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S PERMIT Town of Barnstable *Permit#
Expires �icsue date
Regulatory Services FeeMAM
• st►xrtsr •
s Thomas F.Geiler,Director
3 A�
- , .ALE
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bainstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not.Valid with Red X-Press Imprint
Map/parcel Number
Property Address L"CC:i kJ-5
❑Residential Value of Work 00y Minimum fee of$35:00 for work under$6000.00
Owner's Name&Address
Contractor's Name C� � ypir)E . %/p,�Ur/ yTf Telephone Number L!�� Fj 0
9227
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) �2
"ElCorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
have Worker's Compensation Insurance ,
Insurance Company Name. 4 -
Workman's Comp:Policy# � f7`L'� �
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑"Re-roof(hurricane nailed (stripping old shingles) :All construction debris will
( . PP g g ) be taken'to _
❑.Re-roof(hurricane nailed)(not stripping: Going over existing layers of roof)
❑ Re-side 77I / �"� pVC U n1/ IVbpi,
#of doors _3
eplacement�Windows/doors/sliders.U-Value (maxirnum.35)#of windows
.-
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
QAWPFILE ORMS\buildinge permit forms\EXPRESS.doc
Revised 051811
45\. The Cmnmanwear&afMassachusetts
D wftgjt fln o
t ep dustrid Accidents
Office ofbmestigadom
-600 Washinvan Sttreet
Boston,MA 02111
www mass goy/ilia
Workers' Com ensation�n�snrr�.ee Affi• P _ davit:Suflders/CoIItractars/Fleciricians/Pitrmbers
Applicant Information Please Print Lefy
Name(BusiwsdOgzaization(lndividvei):
Address:./6 Haa✓c%� !
-----------------
city/State/Zip: u,/- Phone.#: 5ZV .364--;P
EhO=D
an employer? Check the appropriate bay
a employer with / •4. [] I am a general contractor andI 'Type of project(required)::
loyees(full and/or pry-time).' have hired the sub-contractors fi . New construction a sole proprietor or partner- listed on the-attached sheet� 7. ❑Remodeling.
and have no employees These sub-contractnrs have D�honng for me�any capa.ci ty. enpoyees_andhave worworkers' comp.insurance comp•insum me.t• 9: ❑Buildmg addition'red.] 5. We are a corporation.and its 10-Q Electrical repairs or additions a homeowner doing alI work officers have exercised tlieff ❑plumbing repairs or additions
lf:[No workers' comp. right of exemption per MOIL
ance required.]t c.152, §1(4), and we have no 12.[]Roof repairs
employees. [No workers' 13y�O$ler��.- QC_
J
comp.insurance req�red-] _
Any applicant that abecks boa#1=st also BE ant the section below showing their worker'compensation policy information Homeowners who submit this affidavit indicating$ey are doing an work and then hire outside canttacton must submit inew of—davit inm
xConhactors that check this box must attached m additional sheet showing the name of the sub_contractors and state whether or not those�tih 1 aver
employees. If the sub-canters have employees,fbey mustprovidt their wo k=,camp.policymmmher.
-ram an employer that is providing workers,compensatiox information. insurance for my employees Below is the policy and job site
Insurance Campaay Name: THE T/1�,ice 5 �t��ur2�9 �-Cc Co�Oi9 sii'�
Policy#or Self=ins.Lic.# 7 Pi v& G-133_P2 Expiration Date: It —0-
9
rob site Address:_ Hv /,,1 c yistateizip: ✓1/1
tach a copy of the workers' compensation policy declar ation e' she C
_At O
pag ( 7ing 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 c ua1 penalties of a '
fine up to$1,500.00 and/or one-year impnsonmen� as well as civil penalties in the farm of a STOP WORK ORDER and a fne
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
Investi bons of the bIA for insurance coverage verification
I do hereby certify under the pains-and that the information provided above is true grid correct;
Date:
Phone ,�� — 0 9z2!
-------------------------
i
Of facial use only. Do not write ill this area to be completed by city or.town of iciaZ
i
City or Town: Permit/License#
-Issuing A-Uthority{circle one):
.'1.Board of Health. 2.Building Department-3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector i fi. Other
Ctiutact Person: Phone#
tKE Town o a f Barnstable
o�
Regulatory Services
BARNSTABI'E' ' Thomas F.Geiler,Director
'°r�,,�r► Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize E&MDO d 0r-1 - I V p(I,, do o to act on my behalf,
in all matters relative to work authorized by this building permit:
(Address of Job)
**Pool fences and alarms are the responsibility onsibili of the aPP� licant. Pools
are not to be filled before fence is;installed and pools are not to be
utilized until allfinal inspections are performed and accepted.
Signatur of Owner ignature of Applicant
Print Name Print Name
-1 /Z .
Date
Q:FORM&OWNERPERMISSIONPOOLS
i
NOTICE z NOTICE
TO a TO
EMPLOYEES EMPLOYEES
O,�M Svc
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22&30, this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
'(7PJUB-4433P24-8-1 1 ) 1 1 —09-1 1 TO 11 —09-12
POLICY NUMBER EFFECTIVE DATES
BRYDEN & SULLIVAN INS AG 88 FALMOUTH ROAD
HYANNIS MA 02601 r
NAME OF INSURANCE AGENT ADDRESS PHONE#
N—
0
TORRES, ERICSSON DBA 16 HOOVER ROAD
ERICSSON HOME IMPROVEMENT
WEST YARMOUTH
MA 02673
EMPLOYER ADDRESS
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the 1
injured employee. The employee may select his or her own physician. The reasonable cost of the services
a provided by the treating physician will be paid by the insurer, if the treatment.is necessary and reasonably
'- connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
i
that the insurer has arranged for such attention at the
NAME OF,HOSPITAL ADDRESS
oozaae W20P1G02
TO BE .POSTED: BY EMPLOYER,
r
�I1SSItehu c.tt'- Dep:ii-tment of Puhiic Safety" Restricted to WS
4 B.6iird of Building, ,f
., Re�telationti tnd Stantlai cf;' i 1A- Masonry only '
ottstructiDn Stit�ervisor Specialty License RE-Roof Covering
License: CS SL 100546 - r'WS-Windows and.Siding
Restricted to: WS a
, SF- Solid Fuel Burning Devices' "
DM-Demolition only
ERICSSON TORRES ' f:'
,;16,HOOVER ROAD - Failure to possess a current edition of the
WEST YARMOUTH, MA 02673
Massachusetts State Building Code
' A is cause for.revocation of this license.. .
Refer to: WWW.Mass.Gov/DPS
�—G Expiration:-6/18/2012 :` t
('ommissiuner Tr/. 100546
R
License or registration valid for individul use only
} Office of Consumer Affairs&B sines`s Regulation # before the expiration date. If found return to:
1 V-RCSSO
HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business RegulationRegistration.,4163528`; Type: 10Park Plaza-Suite.5170
Expiration 6717/2013 DBA Boston,MA 02116
N.HOME<IMPROV MENT t
„ 1
ERICSSON TORRES x17 } /
1 16 HOOVER RD .\ N
'
-- 1x" — —' Not valid without signature
l WEST YARMOUTH MA.02673.1 Undersecretary ( -
k'
A
Town of Barnstable Permit#
0� Expires 6 the om is!! e
Regulatory Services Fee
anargrasr E,
MASS' $ Richard V.Scali,Director
i639 �0
Building Division
Tom Perry,CB.O,Building Commissioner
200 Main Street,Hyannis,MA 02601 --
_www:town.barnstable.ma.us —
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERNUT APPLICATION - 'RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address• J l- U C 1< ►ram �Ck / ('� 1Lc>d�•C
esidential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name t j, Telephone NumberSO9;,� 66
Home Improvement Contractor License#(if applicable) 1101.766 Email: 6091
Construction Supervisor's License#(if applicable) 0416/ V_C1
❑Workman's Compensation Insurance
Check one:
P-f am a sole proprietor10PRESS
❑ I am the Homeowner 21 2016
❑ I have Worker's Compensation Insurance SEP CC
Insurance Company Name Tfl Iff
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to f
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,Le.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License'&Construction Supervisors License is
required.j/�
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 040215
r
The Conunon>ivealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
-P ivivip mass.gov/dia
Worlters' Compensation Insurance Affidavit: Builders/Contractors/Electricians`/Plumbers
Applicant Info rination • Please Print LeeihIv
Name(Business/Organization/Individual):_' Driyro
Address: dD
City/State/Zip: -L l u4" Of-10 Phone#: sZ6 t,5,779�
Are you an employer?Check the appropriate box;, Type of project(required):`
1.❑ I am a employer with 4. VI am a general contractor and I 6. ❑New construction "
employees(full and/or part-time).* have hired the sub-contractors '
2.❑ [am a sole proprietor or partner- listed on the attached sheet,t 7. E]Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp,insurance. 9. ❑Building addition
[No workers'comp.insurance 5• We area corporation and its r
required.] I officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LE]Plumbing repairs or,additions
myself.[No workers'.comp. . c.152, §1(4),'and we have no 12.0 Roof repairs
insurance required.]t :employees.[No workers' ]3.❑Other
comp,insurance required.]
*Any applicant that checks box#1 mast 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.
lContraetors that check this box must attached an additional sheet showing the name of the sub•eontractors and their Markers'comp.policy Information.
I am an employer that is provtdirig ivorkers coMpensation lnsurance for my employees. Belotp is the pollcy and job site
itrformatlon.
Insurance Company Name:
Policy#or Self-ins.Lie,#; Expiration Date:
Job Site Address: 133 ll u�k r'til S /� City/state;/Zip: ju U ICGL� ,
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 4
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be fortivardcd to the Office of
. Investigations of the DIA for insurance coverage verification.
I do hereby cert y Wer the p�ns a d penal! of erj y that the information provided above is true and correc4 i
Signature: � '' D e• q /
at / � l
Phone Sol �,j -
Ojjlelal use only. Do not if�rite in this area,to be completed by city or.toipn of/IclaL }
City or.Town: Permitucenst:# 1
Issuing Authority(circle one):
1.Board of Health 2,Building Department 3,CitylTown Clerk 4.Tlectrical Inspector 5.Plumbing Inspector
6,Other
Contact Person: _ Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
I
-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,constriction 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 certificates)of
Insurance. Limited Liability Companies a1C)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 f
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 multiply permit/license applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The.Office of Investigations would like.to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call �.
ti
The Department's address,telephone and fax numbers '
The Commonwealth of Massachusetts
Deputment of Industrial Accidents
Office of Investigations
600 washinpn Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-87?-MASSAFB
Revised 5-26-t3s Fax#617-72' -7749
www,mass.gov/dia
oF�rqs,
snaxsre$r.E. : _
wrsee 'Town of Barnstable
Regulatory Services
Richard V.Scali,Director
- -- -- . ——_-_ --- Building Division==
-- --Thomas.Perry,CBO
Building Commissioner' f:
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax 508-790-6230
Property Owner Must
Complete and Sign This Section
if Using A Builder
i
as Owner of the sub*
)-ect property
hereby authorize 11, 1N to act on my bebal
in all matters relative to work authorized-by.tbis building permit application for:
"13 3u �, � ' oU Ic Rai ,
(Address of Job)
i
Signature of.Owner Late
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side. I
I,
Q�WPFU-ES�FORMS\building permit forms\EXPRESS.doc
Revised 040215
P11 fFKER$ C0l4flPE7NSATi0N AND EMPLOYgRS LiABILiTY'INSURANCE POLICY
` IM61176 tion� Pa0e
Atlantic Charter Insurance Company VDAC
NCCI Co. No. 29211 Policy Number• WCV01243701
1. INSURED: Prior Policy Number WCV01243700
Robert Tyndall Producer:
Tyndall Rooting Miller McCartin, Inc. DBA Dowling &O'Neil
PO Box 1093 PO Box 1990
Forestdale, MA 02644 Hyannis, MA 02601-1990
Federal ID Number 999100972
Business Type: Sole Proprietor Risk Id Number:
SIC 9999-NONCLASSIFIABLE ESTABLISHMENTS
Other Named Insured:See WCE106 Other Worl(Places See WCE107
2. POLICY PERIOD: The Policy Period Is From: 07/15/2016 To 07/16/2017 . 12:01 A.M. Standard Time
at The Insured Mailing Address
3. COVERAGES:
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here:MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our
liability under Part Two are: Bodily Injury by Accident.$ 500,000 each accident
Bodily Injury by Disease $ -600,000 policy limit
Bodily Injury by Disease $ 600,000 each employee
C. Other States Insured; Part Three of the policy applies to the states, If any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B
D. This policy Includes these endorsements and schedules:
See WCE105
4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, C/assUicallons, Rates&
Rating Plans. All Information requlred below is subject to verification and change by audit.
Code Premium Basra Total Rate Per Estimated
Classlflcadons No. Estimated Annual $100 of Annual
Remuneration Remuneration Premium
See WC000001
K
Minimum Premium; Deposit Premium:
$650 $7,e94
Total Estimated Premium $9,702
interim Adjustment: Annually Surcharge(s) . 533
Servicing office: Total Premium and Surcharge(s) $10,235
25 New Chardon Street
Boston, MA 02114-4721
6 Ile
Issue Date 07/16/2016 CountersIgned By: Date
opyMht 1987 National Coundl on Compensadon Insurance Form:100mvnt4
C��ie�por�vnzoiacuea�/_1QA_1oac1maleld3
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
.' HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registrationr<r.119766 Type: Office of Consumer Affairs and Business Regulation
2' 10 Park Plaza-"Suite 5170
' Expiration i3/28/201:7 DBA
= Boston,MA 02116 -
WEBB CRAFT DESIGN 1a
DAVID WEBB
25 MEADOW VIEW DR
EAST FALMOUTH, MA 02536 Undersecretary Not valid without signature
Massachusetts -Department of Public Safety f
Board of Building Regulations and Standards
Construction Supervisor
License: CS-046189
DAVID H WEBB -
32 RR Lillie Road ►� t:
Woods Hole MA 8254 7
Arltil�' Expiration
Commisssionne^r` 10/29/2016
Q��fIHErO�yTOWN OF BARNSTABLE
•
IDAUSTABLE,
2639. BUILDING INSPECTOR
4
APPLICATION FOR PERMIT TO ....... ........
......................... .......................
TYPE OF CONSTRUCTION .........
.... .......... ..... . . .. ..... ....... ......
...................
................................................19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ............ ...............n....................................... �-,P. .......... ................................
Proposed Use ... ......4.......
Zoning District ............. ....f-d&2 ,
. ......................................................Fire District .............
...... ..
....................... .. ...................
Name of Owner 4,\................Address .......
F.0 MI 7',,--- '/1
- ., " — A. me I
ES
...... .. Vx .......................... Address .........
Name of Builder
Name of Architect -Ue.V.,.. 1 P;..10-C.j....Address 1k.VA
Number of Rooms ........ .........................Foundation
Exterior ............. ....................Roofing
....... .............................
Floors .7" .... Interior ...... ......
........ . . .... . .
Heating . 01'A ................
....... . ..... Plumbing .......(,S,?4...........................................................
Fireplace ..........................
.JF! ........ .........................................Approximate Cost ..............................................
.!!,. W0,40,
Difinitive Plan Approved by Planning Board --------------------------------19-------- -
Diagram of Lot and Building with Dimensions
C) 0 op
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
. . .......................
Latimer, Dr. Roy
DEC 31 1970
No ..12706... Permit for .... add to
.........single
..........
family dwelling i
...............................................................................
133 Huckins Neck Road
Location .................. ........ ................�................
C n��lle V
..........................................................................
Owner Dr. Roy Latimer 1
r
Type of Construction frame
........................ F
................................................................................
Plot ............................ Lot ................................
r
--.Permit Granted
>> Date of Inspection ..... �.".�-�':. ..........194
Date Completed 19
l
a
PERMIT REFUSED
................................................................ 19
........................................ y
...........:...................................... ........................ ! s
...............................................................................
Approved .,....................................:......... 19
1
...............................................................................
............................................................................... !