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HomeMy WebLinkAbout0013 CONNERS ROAD 0 G 1 a , C SIZyi/o able �FPerm 3 °fi r ' Town 0f Bar�nstG � it#P� 1 Expires 6 months from 'ss ee date Regulatory"Services Fee + HARN5TABLF - r� Thomas F. Geiler,Director Building Division Tom Perry, CBO, Building Commissioner. 200 Main.Street, Hyannis,MA'02601. www.town.barnstable.ma.is Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION . - 'RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number CC Q r Property.Address [ esidential Value of Work 6_000, " Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address tFf�C I i o I�iJ '+a yt ` Tele hone Number 50 ( Z /7 Contractor's Name �' P Home Improvement Contractor License#(if applicable) Construction Supervisor's License# (if applicable) sr�, ❑Workman's Compensation Insurance Q Z010 Check one: ��� . I am a sole proprietor ©'')ram the Homeowner 'TOWN OF .ARNSTABLF ❑ I have Worker's Compensation Insurance Insurance Company Naive Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit: Permit Request(check box) Re-roof(stripping old shingles) All construction debris will,be taken to - Re-roof(not stripping, Going over .1 existing layers of roof) ' side #of doors Replacement Windows/doors/sliders.U=Value.; (maximum .44)#-of windows *Where requ red: Issuance of this permit does not exempt compliance witfiother 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 ,,. equ" ed. f a + SIGNATURE.. y , The Commonwealth of Massachusetts Departrnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 wivw.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl UU � y Name (Business/Organization/Individual): �( j l� �t) ( /v 14 144-1 er Address: GO 0 17 &-k2 5 lea City/State/Zip:06" ' , O -06 Phone #: r 6 2- — R ? 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 6. ❑New construction employees(full and/or part-time).* have hued the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Ne4,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.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.59.1 am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions right of exemption per.MGL _._ myself,.[No.workers._cotnP,..... _._._.._....._..._...._._.._...... 2 .. ...__12.N]_Roof.repairs............ .. ... _ insurance required.] t c. 15f, §l(4), and we have no employees. [No workers' l3.❑ 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 th pains andpenalties ofperjury that the information provided above is trite and correct. Si nahue: ✓`�� Date: Phone# J�CY'6 — ?j�oZ �f?,—n 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Phnne#- Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for.their employees. Pursuant to this statute, an eniployee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair.work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into 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 the ^'Tmembers or par[ner's,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 retumed 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 nuunber. 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 homeowner 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 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 4-24-07 www.mass.gov/dia V Town of Barnstable P�oF�rte r�� o Regulatory Services anaxsrasr> Thomas F. Geiler,Director 7� '"�: ,�� Building Division pTED MA'I A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ` HOMEOWNER LICENSE EXEMPTION Please Print DATE: —(O ( (C] JOB LOCATION: \ 1--) C6210 C 0& -- number street village ..HOMEOWNER": 10 if-11 E� 91- -34 Z-)7-I-) '36,z i I T7 name V home phone# work phone t/ 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 require e Signatur o Ho eowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127,0 Construction Control. HOMEOWNER'S 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 fomr/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC 3 •y <; OF THE royq Town of Barnstable YT Regulatory Services IARN5TABI.E, ' Thomas F. Geiler,Director v Mnss. 039. ;. Q Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 ww vy.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I as Owner of the subject Property, J 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 If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:0 W N ERPERM IS S I ON DURABLE POWER OF ATTORNEY r+= I , Mary E.' Burlingame, of Barnstable. (Centerville) , Massachusetts, appoint- my son, David. B. Burlingame of Barnstable b S.i �;�s: (Cummaquid) ,Barnstable. County;. Massachusetts as my attorney, to conduct all my affairs, with full power and authority to. act in my name and on -my behalf as fully as I could do if personally present . Without limiting . the ' .generality - of my, '-attorney' s powers, I ` s specifically authorize my attorney to do the following: 1.. -To manage and have the general, control' and supervision of all my property and interests in property, . real or' personal, gi tangible or' intangible, ' including .power to buy, sell , lease and mortgage: u 2 . To maintain bank .accounts for me in my name, or. in .the name of my 'attorney, and to make., deposits or withdrawals of money 1 belonging to. 'me in such accounts and to, disburse any .money s from such accounts on -the signature of my attorney. 3 . To pay all my bills and to expend funds for any purposes. which ,u, my .attorney deems for.: my benefit.. . s; 4 . TO collect; demand and,* receive any income, interest:, dividends; rents; 'profits or other property due or.payabl'e to a me . ' 5 . To borrow money', on, my behalf, to execute contracts on my behalf and" to execute' on my behalf any other deed or, instrument, in. my name or, in the name of my attorney, which, in the discretion of my attorney, appears to be necessary or advisable in the management, °of my affairs . 6 . To have access " to all .safe `deposit boxes in my, name and. the ` i right to remove their 'contents : ; K 7 To P ` repave or have prepared` and to sign -tax returns of anyY ;sort on my .behalf . 8 . To prosecute or defend or submit to arbitration any claim by or against' me or' my property and to receive and give full or partial releases. of any kind. 9 . To transfer funds or property ofn mine to, any trust established by me, whether before or after the date of, this instrument . 10 . To do any of the .foregoing in Massachusetts or elsewhere in the United States of America. No person dealing with my attorney shall be required to see to the application of any funds or property paid or transferred. to my attorney. Any person may' rely 'on this power of attorney or a. copy of it certified by. a notary public until 'notified in• writing, of its revocation. I 'nominate David B Burlingame as my conservator,' guardian' of my person and guardian of my property 'shoul°d the need arises'ink the future for the appointment of any such fiduciary' for the protection of my person or estate . I intend that this power of attorney shall not be affected by . my subsequent disability-or ;incapacity. IN WITNESS WHEREOF,. I hereunton set, my h-and and seal this day of November, 2004 t '�', •++44''i 7'!� . ..cl.cx c' � s. u'., r+":rr�� i'�y fi r��`Fyn• f' Ea s r y °'k.>•'K ie:f ,, -r+}�.7� { .ce-'r' ?} Ra ''4'� t. t,.,,,.a y'M". / e xJ i -.r'ep. 11' •i . I ,1. � � 4-'. tYGI. t k ii,F: Y i 1„ 7! t • b COMMONWEALTH OF MASSACHUSETTS Barnstable, ss ,November 2004 Then personally appeared the above-named Mary E . . Burlingame, known to me personally, and acknowledged t e foregoing instrument to be her free act and deed, before me, �. Notary. P ,blic My.Commi sion Expiresc� ,' 2'u �} .? �ii�_, t '7 ��-'fit 3 h..f::�:- .� ..� ,+ -..��s i��2?:'. sil1.?�=f'1�I h..7;3 7 .�. � s ::, � w �3 4.,�y h tC r� "f�l -.'_}I• l �'C� '�. { �3 ;.h �3u}: �. �."3: s _S ,1 t 6 yn 3.0 ts...,(�'F9.{..� 4 i �C a.� r. i S r u t fa.l� ,_N it 5 j i tx., u4y.},igti`� e°�:`• tom' •.Yi��h..: u,,...,._._,_ -?.�.,� C.�.L..u.sru_.�.u.�M.a_ �..,a...w,....a..,�,_..a..Lu:.�:�,a.W_�r.�:L.4.3�,L..,.�._...�,ar ,.,. f * ao � Town 0f Barnstable Per �tt�" asYl� y Expires 6 i the frsue date Regulatory Services Fee . IA.RNS-rASLE, Thomas F. Geiler, Director v rtass . g ODk �p 1639. Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www,town,barnstable.ma.us Office: 508-8624038 Fax: 508r790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY . Not valid without Red X-Press Imprint Map/parcel Number (3 ' Property Address Jj Coil1�l esidential Value of Work_=0, 0 C� Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address J,)fit �/j��i t/1Gt A-W 4� n r i_ L Contractor's Name f Y7(Jt✓L/ ✓Lgl�l�� Telephone Number S 3/ z—/777 Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance _ Check one: ❑ I am a sole proprietor ��� �s� ���" �- am the Homeowner ❑' I have Worker's Compensation Insurance SEP 2 9 ZOOS Insurance Company Name TOWN n m nr BARN-STABLE: o�. r o OWVI'N yr D!'1Rt"dS ABLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. 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) reside ❑ Replacement Windows/doors/sliders. U-Value (maximum..44) *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 is required. 6 Z dS Qz1l Vq SIGNATURE: ' QAVYWILESTORMSIbuilding permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Irtdusfrial Accidents Office of Investigations 600 Washington Street Boston, M14 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contracfors/Elecfric' Print Le 'bl lumbers A licant Information Please Print Namr, (Business/ rtirxr;on/Individuan: 6Q�1\ VIZ(t 1 Address � _L�-L 19��� � • City/State/Zip: j �} d ?(� �_ Phone.#: 60 '36 Z 'j 77 Are you an employer? Check the appropriate bor: Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New mnstc-=tion employees(full andlor psrt-time).* havr hired the sbb--cont7idors 2❑ I am a sole proprietor or parfntr- listed on the aifached sheet 7. ❑Remodeling ship and have no employees These sub-contcactors have g• Demolition employees and have workers' working for me in any capacity. employees ❑Building addition . [No workers' comb.msTTanr_C Comp.insurance,$ r cd] 5. [] We arc a corporation and ifs 10-❑-Electrical repairs or additions 3, I am a homtawnLr doing all work . officers have exercised their 11.0 Phrmbing repairs or addon ttts myself; [No workers' camp. right of exemption per N1GL 12 ❑goof repairs insurance required.]t 1(4),and we have no employees. [No workers' 13.❑ Othcr camp_insunancc required-] *Any applicant that chccla box#1 roust also fiM out the section below ahoveing their worica�'compa�aE.mi policy information t Hw=wnere who submit this ef5davit in&Mfing they arc doing all work and then hire outside contractors must submit anew afdavitindirafin9 such. t--=tractors that ebmv this box nwat atiachcd an additional sheet showing the name of the sub-coofraLlnrs and state whether or not thosC cntitia have mnployas. Ifthe sub—.onhactDm have employers,they must provi&their wo+-='corn policy number_ I am an employer thaf is providing workers'compensation insurance far my emproyees Reraw is the policy and job site information. Insuranca Company Name_ Policy#or Sclf--ins.Lic.#: Expiration Datc: Job Site Address: City/Statr-/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to sr.=M coverage as rovind under Section 25A of MGL c. 152 can IeaA to the imposition of crimuial pcnaltits of a fine rip to$1,500.00 and/or•onC-year iinprisonmnnt,as well as civil penalties in the form of a STOP WORK ORDER-and a fi of up to S250.00 a day against the violator. Be advised that a copy of this statc=rrit may be forwarded to the Office of lnVnrtiRstim3s of the DIA for ins n=r covers e verification. I do hereby c fy u pa' artd pennide cf perjury that the information provided above is true and correct Si Phone O use only. Do not write in this area, tb be completed by city furs! or fawn officiaL City or Town: Permit/License# ls!gu n.g Authority(circle one): 1.Board of Health 2.Building Department 3. CRT[To ern Clerk 4.Electrical Inspector 5.Plnmbing Inspector 6. Other r� r Fva Phone#: Town of Barnstable �Op'fHE Tp�� o Regulatory Services - - - MST"LEI F. Geiler,Director v Mrs. g �P 0.19. Building Division TED 1u'�a Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 www.town.barnstable.,ma.us Office: 508-862-4038 F Fax: 5.08-790-6230 HO1 IEOWNER LICENSE EXEMPTION �} Please Print DATE: JOB LOCATION: 1-� ` Vl✓1 C,-4 number street C village "HOMEOWNER":��4 �?ot(nrA 1. SO�'3 . -1772 name �- 41 home phone# work phone# CURRENT MAILING ADDRESS: J C-011✓I L��G S I?J �{i K-4- l o biz 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 HOMEON'VNER 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 faun structures. A person who constructs more than one home in a iwo-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 require rgnature of Ho eowner Approval of Building Official . Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the. State Building Code Section 127.0 Construction Control. HOMEOWNER'S 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 parson(s)for hire to do such work, that such Homeowner shall act as supervisor." Many homeowners who use this exemption aie unaware that they arc 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 Hrith 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 hc/she understands the responsibilitics 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. rj oFVEr Town of Barnstable Regulatory Services BAHNSTAELF, ` Thomas F. Geiler, Director 059. rFo a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fak: 508-790-623 0 Property Owner Must Complete and Sign This Section rf Using A Builder l , 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 If property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. tl DURABLE POWER OF ATTORNEY I , Mary E. Burlingame, of Barnstable - (Centerville) , Massachusetts, appoint my son, David B. Burlingame of Barnstable s (Cummaquid) , Barnstable County, Massachusetts as my attorney, to conduct all m affairs, with full power and authority to act in m Y P Y Y "4 name and on my behalf as fully as I could. do if personally present . Without limiting the generality of my attorney' s powers, I specifically authorize my attorney 'to do the following: s' 1. To manage and have the general control and supervision of all my property and interests in property, real or personal, tangible or intangible, including power. to buy, sell, lease and mortgage . 2 . To maintain bank accounts for me in my name, or in the name of my attorney, and to make deposits or withdrawals of money belonging to me in such accounts, and to disburse any money from such accounts on the 'signature of my attorney. 3 . To pay all my bills and to expend funds for any purposes. which my attorney deems for my benefit . 4 . To collect, demand and receive any income, interest, s dividends, rents, profits or other property due or payable to me . 5 . To borrow money on my behalf, to execute contracts on my behalf and to execute on my behalf any other deed or instrument in my name or in the name of my attorney, which, in the discretion of my attorney, appears to be necessary or advisable in the management of my affairs . 6 . To have ' access to all safe deposit boxes in my name and the right to remove their contents . 7 . To prepare _ or have prepared and to sign tax returns of any sort on my behalf . } . 8.. . . To prosecute or defend or submit to arbitration any claim by or against me or my property and- to receive and give full or partial releases of any kind. 9 . To transfer funds or property of mine to any trust established by me, whether before or after the date of this instrument . ` 10 . To do any of the foregoing in Massachusetts or elsewhere in the United States . of America. No person dealing with my attorney shall be required to .see to the application of any funds or. property paid or transferred to my attorney. Any person may rely on this power of attorney or a copy of it certified by a notary public until notified in writing of its revocation. , I nominate David B. Burlingame as my conservator, guardian of my person and guardian of my property should the need arise in the i future for the appointment of any such fiduciary for the protection of my person or estate . I intend that this power of attorney shall not be affected by MY subsequent disability or incapacity. IN WITNESS WHEREOF, I hereunto set my hand ;and seal thisce7&41 day of November, 2004... i t �r� t`^'•g!"�. � ,. .,�� a .:'� �-:�+ i a. r+ 99���'u.• tts r ; COMMONWEALTH OF MASSACHUSETTS Barnstable, ss November , 2004 Then personally appeared the above-named Mary E . Burlingame, known to me personally, and acknowledged t e foregoing instrument ' to -be her free act and deed, . before me, �. Notary P "blic -- My .Commision Expires :��� -3- � �, � �''�' � ;'� ,� � „ .�- r � � .z ,�s ,• fir'" ^ $ tz�, n. a i �TME rOwti Town of Barnstable *Permit# S 5 u 4 . Expires 6 months from issue date v + BAMSTABLE Regulatory Services Fee d MASS. $. 039. Thomas F.Geiler,Director prFO AA°�a Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 -® � `� ITOffice: 508-862-4038 I Fax: 508-790-623.0 JUL 1 2005 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint` TOWN OF BARNSTABLE Map/parcel Number r y 4 2) Property Address ( � '�"' '`` "' ��t✓"''�0 i VResidential Value.of Work f q-6 Minimum fee of$25.00 for work under$6000.00 . Owner's Name&Address • mow+ -4 "N Contractor's Name \J w us Telephone Number Home Improvement Contractor License#(if applicable) 0 ' Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance PC k one: [� I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) 9,Re-roof(stripping old shingles) All construction debris will be taken to - � ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side o7rimo�ture---- ❑ Replacement Windows. U-Value (maximum.44) * Board of Building Regulations and Standards Where required: Issuance of this permit does not exempt compliance with other town d� is HOME IVEMENT CONTRACTOR ***Note: Property Owner must sign Property Owner Letter ; Re istratt�r. 24310 Improve ontractors License is required.;: 007 r idual Signature James Curley V d James Curley _ Q:Forms:expmtrg 287 Fuller Rd. n°k y,• tl~ Revise063004 Centerville,MA 02632 ~ Administrator ` - The Commonwealth of Massachusetts PA Department of Industrial Accidents Office ofInvestigations 600 Washington Street, e Floor Boston,Mass. 02111 Workers'compensation Insurance Affidavit;Buildin lumbin (Electrical Contractors name: address: ci state: zi ��✓ `r hone# 1 �!" work site location li address : I3 (�. C,��� I"` 6/1 am a homeowner performing all work myself. ProjectType: ❑NewConstruction Remod 1 am a sole to netor and have no one working 3n any capacity. . ..r ..y W ., e.: =.l1 exz`C3 ?'.'�: ::, ���Build ng Ad dition �a g I,v T 3 .ter�,,.,"IR .� ..ON is t }K''.'; ❑ I am an employer providing workers' compensation for my employees working on this job. company name, address: city phone#: insurance co. oli ❑ I am a sole proprietor,general contractor'or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company, name:.. address: city phone#:— insurance co. °li company name: address: city phone#• insurance co. oli it . .a t.. Failure to.secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of aline up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereu certify a er t e pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name ��"—`'"` Phone# q [check nly do not write in this area to be completed by city or town official : permit/license# —[]Building Department ❑Licensing Board immediate response is required ❑Selectmen's Office C3Health Department on: phone#; ❑Other 03) nstabYe ar Re u : - �tilatory Services � �sraB�, � =T�iomas=F:_Geiler,-Director . :, :. �: • .-. - , suss, idj9. �$� ;.j3-ufldIn9•.Dinsl0Il To='Rerry;"Building Commissioner - 200 Main Street, Ijyanats,.MA 02601 .-WWyVr.town.ba usta'ble;ma.us Fax: 508-790-6230 ' Office: 508-862-4038 .. � �� Property Owner Must Complete and Sign This Section If Using ABuilder I, (,L►'� 1� , , as Owner of the subject property ' to act on my behalf, hereby authonze:. � in all rriatters relative to work authorized bythis building pemvt application for; ce, (Address of Job) Signatur` of Owner Date - , Print Y�1� • ' Assessors map and 'lot num ...... . " fT ''�Sewc�je Permit number ' _ ?�. .... House number .............'........... ..... .,:......::::....;..:..:.:::......�.... 9B AHH9TADLE ? MA86 . pow i63q 6 , . TOWN' OF BARNSTABLE 1- 'DUILDI � ... IASPECTOR ` APPLICATION FOR PERMIT TO . .......:..................'..:...... ........ . ....................................................... TYPE OF CONSTRUCTION ....« G' r .��0.......pA��.......................... .................:.... ......................... 1 9B TO THE INSPECTOR OF BUILDINGS: The undersigned hereby"applies for a permit according to the following information: /� Location ....... ...... % /ld/. ✓.......... ,�1e..,. .::.::.c%. 11� �'?1ll�.LL� ..... .,�../..����....... ............................. Proposed Use ...s/v...ly:paw........ ................................................................................................. a ......... Zoning District ...... ...........................:...........:...Fire, District ...................:... Name of Owner zvnN0,.qljjz�........:..Address .%.,F cl0-PN- %5....� ........ Name of Builder ...... ..... .. ............::.........:....'..Address ............. .......:.... ` Name of Architect ........Address ' l ����l� Number of Rooms .........................:.....:.........:......................:.Foundation .......... ............................::................................ Exterior ................... .. ..................:..........Roofing ./1.�/ ............,.... ........................... FloorsC � .......................... ..............................Interior .... `kr..., Me.............. ................................ Heating Plumbing ...... lJ. ...................................................:.. " Fireplace ��r 7�...................... ............. ............................Approximate Cost ..�J.... Definitive Plan Approved,by Planning Board ______:_____________:________19________. Area . .....�/.. £.......C...... . "-Diagram of Lot and Building with'-.Dimensions ..... '..Fee .............................. SUBJECT TO APPROVAL .OF BOARD OF !HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS (hereby agree to conform to'all=the Rules and. Regulations of the Town.of Barnstable regarding the above'. construction. Name ��'�o ', � ..: ?!���........... Construction Supervisor's License ..:.v`!.!1.. ............. �r BURLINGAME, THERON 24859 ENCLO E i a No ..! Permit for DECK - Accessory to Dwelling . ... ....................................................................... r k• �, ,. Location ....13...ConrX, Road Location .................... ; Centerville . ............................................................... .......... Owner Theron Burlingame............... . Type of Construction° ...Frame.... . ............. ........... w - Plot ................... ..'... Lot :.......................... � w Y March `l8 83 Permit Granted ... ..... '. . .......1'9 Date:of�n echo ......... ... .....19 � Date Completed ..:.'....(.....�:.....................19 Assessor's map and lot numb . ...................... .:............... o�tHeTo r f /. Q �� :-SeAe Permit number Z B9SBSTA"A 1 House number r Naas .......................................... pp 1639. ♦�OYPYa` TOWN . OF BARNSTABLE BUILDING INSPECTOR /AlAPPLICATION FOR PERMIT TO �A C,("L (�/( ° 'ems' .. ... .................. ............ ..........��.,....................................................... TYPE OF CONSTRUCTION ....�741eLVN;:,.......P CA............................ ... ....... .19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: / Location .......4Z......49,11N61,9..t4'..........FT P., ......1�.��.��,�� '.�...✓../.4. ...... ......Z&r.............................................. ProposedUse ....... UN... ................................................................................:................................I......................... Zoning District ...... /.............................................Fire District ....................... Name of Owner l`r. �.... /1�rL/ �ry� ...........Address .f.,1�.....ce/.�,11�Q/.�... ��.................. ....... .................... Nameof Builder ......�� �...............................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... ���� Numberof Rooms ......�..........................................................Foundation . .........................................................:.................. Exterior ...........................................................Roofing ........................................ . . . . ................. ......... �f� z:... &1 'Floors ................................................ ...........Interior ........ g ................................................... Heating ..................................................................................Plumbing ...... .........................................:............. Fireplace ... ......................................................................Approximate Cost ...2t6..�.. P...... . �.....�..................,..._ 4 Definitive Plan Approved by Planning Board -----------_-------------------19________. Area .. . ............. Diagram of Lot and Building with Dimensions Fee .............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH k OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / Name .nor. .c°. ........ ............ ,` Construction Supervisor's License BURLINGAME, THERON A=251-48 24859 Enclose/Deck No ...Sj,E............ Permit for .................................... Accessory to Dwelling ............................................................................... Location ...13. ...Conn. .ors...Road.. .. .. ....... ....... ..... ........................... Centerville ............................................................................... Owner .TherQR..Bux1ingaMe................... Type of Construction ..Frame ........................................ ................................................................................ Plot ............................ Lot ................................ Permit Granted ....Margb 18.(.............19 83 Date of Inspection ....................................19 Date Completed ......................................19 Engineering Dept. (3rd floor) Map ��� Parcel Permit# House# ,ZZ Coz-xlo I Date Issued cz Board of Health(3rd floor)'(8:15,-9:30/1:00-4:30) 02- 4- ` ,Fee �'w?00 Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept.(1st floor/School Admin.Bldg.) . f dE Defi ' e Plan Approved by Planning Board r . �" 19 WSTf ALLED NCE WfT a i TOWN OF BARNSTABRONMIE E•AND 1I°��IN R��1lL�`d�® S Building Permit A licationy� Project Street Address �� ��f f �/ Village Owner, �� ✓/' ✓�i��i�--�i a Address - -11 C C1�rZd✓1 a�c� Telephone it�, Permit Request / A 0ooll-e i57 176 First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ d (Y a 6 Zoning District Flood Plain Water Protection Lot Size GrandfathereXYes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure / Historic House ❑Yes No On Old King's Highway ❑Yes o Basement Type: 11 ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New I Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas �1 ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number Address (( /y1 Ci License# ��t , �`a,�✓� ��_ 46a//11` C Home Improvement Contractor# f'-rr tt ��✓ Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 2 BUILDING PERMIT ENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. 1 ADDRESS VILLAGE r ! OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION i .. • FIREPLACE ' ELECTRICAL: ROUGH FINAL X - • PLUMBING: :ROUGH FINAL GAS: itOUI;> FINAL FINAL BUILDING-le DATE CLOSED OU, 0 F ASSOCIATION PLAN NIA ' ; +. t r 1 1 f r A L:'J ' 1 �'•ltt. Y !� 15 :+,Ls iil 4 ',y 1 \, s a •-I,; t >i' ..s� t".? t -,.. 1 It. --fii 1)1 -) /�;If } ? {1 :} 4- } t't \« -!r.', Ow 14 i 1F �." t - i (1 p• ( ! I 1 1 , .'. s ct I S p >, d R �1[`` a t'tt 5 t.E}! 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'<„Lx '.t 7 Sr r� a -y�r,lt - 4• ;ru�' ✓a xsarYs'ysa•c. A u�vizsf S �1` +^ ad ''.Nt, shy �s - • � ��u.4 "�s" � �� ,:�-� ��,�, Lra �i. f 3 t�'.s to sa'r r r r, att�ON Zf IN .•; .i, as � � G { .. �N �, �. � 6 e�� ��, y�r _ - ;--.t "*'i fit.-., �� Par �' t G t K•��4 S '.s�'r° Fh'�} ' §�Tk�'. A The Commonwealth of Afassachusettt Department of Indicarial Accidents Ofice0110yesU92110tts .1i w iEa._+� ' 1r 6llll li'ashint;ton Street emu_► ��,'' Boston, Alas. 02111 Workers' Compensation Insurance Affidavit nlicant information• Please PRINT legtbl ' name location: 12hong# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity ��.•; ro• ^t -� ,>.h+•cs=�rr�.wvp.r.,c-en+sp�.� ^^.,s�•? r`*�^,.err, _^'�'f,f,.",.'s'�t _ •r+». e•..ar�+-r,..,»,.�...,e. Fj i......+:..._...:�.....:/. -_•-- _._..::r,.,.`...as,.w;rar,.w.�u:,:...+wi.��?��r, ,x�+:+E,ti....:.:..w��� - --•.:::s.�tL.d.3� -=t......r............�.._�.�...� I am an employer providing workers' compensation for my employees working on this job. coin any name: G address / •tj �/Z / �. / / city: e S��GI Ufa G F/ phone#: insurance co �� e r policy# I am a sole propri or, general con t ractorIpAomeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: �^ company n•tmc address phone 1/1 insurance co. e # ..,.:-..,; .•. +n:a[�«: ..,y�y'-_ ... ;...q....�„ ^x ,»• �.r ". .?+i"'�r, .-^3i'S�`inar!�?ra-.•.?cyc,':rr fix,s.hC' k 4L. is .a'2 - s+�._.� _ company name: address: / v city: hon #• ` insurance co ���?��'�� policy# Atiachh additional sheet if riecessarr�� T;;..s.rr�:' 1Y d sf- Y _r•�,, _ Failure to secure coverage as required under Section'_5A of n9GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. Ida hereby certif}•wider the pains at. enalties of perjure'111apthe in ormation provided above is true and correct. Si-nature Date Print name G- �r�'�y /V/ J /o'l Phone# -7 1� ${official use only do not write in this area to be completed by city or town official city or town: permit/license# ntluilding Department oLicensing hoard 0 check if immediate response is required c3Selectmen's Office C]Ilcalth Department contact person: phone#; flUthcr (revised 319s P1A) . I Information and Instructions Massachusetts Gencral Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an etnploree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An entpl(,)ler is defined as an individual..partnership, association, corporation or other legal entity. Qr any two or more of the foregoing enga-cd 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 dwellim, 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 even,state or,local licensing agency shall withhold the issuance of- renewal of a license or permit to operate a business or to construct buildings in the common-wealth 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 contraet 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. 1_ 6 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 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 atathe number listed below. -77 vt Citv 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 permit/license number which will be used as a reference number. The affidavits may be returned to 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. .»tom ,,... ...__ �.,,,.,<. ._.........�.-.-..4 .-. 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 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 �f °F THE t . � The Town of Barnstable ■nxxsrnsie. 9eb "S ' Department of Health Safety and Environmental Services '°rEo►Mo�' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along wit other re uirements. X Type of Work: i Est. Cost .tS _ CY c� C0 tj OR 5 Address of Work: L/' 2T Owner's Name / Date of Permit Application: �� 9 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 apply for a per as the a ent of the owner: Date Contractor Name Registration No. OR Date Owner's Name