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0043 CHAPPAQUIDDICK ROAD
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I 11 0 '� V A �i rr.t. ��j' �rI r I� -� 'Ir,., '.1y '4 :li' `.i Town of Barnstable BuilCliri . n . � F g e -Post�This"Card�S'o That�it-is Visible:From;thetStreet,;�A rouedI?lans:Must be�Retamed on Job;and this CardMusi,�be Kept�f� ,, 6"3� Posted UntilFinal Inspection Has�Been Made �,� � : � Permit �" , Where a�ertificate;of Occupancy is Required;such Bwld�ng-,shall Not,be Occwp�ed;until a Ftnal I�ns;p�ection,has been made ,.�«.,.-:tea.,- &... ..�>., ,i 1;1 ...�.:!,YF:•.,.;s�.. «>,., ., .;,:r ,..� .. ,...:�,.YE�: .:, ,,. .t ./�<`. ..,o,....:�.: .„ `.,aa:,,�.«,..._ ,,.,.�,.,�:,,.f. "' ',.-.sw,,.,,,.,..,,.».,�....,._.., '.,:..,,.dr,� ,,,. Permit NO. B-19-1600 Applicant Name: NESHEV, PETER, LITTLE, MIGLENA S& Approvals Date Issued: 05/14/2019 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 11/14/2019 Foundation: Location: 43 CHAPPACtUIDDICK ROAD,CENTERVILLE Map/Lot 170 026 Zoning District: RC Sheathing- Owner on Record: NESHEV,PETER,LITTLE, MIGLENA S& k _ on Nm ae Framing: 1 Address: 43 CHAPPAQUIDDICK ROAD r Contractor L cense.k ' 2 CENTERVILLE, MA 02632 Es#�Pr..o�ect Cost: $0.00 Chimney: D` p escri tion: shed 1Ox20 Pe e"rriit Fee: $35.00 Insulation: , � ee Paid $35.00 Project Review Req: ti Date 5/14/2019 Final: a 'C FEW Plumbing/Gas ; l1 2k - Rough Plumbing: Building Official ,. Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized�by this permit is commenced within sim months afker,issuance. All work authorized by this permit shall conform to the approved application a nd theme approved construction documents cif which tfiis permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning bylaws and codes. g This permit shall be displayed in a location clearly visible from access Atreet or"road and shall be maintained open for p bl insspectiori for the entire duration of the Final Gas: work until the completion of the same. o •,,.. ': Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the B inguild and Fire Offcial"are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: : Service: 1.Foundation or Footing F a < 2.Sheathing Inspection Rough: 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 Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: 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. Health "Persons contracting with unregistered-contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: -� Town of Barnstable t � THE r aildiIl Department Services ti°`�ti $ g D p --, � Brian Florence CBO O r � t s�wsrAsr Building Commissioner Z v p 63 9- time 200 Main Street, Hyannis,MA 02601 Z �rfD µlb 4 pP�gW.towmbarnstable.ma.us 0 Z � --gg Office: 508-862-4038 �, ax SCt�790-6230 rm PERAM9 '�-`'' ��� FEE: $35.00 SHED REGISTRATION p, RESIDF,NTTAT,ONLY � l 200 square feet or less Location of shed( ess) Village Q, Property owner's name Telephone number- 5 i4Lvl><J p � ,�D.� 0 i),(a Size of Shed Map/Parcel# ' Signatrse Date j Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must frle with Old King's Highway Conservation Commission(signature is required) - Sign off hours for Conservation 8:60-9:30&3:30-4:30 PLEASE NOTE: IF You ARE WI'=THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,'THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. 'THIS FORM MUST U ACCOMPAMED BY A PLOT PLAN. Q-farms-sbedreg REV:08/6/17 FILE Z2017-MIP-7157 REGISTRY OF DEEDS BARNSTABLE COUNTY CLIENT- COLLINS & CABRAL, P.C. UNREGISTERED LAND LENDER: CAPE COD FlVE CENTS SAVINGS BANK DEED BOOK 27953, PAGE 185, PARCEL(S) OWNER: JAMES D. MURPHY TRUST PLAN BOOK 224, PAGE 87, LOTS 4 APPLICANT PETAR NESHEV & MIGLENA S. LIT7LE REGISTERED LAND DATE: OCTOBER 13 2017 LC. PLAN SHEET LOT(S) ASSESSOR'S.MAP 170 •BLOCK LO S 26 CER77RCA7E OF 717LE i h MORTGAGE INSPECTION PLAN SCALE 1' a 30' 1 All 1 3 CHAPPAQUIDDICK ROAD, CEN7ERVILLE, MA N/F HALLET 102.319 1 LOT 4 . 20 ° 15,0s0f SO. F . z O 00 00 @ • LOT 5 o LOT 3 to 2 STORY O t � ji t z i 102.00' a 1a5 f 0 CL SKUNKNET ROAD CHAPPAQUIDDICK ROAD SHEET 1 OF 2 COMMA I CERI FY THAT INS PLAN WAS PREPARED /N ACCORDANCE W17H THE PROCEDURAL AND IM MCAL. STANDARDS FOR THE PRACTICE OF I HEREBY CERTIFY 70 THE BEST OF MY KNOWLEDGE LAND SURWMG IN THE COMMONW.&TH OF MASS40WSETI3 250 AND BELIEF 7D THE ABOVE ATTORNEY, BANK AND ClIR SEC770H 6.00 AND WW 77E REMARKS SHEET ATTACHED HERETQ AND THEIR 717LE INSURANCE COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMEN7S OR EASEMENTS EXCEPT AS SHOWN, AND THAT THIS PLAN WAS PREPARED UNDER MY IMMEDIATE SUPERW.Sf0N. t1► JOHN L. UBBY CONSULTING, INC. CONSUL HNG LAND SURVEYORS , 24 LOGAN S7REE7, PV524 NEW BEDFORD, MA 02740 ((�'} q M.(508) 999-0106 � � 011 ,3/1 f_/ .jIbby700ftmall.com r yl Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 3/20/19 Brian Florence CBO Town of Barnstable Building Division 200 Main St. Hyannis,MA 02601 RE: Insulation Permit 19-271 00 Dear Mr. Florence: w N This affidavit is to certify that all work completed for 43 Chappaquiddick Road, Centerville has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey Town of Barnstable _ Building !Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and tthis Card Must be Kept RAM *r^ Posted Until.Final Inspection Has Been Made. f6SP , Permit Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit NO. B-19-271 Applicant Name: William McCluskey Approvals Date Issued: 01/24/2019 Current Use: Structure Permit Type: Building-Insulation- Residential Expiration Date: 07/24/2019 Foundation: Location: 43 CHAPPAQUIDDICK ROAD,CENTERVILLE Map/Lot: 170 026 Zoning District: RC Sheathing: Owner on Record; NESHEV,.PETER, LITTLE, MIGLENA S& Contractor.NamP: ,,WILLIAM J MCCLUSKEY Framing: 1 Address: 43 CHAPPAQUIDDICK ROAD Contractor,License CSSL-102776 2 CENTERVILLE, MA 02632 { Est. Project Cost: $5,000.00 Chimney: Description: Add R-30 fiberglass to the attic. Add R-19 fiberglass to the Permit Fee: $85.00 Insulation: I ne and basement with ex a'ndin basement.Air seal the attic a p g • a p r 85.00 i Fee Pad $ foam. General weathenzation. W Final: .Date: 1/24/2016 Project Review Req: 'LL Plumbing/Gas Rough Plumbing: - Building Official Final Plum bing« Rough Gas: the work authorized b' this permit is commenced within six months after,issuance. Final Gas: it , This permit shall be deemed abandoned and invalid unless y p 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 structures shall be in compliance with the local zoning by-laws aril codes. Electrical This permit shall be displayed in a location clearly visible from access street,or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. i Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Rough: Minimum of Five Call Inspections Required for All Construction Work: _ 1.Foundation or Footing Final 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Final: 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. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building Department Services pzHe r , o awti Brian Florence,CBO o* Building Commissioner , t RARNM rM, = 200 Main Street;Hyannis,MA 02601. ui ac www.town.barnstable.ma us Office: 508-862-403 8 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: (/, I✓. Name: o • Yes; . J. (K,V Phone#: Address: UaU'►c� ,cck ��, Village: Name of Bnsine'ss: �� �L!$ ► � E L�"GJ Type of Business: Map/Lot: R\TrENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,'subject to the provisions of section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the,dwelling. there shall be no increase in noise or odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution A lzr registration with the Building Inspector,a customary home occupation shall be permitted as of right subj ect to the following conditions: • -The activity is tamed on by the permanent resident of a single family residential dwelling unit;located within that dwelling unit. •" Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production-of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other obj actionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. - • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard • There is no exterior storage or display of materials or equipment. • . .There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot contamingthe Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be 0 included. - • No person shall bg employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit, I,the undersigned, wereadan agr , the,abov estrictions for my home occupation I am registering. Applicant _ Date: 1-9 Homroc.doc Rev.06&0116 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L,:-ft does not give you permission to operate.)--`fou m st first obtain the necessary signatures on this form at 200 Main St., Hyannis. j Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: �• �010 'Q�.� J� Fill in lease: APPLICANT'S YOUR NAME/S: /-�lJ�� �- l �V t fi' '" SINES YOU OME ADDRESS: l (JVP� K T CE TELEPHONE b tY VYr r # Home Telephone Number ry � "� AEIN OR : I L: �S EL.O(� C�✓�"l NAME OF CORPORATION: I NAME OF-NEW BUSINESS O 0u( U U TYPE OF BUSINESS �1 Z;CG 0 Lk IS THIS A HOME OCCUPATION. YES N1111 ADDRESS OF BUSINESS l .y. -:.� 1C U:� uLtMAP/PARCEL NUMBER 170 --,M (Assessing) . When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. :MUST COMPLY WITH HOME OCCUPATION• 1. BUILDING COMMISSIONER' OFFICE �,,ULES AND REGULATIONS. FAILURE TO This individual has been i or of any requirements that pertain to this type of business. COMPLY MAY RESULT IN FINES. ut orized Signatur ** j "'�� COMMENTS. 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: �- x i Fo 5�IV_I NT-w Dv �I ° kkAL c Nr- Cyr' � e4), V,tle\f- O L e re VA _ J, k5. ,e:g -S, The Corm ornreakh of Massadrrrseits art er:t a,f Zrtrkatrid Accidefrts _ Ore of 1MWSd90#0= . 600 Waskingtorx Sweet - Boston,4 02H1 ° r��rv�u�na°ss:�,vQ�dra M£ar.leers' CaMpensat anInsurance Affi&vit:Bnilders/ConiracturslE wtricr S/Plumbers lid Infmrmafian Please Print Na=(9u6=K)rg Address: Z-5 &C(tlavc��x �rj V VWOLIAG- Are you an employer?f heekthe appropriate ba= ' 'Type of project(required): I.❑ I am a to veith 4. ❑I am a general contractor and I ❑ 6. New comstucfi(m _ employees(f&audforpart-time)* 'have buredthe sub-comttac-t= listed on the attached sheet. ?- 0 Remodeling I am a sole pmprietor arparEaer- t:sash-con�lractors have ° ship and haze no employees Wiest: 8.°❑Demolition mode for me in any capacity- entplayees and have warmers' 9. ❑Building addition , ca�tap_t„�.��1 [No U?rloers comp.i m=rce, lU_ Electrcal cr addiianpqnired- s ] 5. 0 We are a�corpmatim and its 0 repairs 3_ I am a homeov er doing all officers have exercised their 1 L❑Plumbing repairs or additions. myself[No woilcets'oamp- right of esempfion per MGI. 1L0 Rnofrepairs insurance required_]i c.152,g1(4)6 andwe have no 1J_0 Other employees.[No WoAoess' camp.insurance -] ;Any aprpficm&&stcbet3mbox#lmnitalsofMcItthesectianb9wshuvinAHieirwodnea=pEnmfi aPGHUinfb frmL amlwwaes who submit this affidar9 iarbca=3 tLep use�aia�s>F wnak sud tiiea]�e aulside coatmttocsmmct submit a newt affidaebt indica3ino SLiCiL l fCaascactors tbst chair ibis 6oac must gtiarhed ffi additiaaal sheet sLawmg thenzme of�E sab••conusctaas and state whether ar oat f6nse®ritesha�e employees.Iftbesab-c=uzctmshlvee PIOYws,theg ,pravidethek wake&camp.pGHgam33bm I ant as ersployer tl�atisprouidutg tvariiers'cartrperisrrtirxrt iasriraaca for MY employees $eto�v is the policy ar�ri jah site ir��ormtdion. . Insurance Con.pauy Name: Policy 4t cr Self-ire€Lic_- Fxpiratibn Date: Job ate Addaem Cityl5tate125g: Attach a copy of the workere coampegsatioapolicy-declaration page(shavring the policy ucrraber and expiration date). Fail=to sea=coverage as requiredundes Section 25A of MCL C. 1572 can lead to the imposes of criminal penalties of a fine up to$1,50a 00 andlar one-year impfisonsaenk as we11 as civil penalties in the form of a STOP WORK ORDER and s fine of up to$250.00 a day against the-dolatur. Be advised that a copy of this statement maybe fkvnded fn the Office of lmmstigahons o€the DIA,for insurance coverage VEnficafton- 1 da herdT cergh,as t�Ian�d Ialiieses o,pa jury thattfig informa€raj p'rm rrd abmw trite Ord correct 9D ate- / 1 Phone O,orsid use Only. Do zwt write in this area,to be cmnpTeW by city ar town afJiernt City or Taws: PermitUcense# Lmming Authority(circle one): L Board of Health 1 Builft Deparfinmt 3.Citp Town Qerk 4.Electrical hispwAor S.Plumbing Inspector 6.00ther Contact Person Phone#� 6 Town of Barnstable Building .. )Post This Card So That it is Visible From the,Street-Approved Plans.Must be Retained on Job and this Card Must be Kept Certificate of Occupancy is Req Where a Cetl Final Ins ection HasFBeen Made. .' a3� 0, b � b Permit wired,such Building shall Not be Occupied until a.Ftnal Inspection has been made. Permit No. B-17-3904 Applicant Name: Approvals Date Issued: 11/27/2017 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 05/27/2018 Foundation: Location: 43 CHAPPAQUIDDICK ROAD,CENTERVILLE Map/Lot, 170-026 Zoning District: RC Sheathing: Owneron Record: MURPHY, RITATR <.Contractor Name:, Framing: 1 Address: 43 CHAPPAQUIDDICK ROAD Contractor License. 2 yw � _ Est. Project Cost: $5,500.00 CENTERVILLE,MA 02632 Chimney: Description: Removing Old Kitchen and partiton wall and to insulating xterior Permtt'f : $85.00 walls of kitchen,installing new kitchen . Insulation: „ <Fee Paid:. $85.00 Project Review Req: $ 1 Final: Date 1/27/2017 Plumbing/Gas Ff S` Rough Plumbing: N,Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized.by this permit shall conform to the approved application and the'-'approved construction documents for which this permit has:been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shallbe in compliance with the local zoning•by-laws anii codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: ° Service: G ` 1.Foundation or Footing a r Rough: 2.Sheathing Inspection 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 final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 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). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: cF the rqy, .� BUILDING DEFT Application Number.............................:............................... NOV * BARNSTASLE, * !V 0 g 2017 Permit Fee............65.-.0-0...........Other Fee........................ 11 MASS 9�'OrFD MA'S A TOWN 01=BAtiNSTPat3LE TotalFee Paid............................................................... ...... TOWN OF BARNSTABLE Permit Approval by......... ...........On...�V,:2�k.�...... BUILDING PERMIT ( APPLICATION Map..........I ,, 7..Q..................Pucel.........o. .................... Section 1 — Owners Information and Project Location Project Address �/j} �l G Village auArvl' ve Owners Name /= 11�fi s�s1,15V Owners Legal Address 26- We-si �0,rw-04( City State X�A Zip O (O 3 Owners Cell# I ��'�y2 7 E-mail N S F C--V<e f /G tAO�-CCVA Section 2 —Structural Use (� Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment Sprinkler System ❑l Addition ❑ Retaining wall ❑ Solar YRenovation II _- ❑ Pool ❑� Insulation Other-Specify glyz6y /�&1,C0L��t;(O t,, Section 4—Detail Cost of Proposed Construction S-Oa Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing Total# Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Last updated: 11/7/2017 Section 5 - Work Description e 4U�'►.L O k,j&eIA ova 0,A1t101A w� e ic c t t a`�P u x �! i o�r wo* Section 6—Project Specifics Wiring ❑ Oil Tank Storage ❑ Smoke Detectors (Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane C Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland,coastal bank? Yes ❑ No Section 8— Zoning Information 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 Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes No Last updated: 11/7/2017 Section 9— Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# 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 Section 10 —Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date 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 7_ Oq Cell or Work Number Jr� I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Buildi ' e. I un stand the construction inspection procedures,specific inspections and documentation required by 78 C the T of Barnstable. Signature Date AP UIANPIGNATURE Signature Date Print Name Telephone Number ` 2,j � 2�7 E-mail permit to: �S `Z� J 6G Last updated: 11/7/2017 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 approval Section 13 — Owner's Authorization 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) Signature of Owner date Print Name Last updated: 11/7/2017 ti4�2sZ�L-7 of Town of Barnstable *Permit Building Department Services Ezpires6moVefromissuedate sAaxsresM : Brian Florence,CBO 1- � Building Commissioner® s � (�w� D Mld 200 Main Street,Hyannis,MA 02601 1F.Iti C1 www.town barnstable.ma us Office: 508-862-4038 N0� 9 �0�� Fax:508-790-6230 TOI EXPRESS PERMIT APPLICATION - RESI� 7� Not VaUd without Red X-Press Imprint Map/parcel Number I U Property Address Y5 C4oXna(-) r [Yiesidential Value of Work$ ✓f"Cv,/' Minimum fee of$35.00 for work under$6000.00 Owner's Name do Address �G tr &5V ey- / 9tAt4zu wX_ VJ , ylest Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance . Check one: �I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane-nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side 2 [ ikeplacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: "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 t o Im vem Contractors License&Construction Supervisors License is required. SIGNATURE: Q:1wPFIIM\F0RMSIbuilding permit forms\F.3PRESS.doc 08/16/17 r 3 ?Tie Cow womveaIth ofA&wacltirsetfs Department ct,f radastrial Accidm& Q}�ie o M.Ws igadem 600 Washington,S`kmet Boston,MA t7 HI �rvm- mmxgov1dza Warkers' Campensation Insurance Affidavit BBuildersiC.OntrarurslEI ciansiFlamhers APPUnant Informal an Plme Piint Addrew Are you an eruployer?Check the appropriate broom: Type of project(required): I_❑ I am a employer U'ith 4- ❑I am a general contractor and I 6. ❑New eonsuuction employees(full audloc pad-time)-* have,lured the sob--contractors 2..❑ I am a sole proprietor orpartuer- listed anthe attached sheet I. ❑Remodeling ship and have no employees. These sub-contractors have g.,❑Demolition wonting far me in any capacity: employees and have wo&ers' [No w.od ers'comp.insurance comp.insuranml �. El Building addition 5. ❑ We are a corporation and its 10.0 Electrical repairs or a difions officers have exercised their, ' 3.[VI am a homeowner doing all work - 1 L❑Plumbing repairs or additions Fyself[No workers'gyp- right of exemption per MGL 12.❑Roofrepairs . insurance required-]F c.152,§1(4k andwe have na employees.[No wod=s' a❑Other camp.msmanace required-) ;Any appli=BUtcbedMboaRamst also fiIlocitheswd=belawsbuvdngtbei walea'conmeawkwporkyiafozmadan- Rnmem aus who sabot this smdn,k iL , they ate doing all wax sad Brea h e Gumide contact= mst submit a new afdaek iadks1Wg suds fCanMMM'ss ffiat ehecY tlgz 6aa mast attach sa additional skeet showing tbeasme of die sot►-snafus anal state whe&u ar ant l7mse entities tinge employees.Ifftsnb<==&ctneshm eatpIoyee_%dLeT=stpmuide their workers'comp.pormy number. I am an employer tltatisprm ding workers compensaiien innirance for my empl4wes Retm is tltapa8cy and job site in ormadam Insurance company Name: . Pokey 4 or Self-ins-Lic.4 F-Viration Date: Job Site Address- City/Sta:W4: 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. M can lead to the imposition of criminal penalt"ses of a fine up to$1,50Q 00 and/or one-yearimpcisonmenk as well as civil penalfies.in the farm of a STOP WORK ORDERand a fie of up to$250-00 a day against the violator_ Be advised that a copy of this statement maybe forwarded is the Office of luvesEgatiom of the DIA for iflsuranm coverage verification. Ida heraby cep,f,as t and :allies o f'Ferju y that the inrforwa€wjptm d aboire is bare id correct Sitmatute: Late: Phone ik 02aciaL use caul}. Da iwt wrke art tkis area,to be cvtnpteted by city artonin o}j`idat City or Town.: PerrmidlAcense 9 w Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City1Fown Clerk 4.Electrical Fnsgector 5.Plumbing Inspector 6.Other Contact Person: Phone#: — — 6 laformation, and M5 C ons ' MRCcar- setts General Laws ChBpt=152 reggaes all employers to provide wM k='campeIIsatroII fur their emplayees. , Pursaantto this sty,an w is defined as." .every_ person i a the service of another under any contract of hire, ��3' eXpre W or implied,oral Cr wEit1Ca." Air errrplvyCr is defined as"air mdxvidu pmtaersh�p,association,corporation or other legal entity,or any two or more of the foregoing engaged in a Joint ebzpise,and incln�the legal rcpresenfa&es of a,deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the octet of the - dweT_Tmg house of another who employs persons to do make,construction or repair work on such dwelling house or on the grounds or building appurt thereto shall not becanse of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also sfaius that"every state or local Iiceusi ig agency shall withhold$ie issuance or renewal of a license or permit to operate a business or to construct buildings in the commo.awealth for any applicant who has not produced acceptable evidence of compliance with the h=ra n re.covex-age required." AdditionaIly,MGL chapter 152,§25G(7)stains aNeifhear the co=Pweilth nor aIIy of i s political subdivisions shall enter into any contract for the performance ofpublio work until acceptable evidence of compliance with the insurance.. rez urrements of this chapter have beea presented to the contracting aafozity." AppHcan-b Please fill out the wod3='compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sob-contractor(s)name(s), addresses)and phone Tn— er(s)along with their certEEIcate(s)of hasun$nce. Limited Liability Companies(LLC)or Limited Liability'Pmtaershrps(LIP)wrtffi no employees other.fhan the members or partners,are not required to carry wormers'compensation insmance. If an LLC or LLP does have employees,a policy is reguirtZ Be advised that this affrdayitmaybe s hmrii:ed to the Department of Industrial Accidents for confirmation of m�„�t'coverage, Also be sure to sign.and date the affladavit The affidavit should be-retomed to the city or town that the application for the permit or license is being requested,not the Department of . Tndrist r al Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers' compensation policy,please call the Deparhneot at the number lisfnd below Self-fimued companies should enter their s elf-insurance license number on the appropriate line. City or Town Officials f _ Please be sea e that the affidavit is completes and priotrd.legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inver�nTs has to contwt you regarding the applicant- Pleas n be sure to fill in the pennit/licemse number which will be used as a reference number. Iu addition,an applicant that must submit multiple pennitllicense applications m any given year,need only submit one affidavit indicating current policy information.(iifneoeszaly)and under`Job Sib,-Adams the applicant should write"all locations in (city or town)_"A copy of the affidavit that has been officially stamped or monied by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for f p oiure mmiis or licenses A new aiidavitmust be filled oit each year.'Wh=a home owner or citizen is obtaining a license or permit not iclatrd to any business or commercial vent= (Le. a dog license or permit to burn leaves etc.)said person.is NOT rmp*td to Complete this affidavit The Office of Investigations would at to thank you in.advance for your cooperation and should you have any questions, please do not hesitate to give us a caI L The Department's telephone and fax Crz3mnb CoEmmmweidtb ofrjasnachns� ' Departmmt of la&istdd Aid ents (fie.of�tfzous Boston,MA Q111 Tf,-1.4 617 727-4900 oxt 06 az 1-977=M `AFF, Fax#617-727 7M Re•?ised4-24--07gQ��c i f �WE Town of Barnstable Building Department Services B" Brian Florence,CBO 63q. R�� 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• ,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) **Pool fences and alarms are the ons resP tY of f the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPERMLSSIONPOOLS Re ..09/16/17 Town of Barnstable Building Department Services Brian Florence,CBO ox� . ' Building Commissioner 200 Main Street, Hyannis,MA 02601 • PAIMSTAINEA MARAL www.town.barnstable.maus Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION � .. Please Print DATE: 7 JOB LOCATION: 7 ✓ C.FLU lit i ilk � �r�j��e number street village "HOMEOwNW: Pe-rAk -.I fp-sHa14 04�2,f name �J hpompe�phone work phone# CURRENT MAILING ADDRESS: 2 IJ IJf C�A ItI y o l ' 02� 3 city/town- state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undeisi "h o ee' es that he/she understands the Town of Barnstable Building Department minimum inspection procedures an re nts d that he/she will comply with said procedures and requirements. Signature o eowner 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 FXF31MON 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 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. Q:\WPFILES\FORMS\building permit ficmu\EXPRESS.doc 08/16/17 A Town of BitableEVires �� ��®�y ����:�� Fee.-. 6,�roMLsf�mniis-date ¢ (/L�� U �a o 163g. ���' Richard V.•Scali,Interim Director '�annl�'tR Tom Perry,CBO,Building Commission ei '%, .200 Main Street,Hyannis,MA 02601 WMIlAown.barnstable.ma us Office: 508-862-�?038 7- ax:S� muss nwr L-APPLICATION RE9E'Dft1a' DOI Mot Yalfd w1t1zozzt Red X-Press Lnpzrnf Map/parcel Number- 0.7- Prape y address i K < FoC, e . i residential Value bf Work-$ 3,22YU — Minimum fee of S35.00 for zvork underS6000.00 , Owner's Name&Address 1 tC� / /V✓ ll can - vicl ;: - _ . Cede v (e Ao2 Contractor's Name� n al, �• S� C 6�1 Nen n i Snit Telephone Number[tiO l))Z2 k k Z-n Home Improvement Contractor License_(if applicable) /_ 73-2-L1S Email: Construction Supervisor's License s(ifapplicable) 0 g S 7 n 95Workman`s Compensation Insurance Check one: ❑ I am a sale proprietor " ❑ I-am the Homeowner I have Worker's Compensation Insuranc: Insurance Company Name--A roo i a ut .1.n oto Vdoifcman's Comp.Policy T lr�lC q�8p S S 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 m ❑.Re-roof(hurricane naffed)(not stripping. Going over. existing layers of roof) ❑ Re side M eplacement Windows/doors/sliders_U value ,3U (maximum 3 r of windows T of doors:C! ) - ❑ Smoke/Carbon Monoxide detectors d floor plans marked with red S and inspections required. Separate El&i icai&Fire Permits required. *191hi h required. issuance of this permit does not exempt comotiance with other tmvn depamnent regulations,i.e.Historic,Conservation,eta "*Note: Property.., �?wner mtrs't sign property Owner Letter of Permission. A copy o the Home Improvement Contractors License&Construction Supervisors License is required. _ SIGNATURE: Q 1WPF1LES1F0R1%1S1Wdd'mg pmmt fbnMV aTMS.doc Revised 061313 ` .. .'• .0 l J.LEatfBdtni4 RENEWAL BYANDERSEN WA gr#17MS m,5abspa - -9va�eo�Fer� �i�datcs,,l�C;d�/n � a� •. B by Aiadernea ogSmr lt�a�E i®d j CUSTOM WMDOW A�DOOR REMODELING AGPX etrct3l'�� _ o�� t -17 - ®tya�6Sxsld�ess,GgStmmre �$cCale d;lhrih.Bm. �' .. r ' 6Yg rl�tti aatfi�a I+IeSv *?t4uc ,sr asdaa ;with i rrsrmI snd:@OPitcom date khc,"i and the eaxa3m of & ea �aridu"a�i�tdlfpd�p�sII�hE�� '� �dk").�..r OIe �Co�c��-�BOol1F TctdJo6Arc>oaute _ ! vjpd SadMim,'Cqw, meted a yrnerit. ralCash aftmoced , /� ��r 11 C1�st.�Crdwad[#3�41:"�,�, - J►'' - •' Credt G:�ds are a,ciEpin�ler�tp�rc ankyr-rnaxtrcu;m t.'•�ar;iu 14WIM as�of lob Om:— - Pf°1 dP�oae we Credo dcrd�latuac ,N BF Lfim imu' '° ' e deg¢:damin0a ii 5 #d tab and dsa �noQ oin Sub t 9,{ asis 5utaes�r�l f d j�Ib s 2oc be rnzm IeP erOLU Cm,ofeaon a job(;)i� - ?' Ulm;;aiidI mu3i M. 6w ratdkr��,'�ck ok �impws and unaltx#tAadsl Nett thdo Avedteut vaaa fttcs ate anal rt'. mdexabL-ad5nK''ietrree,tare garde qI s _ _ .—— tliiene aiilal of f tss it,l id Ags�e+> n�,Hard esslnease terans':of t! f : a -- +e+�me alOd iu(ri,�a emu] Bp edr gad d9ied ra"gnf th g t, tle a turn area edNc ti oea e�O"�c&eaan„a'the date�at,cri+tea�fraw�e�i��Jl�a i iofs�ed:of Bik ''it m ell tlaiaA�reem�DOsYpT S[OPI1'Fll'$C01�I'TRA4�T I�TAEItE Aj�:��f HLtiI�1H�dCES I(1 kc &r iel'd'S s aw&)N.-e a is Buyer Ql Da notnsn tt v mat lj'ao aT t6s�stcee Fateud l�d,fite the a�rscd test®;: 1,®`the�.tiALtV 'Lllenl9'Y .FK 'POd•°aa 6auiva ttU4 L.(2) iioeatftledt*9%Crijr;rq$ s'. rer�edtttGtTse:f3me:y6�iilgal;- zE: Yaw saagy �Y amine gayraff tiicEoilC d f due.rtuder tlid;aAy ' ,i1®a itu so doll j a mLi 1 C En¢etl to --w w pardal r ai o£ #n mdt : t►�ls.f.u�r� acep� tba�eacbLaiEL az rrpgawdi,Fuueelta9edlanderta .arq e7i7r:eeeement if�nu b�. atd��'else m� :oe a'Ar�eH ogee:of t&e'sr3iec,p f5e ailterat�oe hsr mn;rii offiee PY B a o c�sfia�v din}$�- dot t y a cartrfi bpi Ww& eotlutea tliaa na m $s the timed is ar diy aR'**r4 Ve d o ;wN&tlr b1z er�g iBe- ' >t ga[aa tLieD dtltsve�i err oat ata IGc:tlxc a a�ez of •N y auk 1►a1a.anwbik cpaalaog ad7trde�lbrniatt (ilslmarl'eitofhifer°sr�gLts4 B!�''�xm�ds�d s�tdiipa*�u�sdl�y$� be.l.La�1tG'o� Rratx�8aa7c�;, ( ' 77 �nezval� Lti' ootlDara�l'o�B:�amd 13uy'��� • x f•.: Y011.4 TME,BUY'lRM: Y cA,.NcEL TH[R R"TTAih'G AY ANY TME.PRIMTO,MDNIQFI1',DF,THE, S.SDAY .IMR%TZ,OF:TMT41 I IIi i�T r ATIAf}]SDAl'OL"l FCA2Y(:�Ld.AITOrm .: n t1ltxTiCEOF ti NCd:B.kU _ TroN Darts of�n ct2.l�at�r ; �' saes ar T�naae., Yu�,rLssr met 1iln traitaactaarne w��►mNt iEryr pa�altj�r. c�911ig,Lboo,'.Lf�Ln' ; two bcttlta## firornr tlhe abowe;da N jpatt t�Ltl,arry I threscs9nesa dam,firom the a IF yidn tN� > P�PY trtded .arfryr pa *+e n+ade byr"lnotc uiodar idt¢ t` PPeesle (�r. i pa'rnen made!�7 ,ow tf>* Cantrree er Salc,�'r7!� e� k utsfsurte7yt d e;Contract ar$a%and!. ne fin* twruent e, uta. 11ryF`yoiP v�l `t+¢tue,ted'vvithlrt `Iwtto¢s#.d8llf#fFi�isrlrfng i' YM wrlll tit mot widurt tam buif�ss d�(,�Iorvl»j retd tlw Selr of yaLir c>EnosfXafiion t`o�ce, amd arry t th¢'S$Iler 'yot tRation nab`�*dl ► 9ElAtltAeNt•'arssirtg Out of tTxt i7!iYiSft#rortr will be �ty! htfiee�tt sat Yo F nn8 oast the tmatatlpnIi bar cancel" ujcancel� ursiusfit�alci la k.to,choSaflar car ewtf �ei�tcelL rnrst r*kq•a+z1lab�ato teShcor' ®t yinrr casid'eraeo,in'subs6enrt�xtrjr $uudl"condition.as whew II.,at your"�ti r!y asOBd' ditioru�sawhan rr OVA e!rafr gooEis e��lCvei d oo yea urrdsr tltfs Gar,ti tar li:.reee tirod,,s:ry dalkersdltiP u t�der t Count ct ' ,s01`'yW'1ZIa�``�fryf�tiwf911f�'co/T /,l 'kfMCgf1�4NCtiiJs'o�''p Si �Pdtffn'i�I.tytd'tfFWll.Hls'-- ,�,'�Ritltaranit�YGYIi t Se[iar ro�ral5rr 4ttc rn n s9t�ptrnent of t#io Sa d's'nt ttoe Ilse feller re�rt! Nio re um, pment 6Fth�l;oods at dho Selz h eeaa��vnsa an�',rhtc If you do rnahs dW s arad3ble Seder$" lt16C etsk.fi you,d!o make � m,�ahl.. tp 8dkr arut tFie Sdfs :Boas net pfetr diem UP:. - nI •:`,4b tM and ffLe Wir clbwrry ,-plt UP wftleff tur rtty�F#of tf _datm of catrrc�la tOft Pu'' r trataler or i Vw'eMr of thr dale of esr�amation, .�1'row'",or dispmn a$tt4d�adt witl�aut�X furtl.ar obTrYation.If you 4 IC dlspase of Pfw: ids? Qut airy i�mor abli�affion:IF yapu fait to mati�t ttie good#�vaiFabla to tht Salter.or If Prow agneo jj to rr;�be thegbaxii mradalble to tbibSaer;sr Wyop qgeee torMm*ajoads,todio 3¢Ifer, do*then 7ou P to rat ll tt & d4,a Seller and(off to c6 saq then Ou ieic►a,,Iiable for performamm odor)obfrgatmns under,dw: r ,rerarain Ifallle r P¢ Of"ell"cridi ieny under tie Calf#t+>vcx:Tb ttutcel tfJs e� tfoit;triatl or- fa a signed Conmce.Tb OinxA tr s �l or d'elirer a sued d copg vl"this eanc�l!?druo"'"UH ar btliar •t and d POW of cwWaRitfan'emt" or arLyr offer vdtnen nc d'ce:ar send a t l to Ratcw'Et r A=of t,wraten'r''.>ce�or semi a bf_a�m:ta Removal byAndemm'of lioutharrn iArm Enzlm d'�t 61ori Rim&Lkcofm , !� Nevrx !M 26 Al6ien Llan d;Lincoln,Rl 4�8i5 M)T LATER THAN MIDNIEtHfi NtTf F.AT@RT�lDI�IICFIT OF 1. FHEAREBY CANCM-THISTRANSA:CTIOW F rf� ey,CAWEILTFiI5TR14hf5ACl tGl) ' " B�eti i(�trw, L+M¢[l�tase: LIsl. sue; MYe w ... ;ous,;•f Rl�h r'V►'►fi BLryao Capp Yeiaar r Eap)r kr. Southern New England Windows d.b.a Renewal by Andersen of SNE Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS4)95W BRL►N D DB,NMS-6N. 7 LAMBS POND' Chartlon MA 0107 Expiration Commissioner 09108=16 i L/� �t9/I!?/h2Cl�l2Ll�E'�2�G a���!t'(,r;L00G�C�Z4!lb�Ct Office of Consumer Affairs end Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement-Contractor Registration RegistaWn: 173245 Type: Supplemnt Card SOUTHERN NEW ENGLAND WINDOWS LL ' E orallm: 9/19/2016 DENNISON.BRIAN — — --— 26 ALBION RD --— LINCOLN,RI 02865 Update Address and return card.Mark reason for change scA i o aoraosm 0 Address C Renewal 0 Employment tmst Card +�,40�aromvtodarnc�l�yle� ce of Conserver Affairs&Business Regulation License or regivtratios valid for bdividui one only IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Office of Consumer Affairs and Business Regulation won' i? Type 16 Park Plan-Suite 5170 Expiration.- 9MOM16 Supplement,;ard Roston,MA 02116 SOUTHERN NEW ENGLAND WINDOWS LLC. RENEWAL BYANDERSON DENNISON BRIAN 28 ALB10N RD � I - LINCOLN,11102865 undersecretary Not valid without signature The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations ' I Congress Street, Suite 100 Boston, MA 02114 2017 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): SOUTHERN NEW ENGLAND WINDOWS Address:26 Albion Rd City/State/Zip:Lincoln, RI 02865 Phone#.401-228-9800 Are you,a_n employer? Check the appropriate box: Type of project(required): I am a 4 20+ . general contractor and I 1.� I aid a employer with � g 6. New construction employees (full and/or part-time).* have hired.the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. FI,Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no ,,,,// employees. [No workers' 13. Other (!f`k�(� comp. insurance required.] C411 *Any applicant that checks box 91 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp_policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:ARGONAUT INS. CO. Policy#or Self-ins. Lic. #:WC 928058352394 Expiration Date:8/21/2016 Job Site Address: ' .cljic City/State/Zip: ao,�441"V;tlo, HA 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' 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)risurance coverage verification. I do hereby cerVA under the and penalties of perjury that the information provided above is true and correct Sign Lre: c Date: 12 -30 -I S phone# 4012289800 Official use only. Do not write in this area,to be completed by city or town offrcial. 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#: f SOUTNEW-01 SHETTYSHT ACOR�� DATE(MMIDDIVYIIY) CERTIFICATE OF LIABILITY INSURANCE 8/19/2015 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 NAMEACT : Willis Certificate Center Willis of New Jersey,Inc. PHONE FAX c/o 26 Century Blvd A/C No Ext:(877)945-7378 A/c No):(888)467-2378 P.O.Box 305191 ADDRESS:certificates@willis.com Nashville,TN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC C INSURER A:Selective Insurance Company of Southeast 39926 INSURED INSURER B:OneBeacon Insurance Company 21970 Southern New England Windows LLC INSURER C:Argonaut Insurance Company 19801 D/B/A Renewal by Andersen 26 Albion Road INSURER D: Lincoln,R102865 INSURERE: 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. I�TR TYPE OF INSURANCE INSD WVD POLICY NUMBER AMID Y EFF MWDD POUCYEXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR S 2029459 08/10/2015 08/1012016 PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY a JECT LOC PRODUCTS-COMP/OPAGG $ 3,000,000 OTHER: $ AUTOMOBILE LIABILITY COa accidMBINED SINGLE LIMITent $ 1,000,000 E A X ANY AUTO S 2029459 08/10/2015 08/10/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE S 2029459 08/10/2015 08/1012016 AGGREGATE $ 5,000,000 DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 0000068028 08/21/2015 08/21/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C rorkers Compensation C928058352394 08/21/2015 08/21/2016 See Attached DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Evidence of Insurance !�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered.marks of ACORD Engineering Dept.(3rd floor) Map,::. "�Q Parcel 4ermit# House# - Date Issued VBoard orHealth(3rd floor)(8:15 -9 30/1:00-4:30)/% Y�� ®� Fee dam- Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept. (1st floor/School Admin. Bldg.) �IHe, Definitive Plan Approved b Planning Board �,� 19 pp y g SEPTIC S T �E STALLEa 6ANCE TOWN OF BARNSTABL woTH { Building Permit Application ENVIRONMENTAL CODE AND Project Street Address TOWN REGULATIONS —mac Village CC--'-r\ e1 V1L-ie- ll Owner ::11'bm es Address Telephone Permit Request First Floor "square feet Second Floor square feet Construction Type '. �- Estimated Project Cost $ Zoning District Y Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family 2"' Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes CR o On Old King's Highway ❑Yes UNo Basement Type: al'Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing !7 New First Floor Room Count Heat Type and Fuel: fIGas ❑Oil ❑Electric ❑Other Central Air ❑Yes 4<0 Fireplaces: Existing New Existing4maa ¢coal stove ales ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) ❑None ❑Shed(size) " ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor Worker's Compensation#' r. NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,.AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO.. - SIGNATURE DATE -,S-1�1 BUILDING PE OMITENIED FOR THE FO LO IN REASON(S) " FOR OFFICIAL USE ONLY + PERMIT NO. DATE ISSUED' MAP/PARCEL NO. ` ADDRESS, VILLAGE " OWNER DATE OF INSPECTION: i FOUNDATION FRAME - INSULATION < FIREPLACE ' ELECTRICAL: ' ROUGH FINAL PLUMBING: ROUGI-) FINAL t.> n.-1 GAS: ROUGH FINAL a FINAL BUILDING a s cn, DATE CLOSED OUT ASSOCIATION PLAN NO:; „` '' The Town of Barnstable 9 $ Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crossen Office: 508-790-6227 Building Commi: Fax: 508-790-6230 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. t pe of Work: �k.- `��'��its (P Est.Costlle- dress of Work• I GYM, Vwner's Namte of Permit Application: — I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL G 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the a en the owner_ . - e, Registration No. Date nip • =� Tile Cunu1101fircultk of Afassachusctts �;;,i 'i.�; •f;� Department of Industrial.4cridents ;:.. �jg;l...:�i 600 !t iasbin,�tutr Street ,• ``. tis'tmt.May OZlll �. B Workers' Compensation Insurance Affidavit i HER int•rot itiri-* �— - •_•-- . ...._. __r�-A�. ._....^. -•.._..�...,r..—•—•-----•"__....—.._---- ---- ✓name --r (/� c, C I C, �• LL e- t`f\ A-S S lion.s vt:i — t ( �✓lllTP r�v� I am a homeowner performing all wort: myself. Q I am a sole proprietor and have no one working in any capacity �..,��....--..�...-.- • ter.. ...�-. w-..��..«.�-.��.��«.�.r-v.w�cr•`..�..'�n!�•"�,.��_ _,__�_ .. .�.r I am an employer providing work compensation for my employees working on this job. G P p _ nm umv nomr. - 'lddrocc• t`. hnne It• inuir,mce rn. _ _�.............��.. — — - ,G I am a sole proprietor. veneral contractor. or homeo��ner(citric arc) and have hired the contractors listed beio�ti N; the following workers' compensation polices: cnm nnv nitnc• ltitlrccr franc a• citN.. cnmrinnv n•tmr• ;tddrrsc� ftnnc rf• city- oil •� �� insurance en -- Attach additional sheet if neeesiary ;= ;�:::. :`= •yam' ""'"� Failure tilt secure cnverace as required under Section 25A of AIGL 152 can lead to the imposition of ertmtnat penalties of a line up to 51.50U.UU une cars' imprisonment ns%veil as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understane COPY'if this stntentcttt may be funvarded to the olrce of investigations of the DIA tar coverage veriGeation. I do hercht•crtri v 'idrr the pains and penalurs o rrjurr that the information provided above is true and correct. Date Signature 4 Phone Print name ''nflicial use Univ do not write in this area to be compicted by city or town oirctal permitilicense 0 r'►13uildin.Department t tit} nr tnrn; auccnsing hoard QSeieetmen's Office • .• ___...,:,..,. .....,.,�.�;c rcautrc r�ttc�lth L)cnartment lassachusetts General Laws chapter 152 section 25 requires all employers to provide workers' coinpensation,for thci nPloyees. As quoted from the "la��'. an cmplgrce is defined as every person in the service of another Winder ail\• mtract of hire. express or implied. oral or written. n rmplt►rer is7!dcfincd as an individual. partnership. association. corporation or other legal entity. or any, two or more forcuoina enanued in a•joint enterprise, and including the legal representatives of a deceased employer. or the =civer or trustee of an individual . partnership. association or other legal entity. employing employees. However tltc .•ner of a dwelling_ house having not more than three apartments and who resides therein. or the occupant of the cilin" house of another who employs persons to do maintenance , construction or repair work on such dwelling, hou on tit: arrunds or building appurtenant thereto shall not because of such employment be deemed to be an employer. :;L chapter 152 section 25 also states that every state or IocaI licensing nbency shall �vitltltuld the issuance or 10v:tl of a license or permit to operate a business or to construct buildings in the contmonvealth for any Aicant who fins not produced acceptable evidence of compliance with the insurance coverage requi-red. ditionall•,. neither the commonwealth nor anv of its political subdivisions shall enter into any contract for the form-ance of public work until acceptable evidence of compliance with the insurance requirements of this chapter hn n presented to the contracting authority. )hcants sc fill in the workers' compensation affidavit completely, by checking the box that applies,to your situzz:on and )Iying company names. address and phone numbers as all affidavits may be submitted to the Department of strial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit~ The ovit should be returned to the city or town that the application for the permit or license is beinc requested. .he Department of Industrial Accidents. Should you have any questions regarding the "law- or if you are required :an a workers' compcnsatior; polls}. please call the Department at the number listed below. or Towns be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of Titdavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas ^e to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to :paranent by mail or FAX unless other arrangements have been made. Tice of Investi=ations would like to thank you in advance for you cooperation and should you have any questions. do not hesitate to _ive us a call. . ,epartment`s address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office al Investigations . 600 Washin;ton Street Boston,Ma 02111 fax #: (617) 727-7749 Phone ': (617) 727-4900 ext. 406, 409 or 575 _�. TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. " DATE (/JOB LOCATION y U( 1 /Z ' \� L Number Street address Section of town -/"HOMEOWNER R �. Name f Home phone Work phone PRESENT MAILING ADDRESSL,ru i t Q ,vj Z,L -e- 3 Z_ City town State Zip code The current exemption for "homeowners" was extended to include owner-occupi dwellings of six units or less and to allow such homeowners to engage an in dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person (sj who owns a parcel of land on which he/she resides or intends to r side, 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 structure. 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 Offi: on a form acceptable to the Building Official, that he/she shall be resnons: for all such work performed under the building Permit. (Section 109. 1. 1) The undersigned "homeowner" assumes responsibility for compliance with the Building Code and other ,applicable codes, by-laws , rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirement and that he/she will com 1 - with said cedures a requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OF IAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. e�Qyo*THE TOWN OF BARNSTABLE STAELL 1639. D MAI A,. WILDING INSPECTOR APPLICATION FOR PERMIT TO ........... TYPE OF CONSTRUCTION .... ... .............19.20 TO THE INSPECTOR OF BUILDINGS: The undersigns) here y a plies for a r.m0 . according to the foll.o..y...i.n......information: Location .... leL............... . .. .. ........... . ......... . ......... ProposedUse .... .............................................. ......................................................................................................................... Zoning District ....... ....................Fire District ..... -------------- Name of Owner ...................Address ......... Nameof Builder ....................................................................Address ..............................j..................................................... Nameof Architect ..................................................................Address .........................................I........................................... Number of R C-1 00 S .. ..........................................................Foundation ............................ ....... ......................................... 00 s Exterior ...................... ...................................................Roofing ......vim.. . ... ...... .... ......... ........... .................. e7o-j�-� 141 Floors ...................................................Interior .... ........... ... Heating ......../................e...........kl'�.......................................Plumbing ...... ........................................ )-- — 4T7��Fireplace C..................1.et ...I ...77�1 ....................................Approximate Cost ...... ... ......... ............ ..................................... Difinitive Plan Approved by Plan ngg Board a rd --------------------------------19--------- /vvv Diagram of Lot and Building with Dimensions 7 6 // j Q W < 0 U-j 0 CL 0 U-1 (D > 58 im xr ovi 0 a. LL fj,, 0 0 401- >: UJ --D UJ U UJ LO < LU CL i5l: LU F: a- < a. I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable re>gardi e above construction. Name ... ................... . Small, Alan DEC 31197O No ....13042.. Permit for ... one story, .... ......................... single family dwelling ............................................................................... Location Lf �PPaquiddick Lane Centerville ..................................................... l Owner ...........Ala.n..Small. ` ... .. ...... ..................................... Type of Construction ......... rame i ......................................................;......................... Plot ............................ Lot .. /....................... y Permit Granted ........Ap? 19 70 Date of Inspection .......1970 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 I ............................................................................... i ............................................................................... } i Approved ................................................ 19 ............................................................................... k ...............................................................................