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0048 CHILDS STREET
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"f .� Town of Barnstable i ng� ' Post This ewxaxrx,�rw.e as `e f d So That it is 1/is�bl ;Plans,MubeRmpe Provd Car ed on Job,and,,th�sCard Must bg e.Ke"p t Posted Unt 1 Fina ° Where a Certificate of�Occupancyisftegw�red,xsuch Building shallallot''=be Occupied,--until a Finallnspection has be'enmade Permi Permit NO. B-18-1437 Applicant Name: SMITH, BEATRICE D Approvals Date Issued: 05/14/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/14/2018 Foundation: Location: 48 CHILDS STREET,CENTERVILLE Map/Lot. 249-009 Zoning District: RD-1 Sheathing: Owner on Record: SMITH, BEATRICE D Contractor Name Framing: 1 41, Address: 50 BLACKBERRY LANE Corit�acto License � ,4 2 HYANNIS, MA 02601 " l E t Prroiect Cost: $3,200.00 Chimney: Description: reroof �PermitFee: $35.00 = 'a Insulation: Fee Paid . $35.00 Project Review Req: '� Datek 5/14/2018 Final: Plumbing/Gas Rough Plumbing: Building Official �= Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authored by this permit is commenced within six,months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl ation and theepproved construction documents for which th s permit has been granted. g jw ' All construction,alterations and changes of use of any building and structur&tfiall tie in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or roa&and shall be maintained open ford public inspection for the entire duration of the work until the completion of the same. k Electrical The Certificate of Occupancy will not be issued until all applicable signaturestby the Building and Fire Officials are3provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: ' 1.Foundation or Footing r .<.o. ? Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 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). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT s_ p ph Application number.............. . .......... ......... t� Issued................................ .... ......................... MAY NAM 1 ►` 92018 Building Inspectors Initials. ..... ........................... AMIA A' q Pepp/Parcel . TOWN OF BARNSTABLE � EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: y� COPLDY S—, CctJTRW I L1 NUMBER STREET VILLAGE Owner's Name: &prtk ` "—do ,S Phone Number �—aa Email Address: i �tnf��� YA�foO co,� Cell Phone Number ? SAA Project cost$ 3ac0•CC Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Q Siding 0 Windows (no header change)# 0 Insulation/Weatherization Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to L?ot�pmk ; *- pt6pcn his Por/IZ. CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) I Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X 1 , X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPMLC4NT9S SIGNATURE Signature Date 9 /8 All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ADAM TRAVERS Address: 48 CHILDS ST City/State/Zip: CENTERVILLE, MA 02632 Phone #: 508-232-1600 Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with. 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' insurance. 9. Building addition [No workers comp.comp. insurance p• required.] 5. We are a corporation and its 10. 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. ✓ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 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 and trans and penalties of perjury that the information provided above is true and correct. Si nature: Date: 5/2/2018 Phone#: 508-232-1600 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Town of Barnstable Regulatory Services �F1HE rp� Richard V.Scali,Director Building Division BAMSrABLE, ' Tom Perry,Building Commissioner 9�A NABS,.16 200 Main Street, Hyannis,MA 02601 rEC MAC a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 5/2/2018 JOB LOCATION: 48 CHILDS ST CENTERVILLE number street village "HOMEOWNER":JADAM TRAVERS 5082321600 name home phone# work phone# CURRENT MAILING ADDRESS: 48 CHILDS ST CENTERVILLE MA 02632 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requiremen 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 form/certification for use in your community. ,. Town of Barnstable Building i K wu+ cwis Post This Ca, So That it is Visible From the Street Approved Plans Must be Retained on Job and this Card Must be Kept r . MASS, ,$ ,his Final Inspection Has'Been Made Permit FD taaya' Where a Certificate of Occupancy is Require such Building shall Notbe Ocpied until a Final Inspect�onNhas been made $ Permit No. B-18-350 Applicant Name: Michael G Cicirelli Approvals Date Issued: 02/06/2018 Current Use: Structure Permit Type: Building-Smoke Detector- Fire Alarm Dection Expiration Date: 08/06/2018 Foundation: System Map/Lot: 249-009 Zoning District: RD-1 Sheathing: Location: 48 CHILDS STREET,CE.NTERVILLE Contractor Name: , Michael G Cicirelli Framing: 1 Owner on Record: SMITH, BEATRICE D Contractor Licenses 37424 2 Address: 48 CHILDS ST - Est Project Cost: $500.00 Chimney: CENTERVILLE, MA 02632 ; Permit Fee: $35.00 Description: upgrade smoke detectors Insulation: Ftee"Paid: S 35.00 Project Review Req: Dater 2/6/2018 Final: Plumbing/Gas ' Rough Plumbing: 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 documentsfor which this 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 by""laws and 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 provid d on this permit.e Minimum of Five Call Inspections Required for All Construction Work:; , ". y Service: 1.Foundation or Footing § L Rough: 2.Sheathing Inspection a _ •. .: ..- 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection 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). -- --- ----.- --.- --- Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ,14 f Name(Business/Organization/Individual): ! <(G C(C l Address: City/State/Zip: 44,t 5 M 02.1'01 Phone#: Are.you an employer?Check the appropriate bog: Type of project(required): 1.El am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.[Z I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' � 9. ❑Building addition [No workers'comp.insurance comp.insurance. 10. Electrical repairs or additions required..] 5. ❑ We are a corporation and its ❑ p 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 comp.insurance required.] *My applicant that checks box#1 must also fill out the section below sbowing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of 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 certi er the and penalties of perjury that the information provided above is true and correct Si ature• Date: 6 Phone#: 77yrel0- —*-0-7 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152,requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person iri 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 f public work until acceptable compliance with the insurance table evidence of enter into any contract for the performance o p p 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The CommonwWth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Rostou,MA 02111 Tel.#617-727-49M ext 406 or 1-877-MASSAM Fax#617-727-7749 Revised 4-24-07 www,mass.gov1dia Accela Citizen Access Page 1 of 1 Hrnour:ccmanisLlz� Rc�is'er_fcr.an kccoun?1 Lggir, epLACE Browser Compatibility:;%v'th the eiease c?to :,'•'�' ' Need Help?For technical assistance i us�,`pi .y }I�� gbf21� F�(h3cen: Parary LPLACE Help Desk Tean)at 1844j/3 3/522- 3, hours gf 7:3 AM-5:00 PM Mcnday-Frday 4rf L i kL ifl ire 't'v.'fi Fi and�b alth and Federally observed holidays.If you prefer,you can also e-mail Lis at ePLAC�: It I Sk�3;Sf<:.°e.rr5_Lis.For assistance with non-technical issues,please contact the issuing:agency direct;y usii,g tl?e links below. ::".1aric as FieaU? - Contact Alcoholic beverages Cor:trol.Com"53ion,,_.,-..,._..,.,..._ ....._.__------..._....m._...............................i Contact Divis on of Capital Asset Manage ent and Maintenance Contact Cie_ar?,fnerit,of Lr tx:?'Standards.. . Contact Division of Professional.Licensul'e ranslation Information-: ick Here To apply for an Energy and Environments?i r1 lairs(DEP.MDAR or f SCR.permit of license,please click here. Document Attachment:in order to upload required documents,this system requires Microsoft Silverlight,which can be downloaded for free here;. Convenience Fee_Please note there may be a convenience fee for all online credit card transactions.There is no fee for online payment by check. Home Manage Licenses,Permits&Certificates File&Track Complaints Please re;far to the L.ice;n sir g Ewity s,,"Ibsita fo,a.^'di?ionai inrcrzr:,a?ion regr.rtiing':iie sta?us arm discipi r:e ir'orrr?allot,short:Ge1ow. P-r r}Pi-intonnaiion.please vast the C)Pt._weini_, . f Of h.b,C.I:?t^r^7dllorl,()iY.2S0 V!51l the h.7':,.. i Information Pertaining To: Journeyman Electrician 37424 I Licensee Detail License Number': ?424 Licensing Entity: .safd^ ..,c.._Exa'mMers c ;:icct L•:ons License Type: journeyman f:.ec:trician Type Class: E License Issue Date: 03/08l1995 License Expiration Date:- t;.'!:1/20") Status: Curren; Current Discipline: Prior Discipline: Name: MIC HA.EL G CIC P.H.L: Business Name: DBA Name: f Public Documents I https:Helicensing.state.ma.us/CitizenAccess/GeneralPrope,rty/LicenseeDetail.aspx?Licensee... 2/6/2018 • g a s £�� 3 `✓ , „ { < � f 5 € - r s } { g ¢ �^ , r + , t ` < i £ 5 t , t } t i 7 i r g gg .� 3 l i f 3 { 5'} x > 141 q , W ,rt 3 } . i f C { ? € < I i 3 fl a r i a d � h z -VIEWED t ' t d _ f MO�KE D fiEDTORS R } fLY6 ; g Cz S ; m IREDEPARTMENT DAT& . i H.x�tG F.DR.PtRM NG ITI NA7.URESARE.REQUIRED X' ' .............................. Uf GiJ kS k� SINE Town of Barnstable Building Department Services BAMSPABLB. ` Brian Florence,CBO Mnss. 039. 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, fi✓i e Siyr! ,as Owner of the subject property I c hereby authorize&�4 PSGJ C 16, fed to act on my behalf, in all matters relative to work authorized by this building permit application for: g? C k A5 (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signa re of App cant Print Name Print Name oz—(9— Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 t pF THE r, Application Number.......0 - ( ,9- 3 SO .'.................................................. � c * STABLE, J y MAes. g Permit Fee.........v........................Other Fee........................ 0 9. ��ED MA'S A Total Fee Paid............................................................... ...... TOWN OF BARNSTABLE Permit Approval-by......... :. On... � t ....... BUILDING PERMIT Map........................................Parcel............................................. APPLICATION Section 1 — Owner's Information and Project Location Project Address ,,GCL Village Owners Name Owners Legal Address 14 City. 0—e/2 T-e-s-vi 4 State / IC, Zip o 2 C.o Owners Cell# E-mail 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 ❑ �r�System ❑ Addition ❑ Retaining wall ❑ Solar• �P ❑ Renovation. ❑ Pool_ ❑ Insulation FES 0 610�8 Other—Specify. TOwNOFBQ A o. Section 4 - Work Description AJA 1-wC2 .5/nz 1e_s `ho s T of i ,marl I I M 2)n17 Application Number.................................................... Section 5 —Detail Cost of Proposed Construction /,!!�^o� . Square Footage of Project Age of Structure Dig Safe Number Total# Of Bedrooms (proposed) # Of Bedrooms Existing (P p ) 110 MPH Wind Zone Compliance Method . ❑ MA Checklist ❑ WFCM Checklist ❑ Design j i Section 6 —Project Specifics III ❑ Wiring ❑ Oil Tank Storage moke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public El Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ 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 Application Number.......... Section 9— C n i5le-1 rt u w01 Name GGtae (IC, I rLL Telephone.Number Address f Z 1 'Pi n e- City #4 4 o. State 'p4jo_ Zip o2-G G License Number 3 7 Y 2- Z( 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 Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature b Date - 1 . Print Name &L e- CtC 1 rti l l Telephone Number E-mail permit to: /}?!�i e— �GG! r�l '7 Z .Qj G B" a-c - c o M Last undated: 12/28/2017 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 T act imrintPrl• 17/7R/1017 e Lo7`�3 I"E.T TOWN OF BARNSTABLE i BARNSTABLE, i 9� 0639. �`� BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........ ........... 00, 2 . .1� ...:./ s�rtr.:' ............................... / //�`�' �� TYPE OF CONSTRUCTION ............... ........................ ... ...1.....19,,1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ............ l.l..1d' s......... .t .� j............ 11 �7 /.�t!f..l ram:........:....... ProposedUse ..................l .I�.............................................................................................................. ....................... e Zoning District ................. Fire District .......... .................................. Name of Owner .. 5. ,C'l.�f✓L... ��?.!✓..�t.......Address ................................................................ Name of Builder ... rli'L k4eW..1:AA.jd4Address ..��.`1�.. 1ri.L.l .S .... ............................. Nameof Architect .......... '+".�........................................Address .................. .. ............................................................ Number of Rooms ......................... S...............1 bµ '........Foundation / ;�gt 4.noo ..... Exterior ........... 1'G. 7..................................... ...Roofin ..... :S,jJF1.!l /. Floors .......Qe4..k..................................................................Interior ..........7: ..ke—hC,t. v4:.��........................................... v Heating .......<91............................ .........Plumbing .....� �� Fireplace ..........a.v ............................................................Approximate Cost ......ram r �d c�o :7777::\~ r Definitive Plan Approved by Planning Board ________________________________19 Diagram of Lot and Building with Dimensions v - SUBJECT TO APPROVAL OF BOARD OF HEALTH eo Lei •m �b IQ 5 Lit 0 lLijH� 1 OG < 8� _ a� - LU Q H ly U �'c-� >J- s 3 - k CL Lij r- !� w �' C 62 LO < (/ >- z+ F" < k. Qz f � I I hereby agree to conform to all the Rules and Regulations of'the Town of Barnstable regarding the above construction. Name .. .4 -,n�. Smith, Mrs. Elaine No ...14971: Permit for one story single farm d.................................... dwelling g family g LocationF ChildsStreet ............................................................ Centerville .................................... Owner .........Mrs. Elaine Smith ........................................................ Type of Construction frame $ ................................................................................ , Plot ............................ Lot ..............#................. y A ril 24 � Permit Granted 19 2 t......p..........................� } p �/ 2S- 7-1 C 19c Q� Date of Ins ection ..,7 ...... ... ^, Date Completed ... a PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ f ............................................................................... l - I ............................................................................... ! Approved ................................................ 19 ............................................................................... ............................................................................... l Town of Barnstable *Permit# Expire 6 err from issue date Regulatory Services Fe ' �� Thomas F.Geiler,Director SE �, Building Division 4 Tom Perry,CBO, Building Commissioner TpWN OF BARS 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us -Office:17.0§ ,2=4038' 20 ®� Fax: 508-790-6230 "����ONMREWS PERMIT APPLICATION - 'RESIDENTIAL ONLY "nh'/�OTq Not Valid without Red X-Press Imprint Map/parcel Number Property Address 0 lei 1 u t�S ��• CQay\ ��to iMA Od(p 3"as. �)Residential Value of Work.l 2,157 Minimum fee of$25.00 for work under$6000.06 Owner's Name&Address A j fi 1Q C 'Y�.� y� 0\C Contractor's Name S OT4✓1 K I 00►'Yle_ Tv►,o IV-trn _r, Telephone Number Home Improvement Contractor License#(if applicable) 1 0 3 7 5 7 Construction Supervisor's License#(if applicable) Vorkman's Compensation Insurance r Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (p]Thave Worker's Compensation Insurance Insurance Company Name�ds,'o CA jtA Workman's Comp.Policy#__ I,JC 77ou `{9 4 3 I o 1 Copy of Insurance Compliance Certificate must accompany each permit. r Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping, Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders. U-Value (maximum.44)#of 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. ome Improvement Contractors License&Construction Supervisors License is SIGNATURE: Q:\WPFILFSTORWbuildingpemvrm t fos\EXP S.doc Revised 090809 Offce�t o um'r t airs sines a on, Lieense or registration valid for individul use only... HOME IMPR01FEMl=NT CONTRACTOR before'the expiration date.-If found return to:' RegI tration:r 03757 Type: Office of Consumer Affairs and Business Regulation Expiration: 12 Private Corporatic! �� 10 Park Faza Suite 5170' R.: Boston.;MA 02116' S KLE`FIOM 1' tNG. grad Sprinkli: _ ,J i 99 arnstabte Rd ' �_ Hya'nrsiS,trll7F 026 °. - i' Uiidprsecretary Not valid without sign tore x: ti Masstte.hutietts- Department of Put fic $xfet� " Restricted to OOr; Board-,of Building; Regulittions an.d Stanttards ; 00-;Unrestricted r Construction Supervisor License i 1G-1`2 Family Homes License: cS 6643 �i Restricted to: 00 BRAD.K SPRINKLE rR Failure,to possess a current edition of.the 190 LQTH'ROPS LAND ' ' `- Massachusetts State Building Code W BARNS ,ABLE, MA 02668 is cause for revocationaof this license. Refer to:' WWW.Mass.Goy/DPS Expiration: 10/8/2011. ('ununissiunri Tr#: W8 , ® DATE(MMIDDIYYYY) Rv CERTIFICATE OF LIABILITY INSURANCE OP ID DS SPRIN-1 01/05/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A'MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER.THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 I Phone.: 508-775-6060 Fax:508-790-1414 INSURERS AFFORDING COVERAGE NAIC# INSURED 41NSURER A_—_Associated Industries of KA _ INSURER-B: Sprinkle Home Improvement Inc. INSURER C 199 Barnstable Rd INSURER o Hyannis MA 02601 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATEM IM DD/YYYY DATE MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY _ PREMISES Ea occurence) $ - - CLAI MS.MADE F�OCCUR i MED EXP(Any one person) $ I I PERSONAL&ADV INJURY . ,$ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPlOP AGG $ POLICY PRO• - 'LOC - r JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO" I + (Ea acadent) $ I _ I ALL OWNED AUTOS BODILY INJURY I$ SCHEDULEDAUTOS (Per person) { HIRED AUTOS BODILY INJURY NON-OWNED AUTOS I I(Per accident) $ • _ PROPERTY DAMAGE i (Per accident) I$ GARAGE LIABILITY I AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC -$ I AUTO ONLY: AGG $ EXCESS I UMBRELLA'LIABILITY EACH OCCURRENCE ^^'$ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $. RETENTION $ $ WORKERS COMPENSATION TH- AND EMPLOYERS'LIABILITY IN TORY LIMITS ER A ANY PROPRIETORIPARTNERIEXECUTIVf�—I AWC7004943012010 01/01/10.I 01/01/11 E.L.EACH ACCIDENT s500000 OFFICER/MEMBER EXCLUDED? — (Mandatory In NH) ; E.L.DISEASE-EA EMPLOYEE $50.0000 . If yes.describe under SPECIAL PROVISIONS'tielow E.L.DISEASE•POLICY LIMIT $500000 OTHER. I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION " SPRNKHO DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR'TO MAIL 10 •.DAYS WRITTEN NOTICE TO"THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, Inc- IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax #508-775-1350 Margo Mack REPRESENTATIVES.g AUTHORIZED REPRESENTATIVE 199 Barnstable Rd. Kelley A.Sullivan annis MA 02601 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo,are registered marks of ACORD w t � Town ofBarnstible ° Regulatory Services . . ` _ Thomas F.Geller,Director . . . , irusv. �► �E 6.196 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 as Owner of the subject property hereby authorize r 2 'to act on my behalf, in all matters relative to work authorized by this bunding•Pertnit application for. �155 Chi l�s 54- C'j` v� ..(Address of job); R, .;. Signature of Owner Date ' PnntName .-- If Property Owner is applying for permit please`complete•tlie Homeowners License Exemption Dorm on the reverse side. 'I n-RnR MR-nVnjRR PF.R'WT.C.1Z1nN �'- -The Commonwealikof Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.9"Idia- Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information 1' Please.Print Legibly Name(Business/Organization/Individual):S 6{i J1 II`.�� tt�yVl� M 4 fbV2 MP A' Ad&ess• l9� �t�' _MS 101e Qot City/State/Zip: &4=6 MA 014R(00 Phone Are you an employer?Check the appropriate box: Type of project(required): ,- 4. I a general contractor and I I.LJ l am a employer with� � am 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or p listed on the attached sheet. 7. El Remodeling ship and have no employees These sub-contractors have g• O'Demolition workingfor me in an capacity. employees and have workers' Y P tY• _ _9. ❑Building addition insurance (No workers'comp.insurance comp.ins required.] 5.-0 We are a corporation and its . l0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No.workers'comp. right of exemption per MGL. M[]Roof repairs required.]t c. 152,§1(4),and we have no . insurance re employees:[No workers' 13. 'Othe` t?.✓t' _ comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my,employees. Below Is the policy and Job site information. n Insurance Company Name: QSSOC.i R�SA —s,—k. u5�f es Policy#or Self-ins..Lic.#:AUX, Moq9q .301kbio Expiration Dater ot tot 4{ Ux '�d S ci /state�zi &� tl�`l�� # G.2-( .3Z Job Site Addrets:. ty P� Attach a copy_af the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to seguie coverage as required under.Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$I;S00.00 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 insamce coverage verification 1 do hereby c r unde ins and penalties of perjury that the information provided above is true and correct: Signature: Da • Phone#: Official use only. Do not write In this area,:to be completed by city or town offlclaL City or Town: Perrnit/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#: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map, Parcel `C u mil. Permit# 03�8 Health Division Date Issued ` ` L_` Conservation Division Zo0 Z 9r"Z_._. Fee 8 l Tax Collector ', IV 900t e 0 tf Treasurer SEPTIC SYSTEM M UST BE Planning Dept. INSTALLED IN COMPLIANCE VM TITLE 6 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address `A C e h4 11. 0 Village qq Owner rf-NRS tjiU—Nwm Tn-) Address Los Telephone 1— 6—PE—�)`7 1 — :�b-7 ? __ 1q-- Permit Request (��nov� '�n �Y,ts+ Cr0f 9 67-6 ar)A Xh- A 6lqs Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Woo Lot Size 00, -5�4 i+ Grandfathered: ❑Yes ❑ No If yes, attach supporting dc imentatia'rxs .sy Dwelling Type: Single Family R( Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 0 On Old King's Highway: ❑Yet to ca Basement Type: Full ❑Crawl ClWalkout ❑Other o r CA fit Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 'Tyyp new Half: existing new Number of Bedrooms: existing `Two new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas N(Oil ❑ Electric ❑Other Central Air: ❑Yes N(No Fireplaces: Existing I New 1 Existing wood/coal stove: ❑Yes Y o Detached garage:❑existing Cl 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 N(No If yes, site plan review# Current Use 66V-CA( Proposed Use Fwr�-„Lc , fLoc�rn BUILDER INFORMATION Name w iWortA t , i l Sii?, Telephone Number_- Address t)--e_ License# 01009 1 P,4�(vy a Home Improvement Contractor# 1 I Lk Worker's Compensation# f I y ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO C�r� b"V e A►�► 5 J:CSIGNATURE �/� /� !?� DATE 1-( 13 � FOR OFFICIAL USE ONLY , PERMIT NO. DATE ISSUED ., Lam---• '_ MAP/PARCEL NO. ADDRESS n VILLAGE OWNER. j v DATE OF INSPECTION: FOUNDATION !, FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t'i PLUMBING: ROUGHnq FINAL ' GAS: ROUGH— FINAL � FINAL BUILDING yoL_ DATE CLOSED OUT - i " t'3 C i = eJ J { ASSOCIATION PLAN NO. •1 77te Commonwealth of'Massachusevs '= = Department of In&uvial Accidents -�' �� -� ; 0lrfcaollmastlO�o�s 600 Washington Street . Boston,Mass 02111 `•' Workers' Com eD3a#l0n bsura r_Affidavit name L J i L-i, ra rn �4 F�1 4 location 99city N -�n►� ❑ I am a bomsownu perfimiiag all work myscIE a sole proprxictor and have no one woddng is anv c�actp . ❑ I am as empl p---,.}... dmg:wmJ='oo�uoa for M ees em iQp wading as this job. .............. ..... ..°J.,-.L"'°°I..T}:�•}:{:............... .... '- . ,..,:w ... ... '. "eY"Q?�`2�h?:;""?��:""^.'�'��:.}}^•"."y'>'"'""`.:><w":,":,.,�.,..M:w:.,,,;:... 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Z<:w •.e.w 3 eR�cey axa - .., .}::..•'i.:12`•'u?:{. [Ct0. :......::-:::•:::..,;.;.�3.. :......::.:::. FaQme w seesD;e�i+as tegatesd smdar t?eodoa ZSA otMQ.IS2 salaad to the im�asilisad�Pessaitld da Lbs•aP to S1.Sooao and/or o��es+tmpriso�tasweIIasef�peaattlefnthetoemotab'1�OPW08]COBDFBda�eadi100.00adgapimtm�I���a �P7 of thts atasemmt�f be forwardrd to the Ottice of Ian�d�of lhs D7Afar.as�+�rs�0astlad I do hoeby cadfy+undo de paua amd pa wMa ofpfffiny e®iwe p^wridedabave is trine ivia correct DateMO Pzmt name w LL,r ,4r e otadal use oniy do not wefte is this area to be eempieted b7 dtj or on o@dai c ty or town: paadtAieeese 11 ❑Bnadia;Aep ua-ut QLkessiat Bow ❑che&if tmzmdh"reapome Is ngmred ❑Sd LM De'a rMaOface - ❑Health Dep�cut contadperson: phasseN; — �pther�_ (ter��u 0195 P1Al ' Information and Instructions ` Mas sachusetts General Laws chapter 152 section ZS requires uesall employers wto provideworkers cortm, ensation for their emplovees. As quoted from the "law", as employee is defined as every person in the service of another under anv corn of hire, express or implied, oral or written. An emplover is defined as as individual, partnership, association, corporation or other legal entity, or anv two or more of deceased emP lover, orthe rec n,e: or the-foregoing engaged is alourt enterprise, and including the legal represeadazzves trust of a trustee of as 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, ea ntractim or repair watic on,such dwelling louse or on the gmun s cr building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local,Ucensing 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 app0cznt who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,ne4+ rthe commnaweaith nor any of its political subdivisions shall eater into any contiact fior the performance of public work-until acceptable evidence of compliance with the Fisurance of this chapter have been,presented to the contructin authority. - Applicants Please fill is the workers' compensation affidavit completely,by chedin the.boa that applies to your mad supplying company names,address and ph numbers along with a certificate of insurance as all off davits maybe one submitted to the Department of Industrial Accidents for caafamaidem ofinstzrance�8F- Also be sere to sign and date the affidavit The affidavit should be.retained to the city or tow athat the application for the pemut or license is being requested,not the Departtaeat. of Industrial Accidents. Should you Dave any questions regarding the"law"or if 3'cu e required to obtain a war]= compensation policy,please call the Depa�aet at the saber listed below. at City or Towns Please be sure that the aff davit is complete mad printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill oat in the eveat the office of -has to contact you regarding the applicant. please be sure to fill in the penaitllice ase number which will be used as a reference mmmmlier The affidavits maybe retuacd t" the Department by mail or FAX unless other=angements have been made. The Office of Investigations would ble to thank you is advance for you cooperation and should you have nay questions. please do not hesitate to give us a call. The Deparuamt's address,telephone and faxnumber. The Commonwealth Of Massachusetts Department of Industrial Accidents Me of lavestluations 600 Washington street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Table JS.Z.Ib(condamon Prescriptive Paeln;es for One and Two-Faasiy Rdidmdai Boildtnp Saaesd with food Fade MAXIMUM MIIYRHum GLL26Mg GLang Ceiling Wall floor Baaemmt Slab cucy Area'('/•) U-wluc, It vatud R valuer R•val� wall � �a Paci=e. &vabas� 9"1 to 6500 Headog De6ese Dam Q 12%. 0.40 38 13 19 10 6 Normal R 12% 0.52 30 19 19 10 6 Normal S 129.'. 0.50 38 13 19 10. 6 IS AFUE T 15% 0.36. 38 13 25 WA WA Normal U 15% 0." 38 19 19 10 6 Normal V 15'/. 0.44 3E 13 25 WA WA tl AFUE W 15% 0.52 30 19 19 10 6 33 AFUE X 18% 0.32 38 13 25 WA WA Normal Y 18% 0.42 3E 1 19 2S WA WA Normal Z lg% 0.42 3E 13 19 10 6 90AFUE AA 18% OJO 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: �I I 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q-AA-see chart above): - 3 g F©r- L�-�� R, -30 r 2 w �-E-(� Co m L L pow (�► a�n OP, NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f980303a Footnotes to Table J5.2.1b: ' Glazing area is the ratio of the.area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area. expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft'of decorative glass may be excluded from a building design with 300 tt'of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used ' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R 30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values,represent the sum of the wall cavity insulation plus insulating sheathing(if used). Do not include exterior siding,structural sheathing,and interior drywall.For example,an R_19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, . or garages).Floors over outside air must meet the ceiling requirements. Tl:e entire opaque portion of any individual basement wall with an average depth less than 50%below grade must me=: the same 'R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned br.,ements must be included with the other glazing. Basement doors must meet the door U-vaIue requirement d_scribed in Note b. 'The R-value requirements are for unheated slabs.Add an additional R 2 for heated slabs. ' If the building utilizes electric.resistance heating use compliance approach 3;4, or 5. If you plan to install more than one piece of heating equipment or mote than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J51.l a NOTES: a)Glazing areas and U-values are maximum acceptable levels.Insulation R values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35.Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c) If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two er more areas with different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted avenge U- value of all windows or doors is Iess than or equal to the U-value requirement(0.35 for doors). 43 t ' i I � �lle U/O�/h/I�LO�I2CI�elLGL/L Y:. BOARDZF BIBLDING REGIU AT1O1�$ 'License CtASTRUCTIORSUft, I'sOR r Numberl ffg 010094 ° I j" Birthtdate ®71911940 t 1P,��9�Q��49fZQ03 Tr.no: 4143 Reslsricfed (0 WILLIAM H FIELD=� `y 99'NiE1%VTON AVE \ �, r • BRAINTREE, MA 02184 Administrator -eT �omvnzonuiea o�✓�aagczc�usaet Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Regi�tca#�'on a14539 • (�Expir�aaaton b9'/�8/2D03 r YPe tlildjy idual WILLIAM H.FIELDS 3 WILLIAM FIELD 99 NEWTON AVZZ— E ~a� BRAINTREE,MA 02184 , ' Administrator RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $Z5.00 " Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE M9 square feet x$64/sq.foot= VIJ x.0031= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq.ft , 120 sf-500 $35.00 ©� >500 sf-750 sf 50.00 >150 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney V x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee projcost f . N v ��DsT/oN } rf. ' CERTIFIED PLOT, PLAN LOCATION SCALE . . . . . . . .. . . . DATE PLAN REFERENCE OF ,ems �3 ELLEY No. 26100 0 . . . . . . . . . . . . . �fy. 'j'fCPS1ER�� " 1 CERTIFY THAT THE Via?/sTi.�lG 1.76t/G LUNG 1 LAB g SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. DATE REGISTERED LAND SURV OR l . 1 q The Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building Division Peter F. DiMatteo, Building Commissioner 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date y 16ad, 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. p Type of Work: ' , X g+fn Estimated Cost I 00c) Address of Work: Li f C-4 tLJQ9 C'�4cr—Q ,, (if Owner's Name: wl e— 'n'12S w i U-.i 4 yr r n l'tom N Date of Application:_ I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑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 c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby ap ly for a permit as the agent of the owner: ' q T s--3 Date Contractor Name Registration No. OR g1orms:Affidav :rev-122001 FIELD P%EM,ODEILIINGI Additions • Remodelind •Kitchens • Vinyl Siding •'Replacement Windows d � ue tb f � . '!DXt"gc o nnkA4cA 118 Howie Road, Braintree, MA 02184 Tel.:781-843-1219 3 ' FIELD ODELING Additions • Remodelind • Kitchens 's Vinyl Siding Replacement Windows � � n ccn Cr (ZACC9 AN l �.►pts �,.,� � t z (A I+ PULYZ .ry;,ls 118 Howie Road, Braintree, MA 02184 Tel.:781-843-1219 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map y q Parceldac9. Permit# f%✓ ' Health Division J - � : Date Issued Conservation Division Fee� .3. Tax Coll +�10k1 flel ' SEPTIC SYSTEM MUST BE Treasur INSTALLED IN COMPLIANCE ' Planning Dept. ` aITH TITLE _ _ Date Definitive Plan Approved b PlanningBoard ENVIRON E911TA r! �7 BIND Historic-OKH' Preservation/Hyannis " Project Street Address l'!-I J`lalS F , Village feel— Owner,�� ;�.G1i2S ��� ,� t� Address y� Ca/�fildc 57 e,--IJ> Telephone . 477f do 7 16 Permit Request Red FL4 AdZ61,ion �EY-157-1✓�� Square feet: 1 st floor:existing roposed 2nd floor:existing proposed Total new Estimated Project Cost ✓ Zoning District Flood Plain Groundwater Overlay Construction Type + Lot Size (90 a 0 ICm Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family Two Family ❑ . Multi-Family(#units) Age of Existing Structure 0— ?'�o yi s • Historic House: ❑Yes Pd'fVo On Old King's Highway: ❑Yes QlVo Basement Type: ❑Full Crawl O 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 _ k Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: 6Zo ❑Oil ❑ Electric - yp ect c ❑Other Central Air: ❑Yes Fire laces,•Existin New Existing woocoa �No p g � g d/ l stove: ❑Yes- 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❑ 4 Commercial ❑Yes ❑No If yes,site plan review# Current Use ' Proposed Use BUILDER INFORMATION Name �, �L%S�® S <Telephone Number 721- Address eq) of4 License# Qa 6C _.A4 0 d C Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 17 SIGNATURE DATE - oZ_ ` 131- Y l 4 •. . FOR OFFICIAL USE ONLY t' - PERMIT NO. Ale DATE ISSUED a- - - ram. L , n • ,,;, f •, MAP/PARCEL NO.t , i. 'ry .y j • t . ' , ADDRESS i +_'VILLAGE - - - 77r ..OWNER • - 4 '{ " - . .s .i r., t _ �, � � _ . r"• 1 ._ + � Nam. � � t � ;? .. - , • ` r a � r, `i DATE OF INSPECTION r ij FOUNDATION Q" FRAME � � � -. •. r _ ._ > INSULATION FIREPLACE 4, ELECTRICAL: ROUGH'S FINAL PLUMBING: ROUGH: "1 c." FINAL ', • - :- r - , GAS: ROUGH- . FINAL FINAL BUILDING r DATE CLOSED OUT: e f ICE (,.1 • • J ,. • f — - � rr• ASSOCIATION`PLAN NO. Vr r / j yco CA- /YIP AAAwt ws . • -ae ME .vkwood I.a 100,o a e...def, t t s Oc uA ie✓ Lk r'I ff - Mwo G (.✓l, 1 I1 CWKM�— __..—__.__ W !TceTry� .FL.a.• 'rw-w.--Zoo..-'w y C PALTSIOS E SON.- 183 LONGVIEW DRIVE � �,e,.�� Jre:�,�,��,,��•,�,, f CENTERVILLE, MA. 02632 ° A�OVEO•r' Mh o 771.,410 BUILDING & REMODELING a� rf LICENSE # 006653 ��E�q r<eNs ... DRAWING^�°E• Z'eoSS...rA rria y .. . . �'�a•.io.eMo�a.�.es•e.rarm I• z 0o• Liar /p=:• ate+ar - — q elf IT • a `I Q JJ y 7• ` I A 1 vwLt !Kr![ p • 'rig. 183 LONGVIEW DRIVE J C. PALTSIOS SON, CENTERVILLE, MA. 02632 °`"�°°� ARPNOWEOBW: DRAWN ,frr5! OA7L• /Y R6W1tED 771-1410 AFOV?^'-°�'"G"' BUILDING & REMODELING LICENSE # 006653 F�� ? O"AMMGNU.-M rw6WwNOAaMO011w+.rs•8L vca `1 38�!. v N P��osen • , �DDsT'ioN 1 CERTI FI ED PLOT PLAN LOCATION SCALE . — r . . DATE 171 i• PLAN REFERENCE .11S.SS®. (� M . .? �. of f�,gf�c�Z. . /. �P`tN �4 UEY N0.261Do c CERTIFY THAT THE L�?/sT�•c!G17�t/ELL�tDG �s� l LAlt�1 SHOWN ON THIS PLAN IS LACATEO ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF _ WHEN CONSTRUCTED. DATE �� ` s�ia�L� 7%1- REGISTERED LAND SURV OR The own of Barnstable Department of Health Safety and Environmental Services Foru��' Building Division 367.Main Street,Hyannis MA 02601 Office: 508-862-4038 ; Ralph Crossen Fax: 508-790-6230 Building'Commissioner 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. r ' Type of Work: ,4 1`T1 0-4 Estimated Cost 30, cam, Address of Work: 6S"7', Ce`'-re,'y, • Owner's Name: 7-4 Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied E30wner 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 c. 142A. SIGNED UNDER PENALTIES OF PERJURY l hereby apply for a permit as the agent of a ow �y . Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav ` I I MAScheck COMPLIANCE REPORT I I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 O I I Checked b /Da e 'I I .I CITY: Barnstable STATE: Massachusetts HDD: 6137 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) ' DATE: 2-18-1999 DATE OF PLANS: 1-18-99 TITLE: Bedroom Addition PROJECT INFORMATION: Bill Smith 43 Childs Street Centerville Ma. 02632 COMPANY INFORMATION: Chuck Paltsios & Son 183 Longview Drive Centerville Ma. 02632 NOTES: MaCheck by Cape Cod Insulation COMPLIANCE: PASSES Required UA = 81 Your Home = 79 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA' CEILINGS 308 30.0 0•.0 11 WALLS: Wood Frame, 16" O.C. 401 11.0 0.0 36 GLAZING: Windows or Doors 47 0.320 15 DOORS 20 0.140 3 FLOORS: Over Unconditioned Space •308 19.0' 0A 15 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool"the building shall be no greater than 1250 of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date I MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.01 Bedroom -Addition DATE: 2-18-1999 Bldg. I Dept. 1 Use 1 I _ , 1 CEILINGS: [ ] 1 1. R-30 Comments/Location 1 ' 1 WALLS: [ ] 1. Wood Frame, 16" O.C., R-11 Comments/Location I - 1 WINDOWS AND GLASS DOORS: [ ] I 1. U-value: 0.32 I For windows without labeled U-values, describe features:. I # Panes Frame Type Thermal Break? [ ]' Yes [ ] No I Comments/Location I I DOORS: . [ ] 1. U-value: 0.14 I Comments/Location I , FLOORS: [ ] 1. Over Unconditioned Space, R-19 I Comments/Location I I AIR LEAKAGE: [ ] I Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. When 1 installed in the building envelope, recessed lighting fixtures 1 shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or I gasketed to prevent air leakage into the unconditioned space. 1 2. Type IC rated, in accordance with Standard ASTM E 283, with no I more than 2.0 cfm (0.944 L/s) air movement from the the I conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure I difference and shall be labeled. 1 VAPOR RETARDER: , [ ] I Required on the warm-in-winter side of all non-vented framed I ceilings, walls, and floors. I 1 MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be clearly I marked on the building plans or specifications. .S I DUCT INSULATION: [ ] I Ducts shall be insulated per Table J4.4.7.1. I I DUCT CONSTRUCTION: [ ) I All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealed I using mastic and fibrous backing tape installed according to the 1 manufacturer's installation instructions. Mesh tape may be I omitted where gaps are less than 1/8 inch. Duct tape is not I permitted. The HVAC system must provide a means for balancing I air and water systems. I TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual I or automatic means to partially restrict or shut off the heating 1 and/or cooling input to each zone or floor shall be provided. I I HVAC EQUIPMENT SIZING: [ ) I Rated output capacity of the heating/cooling system is 1 not greater than 125% of the design load as specified I in Sections 780CMR 1310 and J4.4. d I [ ] I SWIMMING POOLS: I All heated swimming pools must have an on/off heater switch and require a cover unless over 200 of the heating energy is from I non-depletable sources. Pool pumps require a time clock. [ ] I HVAC PIPING INSULATION: HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in.) : I PIPE SIZES (in.) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" ,2.5-4" I Low pressure/temp. 201-250 1.0 1.5 1.5• 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 I Steam condensate any r 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: I Chilled water or 40-55 0.5 0.5 0.75 1.0 1 refrigerant below 40 1.0 - 1.0 1.5 1.5 I • [ ] I CIRCULATING HOT WATER SYSTEMS: I Insulate circulating hot water pipes to the following levels (in.) : I I PIPE SIZES (in.) I NON-CIRCULATING I CIRCULATING MAINS& RUNOUTS HEATED WATER TEMP (F) : RUNOUTS 0-1" 1 0-1.25" 1.5-2.0" 2.0+" I 170-180 0.5 11.0 1.5 2.0 I 1407160 0.5 I 0.5 1.0 1.5 I 100-130 0.5 1 0.5 0.5 1.0 1 ----NOTES TO FIELD (Building Department Use Only)------------------------- ` .. fie �ji onviywacu�ea�i o�✓�ac�zu�ell y �? DEPARTMENT OF PUBLIC SAFE?!' i CONSTRUtf'.M. SUPERVISOR LICENSE 1-7 Expires;2211999 0912211944 RestrtcteC Ta 00 . RLfS O A.PAVS IOS 183 LONMEW OR CENTERVILLE IAA 0262,2 _ OT F d �YJ Y � ���� ;Ty},�4 '^ t�/G�►�✓Y4((OGfWfUO(fCfO y 'Cc"'T' �� HONE IMPROVEMENT CONTRACTOR d,�,� �Regtstration �L14644 hf t k TyPe4� INpIVIDUAL}£ �,�Y ;1 Wi ation� 10/08/99 KPa 4 � PALTSI05 BLDfi' REMODELING 44,-rs � GHARLES fi PALTS70S N �3 LO6VIEW DRY f A ^°""'"'NATO "CENTERVILLE NA 02632 " --- - The Commonwealth of Massachusetts : Department of Industrial Accidents 01frce 9110sesti9safts _ � =>' 600 Washington Street ,+r Boston,Mass. 02111 77 Workers' Compensation Insurance Affidavit name: �0r le S 2A 1 - ICE location: 4-23 loe city nhone# ❑ lAma homeowner performing all work myself. T am a sole pro rietor and have no one workin in any capacity �0%%// %%%/� %/%/%%%/%%/%%%%%/% %%/ �IZI%�O%///%%/%%%%%1�%%%%�%%/.��� ;; ❑ I am an employer providing tivorkers' compensation for my employees working on this job. compnnv name address: ..... city phone#: insurnn a co. oiicv# am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who haV'e' the follo«ing workers' compensation polices: comnanv name: ... .. .... ...:.;...,......... address: - city: phone#r insurnnce cn. oiicv# comnanv name: ` address city- phone#- . Insurance co, olicv# :::...:. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S1.So0.00 and/or one yeah'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that s copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. 1 do hereby certify undeFAC pains ies perjury that the information provided above is true and correct Signature Date Print name Phone# —7 71 lVlo Econtact use do not write in this area to be completed by city or town ofIIcial permit/llcense# ❑Building Department ediate response is required ❑Selecting Board ❑Seiectrnen s Ottice ❑Health Depar�ttrnt phone#; ❑Other (rrA6CQ 9%95 PJA) ..:... .. .:: ...:.... . Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any coat.-" 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 receive: 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: 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,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. FF Applicants .Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. ��//%/%i� i!i /%���i/��i �/� % �% ��71111 City or Towns 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 peimit/license number which will be used as a reference number. The affidavits may be returned io the Department by matt or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Offlca of Inllesuanuans 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375