nts O fXcc Of JzyeStlgativas 600 Washingtan Street Boston, MA 02111 TQL # 617-727-4900 ex[40fi w 1-V7-MASSAFE Fax## 617-727-7749 Revised 11-22-06 www.MaSs.gov/dia i �oiflijE � Town of Barnstable Regulatory Services B NSMBLE'�; Thomas F, Geiler, Director �prF 6:% Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.to)vn.ba rnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign. This Section Zf Using A Builder I, , as.Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) ®7 Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on th'e reverse side. Town of Barnstable P�C)p'tHE Tp�� Regulatory Services Thomas F. Geiler,Director • BARNSTABLE, F MAC Building Division Arfp MAC n Tom Perry,Building Commissioner . 200 Main Street, Hyannis., MA 02601 A wiY.town.b2rnstable.ma.uS Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Plense Print DATE: JOB LOCATION: village number street "HOMEOWNER": work hone# name home phone N p CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF H0114EOWNER Persons) who owns a parcel of land on'which he/she resides or intends to reside, on which th.ere 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 muumum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. ITOMEOWNER'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 iog.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 ora 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 writh a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require;as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. ✓fie Ui omvasoozcu �;•- , Board of Building Regulations an Standards, il HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only before the expiration date. If found return to; Registration: 140157 J{ Board of Building Regulations and Standards Expiraton 9j 9/2009 Tr# 133523 ( One Ashburton Place Rm 1301 Type: Individual Boston,Ma.02108 i JAMES R MEDEIROS JAMES MEDEIROS`� r 696 ROUTE 6A 26 YARMOUTHPORT MA 0267: 5 i' Administrator Not valid without signature ._ \-lassachusetts - Deliartmcnt of Puhlic S,tfet� Board of Buildin!u Re�aulations and Standards Construction Supervisor License License: CS 66658 Restricted to: 00 JAMES R MEDEIROS 696 RT 6A YARMOUTHPORT, MA 02675 Expiration: 4/16/2011 Tr#: 5104 ('ummisciuncr ' I F I L•Es MIP 12961 CENSUS TRACT 132 CLIENT : Forman Kirrane & Terru DEED BOOK PAGE OWNER: Ro197 se M. Medeiros PLAN BOOK PAGE LOT APPLICANT: same ASSESSORS PLAN :.- PLOT MORTGAGE INSPECTION PLAN OF LAND LOCATED AT 1519 NEWTOWN ROAD COTUIT, MASSACHUSETTS .SCALE : 1 = 60' ' P-� ;� OCTOBER 15, 1998 X 50,100 S.F. OF °N D �'1519 1 STORY / STO1,1E ►�J EWTowN ROAD I CERTIFY TO DUNNING, FORMAN, KIRRANE, & TERRY, CAPE COD CO-OPERATIVE BANK, AND ITS TITLE INSURANCE COMPANY, .THAT THERE ARE NO VISIBLE ENCROACHMENTS OR EASEMENTS EXCEPT AS SHOWN AND THAT THIS •PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERVISION, THE LOCATION OF THE DWELLING AS SHOWN HEREON IS IN COMPLIANCE WITHTHE LOCAL APPLICABLE ZONING BY-LAWS WITH RESPECT TO HORIZONTAL ��"��Mgssgc DIMENSIONAL REQUIREMENTS, ? F.T Gs� R. , THE DWELLING SHOWN HERE DOES NOT FALL WITHIN 3 FERRE A A SPECIAL FLOOD HAZARD ZONE AS DELINEATED ON N6 2 �16 o! A MAP OF COMMUNITY #250001-0015C DATED 8/19/85 BY THE F. I .A. THE EXACT LOCATION OF THE BUILDING SHOWN CAN NOT BE DETERMINED WITHOUT AN ACCURATE INSTRUMENT SURVEY, �'; �;; Kennet11 IZ. Ferreira . Engineering, Inc RO.B6x 1903 New Bedford,MA 02741-1903 A Tc 1:508 992-0020♦ Fax:508 992-3374 GENERAL NOTES: (1) The declarations made above arc on the basis of my knowledge, information, and belief as the result of a mortgage plot.p.lan tape survey, inspection made to the normal standard of-care of registered land surveyors practicing in' Massachusetts. (2) Declarations arc made to the above named client only as of this date. (3) This plan--`was not made for recording purposes, for use in preparing deed descriptions or for con—structions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may be accomplished only by an accurate instrument survey. SPILLBR'S I ( I i ` I i 1 I i ( i - I— I i ! I i 1 I I i I j i j I I j y I ! I j I i , + ! �� ! I ; i I ! 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