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Town of Barnstable IEcE� �T'X
KASS 200 Main Street, Hyannis MA 02601 508-862-4038
Application for Building Permit
Application No: TB-17-367 Date Recieved: 2/10/2017
Job Location: 148 ELIJAH CHILDS LANE,CENT ERVILLE
Permit For: Building-Solar Panel-Residential
Contractor's Name: SOLAR CITY CORPORATION State Lic. No: 168572
Address: 24 ST MARTIN STREET BLD 2UNIT 11, Applicant Phone: (508) 640-5839
MARLBOROUGH, MA 01752
(Home)Owner's Name: LYONS,RONALD N& LEA M Phone: (508)428-8741,
(Home)Owner's Address: 148 ELIJAH CHILDS LN, CENTERVILLE,MA 02632
Work Description: Install solar electric panels on roof of existing house with any upgrades,when applicable,specified by
Design; To be interconnected with home electrical system. JB-0263580 12.604KW 46 Panels
CD
a - ' T_;J
Total Value Of Work To Be Performed: $18,000.00 '
Structure Size: 0.00 0.00 0.00
ems, e-c9
Width Depth Total Area,
I hereby swear and attest that I will require proof o`f workers'compensation insurance for every contractor;subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from.coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: Nathan Tissot 2/10/2017 (508)640-5839
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost $18,000.00 Date Paid Amount Paid Check#or CC# Pay Type
Total Permit Fee: $141.80 2/10/2017 $141.80 XXXX-xiooc-XXXX- Credit card
5477
Total Permit Fee Paid: $141.80
a
Town of Barnstable NE+cE�101
`M. ' 200 Main Street, Hyannis MA 02601 508-862-4038
`-'
Application for Building Permit 51
1
Application No: TB-17-375 Date Recieved: 2/13/2017
Job Location: 28 CENTERBROOK LANE,CENTERVILLE ao
Permit For: Building-Insulation-Residential
Contractor's Name: } Elwell H Perry State Lic. No: CS-104088
Address: Acushnet, MA 02743 Applicant Phone: (508) 992-5770
(Home)Owner's Name: STEACY,CHARLES G &PATRICIA D Phone: (508)292-5590
(Home)Owner's Address: 28 CENTERBROOK LANE, CENTERVILLE,MA 02632
Work Description: 7 hrs.Air Sealing. Weatherstrip and sweep Tdoors., Install 6"Cellulose to 525' open attic. Install R-19
fiberglass and 2"Thermax to 200' kneewall slope. Install 2" Thermax to back of attic hatch. Install 1 roof
mounted flapper and exhaust hose to bathroom fan. Install 48 prop-r-vents. Install(8)4"x16"soffit vents.
Total Value Of Work To Be Performed: $2,754.00
Structure Size: 0.00 0.00 0.00
Width Depth . Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor;subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 598).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by,
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to.have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge and belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: Elwell Perry 2/13/2017 (508)992-5770
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost,: $2,754.00 �Date Paid Amount Paid Check#or CC# Pay Type
Total Permit Fee: $85.00 2/13/2017 i $85.00 XXXX-XXXX-XXXX- Credit Card
....... 4419 ....:
Total Permit Fee Paid: $85.00
Commonwealth of Massachusetts,
.- U
MaP �' Pareel
�
Date: `�. 1 ��`au►2 : DEC 2012 P;;rmit9
Estimated Job Cost: $ SOQ .Ud rmit Fee:
I UVVN OF BARNSTABL
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License# Applicant License# c-
Business Information: `� Property Owner`/�Job�Locati n°lnformation::y-,t,
Name: Name: a
ut - L.
r
Street: Street: (4 8 E L- IT" C 141 L. SS L N
City/Town: City/Town: Cr--NT '-'(LV ILCt< V4,A 0 32.
Telephone: Telephone: 50 t 122;-1-7 Lf i
Photo I.D. required/Copy of PhotoI.D. 'attached: YES _ O
Staff Initial
J-1/M-1-unrestricted license
J-2/M-2-restricted to dwellings 3-stones or less and commercial upxto 10 000 sq.ft. /2-stories od; ss k
Residential: 1-2 family Multi-family Condo/Townhouses Other
Commercial: Office Retail Industrial Educational
Fire Dept. Approval Institutional Other
Square Footage: under 10,000 sq. ft. V*' over'l0,000 sq. ft. Number of Stories:,
Sheet metalwork to be completed: New Work: V�f Renovation:
HVAC Metal Watershed Roofing . Kitchen Exhaust System ✓"
Metal Chimney-/Vents ✓ Air Balancing
Provide detailed description of work to be done:
yi o p-t< 1 W c W 1 C�-,- C-01fi1 NG" A -1 W �t�►G i�t'�1�`"t t ,
.tom "VA-Mb_, ,� -9i+-t6j6Les Tp [eaukof .OVTLE—r yamT.
+Fo(2
- I
NSURANCE COVERAGE: r :
have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes' No
f you have checked , / ► r'
y (�, indicate the type of coverage by checking the appropriate box below:' �
k liability insurance policy [ Otherltype.of,indemnity ❑, ; .Bond' ❑
)WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage.required by Chapter 112 of the
dassachusetts G .ne I Laws,and that my si nature on this permit application waives this requirement.
Check One Only
(X
Owner a, Agent ❑
CSignatu�re�of Qwner 67r Owner's Agents f ,
3y checking this box[],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
iccurate to the best of my knowledge and that`all sheet metal work and installations performed under the permit issued for this application will be
n compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
Progress Inspections
r t.
Date _ Comments
V oS /y �iGL �a D 4/b Zz �
Final Inspection
Date Comments
Type of License:
3y ❑ Master. t
-1,Master.
J.s'*) `f +~i
'itle ❑ Master-Restricted
;ity/Town is, V .F
❑Journeyperson ��
c e
lermit# 1P
❑Journeyperson-Restricted License Number: ,
❑ Check at wvvw.mass.gov/dpi
nspector Signature of Permit Approval
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston;MA 02111
.www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name(Business/Organization/Individi4: Q6
•Address: d E L 14 il.ns. �.►
City/State/Zip: C ka,11-f-Vi WF \vo, 9M-32 Phone-t. qVk. - 914 t .
Are you an employer?Check the appropriate-box:
1.ElI am a employer with ����a general contractor and I -Type of project(required)
. employees(felt and/or part-time).
* have hired the sub:-contractors 6. ❑New construction .
2.❑ I am a'sole proprietor or partner- hstrd on the-attached sheet 7. Remodeling
ship and have no employees These sub-contractors have 8. El Demolition
working for me is any capacity, employees and have workers'
co insurance.$ 9 .0 uilriin. addition,
[No workers' comp.insurance _ �� .
`We are a corporation and its 10.7-Electrical repairs or additions
required.] 5• El
.3.
officers have exercised their El am a homeowner doing aII work 11.❑Plumbing repairs ar additions -
myself [No workers' came right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no Other
employees. [No workers'
camp.insurance required]
*Any applicant that checks box#1 must also fill out the section below showing tire's workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contactors must submit anew affidavit indicating such.
*Contractors that check this box must attached an additional short showing the name of the sub-contractors and state whether or not those entities have
employers. If the sub-conixactons have employees,they must provide their workers'comp,policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /
Policy#or Self-ins.Lic.M. ExpirationDate: s
Job Site Address: Qty/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 ofa
fine up to$1,500.00 and/or one-year impnsozmnent;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 insur-mce coverage verification.
I do hereby certify under thepains-andpen ' s of perjury that the information provided above is Prue and correct
``:Date: 1 01®
Phone#
Official use only. Do not write in this area, tb be completed by city or town official
City or Town: PermitUcense#
-Issuing Authority(circle one):
."I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
I
The.Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
.600 Washington'Street
Boston,lll ,'02111
•Y• '� www.»zass:gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ,' Please' Print Legibly.
Name(Business/Organization/Individual):J w Z I C ,V �.�Tt7
Address: `n kn i ie�� 5, 5
ai
City/State/Zip:. /17 4 0 2,S:3- Phone.#: J
Are you an employer?Checkthe appropriate box:. Type of project(required):.
4. I am a general contractor and I
1.❑ I am a employer with ❑ 6. ❑New construction .
employees (full and/or part-time).* have hired the sub-contractors
2.g I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
workingfor me in an capacity. employees and have workers'
.Y P tY t• 9. ❑,Building addition
[No workers' comp, insurance comp.insurance.
require ] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions _-
3.❑ I am a homeowner doing all work officers have exercised their .• 11.❑Plumbing repairs or additions•
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
q ] employees.[No workers' 13.X❑ Other�'d
comp.insurance required.] • . . . V '` Zn�G
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional'sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding 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 verification.
I do hereby certify under-the pains.a penalties of perjury that the information provided above is true and correct
Si afore: Date:
Phone#' �
Official use only. Do not write in this area,to be completed by,city.or town official.
: City;or.Town ` R PermitlLicense# '"
Issuing Authoriiy-(cn-cle one)
1,Board of Health 2 B.tiilding Department 3:'Ctiyltown Clerk 4yElectrical Inspector .5,Plumbing Inspector
-6.Other ry . Y .
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires.all employers to provide workers'compensation for.their employees.
Pursuant to this statute,an employee is defined as"...every person 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
c wner 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
cr 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 aiiy conizact for-the performance or public work until-acceptable cvidicnce ofco:rpliY.c—_-wit the ins r
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),addresses)and phone nil er(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
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"
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 fo any business or commercial venture
(i.e.a dog license or permit to balm 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 Coznmoiawealth of Masao usetts
Degartwnt of 11zduslxial Accidents
Office of fnvestgat!oas
60.0 Washiiigton' t
S
BQo ton, ILIA 02111
Tel #617-727-4900 ext 406 of 1-977 MASSAFE
Fax##617-727-7749
Revised 11-22-06
www.ma.ss..gov#dia
�11 E Town of Barnstable ,
Regulatory Services
• saxtvsresr,E, Thomas F.Geiler,Director
y >rrnss.
1.39. �•0� 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
HOMEOWNER LICENSE EXEMPTION
Please Print
jrJOB:IACA7T0N 140
number street village
HOMEOWNER 910 U N-3) w o `t— Lt Pt
name home phone# work phone#
'C_URRENT MAILING ADD tRESS: 14 Qj 1-k ftA u4►iLw. l,-M
C167NV,� It L tYl�R Q�6�VZ
city/town i� ie dwellings state zip code
The current exemption for"homeowners"was extended\toinclude ocaner-occupied d dwelli of six p � 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 for all such work performed under the buildiiigpermit (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements. }
Signature of Homeowner
Approval of BuildingOfficial
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 alicensed
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, j
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a fora/certification for use in your community.
Q:forms:homeexempt
i�
4
�THE Town of Barnstable
Regulatory Services
RARNSTAS
MASS Thomas F.Geiler,Director ;
1639.
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www-town.barnstable.ma.us
Office: 508-862-4038 F 508-790-6230
r .:i J't"Property Owners Miist* .tit
Complete and Sign This Sec
If IJsuig A'Builder
zt- 1. 1 -� i � 1` t �� � -j •�� i
p
I, Ownet of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this b ding permit
(Address of J )
*Pool fences and alarms are the responsibility of th pplicant. Pools
are not to be filled-before fence is nstalled and pools are of to be
utilized until all final inspections re performed.and acc ted. x,
Signature of Owner Signature of Applicant
Print Name Print Name
Date
WORMS:OWNERPERMISSIONPOOLS
9 �
�oFtHErOw Town of Barnstable *Permit#� CtZ/ ' 377C
ti
O,^ Expires 6 months from issue date
CV
BAMSTABLE, : Regulatory Services Fee:D�
9 MASS. moo'
s Thomas F.Geiler,Director
ATED AAA a
Building Division ��
Peter F.DiMatteo, Building Commissioner
200 Main Street, Hyannis,MA 02601 JUN 1 9 200vf
Office: 508-862-4038
Fax: 508-790-6230 TOWN OF BARNSTABLE
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number I ��
Property Address I � /i �/� C " 3" ��j c L,ci�crr'7�� /�� .� O_2c 2
esidential Value of Work tJ���0-
Owner's Name&Address Ze25, 1zS�O.c/J
Contractor's Name VZLOWXJ Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) (is 7�097
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
Cave Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy# fL/G 1115�" 6/- 93
Permit Request(check box)
❑ Re-roof(stripping old shingles)
❑Re-roof(not stripping. Going over existing layers of roof)
/ /
Re-side 1 � � `
[placement Windows. U-Value (maximum.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
Signature
Q:Forms:expmtrg
Revised121901.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
w + 600 Washington Street
Boston,MA 02111
M ,• '� www.mass.gov/dia
'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Dame(Business/Organization/Individual): Z)CS 4 go
Address: dZ/7 ThC)/W tip� ?S7,z
City/State/Zip: tit Phone.#: SQ�� `7�/` c3//�
Are you an employer? Check the appropriate box: Type of project(required):•
1.[ aam a employer with Zlx 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
workingfor me in an capacity. employees and have workers'
Y P tY• $• 9. �Building addition
comp.insurance.
[No workers' comp.insurance
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance,required.]t c. 152, §1(4),and we have no
employees. [No workers' . .13.0 Other
comp.insurance required.] .
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
LContractors 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.
Iam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name: ,t, all oelo.. '" a,,- PIR4
Policy#or Self-ins.Lic.#: 00- ./7 z�Z 90 Expiration Date:
Job Site Address: /�l� G 6/.qcl eh/(,ctS �v City/State/Zip:&TI a�icLo, map 0�632
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains a enalties of perjury that the information provided above is true and correct.
Si afore: u-� Date: �z/ 7
Phone#• 6aj' CT
Official use only. Do not write in this area,to be completed by city or town of icial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions Y.
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicant who has not produced.acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C( )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 cants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contiactor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members 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.
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 io 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:
e Commonwealth of Massachusetts.
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 ext 4.06 or 1-877-MASSAFE
Revised 11-22-06 Fax 4 617-727-7749
www.rnass.gov/dia
RSG Ins. Aqcy. Page: 001
Client#:23059 OCEAINCI
ACORM CERTIFICATE OF LIABILITY INSURANCE us;sroD"�)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rogers&Gray Ins. Plymouth ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
341 Court Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.0.Box 3700 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Plymouth,MA 023613t00 INSURERS AFFORDING COVERAGE
INSURED NAIC 8
Oceanside Inc INSURER A: Arbella Protection Co
217 Thornton Drive INSURER B: Insurance Company of the State of PA
Hyannis„MA 02601-8105 INSURERC:
INSURER D:
COVERAGES INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER DALITEYflENYI�/DOC PDATE ENBN/pD n� LIMITS
A GENERAL LIABILITY 8500029947 01/01/07 01/01/08 EACH OCCURRENCE $1000000
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ISE $1 OO 000
CLAIMS MADE a OCCUR MED EXP(Any one person) $5 000
6
PERSONAL&ADV INJURY $1 000 000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s2,000.000
POLICY JECT
,)ECT LOC
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT
(Ea accident) $
ALL.OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY(Per person) $
HIRED AUTOS
BODILY INJURY
NON-OWNED AUTOS (PeracddenQ $
PROPERTYDAMAGE $
(Peracddent)
GARAGE LIABILITY
ANY AUTO AUTO ONLY-EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY
EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE
r
ETENTION $ $
OMPENSATION AND WC1766193 01/01/07 01/O1/08 wCSTATU• OTH• $'LIABILITYETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $500,000
MBER EXCLUDED?
e under E.L.DISEASE•EA EMPLOYEE $500,000
VISIONS below
OTHER
E.L.DISEASE-POLICY LIMIT $500 000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
kT
D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
FORINFORMATIONALPURPOSESONLY HEREOF,THE ISSUING INSURER WILL ENDEAVOR ToMAL 10 DAYS WRITTEN
TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
ENTATIVES.
RIZED REPRESENTATIVE
AIA
ACORD 25(2001/08)1 of 2 #29365 �� t
JB 0 ACORD CORPORATION 1988 .
I
l� fiuveczl.C�r. ../� uaeCCd
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 100121
Expiration: 6/9/2008
Type: Supplement Card
OCEANSIDE,INC.
PETER LAROCHE
217 Thornton Dry
Hyannis,MA 02601 Administrator
_ •. '�aW�°'"�'"' � .,. ..��^ l/M9I7/llNJ4T.C!/@[6G/il O�✓I�LC[GSR�YU"'��^�yy.,, ^.
u, Board of Building Regulations.and Standards
w: Construction Supervisor License"
°a License;,CS 73097
,L I
Bir#hdate 4/3/1957
'Explrai6t 11 /2008 Tr# 7187
iF
Re on?-- 00 '
rr:
PETER ALAROCH�
7
- 18 CEDRI
O ROAD
CENTERVILLE,MA 02632 Commissioner
Per
�oF1�l Town of Barnstable * mit#. Z
NAP O,� Expires 6 months from issue daie
BAMSTABLE, ; Regulatory Services Fee D 1 D
MAM
i6J9... �0'� Thomas F.Geiler,Director
A,Ea Building Division 'A Re.
Tom Perry, Building Commissioner pF RNj M
200 Main Street, Hyannis,MA 02601 gut �T
Office: 508-862-4038 - TOwNOF 9 ZOOZ
Fax: 508-790-6230EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY egRNSTge L
Not Valid without Red X-Press Imprint
Map/parcel Number ��, cJ IOT�pc�
r
Property Address
(Residential Value of Work j 4 �
Owner's Name&Address
` Contractor's Name Telephone Number
Home Improvement Cont,Zricense#(if applicable)
Construction Supervisor's License#(if applicable)_ Q�o�o30
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I.am the Homeowner
VI have Worker's Compensation Insurance
Insurance Company Name ta
Workman's Comp.Policy#
Permit Request(check box)
Ve-roof(stripping old shingles) All construction debris will be taken to 1
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows. U-Value (maximum.44) m
❑ Other(specify)
'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
Signature v��
Q:Forms:exp g
Revised121901
meA
. . �: The Town of Barnstable
• aAatvsrnJ= -
9 Department of Health Safety and Environmental Services
Eo Meg' Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
SHED REGISTRATION
C[ti L. C_P-JyT---)L\l' 1 LLE �A A-
Location of shed(address) Village 0�6
Property owner's name Telephone number
Size of Shed Map/Parcel#
Signature Date
Hyannis Main Street Waterfront Historic District?
Old King's Highway Historic District Commission jurisdiction?
Conservation Commission(signature required)
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
Q-forms-shedreg
AT200'`5
Zt4ons locatfom of-property: Ga,nt�rvtilla
w
7.
� WV (�'f• I f 1Y
i
PAsc�m -
wq
story
di
;65 Z
48
K I
16, tot"68
r�
S
r
_ -
z 'f w
) s
r¢,f 3?575 f t_� ood CruJ'e:zsaool oo fS G fWod eoti¢: '"OR PAUL' 4N
here CeCtlF1-J`�tttatZ�1t811t0ti'tgage impeet'da %va pt�pQY'+i3C��01 Ro
UV nn& Wyr iv T.C,. 8r`Fi r5t C!+iize no eFa- Cre d�i,,t,� L�L � ,,nion�� o ty
• o
hawr& =cc wi6 an,Active daft of 8 -19-85 an4 wile locaiiom o�
the dwelling doss ccm�#'arm rto the local�orurtg 6y laws in.¢fct�
of the ante oFconstrua om w& reswctto horhorltut d (0= Scale: V -4_
5¢t�ctclz or is Q KL'111�t"ft�prm VtDiat� n.¢t�1�(Ol�C2t1'Let Lam' Date: 12 - 2� -9,�j
!:crcctwn, under A=. General Laws Chaptw4oX-Seato' 7. File No. loA72-ga
t PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey .is necessary for a precise
determination of the building location and encroachments, if any .exist, either way across property lines. This plan must not be
used for recording purposes or for use in preparing deed descriptions aid must not be used for variance or building plan
purposes. This:plan must not be used to locate property lines. Verification of building locations, property line dimensions, fences
lot
or lot configbration can only he accomplished by an accurate instrument survey which may reflect different information than what
is shown hereon. Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE PURPOSES ONLY".
COLONIAL LAND SURVEYING COMPANY, INC.
269 Hanover Street Hanover, Mass. 02339 Phone: 617-826-7186 • Fax: 617-826-4823
SPILLER'S 588207
. r
121
Assessor's; map ands lot number ...
j , �0*THE
Sewage Permit number � . SEP
TIC SYSTEMTADL
INSTAL
Home number ..... ..... ... ... n
Ho �
r. ITH TITLE 5 O ypY a�
TOWN OF BARN`.S '� MEErALcO® .
' BUILDING INSPECTOR ti
APPLICATION FOR PERMIT TO .. < ........:....� '. ;.:. ,, '
TYPE OF CONSTRUCTION ....... Z.�. X
¢ } c........ A..1
................ ......19. / "'
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ' � .. .: .... /�':............ k................................................ ...................................
• .
ProposedUse ..(�.. .. .. ..................................................... ............... ................ .. .................................
Zoning District ...Fire District .........
Name.of Owner . .... ....t.............. .........:.........Address ...................................................
_....Name. of -.e,uilder..... Address ........................................................
f
Name of Architect '. .. ..Address .. ........... .................................................. .......
....... Foundation ....... ...........
Number of Roo s ......... .:.....................
Exterior .... .. ........`... ................Roofing ......................... ..............
�• r .... ...... ...
,
Floors ................:Interior •.......... %���ji- .......................................
............................�............... .. r ..`!!�C!!ye J ....
Heating % �. ..Plumbing �.....
Fireplace .. .... .. .. .. ............ ...........................................Approximate Cost ..... !Ta...Z.I/............ ................................`Q
Definitive Plan Approved by Planning Board ________________________________19________. Area ...:zc.7.... .............
Diagram -of Lot-and Building.-with. Dimensions Fee 7
SUBJECT TO .APPROVAL- OF:,BOARD-',OF -HEALTH '. � �
...Sn
•
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable reg rding the above
construction. s
.0
Nameo. . ................... ..... ..............................................
SMALL, ALAN
' 4
1�No .2343� ermit for .Orie...StQzY...........
. ...Fami1.y...Dwz.0 i.n.g................
Location ...Lot...#65• ...148„Eli:j a'h Childs .L-n.
Centerville.....
OwnerA.lan. . ...Small... . .. .. ....... . .................. ....... ...........
~ Type of Construction Frame
........ .................... t -
t
Plot ........................ Lot ................................
Permit Granted ..•.S.eptei.nber.. . ..8.1.....1-9 81
. . ... .. ..
Date of Inspection ....................................19
Date Completed .. ..... ......:....�Q'" ..1931
r
PERMIT REFUSED E
/.............s ... ...:......................... .. 19
............. .q -' ... ......`.: . ...... :
t ............... +" � ....................................... �
. ........... .3 ........................................
tApproved f ...................................... 19
.... ,... r . .. .. .
• rem �' ��/�/ �,
0-4
Assessor's map and lot number .............:.............................. THETo�
Sewage Permit number tA
•• = BABB9TADLE, i
House number ..................................... .............................. 9�O NAG �a
�9
a" 0MPYO•
TOWN OF . BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ., fir°.........
TYPE OF CONSTRUCTION ........:.! ?';s - ::.................................................................................................
.......... .. ................... .......19.�z
TO'THE INSPECTOR OF BUILDINGS:
The undersigjne�d hheereby applies for a permit according to the following information:
Location :f`;!" C...`° .. ` * :...4.:...... ............................................................... ...................................
ProposedUse ../ ' ....:,. ..................................................................................................
ZoningDistrict ......„.....t........................................................Fire District ..............................................................................
r �i. � ff
Name of Owner C �-' .:.: L s r,�+"' ..................Address .......... s� a c G ............................................
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
a
Number of Rooms ....`— ........................................................Foundation ........ ` l:c.zr
....................................................................
�.. f / r !:.:l. k
Exterior .....::�:� ��`....�.......................................................Roofing .........:....... Lf...............................................
Floors ..................Interior r s /.� ., !`
Heating . .. ..........................................................Plumbing ....... .:........ ...........................................................
Fireplace ..... . .;C..✓. �?-9 �:..+. ..........................................Approximate Cost .....f...... ...i... .................................
Definitive Plan Approved by Planning Board ________________________________19--------. Area .... .7.21. .................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
i
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
........................................................-
Name ....,.;...... .
SMALL, ALAN P,�=171—2 41
23434 permit for One Story
No .............
Single Family Dwelling
...............................................................................
Location ...Lot #65 148 Elijah Childs Ln.
.................. ................................
Alan Small
Owner ..................................................................
Type of Construction ..Frame
........................................
................................................................................
Plot ........................ Lot .................................
Permit Granted ....September... .......19 81
Date of Inspection .................. .................19
Date Completed ......................................19
PERMIT REFUSED
.................................: ............................. 19 '
............................u ................................... _ ........
.............................,./...................................................
'mar...... . .. --................
Approved ................................................ 19
...............................................................................
...............................................................................
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TOWN OF BARNSTABLE Permit No. .2343'1._:
Building Inspector ..;
Cash ---------
�OV0 OCCUPANCY PERMIT Bond __ —x(Q�
"No building nor structure shall be 'erected, and no land, building or structure shall be
used for a new, different, changed, or enlarged use without a Building Permit therefor
first having been obtained from the Building*Inspector.No building shall be occupied until a
certificate of occupancy has been issued b`y 'the Building Inspector."
Issued to Alari Small - Address Centel e ill-e
lot A5 149 Eliiah Cbilda Laup. d2nt:exville
Wiring Inspector fi �- Inspection date W r'
Plumbing Inspector .� r,� r � U Ar Inspection date
Gas Inspector , � 6�r R� P Inspection date �P
w Engineering Department �� �+ Inspection date
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THIS PERMIT WILD-NOT BE VALID, AND'THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS.
µ �� ............................................Building Inspector �.�__