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0137 CHILDS STREET
1157 Y 'V �',.......... Rle, tRg qAQt,1,9 M "n IIrq� 'vV,,XtM Ull" �Affi',6141 ii�t�% -gl� + pi", i-N f,,,%Wffl O"Q �;`?�,", p�i N11 av-1 MAP-- A "Vo T ............... % gill., W11 1w ERR, r 'mom '7 f 13)1 V Estill Town of Barnstable *Permit# qS9 ` � 16 Regulatory Servlces Egee 6 months from issue date sAartsrAsi�;�� MAss.J�' Richard V.Scali,Director 639. � �S Building Division �j Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address t S �_)T �p 11 (�I s? f ► l Q [Residential Value of Work$ 7,50 U 0(� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Leon ! ►'1 ( ( h E I O V C_ /3 7 Gh (0 S 5f Cen e /Y?ct aa&3a Contractor's Name - Telephone Number_,00 -0q_qq 0(0 Home Improvement Contractor License#(if applicable) /X0 $$I Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: [v]�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 to ❑�e-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 'Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. oe SIGNATURE: Q:\WPFILES\FORMS\building permit formstXPRESS.doC 06/20/16 Massachusetts-Department of Public Safety . Board of Building Regulations and Standards • _ :,: _;;fir - COnstr uctio33 Supervisor , License: CS-102185 EARL T SPAIN 46 Mifin Street s Sandwich MA OZA63 � r Expiration Commissioner 1=612016 - 1 Camon ns&/Bu ess Ra Mateo relfi Ucense or registration valid for individul use only ;� Ofiiee of Consumer Affairs&Bss,ness Regulation HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _ Rmjtstration: z 1777g7 Type- Office of Consumer Affairs and Business Rtgulation _ Expirations=2/3 2 48 DBA IU ParkPh+7a-Smite 51T0 `-`—_ Boston,MA 02116 - —= , KT.SPAIN CONSi;ii G kM: KARL SPAIN 46 MAIN ST. SANDWICH.MA 025M - - Undersecretary gotidwithout iguature 17m Com omveah*ujfAfassadtresetts DepartmentafludasfyidAccidentr f},f ke of LTwndwatzow. 600 Wash fivi n S`freet Boston,MA 02111 1prv11L tarassg4ov1dia Warr.Ivers' Cumpe 7nsurmice avat:BidWex-lCuntracwrsJEIectdcianstPlunbers 1 pp Tllf�T�11a 31 PleasePrn ep6 -IX)C ' 1 Address C Ciwsta ( �15Phow-,g--. 509 -DIL Are you an employer?(Merkthe pprapriate om Type of project(required): I.El am a employer with 4- [�]I am a general coafxsctar and I 6- ❑New c oasttucEic.n employees(full audfor part-limed* have fired flte sub-co zs . 2.❑ I am a sale proprietor orpartuer- Pisted onthe attached sheet:` 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition Waddng forme in any capacity. employees andhave xga�kess'. 9. .❑Build addition [No Woders'comp.insurance comp.;,, �. t required.] 5. ❑ We are a corporation and its 10-❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exErdsed their ' 1L❑Ph unbsag repairs or additions myself[No ivorlmrs'cony. right of eseargtion per MGL 12.❑Roofrepairs i sizancerequired.]i c.152,§1(4k andwehavieno employees.[No wotners' 13.❑Other cam.msmance mquir ) •Any gg5Cst6diat checsbos#1 mast alsn fiIIouEths sectiaabelow�uiag Ehesivodces'compeasstinapoyeyia��s�io� T M=eowaem Who subogt dm sSdaei€m sacb fCm=cm=Such,—V1Msbaa mast%ttgr1ledEMaMiti®a1 Shed Sbouingtbenameofthe ZeLd Stem WhelhefatnotfhuseeMdJeshsve . employees.I€thecshase�piofers,�e}'�stP�'� ��'�P•F�F�� . lam an $etaar is tha pa cy and jab site igfm matiars Insmaace Company fame: Poficg or Self-ins Lic_;i` ExpiratiaaIke: I` Job Sit e Address I ��I I�5 �_C ylSkate��sP:�O.tfl 'V 111 .1 t lLl C)R&3. , Attach a-copy of the workers'compensationpolicp declaration page(showing the policy number and expiration date). Fair to serum coverage as required under Section 25A of MO—m 1572 can lead to the imposition of criminal penalties of a fine up to SUOD OD anAllor coi-e--ye-a-rimprismunenk as well as civil penalties in the fay of a STQP WORK ORDER and a fine of up to$250_00 a day a6pinit#lie violator. Be Fr(hdsed'tlrat a copy of this statement maybe forumrded to the Office of Investigations ofthe DIA for insuraace coverage terification- I da 1=49bb cerftfy riudsr pains andprnatfies of per ury fltatfha irtfaruta€r=prmtrledaboi%is tru8 and correct �--- Date: s —I� Phane U,ociat uss arty: Do twt wrAr in dib area,to be armpked by city artoorn uo`rciaf City or Town: PermbfLicense:9 Issuing Autlmrity(drde one): L Board of Health 1,Buffffing Depwimeat 3.CitylTown Clerk 4 Electrical Faspect4r S.Phanibing I>sspector fi.Other Comfac t Person Pltoat#- 6 Taformatio)oL and 11astructious h6LRs:achmc:tfs Ge�nexal Laws chapter 152 rega¢es aU employ=In provide workras'comPensatton for then'=Playees- p this statafr,an employee is defined as¢.everypersanm the service of hex under any coixact ofhfir, e-,sprass Cyr implied oral or written." Aa emplayEr is defmcd as an.individual,P=ft=[ship,asso�iion,corparafian or of im legal euttty,or any two or more of the foregoing engaged is aJoint ,and.incbicrmg the legal reg¢esenfafjV=of a deceased employer,or ffie receiver•or t mst=of an mdividnal�pat=ship,association or ofherlegal entity,employing employees- However tbs owner of a.dwtHmg house having not more than tbrw apmtmm s and who resides ffim=3,or fhe occupant of the - dwelling house of another who employs pesom to do maft±== e,cans 77"t on or repair wow on such dweIImg boIIse thereto shaUnotbw=e ofsoch emplayme�be deemedt o be an employer." or on the grounds or bmldmg app � MCM cbapfer 152.§2SC(6)also states that"every state or local licensing agency ShZ withhold fhe issnance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for auy, applccannf who has notproduced acceptable evidence of cdmpliauce with the*nv*ance.coverage required." Addt onally,MCrL chapter L52,§2:5C(7)sus-Neither the crn,rmrnrwea if nor a'ay ofits poIifical subdivisions shall enter into any contract for the pert ance ofpnbho work Until acceptable evidence of complia;nce-With the insur-ance. mTm-,rments of•finis dupfiexhave beta preseo:tEdm the conhdMg aCdhOXity." A-pplicants Please fiII opt the-worI =' compensation affidavit completely,by cher�ib a bones ffia±apply to your sifuafion and,if necessary,supply sub-contractor(s)name(s), addresses)andphamrmnber(s) alongwiththea ceat£tcate(s) of insurance. Limited Liability Companies(LLC)or Lfinite d LiabtiityParfu=:sbips(LLP)WI&no employes other than the members or pminexs,are not regrm-ed to caay wort= a compensatim imsm- ce- If an LLC or LLP does have =Ployees,apolicy is rup red. Be advisedthatthis affidayhmaybe snbm�ed to the Department of Industrial Accidents for confnmation of insurMMee coverage. Also be sure to sign and date she affidavit The affidavit should be retnmed to the city or town that the application for the peunit or license is being requested,not the Department of Tr±,�Arcidmts. Tx)uldyou have any guest ons regardmg the law or ifyou a=e recpmed�obfa�a wori�rs' compeusationpolicy,please call fheDepartme tatfhenumberliste:d below. Self-fi sUrC:dco3mpm je:s should en rtheir self-hisoranm Iicense number an fire appmpriafe line. City or Town Officials Please be scam that the affidavit is complete and prhted legibly. 'Ihe Department has provided a space at fhe bottom of far-affidavit for you to fill out i a the event the Office of Invm-dg t�has to contact you regal ding the applicant Please b e sure to fEU in the pennL' cense rntnber which will.be used as a reference amber. In-addition,an applicant that must submit muhiple pe�m*Hiic �e apphji E ions m any given year,need only sobmrt one affiday$mdicafmg csrent policy,information(if n=msazy)and under"lob She A_ddres"fh e applicant should write"all locations in (city or: town)-"A copy of the-affidavit that has been officially stamped or maned by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for futse permits or licenses A new affidavitmust be filled out each year.Where a home owner or cifi=is obtaining a liccase or p=itnot=elated fo any bnein�or commercial venture (Le.a dog license or peanit to bum leaves etc.)said person is NOT regn¢A to Mete this affidavit The Office of Investigsiious would Like to t>iank you is advance for your coopeaaiian and should yom have any questions, please do not hesitate to give us a call The Departmmfs address,tcleghame and fax rsmber. Deparfinet of yak Acaidm t% $a MA 02111 Ta 617- -4900�4€6 or i-a MA q Fax#617 727 7749 Revised 4-24-07 ma�.grrgia Office of Consumer Affairs and Efusiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration s— jc Registration: 180881 . T Type: Corporation 4 ; Expiration: 1/23/2017 �Tr# 262110 M.B. HOME IMPROVEMENT,:INC . MICHAEL BERNSTEIN 53 CONGRESSIONAL DR , YARMOUTHPORT, MA 02675 ` 1 Update Address and return card.Mark reason for change. E] Address Renewal ❑ Employment ❑ Lost Card DPS-CA1 Co 50M-04/04-G101216 ✓/ze '�°�rrr'a°�uvea/ i o�./�czaaac/u�aet7a License or registration valid for individul use only Office of Consumer Affairs&B smess Regulation g y HOME IMPROVEMENT CONTRACTOR , before the expiration date. If found return to: „ Registration:- J.80881 Type: Office of Consumer Affairs and Business Regulation VM. . Expiration 1123%2017 Corporation 10 Park Plaza-Suite 5170Boston,MA 02116 E I M P RqYIE-M ENTzr INC;I,, MICHAEL BERNSTEIN , } 53 CONGRESSIONAL DR YARMOUTHPORT MA 02675 UndersecretaryNot valid without signature g b ¢' �f 4 . n r aoi :12L)cl nf scas�,,JLLI cot (had &rn�s-�(*O laic. b a�e- b �'reLl (3,S rT), i �s I L Lonfmc-4ni- rnc � 'A-)rAl. n {- �C 'U GL CALE)c ril +he I'OLS5.,de n_r M�tL_ n1clel &,rn,(s.!Ln� 'r i ji ,. ` l i 1 . c ' '� f .'o Town of Barnstable Regulatory Services Richard V.Scali,Director. %639. ► Building Division Paul Roma,Building Commissioner 200 Main street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder ILeaq M , C�, 1()-Y , as Owner of the subject property hereby authorize IU�aP to act on my behalf in all matters relative to work authorized by this building permit application for. J37 A IdCe, -fir o Ileffla. ,G S-� v (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. S ture-of Owner Signature of Applicant Z,-eon W I",, '(e 1 V mrl /t�-� Print Name Print Name . Date Q:FOR.MS:O.WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services px Richard V.Scali,Director Building Division > . t Paul Roma,Building Commissioner KAM i639• ��i� 200 Main Street, Hyannis,MA 02601 Ep www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER":_ name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-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 requirements. Signature of Homeowner i 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 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 forms\EXPRESS.doc 06/20/16 Town of Barnstable Q� 5 hz# Regulatory Services ` Thomas F.Geller,Director ` MASS 'g Building Division 639. Tom Perry,Building Commissioner 200 Main Street, Hyannis;MA 02601 www.town-barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# � FEE: $ SHED REGISTRATION 200 square feet or less Location of shed(address) Village sod 77e= 1V1/' -� Property owner's name Telephone numbercv - fug pos Y X Size of Shed Map/Parcel# Signature �)/ v Date Hyannis Main Street.Waterfront Historic District? �> Old King's Highway Historic District Commission jurisdiction? Ao If over.120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3-304:30 PLEASE NOTE: IF YOU ARE WITgIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE, PLEASE SEE THE APPROPRIATE COMNIISSION FOR DETAILS. TIIIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN . l Q-forms-shedreg REV:05201 t AAH PC 1y•40 jF N 7 10.00 LET 82, r 20, 9p0 N , 1 t ti °off , r � 3 �4• yo . � o :�4 Q` z ♦��y°h, von 75.57 N 86'43,50"l✓ PLOT TO THE BEST OF MY KNOWLEDGE. THE PLAN OF LAND BUILDING SHOWN OM THIS PLAN IS AS. L OCA TED IN. . IT ACTUALLY EXISTS AND CONFORMS TO BA PNS TA BL E MA SS THE ZONrNG REGULATIONS IN T ,N OF BARNSTABLE. REGARDING YA TBA `S", PREPARED FOR DATE:AUG.12. 1998 / DAV;C JOSEPH SULL I VAN i i SnFJi ;Ki S. l ;# DATE.'AUG. 12, 299B SCALE' ? "=40 FT. aP FLOOD ZONE NON—HAZARD CAPE 6 ISLANDS ENGINEERING D-62 B2C �tik LA;'_ �" MA SHPEE — MASS. . U } , _ . :mac ► bzz�-`f F�► r Town of Barnstable *Permit# �p Expires 6 mo the fr ue date Regulatory Services Fee . • EARNSMELE • ` 9c� 6 9. Thomas F. Geiler,Director (� m f �lED MA't a Building Division Tom Perry; CBO,_ Building Commissioner 200 Main Street; Hyannis, MA 02601 _ www.town.bamstab le.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL-ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 31 c2 4%L--0 s 57 l LLB ❑Residential Value of Work � Minimum fee of$35.00 for work under$6006.00 Owner's Name&Address �©S� �QLL-1VA%,4 S'A ME Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ". "PRES PERMIT ❑Workrnan's Compensation Insurance . `PR f 901.` Check one: ❑ I am a sole proprietor TOWN OF BARNSTAF3L . �1 am the Homeowner ❑ I have Worker's Comperisation Insurance , Insurance Company Name Workman's Comp. Policy# # Copy of Insurance Compliance Certificate must accompany each permit.: Permit I�uest(61ie6k box) ❑ Re-roof(stripping old shingles) All construction debris will be taken:to ❑Re-roof(not stripping. Going over existing-layers of roof); [rRe-side #of doors ❑ Replacement Windows/doors/sliders, U-Value '(maximum :44)#of windows *Where required: issuance of this permit does nofexempt compliance with other town department regulations,ix.Historic,Conservation,etc. ***Note: Property Ownei.must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required: SIGNATURE: Q:IWPFILESTORM _building permit formslEXPRESS.doC Revi,aeri n701 1 fl r The Commonwealth ofMassachusetts t ,; I Department of Industrial Accidents x� T d Office of Investigations 600 Washington Street Boston, MA 02111 \c- www.mass.gov/dia . Workers' Coin&nsation Insurance Affidavit: Build ers/Contractors/Electridans/Plumbers Applicant Information Please.Print Legibly Name (Business/Organization/individual): Address: City/State/Zip: t '�J' i V= 83 2-- Pkione #: Are you an employer?Check the appropriate box: Type of project(required): 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers' comp. insurance 5- ❑ We are a corporation and its �quired.] officers have.exercised their. 10.❑ Electrical repairs or additions 3. l am h homeowner doing all work right of exeption per MGL 11.0 Plumbing repairs or additions myself. [No workers'. comp. c. 152, §1(4),and we have no 12.0 Roof repairs . insurance required.]:t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicatingthey are doing all work and then hire outside contractors inust submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy 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 yerification. I do hereby ce ify under thepqyns d penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area;to be completed by.city or town official City or Town; Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. Cityfrown Clerk .4. Electrical Inspector=5: Plumbing.lnspector 6.Other r ,,+o Phnne#- A 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 in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons'to do inaintenance,'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 bean employer." r MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or,to construct buildings in the-commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than thb members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the 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. Y g Y g PP Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. 'The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations' 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.govldia ���Txe ray Town of Barnstable �w o Regulatory Services Thomas F. Geller, Director risers. gb 16.g. ,�� Building'Division PrIF µa{t Torn Perry,Building Commissioner. 200 Main.S2reet,_Hyannis, MA 02601 www.town-barnstable-ma.us Of if ce: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION // Please Print Ios LOCATION: nun er street p village '.HOMEOWNER": l ; ��4Q0 S8 770 — Sf 5- name home phone# work phone# CURRENT MAILING ADDRESS: A L— city/town state rip code Tbc current exemption for"homeowners"was extended to include owner-occupied dwrellinys 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 BOMEOWNER person(s)who owns a.parcel of land on which he/she resides or intends to reside, on which.thcre 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 constrgcts 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 umdcrsigncd"homeowner"certifies that,he/she understands the Town of Barnstable Building Department min; um inspection procedm:es and requirements and that he/she will comply with said procedu=es and requirements. atirrc f Homc Approval ofBu�lding.OrTicial 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 EX-MM6X -The Code states that: "Any bomcowner perfom-jing work for which a building perrnit is required shall be exempt]Term the provisions of this scction_(Scctian 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner amgagrs a parson(s)for biro to do such work,that such Homeowner shall act as supervisor." Many homcowncts who use this r=zption arc unaware:that they arc assuming the responnbilitirs of a supervisor(see Appendix Q, Rules&Rcgbladons for L crsing Construction Supervisors,Section 2.15) This lack of aw =css often.results in serious problems,particularly whcn the homeowner hires unlicensed persons. In this case,our Board cannot procccd against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervsor is ultimately responstblc. To ensure that the homeowner is fully aware of his/he7responnbilitics,many communities require,es part of the permit application, that the homeowner certify that Wshe understands the responsibilities of a Supervisor. On the last page of this issue is e.form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. T T ti Town of Barnstable o Regulatory Services + LIRNSLIBL� ' ` $ Thomas F. Geller,Director - J6 Building Division' Tom Perry,Building Commissioner 200 Main Street;Hyannis,MA.02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-190-6230 Property CNviier Must , Complete,arid Sign This Section - If Using A Builder I, ,/asr subject.property hereby authorize to act on my behalf, in all matters relative to work authorized by this g permit application for. (Address f job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete. the Homeowners License Exemption Form on .the reverse-side. �r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit#STA Health Division V`f c pl q Date Issued 1 I )00Y Conservation Division �� a " `r Application Fee uC/ Tax Collector Permit Feel—�� Treasurer w _«;;ISI,(It4 Planning Dept. �`�--- �-- ""aISTINO SEPTIC SYSTEM Date Definitive Plan Approved by Planning Board 1IoW1ITE®TO3#OF BEbR00MS Historic-OKH Preservation/Hyannis Project Street Address _ 1/t4L.Village I n Owner WX/�Z e/11../✓� Address 197 Al/w_5 g4 Telephone 7 M . �SS Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiorf Ba Construction Type Lot Size 5�7Q , Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. Dwelling Type: Single Family CT Two Family ❑ Multi-Family(#units) Age of Existing Structure /ZJ • Historic House: O Yes o On Old King's Highway: 0 Yes C� Basement Type: 'FUII ❑Crawl ❑Walkout 0 Other Basement Finished Area(sq.ft.) AID Basement UnfinishedArea'(sq.ft) �84a Number of Baths: Full: existing _0?_ _new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: hdGas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes 2rNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes ffgo Detached garage:0 existing 0 new size Pool: 0 existing ❑new size . Barn:0 existing ❑new size Attached garage:g-e*xisting ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded❑ Commercial 0 Yes CNo If yes, site plan review# - Current Use 14 ecs/�-' toj-L' Proposed Use BUILDER INFORMATION Name_/4�- ossrlww,,l Telephone Number 2 S N 11 �� r Address l� �4✓ 4, License# Home Improvement Contractor# I Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO W 141 SIGNATURE — DATE A0 I M FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED t-' J' if r : fi } . it _ - {.• s°�' MAP/PARCEL NO. s�` ~' ,'t� •rL � '•, •, f lam_ .*';:. ADDRESS - } ;'VILLAGE OWNER `¢• ^: t.w,' ; DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL' ..- PLUMBING: ROUGH _ FINAL i GAS: ROUGH FINAL'.' FINAL BUILDING 4- � rr DATE CLOSED OUT W , ASSOCIATION PLAN NO. n I-- { � U r E: fJ ' j z _ The Commonwealth of Massachusetts Department of Industrial Accidents �, _ - 600 Washington Street - x� Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit-General Businesses , o, P ��� r ..������� F ��� �� awe: - - ���•��,.�.: •- .� -� • .. �. • " address: .• A) �'� � '$Z' d3Q 0WIte state: nR . c� Sf w site location full address: I am a sole proprietor and have no one Business Type. []Retail❑Restaurant/Bar/Eating Establishment working in any capacity. ❑office❑Sales(including Real Estate,Autos etc.) ❑I am an eta Toyer with em to es(full& art time). ❑Other //1///////%/=10 //////%///�/%%///%/ � � �//%%///�////� / / / I am an employer providing-workers' compensation for my employees working on this job; com anV�nemC: • _`.,.•_ ;4y,,:;.. "�• .. '' ' hone#• •' • 1100� city: ' • .; . .. .. .. .. .�, .�:°- . , �] I am a sole proprietor and have hired the independent contractors listed below.who have the following workers' compensation olives: com-en name: siddressi. '. Insurance co. - "•fir: ''(:�-(. •.1• .. /. com'an.,name: •• .. i address: ciivi hone# olici#. j •... :• :....:• ,5, VM i required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or Failure to secure coverage as requ one years'imprisonment as well lties in the form of a STOP'wORK ORDER and a fine of$100.00 a day against me: I understand.that itcivil pena copy of this statement may be forwarded to the Office of Investigations of the Dlkfor.coverage verification. I do hereby ee un r ih aims and penalties of perjury that the information provided above is true an corn O 5i�ature i� � Date p n Punt name OSJ� Phone# � J.- -�,"-,• ..� 'r�"',_., -rt¢w,.a,r�_ •Wiz.•;Tree.: VR. otTidA use only do not write in this area to be completed by city or town official permlt/license# ❑Building Department city or town; ❑Licensing Board QSelectmen's Office check if immediate response is required []Health Department phone contact person: #; ❑Other (revaed Sept 2003) - .�suKeif3lL.� n r�" .•-.t yL. 'i yL a, Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"laws', an employee is defined as every person in the service-of another,under any contract of hire, express or implied, oral or written. An employer is defined as an indirndual,'partnership, association',corporation or.other:legal entity, or any two or more of engaged in a ioint enterprise, an the foregoing d including the legal representatives of a deceased employer,or`the receiver 'or trustee of an individual, Partnersh'P, association or other Legal entity,eir�ploying employees. However the owner of a dwer-ing 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 sha11 vfdthhold 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,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting _ authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, 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 listedbelow. 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 perrrrit/license number which will be used as a reference number. The affidavits,maybe returned to ., the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would hlce t_o 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 Unke of Ims9gatlons 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.'406 . k OFZHE ram, Town of Barnstable h Regulatory Services BARNUABrs, Thomas F.Geiler,Director 9�A059. A`0� Building Division ! rfD MAy I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 � Permit no. Date AFFIDAVIT HOME IMTROVEM[ENT 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,efher requirements. .o Type of Work: �� � Estimated Cost Address of Work: IL L,0_3 Owner's Name: Q f Date of Application:_ d/ D I hereby certify that: Registration is not required for the following reason(s): OWork 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 UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY Wpply for a pe t as the agent of the owner: Contractor Name Registration No. OR Date Owner's Name Q:fomis:homeaffidav r RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings $100.00 Residential Addition $50.00 _ Alterations/Renovations $50.00 D `� Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE -� square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIOONS/RENOVATIONS OF EXISTING SPACE 60 square feet x$64/sq.foot= x.0041= 7 plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0041= ACCESSORY STRUCTURE>120.sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$94Lsd.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.0.0= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee Projcost Rev:063004 r 790 CMR Appendix J ' Table JS.Zlb(continued) Prescriptive Paekages for One and Two-Family Residential Bnildings Heated with Fossrl Fuels MAXIMUM MINIMUM Glazing Glaring Ceiling Wall Floor Basement Slab He Arta'(%) U-value= R-value' R-value R-valuer Wall paimeter Equipment Efficiency' R-value° R-valuW Package 3701 to 6500 Hating Degm Drys' Q 12% 0.40 38 13 19 10 6 Normal R 12% 0.52 30 19 19 10 6 Normal S 12% 0.50 38 13 19 10 6 85 AFUE T 15% 0.36 38 13 25 N/A N/A Normal U 15% 0.46 38 19 19 10 6 Normal V 15% 0.44 38 13 25 N/A N/A 85 AFUE W IS% 0.52 30 19 19 10 6 85 AFUE X 18% 032 38 13 25 N/A N/A Normal Y 18% 0.42 38 19 25 N/A N/A Normal Z 18% 0.42 38 13 19 10 6 90 AFUE AA 18% 0.50 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: _____ 3 7 Cam.✓��� 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: !% I / 4. %GLAZING AREA(#3 DIVIDED BY#2): L lO O/0 5. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f980303a I 780 CMR Appendix J 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 ft 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 R49 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. `The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must mcet the same R-value requirement as above=grade walls.,Windows and sliding glass doors of conditioned bz,,sements must be included with the other glazing. Basement doors must meet the door U-value requirement described 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 more 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 J5.2.1 a • NOTES: +0 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 or 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 average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 u Town of Barnstable Regulatory Services BMrtMetEMUM Thomas F.Geller,Director A`e� 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 ABuilder I t1� SJ LLt VATnl ,as Owner of the subject property hereby authorize 7V Ay �Os�S AEI to act on my behalf, in all matters relative to work authorized by this building permit application for: ozC-3 2 (Address f Job) igna tof er Date 5'-"LLr✓'4N Print Name Q-.FORMS:OWNERPERNnSSION I Results Page 1 of 1 Home Improvement Contractor Look Up Enter Search terms separated by spaces. Search terms can be Town/City, Name, or License number Select Search type: OF, AND r OR S earchr ' Search Results Reg..No. Applicant Street City State Zip Name Title Expirati AGING IN 89 PARK SM 137960 PLACE �CHELMSFORD[MA [ ON 0118 ROSAN, 24 JSM OWNER 1/30/20( -RAY 5 DOVER ROSSMAN, 138686 SANDWICH MA 12563 OWNER 5/1/20Q� ROSSMAN DRIVE RAYMOND r 126046 ROBERT 38 FAIRVIEW WINTHROP MA 02152 CROSSMAN, Owner 4/13/20( CROSSMAN ST ROBERT TOKEN 440 Soule Crossman 101214 BUILDERS Rd Wilbraham MA 01095 KENNETH Owner 6/25/20( INC. Total of 4 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.us/bbrs/hic.pl 11/8/2004 f BOAR r D pF 8UI G, iLicense OpNSTRUCTDIOG REGUI-AA'L Ns Nu►rmbe `+ N SUPERVISOR - R esort -� �-YMON®P � 5 Tr.no: 17711 5DpV RO SAND,W C S T \ .� r- H MA 025 `� j Acting g :_._ mis o'ner F - n AA '� rA CAI �► z y ; j ` j • �` t Iz- i � � t z ; fi t TJ :. W nCIA t, c i __ j - �. � � j # /� 111 '' �"' � '. t � � _...�.._._,.a.,,--...-�,�__.. a.,,,�-.r--�---,.. �. Engineering D rd floor) Map o� - ' Parcel �`� ?, P4J Permit# ' House#• V3 7 ra . Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) (� e Conservation Office(4th floor)(8:30- 9:30/1:00 2:00) - Planning Dept. (1st floor/School Admin. Bldg.) �tME Definitive Plan Approved b Planning Board 19 SEPTIC ST BE 'INSTALLE LIANCE TOWN OF BARNSTABLE� wIT 5 ENVIRON Bui�ing'"Permit Application �1 NTAL CODE AND Project Street Address •'' l.0� Village 1L,74fxJ e2 Uf e Owner 5w/1 c �� ��/ '`� Address Telephone,-- Permit Request1.74 e, First Floor do V a o Si square feet Second Floor square feet Construction Type MOB III p2 P '2x V 6aa Estimated Project Cost $ 800 Zoning District ty\U- , Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family f�Two Family ❑ Multi-Family(#units) Age of Existing Structure ,)7 (/1'7/ Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: Q4Ul ❑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 3 • New Total Room Count(noZiinclu ing baths): Existing��New First Floor Room Count Heat Type and Fuel: ❑Oil ❑Electric ❑Other Central Air ❑Yes pN-o- Fireplaces: Existing New Existing wood/coal stove ❑Yes Q-PV- Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size)02`/X. ❑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 fo,nnation Name ) qo>O�A O 'Telephone Number Address License# Home Improvement Contractor# /(? Worker's Compensation#, NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. vt ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE /�,(�/�� /�. DATE UILDING PERM,• DENIED,FORjTHE FOLLOWING REASO S 2C . v e , N FOR OFFICIAL USE ONLY _ re PERMIT NO. ri _ TE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: i FOUNDATION FRAME } ++ 4 INSULATION FIREPLACE F l ELECTRICAL:t ROUGH i FINAL PLUMBING: ROUGH: FINAL r) .:, + GAS: ROUGH$ e FINAL' + ' FINAL BUILDING DATE CLOSED OUT n :E Rt 05 ASSOCIATION PLAN N04 t+I - m r I . The Commonweidth of Massachusetts002M Department of Industri&I Accidents . .....=Ila ffieff oil 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location: city phone# 0 1 am a homeowner performing all work myself. C3 I am a sole netor and have no one working i 5MV C2?a tv VIIIIIIIIIIIIIII14 V111110111M 111 P/1 111 1111,0/1 11 11"111 1 C3 I am an employer providing workers' compensation for my employees working on this job. cam i)nnv name: address: city phone#: insurance co. V0HcV# C3 I am a sole proprietor, general contr2ctor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' cbmpcnsatian.policcs: ........... conivany name: Q-7.0 WtAL Q�P,041 A? Pe�S address- dt v hone y 4 in s.urnnce cm, . .. .......... ............. compaity name, address: city phone M insurance ca. T FaUnre to secure coverage as required under SectioFSA MM L 152;�1 imposition .for. f�STOP WORK one years'Imprisonment as well as civil penalties in 0 =;=Rp. copy of this statement may be forwarded to the Offlce of Investigations of the DIA for coverage verification. I do hereby cerd^under the pains and penalties of perjury that the information provided above is true and corrccit fGj Signature_ V,4/( �3( Date. Print name A��Vx 61 Phone# offld-I use only do not write in this area to be completed by city or town offldal dtyortown: per udWcense 0 Mudding Department LlUcensing Board ❑checkifininted—iate response is required Melecunen`x OMceCOHneauinh Departineumt contact person: phone 0. ❑Other_ .. ... ............... ........ UrAma 9195 PJA) a 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 colr= 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. 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 o. a:.Wer^,::o eM"i^"r.,prannc tan do maintenance , construction or repair work on such dwelling house or on the grounds 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 renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha 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. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation nd be supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may 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 licy,please call the Department at the number listed below. lis below. are required to obtain a workers' compensation po 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 is 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. The affidavits may be returned t^ the Department by mail 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. NONE i/ The Department's address,telephone and fax number- The Commonwealth Of Massachusetts Department of Industrial Accidents 0111ce of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 a , The Town of Barnstable MAM � Department of Health Safety and Environmental Services Building Division 367 Main Stress,Hyammis MA 02601 Office 308-790.4=7 Ralph CxosSen Fax: s08-790-6Z30 Building Cammusioz: For office use only Permit no._ Date AFFIDAVIT SOME IMPROVEMENT-CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL a 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 czccptions.along •th other requirements. d Type of work: ' •� � Est.Cost Address of Work: / r Owner's Name Date of Permit Application- O :/� — i hereby certify that: Registration is not required for the following reason(s): Work ezciuded by law Job under SI.000. Building not owner-occupied Owner palling own permit Notice is hereby given than: OWNERS PULLING THM OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR RBITI APPLICABLE PROGRAM OR GUARANTY FUNDWOR'C Do NOT UNDER MGL r 142A � ACCESS TO THE ARB ALTIES OF PERJURY SIGNED UNDER PEN I hereby apply for a.pe it as the ag t of the owner. 4a�/� te Contractor iY a Registration No. OR Owner's Name Daze 73004RAppawkj Table J=b(eoadaaed) pmailldve Padngm for One and Two4hmilr ReatdentW Building Hated with F Fneb MAXIMUM mmmuM alaaug Glazing Ceiling Wall Floor Basemeat Slab HadnwCooling Ana'('h) U-value= R valuer R value' R-valued Wall �1mem �1C[etae pie RrvalI Revalue' 5701 to 6500 Hadng Degree Dare' Q 12% 0.40 38 13 19 10 6 Nommi R 12-A 0.52 30 19 19 10 6 Nomml S I29A O30 38 13 19 10 6 85 AFUE T 15% 036 38 13 23 WA WA Nomud U 1 5% 0.46 38 19 19 10 6 Normal 01 Y,_ 13�%i i�.4r. Aff �a. 01 W Is% 032 30 19 19 10 6 ES AFUE X IgVe 032 38 13 25 1 WA WA Normal Y 120/. 0.42 38 19 25 WA WA Nomml Z 129/. 0.42 38 13 19 10 6 90 AFUE AA Ir/. 030 30 19 1 19 10 6 90AFUE 1. ADDRESS OF PROPERTY: 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: %� 3. SQUARE FOOTAGE OF ALL GLAZING: e� 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-t980303a 780 CMR Appendix J Footnotes to Table J5Z.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 ft of glazing area. =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 R49 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 wridliiulled J GI:G auu laic vcut au.0 Yv uvia of tl:e^0f.'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. ' ion of an individual basement wall with an average depth less than 50%below grade must The entire opaque port y walls. Windows and sliding meet the same R-value requirement as above-gradeg glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described 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 more 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 J5.2.I 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 or 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 average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 DEPARTMENT OF PUBLIC SAFETY e}} Al d CONSTRUCTJO.k,,SUPERVISOR LICENSE Nulil r Expires: --- Restr� tedTa 1G GAEGORYI PETERpS 199 M fk-ST." MASHPEE, MA 02649 15 '- ONE IMPROVEMENT bcONTRAC.DR tstr ioo-ozyp 38 { Y � INDIVIDUAL. F upfrad JOS'EPH Afr�pETERSe� r �� � ap EE MA..01649� ADAAIN TpT t,,, F N 79•19,40"E 210•00 2 L.0T B 20, 100 SF F ••55b� co in cm3¢ o Q 0� 75.57 A N 86'43'50-jr "TO THE BEST OF MY KNOWLEDGE, THE PLOT PLAN OF LAND BUILDING SHOWN ON THIS PLAN IS AS L OCA TED IN IT ACTUALLY EXISTS AND CONFORMS TO BA INNS TA BL E — MASS. THE ZONING REGULATIONS IN T _ ,N OF BARNSTABLE, REGARDING YATBA 'kS" PREPARED FOR ' DATE:AUG.12, 1998 � �.\ °AVID JOSEPH SUL L I VAN j� CH„FILES „ i3 SkNicL ! 6 DATE.•AUG. 12, 1998 SCALE: 1"a40 FT. - - - - - - - ==� ,zsc!�.s.l 44. FLOOD ZONE NON—HAZARD — ��4 CAPE 6 ISLANDS ENGINEERING D-61 B2C MA SHPEE — MASS. a b SHEET NO. NEW ADDTTION FOR THE R69DENCE OF: n � a I 0A.00 ryR���MOVES MR. AND MRS. JOSEPH SULLIVAN NonWSVIN Ul10a�1ES CENTER7,LLE.MASSACHUSH= 061GN5-NURDWG-RFJlOVATIONS m c �= 7 WTNDSONG ROAD FORESTDAM.11A. 026" I-000-211-1202 &r.04695 s, NEW ADDITION ROOF' RIDGE TO MATCH MAIN HOUSE RIDGE IN HEIGHT EX ISTING HOUSE I \ /I EX HOUSE 1 NEW SCREEN PORCH 1 ROOM TO BE DETERMINED BY OWNER 001 I I I I I I I I I I I I I I I I d I I I I I I I I I I I I I I I I +—IO oM coNc.f1LLFD + I I I I I I I I I f SON OTUSES(T19.)FOR I I I I I 1 1 I I I I I I I ALL DECK POSTS.WfTH d I I L J L J A WIN.DEPTH OF V-0' _L J L J L J L J I I I EELOW GRADE I I I ---------------J `--------------------------J REAR ELEVATIOI�L(NEW ADDITION) RIGHT SIDE ELEVATION (NEW ADDITION) SCALE: _ ,•_0. SCALE: ,�,- _,'-V ALL NEW TRIM ECARDS SHALL MATCH EXISTING (TYP.) EXISTING HOUSE \ W.C.SHINGLES S.TO WEATHER .. (T'RJ I I I I I I I I i I I I I I I L-----------------=--------y L-------------------------- -' F'FT SIDE EL T VATION (NEW ADDITION) 1 _ suLE: v-� r-o- f N z n W ZO N n ZO'-d N I C14 C14 1 q 4 I I 2x8' 1 O.C. �iC4 I i N II I I o SOL K $ II I o D s AN n '� �x I RQ gas,0� .. I II 1 I $ o I o € o z ICI» I baQo I.- n a a Q v piq' I I oAz� o xs I b 1 Q mp"09 P a 9 AQ II� I I $off$ Fn I 4 Wo oa mho o M122 II l i yio� 1 �oAiN Z ociti II 2 �Ec Nmo <i p � Q '1 V-d 6'-d 8-d 4-d t�s p8 z E9 IN ? d a ng - It ._a.. 0 Sg o im Q • Q� n A Z Q z m y z 0 CI � m JOB N0. 9813 . DRAWN BY: B.KAM - CNECKED BY: DATE: JUNE 19.1998 SCALE:1/P - 1'-T V • I I i I a 1 O Z N O � C m � o cri i `o I iND.WALL TO MAT EXISTING IN CLG.HT.TO MATCH AW r EXISTING Of M HOUSE \u ;Rol, g a •f; N x GPM ti� 214 .gig -ON ]Z A pr O 1 N O AAm NO m I o n 5 •• i 2 I- F cl i •l yN O �� O I. C N 9 r � I — I o o I U-N N a x m � b gg p F, 0 m C Ym Z m z n In I yo i ti \N I ♦o I I JOB NO.. 9813 . .. ORAWN BY: B.HART CHECKED By, DATE NNE 19. 1998 . - SCALE:VARIES x 0 r e�Pyof7NE TOWN OF BARNSTABLE BAHB91'AFILS, i 639. BUILD109. INSPECTOR APPLICATION FOR PERMIT TO *Fal.. i... l�raM.l ���� � .................................................. TYPE OF CONSTRUCTION .......V1R-e-- ... ..! ................................................................................... r... ....................19.�!... _ TO. THE INSPECTOR OF BUILDINGS:, The undersigned hereby applliiets four !a permit acc-o}rding to the following information: Location 1,0t.t.3.)..........Lie.l I.Q.46......s4,-:�e1.......... . e/.�.V.a&. ..................................................................... ProposedUse ....... .. ...... ...... . ..... . ...... ?!`........................................................................................................ /� -� i Zoning District t.p - ................................Fire District .&na,, uws -. ` �,1 Name of Owner .S.Z.1 ~ � .....Address . �7.14....4��4s . �v1M.l��.c................. Name of Builder \`ovkl'.R iJ...ccmzi Q� . ....Address ?... New -� ............. .�� �� . C�....� .�4' W..... Nameof Architect ...........�f ?t.l.......................................Address .................................................................................... Number of Rooms �. .......................................................Foundatior,-4VJI.. .....R \ Exierior .`!��./.. ... .b........ Roofing ......... ........... Floors ....Q ....................................................................Interior .....-�F'v�! c............................................. Heating �..�.a.Ake..............�.(ir.....................................Plumbing ............ ..... .! :!".......................................... Fireplace U ......��0. U-►a ..........................Approximate Cost ...... .,.A' t?"V........................................ Difinitive Plan Approved by Planning Board ________________________________19________ . Diagram of Lot and Building with Dimensions �-�° • IN SEWA�' .1_I-EE� U5T OB R Fd. OPO Mc7U 0 NS p�,TH SED 1, � � A0r� D�S�OSA1- SAN AN RAINAGF:..15 AR OF BEAN I hereby agree to co arm to all hpku• pa4>�' a tions of the Town f Barnstable regarding the above construction. R1rrs�f �� Q Name ^'`.. d L% f Sappet, Nor. & Mrs. Charles L. � 1 60 ®EC n1 197 No 19 I 3 5... Permit for sto17, ....................... I 1 1 simle family dwelling Locationt. ..Child.s..Str..e.et ............................ ..... .......... .. ...... .... i ......................del?terville................................ . 1 Owner ............xr..........X'.�e.......arles ...S...P.Pet; ........... a 1 Type of Construction ...............frame................ f ........................................................ ................... Plot ............ ........ . Lot .......#32.................. 1 � � Permit Granted .....February 4 71 ............................19 Date of Inspection ....................'.................19 I Date Completed ...1.:1.:..71 e .....19 I - 1 �d 3� PERMIT REFUSED ................................................................ 19 ............................................................................... .................................................. ........................ ............................................................................... Approved ......... ...................................... 19 ............................................................................... ............................................................................... J