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0022 JACQUELINE COURT
q 1a Xr o o U ti Application BAJMqWABM Number... ... . .. /y . .. .. D ........ o MAS& Permit Fee....... Fee........................� 165 Total Fee Paid...................... .............. ...... TOWN OF BARNSTABLE Permit Approval by.... ... BUI]LDING.PERMIT ..........C�2./.0..............Parcel................... ... .... APPLICATION - .77 Section I — Owner's Information and Project Location Project Address ;a3 Village,-B2mdqjjs Owners Name Owners Legal Address &Ce4 City. State mil.6 zi, C Owners Cell# 1509_,US -6V60 E-mail aU4, L EA*"±f Section 2 Use of Structure Use Group_ E] Commercial Structure over 35,010 cubic et Commercial Structure under 35,000 cub V16e14 , Single Two Family Dwelling Section 3—Type F-1 New Construction E] Move/Relocate Acce sory Structur Change of use �;-S-7 ur El Demo/(entire structure) s BasEment I e El, Fire Alarm Rebuild ect— Apartment Sprinkler System Fj Addition Retaining wall E] Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify. Jul Section 4 - Work Description n L \J Last updated. 11/15/2018 Application Number.................................................... Section 5—Detail Cost of Proposed Constructio 9,10GIDDo Square Footage of Project J.� Age of Structure l q. Dig Safe Number J�f(� <,'1 yJ/ # Of Bedrooms Existing Q_ Total#Of Bedrooms (proposed) ©� 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics Wiring ❑ Oil Tank Storage ❑ Smoke Detectors E Plumbing ❑ Gas ❑ Fire Suppression ID/Heating System ❑ Masonry Chimney ❑Add/relocate bedroom j Water Supply ❑ Public ❑ Private Sewage Disposal k ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Delis Disposal Facility: I am using a crane C�Yes El No Section 7—Flood Zone Flood Zone Designation f�p Within or adjacent to a wetland,.coastal bank? Yes ❑ No Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board; n the past? ❑'Yes ❑ No Last updated: 11/15/2018 44 rftsysrlpEjeeiettT ie stt�s. S. 11 +dl . a� Q� Wilding'-:Aden tuilding-:frxsg-ctoi. Goitsenratioii Lx. _ t taffAssgnrrient f:Project k{anagement Stto Prc►�ect Fieyw Nary ' Notify Reviewers of Plans Resut ew Last Rzwewed By:•parzialj ._.r •aadrs'.:�rodPsrva=tt `a'aMm�me"`nt ' a �vrpje tCWrnments8 InsertMuttwLinea# ra - 777771 Y xj'Se .f"9 +.csri r�i °*. -k"�` '�.#s, •, 4 $ h. � .�•� r�.,a �e �{`�" ��. '`,z.'�� t '!' b'���' �'�' � � � r~ + '�,-. Y kwh dal#, r ��t�k �� n '.�:qr;,� '�'� ,��r„� �.�....�. pareiQ 99 7j 38R 201 g �i x. '4t :n }d }b r C{ �..R �+i�'�,�yC; '�'nk�'✓.Y.k h+5ti .�tr3T'�Hh��"P �5� ��'1`i � ��' k'� "< '€ ��' .r �-+�s �'°�`'� ' tY:t'�� ��`�" '� ^ •�'��h+��`�� � ,a���,�5 '�t' ',���,F Ys. �r.i aasd�i`Ss m< 'r`"�"� r �g�, ��:. a s `�+q.,s' f� S tint ice♦ AWL The Commonwealth of Massachusetts Department of IndustrialAccidents Of,Tice of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Jnsurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information JAI� 9 J Please Print Legibly Name(Business/Organization/Individual): Address: GGI City/State/Zip: Phone#: ,C) g r7--� &� `� 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 hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. El Demolition working for me in any capacity. employees and have workers'comp. Building addition [No workers'comp.insurance comp.insurance.: S. We are a corporation and its 10.❑Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11.E 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.❑Other comp.insurance required..] *Any applicant that checks box#1 must also fill out the section below showing their worker,'compensation policy information. t Homeowner;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 thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 and penalties of perjury that the information provided above is true and correct. Signazure: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do 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. 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 to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax numiber. The Commonwealth of Massachusetts Department of Industrial Accidents Qi�ice of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877-MAuSSAM Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia Application Number........................................... Section 9 Construction Supe sor Name Telepho umber Q9' Address LCity CMG -State AM Zip 61 3-21 License Number -Lice a Expiration Date Contractors Email f Cell# O� �°� �(boa I understand my responsibilities der the rules and regulations for Licensed Co on Supervisor in accordance with 780 CMR the Massachusetts S uilding Code. I understand the construction inspection p dures,specific inspections and documentation require y 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date / Section 10— ome Improvement ntractor Name Tele e Number Address City State Zip Registration Number Expiration ate I understand my responsibilities under the rules and regulations r Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code.-.I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy,of your H.I.C... Signature Date Section 11 —Home Owners License.Exemption Home Owners Name: W ,t dou. UaacJ Telephone Number t7O j Cell or Work Number 1 jS I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature� � Date lg 0 Print Name Telephone Number�0 B C E-mail permit to: Vim / IV"-17 __ Last updated: l 1/15/2018 Section 12-Department Sign-Offs Health Department ❑ Zoning Board(if required),,',-.; A Historic District ❑ Site Plan Review(if required), ❑ Fire Department ❑ Conservation OF— For commercial work,please take your plans directly to the fire department for approval Section 13—Owner's Authorization I, aI60wner of the subject property hereby authorize ;' to act on my behalf, in all matters relative to work authorized by 's building permit application for: (Addre of job) j Signature of Owner `` ' date Print Name CIT7S � Y s Last updated: 11/152018 h Town of Barnstable BUildln 9 '. Postg,This.Ca'rd So°Thart is Visible F.rom;the..Stre t=-A roved.Plans.Must beReta�ned on;Job,andsCard Must,be Ke,t * �xr x pp p M osted ` ;,v Permit �W.here a..Cert�ficate.;of.Occu ancs Re airetl wsuch.Buildm shall Not�be Occu ied until a,Final Inspection�has�been,made� Permit No. B-19-1322 Applicant Name: HAYE, HILDA M Approvals Date Issued: 05/22/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 11/22/2019 Foundation: Location: 22 JACQUELINE COURT,CENTERVILLE Map/Lot 210 179 Zoning District: RC Sheathing: - M Owner on Record: HAYE HILDA M Contractor�xName Framing: 1 Address: 22 JACQUELINE COURT Contractor,License s 2 a �o I1 11 CENTERVILLE, MA 02632 Est Protect Cost: $25,000.00 Chimney: � Permit Fe°e: Description: Construction located in the basement.Putting n�a Egress Window $177.50 Insulation: in Bedroom area and Bathroom and a walkout door F 0waid $ 177.50 Smoke Detector Update. r � Date 5/22/2019 Final: ft P IF r -„ Plumbing/Gas Protect Review Req: BASEMENT MUST COMPLY WITH 2015, PLUMBING AND Rough Plumbing: ELECTRIC PERMITS REQUIRED. Building Official N. Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved appl cation and the approved construction documents fo�which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures°shall be in compliance with the local zone g"�by laws and codes. 1_: f This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. 1 � � , ` Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Offici,als are provi is;permit. Minimum of Five Call inspections Required for All Construction Work "r Service: X 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is+nstalled' 4.Wiring&Plumbing Inspectionsto be completed priorto Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: I Town of Barnstable Biiildin V .. .-.5w'..;y .. - f>.,. .— "Y�,g ._':*"""Tt'."'.',"'i""•t. «.. ,.e*!'.—sr ,•..e.-+�.. ..a..-'.+.^'Z^^. ...p.!^6„—!ee" ;9T':k"'y ,�':'"."p'-'*3.r "''T^. .Y :f�. i ostThis"Card So That.it is Visible From the Street.Approved.Plans Must be Retained on;'Job and this Card Must be Kept. w,.MAIiIVBTAr3�-�.. :, ;:✓.' ak.. ^ 'a ..e, W., } x 3,: ,:....4 ;,.� ' ,, "`£.-hie$+l 4 "t 1,, t+`- yf,�". .' + d+,.,,a,.,7 ,.�'^"' Permit ,� Where a Certificate of Occu anc is Re wired such Bulldm shall Not be Occu ied:until a�Final Ins ection has Teen m �Mw_.�S.w36.waatw`aw&�R*;M'w-.hw.w...•.&d5.i�'�.,..:...v.�,+ar✓,.d:aw....:i%,.:.-„_...rr...uaA?,5�sr61�.r.�,an^.A,v,:,:fi4nt—.:Leii4u,e.4«+sa.N.ad4"�E.'Lc.aiv`.d.eWf SF�Sevnw:.w•�J*.2,u.....a'C4:ba.a.«n^:�".lm��,*e4+«e" v.mk`�;:A•.e..i..«.mYR:.r+°::.."G�' Permit No. B-18-505 Applicant Name: HAYS, HILDA M Approvals Date Issued: 03/02/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 09/02/2018 Foundation: Location: 22JACQUELINE COURT,CENTERVILLE Map/Lot: 210-179 , Zoning District: RC Sheathing: Owner on Record: HAVE,HILDA M ,' Contractor Name" . Framing: I. . Address: 22 JACQUELINE COURT Contractor License ; 2 CENTERVLLLE, MA 02632 ( �` Est Project Cost: $9,000.00 Chimney: Description: Reroof, Replacement windows(2), Doors(2) _` g Permit Fee: $45.90 Insulation: Fee Paid: $45.90 .Project Review Req: p 3/2/2018 Final: { x Plumbing/Gas Building Official 28, Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit. s commencedwith n six months after issuance. Final Plumbing: .All work authorized by this permit shall conform to the approved application and the approved construction documentsfor which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance.with the local zoning by-laws-and codes: Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the 11-work until the completion of the same. x I 1 A Final Gas: .. .x •, The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are p ovided on this pe mit. Electrical Minimum of Five Call Inspections Required for All Construction Work: i Y' Service: 1.Foundation or Footing f , y 2:Sheathing Inspection 6 .. ``- t � y 3.All Fireplaces must be inspected at the throat level before je firest#lue Itnmg is installed A, Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame'Inspection) Final: 6.Insulation 7.final Inspection before Occupancy Low Voltage Rough: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Low Voltage Final: Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: IG tKE Town of Barnstable *Permit Building Department Services Expires from issue date snthvsTAar.E. : Brian Florence,CBO l� 1639. � Building Commissioner I (/ 200 Main Street,Hyannis,MA 02601 www.town-_Ts We.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICAT 4 `RESIfDENTIAL ONLY Not Valid without s I Tint Map/parcel Number f IIS I ML f Property Address _ ,WW/,ljN -t GO ❑Residential Value of Work$916u, Qa Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address 1 kt ,ck(Z., �- Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) e-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ®I eplacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors:_ 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: zz QAWPFILESTORNIftuilding permit forms\EXPRESS.doc 08/16/17• W , The CommamreaWt of Maswadiusetls Departirteut&f ru wstrid Acdderrtg -W. - Or we a, M-w-VUI9ations _ 600'F#r=Idngton&reet Easton,CIA 02111 n Fviu m=goRfdia WnrI;e& CanTensaimmice Affidavit$m7derslContracimsJ em"rtcian�humbers ApPHcamt IIIfarmatinn Please Print �A`cidress: COGr�rJ- 30 Lt Are you an employer?Checkthe appropriate b= ' Typeofjroect{regged}: LEll am a employff veith- 4 ❑I am a general contractor and I employees(full anNoe part-ime * have hired the sub-coat actom 6. ❑New construction I❑•I am a sole proprietor orpaitner listed onthe•attached sheet`. ?- ship and have no employees These s b-c=dractors have 8.,❑Drmolifiort wodingg forme is any capacity. employees andhare wormrs' 9. El Building addition LNp 1 pdoa& comp.incun=e comp_ksuramlf required-] 5. ❑ We are a corporation and its 10❑Electrical repairs of addifians 3-4�f I am a bomemmer doing all work officers have exercised their 1 L❑Ph=biagrepairs or additio s. myself LNo wokkars'0QMP- u of exempficm per MGL 12�'Poafrepairs +nsm=e required-]I c.152,§1(4k and we have no employees.[To woAna& 13-❑other n comp.insurance.require&j •Aay apgff Ist cbec sbos#I taa;t aLSa fiII a�thc sectioabe7awslundug lea ceis'compeaseSnupoycyia�aamaoo� #ffameomaeawho sub=d ffm sffid=mdkz mg tky ire doing sU vra$urd 6m him outside contmc m m WCT+ fCaatzaciogibst cbeckt3risbaxmast aitarhea maddifi-al sheet sbouaagdlensmeof fim sob-cnnt=ba-s sad stmatewhed m or not ftse eaddeshnq-- employees p2nu-idetbea wudmm'C=P•13GHUnmlbet I ant art serpla�r Ssrrf;is prauFding worlrers'courpertsrdzart iasrirartce for m}*clrrglay�ees �SeIoly isY7«pafiry�a�rd je7a site informrrliam InsuranceCompanyifame: Toficy,or Self--im I.ic. �piLaizoaDafe: Job SiteAddre CiLYMMW�.tp: Bch a copy of the workers'compensationpolic_-declaration page(showing the policy,number and expiration date). Faitnre to secure coverage as requiredunder Section 25A of Mai.c�15 can lead to the imposition of criminal penalties of a fine up to$1,54a 4U andtor one-gear impdsoumenk as weg as civil penahies in the foim of a STOP WORK ORDER and a fine of up to$25,4-00 a dap against the violator- Be advised that a copy of this sbkment=aybe forwnded to the Office of Investigations of the DIA far mi rimmce coverages oa Fria kersby csrf6,nuder tha pains and peru dtks ofperlary flud 'rs acforma6mpro*vW abmw is bw and correct: C.S e�atnre-, -1 Date: C;L' Phoneir OJEriduwmily. Da not wke in t ds orn4 to be-cinupkad by city artemn ejok-int My or Town: PermitUcense;g During Antlor€ty(drde one): L Board of 131421 h BuTd"ung Deparhment 3.City Tcrwa Clem 4.Electrical hupeetor S.Plumbing Inspecter 6.Other Contact Pierson Phone#: — -- — - - 6 ormation au' d 11astructious M=sa�s Ge= al Lam chap-152 req==-a emgIopea 10 provide works'�e�oa far flies employees. p -tD this sue,an errglopee is defined as.6:e�Peasou in.•f a service of aaotiiet under any Mntc cE ofhae, express or implied,'oral or wnifi-en." An er F&yer is defined as"an indiyidaaI,P=to. sh7p,association.cmpmEtion or other Legal may, any. o or mare of ffi foregoing a3omt else,and mclndmg fie Legales=aiives of a dosed employes,ar ib e receiver or trustee of an in Edd=L p�.iaeasbrp,associat M or other Legal entity,employing employees. However the owner of adw6Ui ghousehavmgnotmorei3ianibree atfinentsmdwhoraa&zt =n3,ortheocc¢p�ofthe- dweIlmg house of another who maploys pemons to do ,r-=skuc ti on or repay work on such dweIlim horse or on the grounds or bm7dmg appmt=m3t therein sbaIlnotbecanse ofsach employmedbe deemed to be an empploymf MGL chapter 152,§25C(6)also stems that¢every.statm or Local Remaking agency shall Wiffihold the issuance or renewal of a licensee or permit to opms d±c a baseness or to constracE buildings zu fine eommouweali$for any applicmtwh.o bras notpr•odnced acceptable evidearce of compr=cew, ML the iasurance.covexageraQ¢tred-" Ad�onally.MCrZ chapt=152,§25�siatxs aNeiihcr the c nor�y of its po7iiical subdivisions shaIl enter mto any contract fOr the performance Of Public work mnfiL acceptable evidence of camplianmwn the msmMce.. requi ==Lf's oftbis chapfeahavebeen.pre$eztt-,dto the MDtLng M1thO1;LtY-7 A-ppHczn-& . Please fl1 oiot the woz=7 compensation affidavit completely,by chug the boxes that apply to your situation and,if n=essary,srPply sal>co (s)name(s), (es)and plumencznbea(s)alongwrhffi==-fficste(s)of insurance. LimitedLiability Companies(LLC)or LmzitedUabilityParf mnLips(LI P)'withno emPloy=other thm the members or pmtam-4 are not rtgo±md to naay workem' compensation iosm-ance. If an LLC or LLP does have empIoyee4s,apolicyisrequmrd. Bea visedthattiusaffdayitmaybesobmutedto,theDepar(meuttofindasdal Acciderds for conEn=Latim of msmm=coverage Also be sure to sign and date the afMdagii: The affidavit should be•retnmed to ihm city or town that the appliraion foi the,permit or license is being requested,not the Department of I ca minis Shouldyou have any T=siions regmdmg fiie Iaw or ifyon are required in obtain a wozicers' ��ationpoRcLplmsecaIItheDeparbaeotattben=berlisfedbcl0w Self-ins�n�d�mPanies shoalden rtheir self-Ins„rance license.nu beron.the line City or Town O$riais - r Please be sore t�i3ie a$idavjt is complete ansiprmted legibly. The Deparbneathas provided a space at�boifcnn . of the affidavit for you to fM Ott in the event the Office ofjnycstigafi ems has to con act youregardmg the agphcant ?lease be sure to fill.in the Pex it. cease number which will be used as a refrnce n=ber.In.addition,an applicant that must s:abmdt multiple penIItUc`ense applications in aay gmayear,neei only submit one affidavit indicating erno:ent policy infozzznatiaa[if n Y)and under"job 5Je Address"the applicmrt should wnii�"'aU looafions m (may or town)--A copy of tam affidavitthat has bee.officially simaped or marked by the ccif r or town maybe provided to fete ' applicant as proofthat a valid affidavit is on file for faun e'permi�s-or licenses. A nevi affidavit must be fMc&Di t 6s rh. year.'QZhea e a home owner or citizen is obtaining a license or permit not rrlaiod;D any business or oommeacial veotcae (_D. a dog license orpeanittobvmleaves etc.)saidpmsonisN0T to crap affidavit The Office ofIn. 'nn wovldIzketnthankyouaadvanm for your coopenationand sbouldyouhave any4 =, please do not he sibdM to givens a c Z Tb,5 DeZ7tro ,%ad&-=%inIephone and.fa5c numbea: Departiamt GfhidmsftiA AccUenta (504-Waingtau St=d lanstmslA E11I -TrL 461'-'27-49W cxt4Qf m 14 M&& Kevised424-07 � � Town of Barnstable Building Department Services ` Brian Florence, CBO ►` Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder I, YlLdo- ,as Owner of the subject l property hereby authorize to act on my behalf; in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature ct Owner Signature of Applicant Ni Ida, -ems Ida, —t--, Print Name Print Name Date QY MS:OWNERPEFIMSIONPOOLS Rev:08/16/17 Town of Barnstable • Building Department Services Brian Florence CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us 1639. Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE F.REWTION ^ �DATE:- �n I �y Please Print .,C- d� — l �S /e JOB LOCATION: o�� /,t.(dn.A� �Gvtd Qnt'�Vt� /)))0 numbd ly street village "HOMEOWNER": s -ja, 509 FSZ;S-o name ` home phone# work phone# CURRENT MAILING ADDRESS: CG 70 cityhown 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 buildingpermit. (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. ignature of Home er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. ' Q.\wPFnM\FORMS\building pemrit forms\EXPRESS.doc 08/16/17 J TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map V 0 Parcel I 1 Application Health Division Date Issued O 1 8 Conservation Division Application Fee Planning Dept. _ Permit Fee 3i Date Definitive Plan Approved by Planning Board pk �ol�S/j3 Historic - OKH _ Preservation / Hyannis Project Street Add1ress ��+.c�G�1 n@ CO�r� Village Cen�-et'v I�P. Owner kA Address SU.f Telephone Permit Request N R-3 o St l\,O6Sl_ :AD -k 1 e 66 4; NO 3 a lOjt, 40 film - m �' � t°. 7ti! P�a n4. u� k�, c� �a�1�n�n �vr�► Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type C7 1 Lot Size Grandfathered: ❑Yes ❑ No If yes, attac�supportindoou nentation. Lo,Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) _"' Q ,:: an Age of Existing Structure Historic House: ❑Yes ❑ No On Old King s Highway: ❑`Z. s ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other `s Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Lod Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new i - TotaltRoom Count (not including baths): existing new First Floor Room Count ti Heat-Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing .❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes XNo If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 318 Q Wk5kek, Name �1 �tTk.. Telephone Number Address 3 �%A'I Q License # -1c 161TT L )�C44164h f DWb(114 Home Improvement Contractor# i 313 Worker's Compensation # I�/ �, 335 3 7 0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL"BE TAKEN TO \ �MneU•"�' SIGNATURE DATE to "l J FOR OFFICIAL USE ONLY a ' APPLICATION# '-DATE ISSUED MAP/PARCEL NO. a ADDRESS VILLAGE r OWNER f DATE OF INSPECTION: t 'MAUNDATION` a FRAME INSULATION. FIREPLACE ELECTRICAL: ROUGH FINAL ;T PLUMBING: ROUGH FINAL ,y GAS: ROUGH FINAL " FINAL BUILDING DATE CLOSED OUT' ASSOCIATION PLAN NO. A r z Housing Assistance Corporation Cape God HOMEOWNER WEATHERIZATION WORK PERMIT & FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. I Xbz& hereby consent to and agree that weatherization work may be done by the eatherization Program of Housing Assistance Corporation (herein after referred as"Agency") on the property located at: The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some.of the following measures: Weather-stripping &caulking of windows and doors, insulation of attics, sidewails & basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home I agree to the following: 1. 1 give.permission to the `Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5) years after the weatherization work is completed. I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature)! -- Date: � t Agent: (signature) ;OIL Date: T,- 10 -� 13 T— e I HAC approved Weatherization Company : All Cape Energy Cape Cod Insulatio ape Sav Efficient Buildings,LLC _ Frontier Energy Solutions, L-ohr- Sons, Resolution Energy The Commonwealth of Massachusetts ry„ ."- Department of Industrial Accidents Office of Investigations " - -_ "`► I Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leliibly Name (Business/Organization/Individual): Cape Save Inc. Address: 7D Huntington Ave City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-398-0398 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with _ 4. ❑ 1 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- These on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have' g, ❑ Demolition employees and have workers' working for me in any capacity. 9. ❑ Building addition [No workers' comp.insurance - comp. insurance.' . required..] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] 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' 1J•❑✓ Other Insulation comp.insurance required.] *Any applicant that checks box#] must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Technology Insurance Company Policy#or Self-ins.Lic.#: TWC3353968 Expiration Date: 04/09/2014 Il Job Site Address: C o °L City/State/Zip: CP J V t Q Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the aims and penalties o er' that the in orfnation provided above is true and correct. - -_ --_ - - Date C �' . Si nature: ' Phone#: 508-398-0398 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: frD DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 4/9/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME C Colleen Crowley Risk Strategies Company PHONE . (781)986-4400 I FAX No:(781)963-4420 15 Pacella Park Drive A Suite 240 INSURER IS)AFFORDING COVERAGE NAIL Randolph MA 02368 INSURERA:Selective Insurance INSURED INsuRERs:Safety Insurance CompanV 33618 Cape Save, Inc INSURER C.Technology Insurance Company 7 D Huntington Ave INSURERD: INSURERS: South Yarmouth MA 02644 INSURERF- COVERAGES CERTIFICATE NUMBER CL134960509 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I�TR TYPE OF INSURANCE DDL S POLICY NUMBER MMILDD YY MMIDD POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 100,000 A CLAIMS-MADE ❑X OCCUR S199448001 0/16/2012 0/16/2013 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE Ea accident L M 1 000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 208200 1/6/2012 1/6/2013 BODILY INJURY(Per accident) $ AUTOS AUTOSNON- IVIED PROPERTY DAMAGE $ X HIRED AUTOS N AUTOS Peraccident X Underinsured motorist BI split $ 100,0001 A X UMBRELLA LIAB X OCCUR 199448001 0/16/2012 O/16/2013 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 RED I I RETENTION$ $ C WORKERS COMPENSATION Officers Excluded from X STATIT I OER TH- AND EMPLOYERS'LIABILITY ANY PROPRIETORfPARTNERIEXECUTIVE YINCoverage E.L.EACH ACCIDENT $ 500 000 OFFICERIMEMBER EXCLUDED? NIA 3353968 /9/2013 /9/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE,$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD G,Additional Remarks Schedule,if more space Is required) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc_, and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION (50 8)790—2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corp 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE chael Christian CLC �� d. ACORD 25 2010/05 - O 1988 2010 ACORD CORPORATION. All rights reserve t Massachusetts-Department of Public Safety' Board of Building Regulations and Standards Construction Supcn Nor Specialty License: CSSL-102776LY - ` WILLLkM J MC CLUSIKEY:- `- 37 NAUSET ROAD t West Yarmouth MA 02673_1 Expi rat lion Commissioner 06/28/2015 Oli eowmwww" Office of Consumer Affairs and 2usiness Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 Type: Corporation Expiration: 3/14/2014 Tr# 222184 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH, MA 02664 - Update Address and return card.Mark reason for change. Address () Renewal Fj Employment r', Lost Card DPS-CA1 0 50M-04104-G101216 2,, ✓fie -Consumer Affairs &�i �ness Regulation License or registration valid for individul use only �� Office of Consumer Affairs&B sines Regulation � Y HOME IMPROVEMENT CONTRACTOR ' before the expiration date. 1f found return to: __ Registration- -_-.171380 Type: Office of Consumer Affairs and Business Regulation " R 10 Park Plaza-Suite 5170 Expiration: 3/14/2014 Corporation ' Boston,MA 02116 CAPE SAVE INC.' - WILLIAM McCLUSKEY; ="= 7-DHUNTINGTONAVENUE g P� SOUTH YARMOUTH-MA:02664 Undersecretary Not valid wit o signs Cape Save Inc. TOMB OF BAR BSITABLE 7-D Huntington Avenue . 51 South Yarmouth MA 0266 �13 t��� 1 Tel: 508-398-0398 Fax: 508-398-0399 DIVISION 11/11/13 Town of Barnstable . Thomas Perry CBO Building Commissioner 200 Main St.Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 22 Jacqueline Court, Centerville has been inspected by a certified Building Performance Institute(BPI) Inspector. Ceiling: R-30 cellulose All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map_C / Parcel ZZ 1 k LE Permit# 620 I Health Division __W 9-7 Co o� a S-bw f�T i�n°'fi`�2 o n�y a ��03 sup Date Issued 0 Conservation Division v I�[$ -6 Application Fee d' „. Tax Collector Permit Fee C, Treasurer -~' fV O SEPTIC SYSTEM MUST BE � / INSTALLED IN COMPLIA �2//,3/63' Planning Dept. j,E$ Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address 2 ZZ Village C E'er of v t t, f Owner Address Z2�14�Qp?g Zlo CT City-00- U)I- Telephone r��o Permit Requests R,-,'A e q k2AM wti Q. (�:op x 9 S° Uy'l DN.W l ild ow s, �oilP �� 3�Z 11�./�oVic) WCkP_L'( Ap 14' x22' w4 c, ykxA i-,on wmk WIA doo Cr 2c , ?., S A C l� QAr — C., Lei Y'o o 0M. ; 61 room# Square feet: 1 st floor: existing proposed 2nd floor:existing proposed G- Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes :KNo If yes, attach supporting documentation. Dwelling Type: Single Family 5Q Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ®No On Old King's Highway: ❑Yes U No Basement Type: ®Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ®Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes a No Fireplaces: Existing New 0 Existing wood/coal stove: ❑Yes 0 No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:CR existing ❑new size Shed:®existing O new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 04 No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name �'/�'r2�C �% �Gy�-G� 1 k 7W Telephone Number - Address ;2.�z T4c e4-7 e License# Home Improvement Contractor# - Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING F 0 THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO. i I3ATE ISSUED MAP/PARCEL NO. ` . ADDRESS VILLAGE OWNER ;~ DATE OF INSPECTION: FOUNDATION FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGHS rC FINAL 14 GAS: ROUE I '� FINAL FINAL BUILDING5 Q` DATE CLOSED OUT ; )' :n ;t ASSOCIATION PLAN NO. `pFTHEfp The Town of Barnstable nrP pw BARASS. MASS. • Department of Health .Safety and Environmental Services Y 0 1639. ♦0 PfFDMP+N Building Division 367 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: J, Sr--z.-c, 7 Map/Parcel: ;2-/O Project Address: '.z J Q v L i iy v z T Builder: G w ff C�iYr�/z✓�u..� The following items were noted on reviewing: 0 3 `° Rix r,-��, 3� `0 3 �✓�GLS �T�G � iG�N� �> /� u�M is�� /�iU-r�-�"/�vG /✓�Tii�i L s •�,ta c� ✓r�i.v�- �jr•�5 Ti�,r� a/- �.e Vf-71V Reviewed by: - Date: �/13 a-f q:building:forms:review f — The Commonwealth of Massachusetts Department of Industrial Accidents Office ofliffyie gatiaas 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit lo C cation _ r►C t Zd LL A T)hone# ci I am a homeowner performing all work myself ❑ I am a sole r rietor and have no one working in ca acitp ///%��%%%%%O///�/%%/%%////1"111 I am em 1er rovld. workers'm w mP nsation far mp employees working,on this•job.::;?.}::.J:.}}}:•.Y±•.`:.:{><::::<'>}t:.;:;.:.>.;�:=;::�r;:Y{;:;,;;kr�<:�:; :;:: co e . .name:. . .. ... .:.........:::...........:...:..,:.r...J:........ t.�:.;, .......:;.}•,.<::<$:i<: •;::<:::s>: ................ .................. ...............n.• ............v......• .........�....... ....,............ .n......+':'t4{{::... .$:}L}':....{;.,n:::':win ..... .... .......................................:.............. ................r.v......... :v.. +:r.....,•n•...t.... ..`::...:Y•:.::v':4 `t:v:w:{+>.S•7'•xw.•. ...r....... ....n............•:•:::::::.v::.......... .::.::.............:..::::n.v:n.:nv:.....,.• .w:::.:r;..•.....+.':t...�.,(i,::J':S:ti.,.....n..r7:.i•.v.',`.?�.:{i4;^;;. .r....:7.:...........:.:•:............:..,•:•..:....r.......... ... ..........:n. r....... .. ...... ...... ..n...r.:. ...,........... ................,.........: ... �v....w:::::r.v??....-::::::n•.w:r:.n•••.w:.:w:•;:::: :•,....;... qx v..:..:vvv:......r,...•w::.v..........r.::x:::•:.:...........vf.{v:.:...........:w.vr::.........:::.v:::v:::7n•n n..r...::v;}. ,.•,:::nt•; ?.,vr::4�}:.:4..w+,.:t::tv;:::.:/:..........:•..............:w.: .:x..7..v:.:...... .t..:::n.............;.:....... ..,.......... v..;.;;..... v':+•Y:v:{•±i??v±:w::::::.v;:::.... .... .....v:...........:...{...t n'Y.....+.•:?r:......n.v n:::.........,...::::..nv::::.v.v::n:::...::•:•:v:•::::::.v:±!.}}:{?... ... ;..: ...... .v:::.v:n•.,..::vr7::::n•n:•:n.....n;.r.n..;;• .n•:..:•:nv.. y �.,yS�... .. ........:.............. ...:...........:::.v::.n:+:`...nn?.::v:;r.rrn;•.,v:::•.h•::;.:::.v.:.;•......,:•.::t::{:•:::::.:,;••},.,v t..A••k#�i�^>:::v.:. . .- ....... ..........v::;?•,�}Y}:}}J}::•v:.}}:L•}}7:•}:2^:•}77:•:i:};ry;{?y:•6;{•J}}}:??w:...•.v}:4}}:•}:v::+:::?.}}t'•:3;:�;.}}'v.:v:?•:n!•%•:;•,'•;•}:.;r;,J,} ... ....... .,..... :........ ........ .n.,.., ry.r.t•::•::rw::::.,v .hv:v:.l•}•n}::vn.:4{•}:. ..nr. ......: ...rn.... ........ ....... ...........w..,.... r:vv•v:•v. +:::•.n::f. ..... ...: ......... .......r ........ ..................... v{};r•.v:.v....w,+.}'?v:{vb:•7'r$}•.y,:n±:i:v:• .v?4:•v$}}:•}:4:•'r ............ .xn......• ... .....n...• .n..,......,}• ....,.....r. .........................::::..........n•:nv:::n•:.}v.v}}:•}}:•7}}.n•....;'.,:.:n•:.:v:L:{{•`}}:::::. .. .. ...... .....:..........:•::.•:.................;.....v..:.....:....•v::::::nvn:•:•-•.;:.}}:nt•;•::::?•}'•}? :w:::..........v..•::?w:::::,v::'v ti•}•.:{:+ir:.•::n v, •v:;'r,•ti•$'}}•..n.:}:.vn•:n•: ... .....+.....:................:..:..................:................ one#.:.::,::::::.•.::,.::,.::•}•.:;.l:L:{.{;.$;:r:..:�:+.} :..................:.............:.:.............::: :::.:::.:. .:......... 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Xi v:•::•:+.•::..r......n.•:r::?{v:•n;'+v•.::?:+.•.•}v,{•:'++ ,?•:`i;}:•i•}}}::v v:::n.v.7•�:n}'v::.. ...n. .r..... .....f.. ... •:v:v::v:;i:}7? ...........:tiL$:{•}...r w:••:.•::?::rv,:•r7}i}:•}$i:i:$::••n;{::.:{:nv. ? ..:::::.::n:::;::::::•}}}:+:}} ......................... ....}}}:•:^$:;$i7'{•i:•'f.?}t•:i•}:SL•}{::::t:•::.......................:.....,...r..v.....vw:t:r:.t;:...,.........v}. .... .: 00 and/or Faflme to secure coverage as required tinder Seaton 25A of MG 152 can lead to the imposition of criminal penalties of a One up to S1,500. one yam,bnprlsonment as well as civil penalties in the form of STOP WORK ORDER and a the of$100.00 a day against me.I tmdetstand that a copy of ails statement may be forwarded to the Office of v arsons of the DIA for coverage verification. I do hereby certify under Apains arcdrpe l 'es edury that the information provided above is true and correct. Date Signature Phony# S'p 7�I Z Print name official use only do not write in this area to be completed by city or town oMdal peradt/iicense# ❑BvDding Department city or town: LILicensing Board OSelechnen's Office ❑aeck if immediate response is required ❑Health Department phone#; _ Other contact person: ' (wise 9/95 PJA� 7 Information and Instructions ' lion for their e es all employers to provide workers compensation on 25 r Massachusetts General Laws chapter 152 sects q� employees. As quoted from the "law", 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 section 25 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,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and company supplyingany names, address and phone numbers along with a certificate of insurance as all affidavits may be R. submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign an fi: date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you being requested, are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitMcamse number which will be used as a reference number. The affidavits may be retaari 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Inyesugauuns 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 °FtME,°s� Town of Barnstable Regulatory Services BARNSTABLE, ' Thomas F.Geiler,Director 9�plf 3;�a Building Division Tom Perry,-Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction, alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ' 'A YP � o Type of Work: "Re p16�e �QAa e. info homt �JDrLl den �/ stin,ted Cost �z �� p Address of Work: 7iZ I-ACQ U�11 t) Owner's Name: eouCIG `r` I I Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 []Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGt c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Wame Registration No. R Date �(twne?`s Name RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 gip. Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE >: square feet x$64/sq.foot= c� /, S 6 q, x.0031= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq.f� , >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building pit square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) i Deck x$30.00= - (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee i� projcost t t r The Town of Barnstable Regulatory Services Thomas F. Geiler, Director , Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis MA 02601 t Office: 508-862-4038 Fax: a 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: J JOB LOCATION: 7— �-w if PyFIL IV E e--7' number street village "HOMEOWNER": �,G,c �� L[y j -7 name home phone# work phone# CURRENT MAILING ADDRESS: 2 Z 4-4 PC /'Uc ei 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_pemut. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. 8 The undersigned"homeowner"certifies tl at he/she understands the Town of Barnstable Building Department um inspecti n p ce- -ores and requirements and that he/she will comply with said procedur and requiremen . e Signature of Hom E Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming.the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. TOWN OF BARNSTABLE Permit No. -----.----__-_ Building Inspector ruaCash ----------------------- oO�O YPY OCCUPANCY PERMIT Bond -_--_--.....____ llg "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 by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. .....................................................1 19......__ ...................................................................................................._....._._ Building Inspector ��1lYaL rAMIL�( - _. �a=171�bpNt GO / r�ac�� >~L.C:•.,v _ t Io � �.. - ��o Ca.f.v: •�r0•� -; ��T-:G -rl�+-.1K. _ ��o.r (SG % • ��r7 6.F?D. 1 SU,r-WALL AUK - tSv �. sr-rotit Ae�sa e Sic) sr-'. 0..0 Sri: l •o z 5c7 C�.PD. /Co " TOTAL. "DESIGN = -4'L5 �p TOTAL. t v�9• } ->ai��( 6�P.'i�. .•.t` I (°lo thtIQ' OQTZS ' i 1 ' Per ' '•p, AAI OF mc*4.06) •sty /y�EP y �+ OL rcp� �i';�4 /C� A N E•.�,' b ty `. .� ��j"G/-lQ' ti Jor 10y4 c�. ., t � • 1•Np s 100.0 >... CO ..ice iuv• 9 7,o ;;j Lo9�1 Id��oe tOoo luJ. •� . Iw. c„o�. 9G•Y '` Z InM ! Ta*1K gli PIT 1 1 C. l..o PL.AaV-I P2oy=-t LE sro,vg LoGAT1OtJ GENT�2v Il_L E 1.10 SGQ.L�- GAL[ i N`.40 �7► AT! �'/3/ /i4 8o pt:A 1.1 R r F`2E��_�.1 GE i f" ( Ct:;iZTI I= Tl4AT T{-SG CFO U Nam.&,-T t-IE:t,'(-LSIJ Gcw�r'L_�!S W ITk TI-U : -JIVE 1-1 L.O 7- 1� I our ScTt��cV j7CQUIgZeA.1&.WTS OF Tµ.� -Tow Q LA,,K $k-,z cl o pG . 5 -1 ; �� RcGtS rtf:�=� tJI.I•l� ;tJ�v�Yo�� MA.0 {wSre� r=��� ,uc_•/� � ,� Y►ac_; c�Fsr,��"r, ,lt�wuc� n.Nll_{rn,I.�-c-- 3AME-s ic. SM ITt �.e.• nr� Y` .l_IlJi rrer--r, 're. .1)h'1'1'.('�r(1►Ilr 11� •.� ( �As es S is map and lot number G.� � -A3 ..0 ..o............: � X. �,� 1 fT�T� Sewage Permit number ........................:............................... SEPTIC $Y�M M QQ /CAM L E, House number .��.................................. �. ?.�.................... �+.cY IN MMVV. . � EN VI VII�ITH ALE 5 °tea Mix.��Om �OmTAL CODE TOWN OF BARNST ULATIONS BUILDING . INSPECTOR APPLICATION FOR PERMIT TO ......Build. Single. Familv...Dwelling ........................ TYPE OF CONSTRUCTION Wood frame :+ a..... .................19....8O TO THE INSPECTOR'OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .................hOt...l?...Jacquela�ne. court.....Centerville............................... ............................ ... Proposed use .......Single...Fam lY...Dwell 49........................................................................................................... Zoning District .....Residential ,,Fire District Centerville-Osterville Name of Owner ...James K. Smith Address Barnstable ' James K Smith Barnstable ,. Name of Builder .....................t..............................................Address .................................................................................... .Name of. Architect ..................................................................Address .................................................................................... Number of Rooms ............... ..................................................Foundation ...PQvx.ed... Q Cx'E.tie..:.....:.......................... Exierior ....................................................................................Roofing .........Ai .114,lti....aS.�,7nel..u................................. Floors ...................WaU- ...t.Q...Wall..................................Interior ......... atkw.Drywall ................................... Heating ........... ...Ga.s...........................................................Plumbing .......2...baths.......................................................... Fireplace ................One...........................................................Approximate Cost ............$40.9.00.0............................... ..... Definitive Plan Approved by Planning Board ________________________________19__:_____. Area ..........! AOCI ` , Diagram of Lot and Buildin with Dimensions 9 g Fee -..: ................:...... SUBJECT TO APPROVAL OF BOARD OF HEALTHQ/v,� -3 cc 9 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... W.. ... ........................ SMITH, JAMES -.K. No .2.97.6.3 Permit for One_..Story ....... ..... ........... SinglSingle Family... e..................... ........... Location ...!Taqqueline Court ...................... Centerville . ............................................................................... James K. Smith Owner .................................................................. Type of Construction XXAMe........................... .................................................................... ........... Plot ............................ Lot ................................ December l5'- 80 Permit Granted ........................... ...... ...19 Date of Inspection .....................................19 Date Completed ......................................19 C; PERMIT REFUSED .............. .... 19 4. t; .....4ff.............................. C11 ........... ........................ ...................... M U., 40. .............................................. C, .......... ............... ......................................... :2 C'N C Approved ............ 19 ....................... ......................................... ............. Assessors map and lot 'number ,�' ('�k -...:........:......................,....... ��1�f � •r -- THET�� 4 Sewage• Permit number ........`...fj.......................................... ro�Q Z IMUSTAX E. i HOLY a nu MAS& number ..:........................................I............................ 9�p t639. 00 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........`tti.:�l SiXl.:ry'le P.-anily �rellin ............ TYPE OF CONSTRUCTION rkod frame... ..................................................................................................................................... ..... ...5::................ ..................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .................Ln-. ..7.F..'��i,cnix?�„]..ne cQ�.ir— ....Cente1"G.1.�:�: ..................:............ Proposed Use .........5?,7 ^�Lc...."ami1'c...lwellznrr........................................................................................................... Zoning District .......Rosdentia enterville-OuiC ?vi leresrc ... Name of Owner ....J.am s..K."... 11]. 1..............................Address ..........T�qr^nptab1e................................................ Name of Builder AaMe.0 K. 19ra; -th.............................Address T'r3table .Name of Architect ..................................................................Address .................................................................................... Number of Rooms ..................................................................Foundation ....701.11-e-f?...(.:.0PCrP.t ..... .. ..................................................... Exterior ....Roofing .........f.. tlh.'ti. .................................................................... Floors Ial i �: 1.l xs�'sf . rr.a ..........................................Interior ......... . . x......T'hm... . i.`. .................................... Heating .................r^...............................................................Plumbing ..............'?:^..':':............................................................ Fireplace �. ...............Approximate Cost `I''s• f1C t("l .................................................................. Definitive Plan Approved by Planning Board ----------------------_---------19________ . Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH ' y ` I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ..r:�f:! �.... .... ........ ...................... ` �' L SMITH JAME�( A 9 { No .:2.276:3.. Permit for One Sto y ......... Single Family Dwell ng •3 r Location 22...Jagq. ...CPu 6-t Centerville ............................................................................... , Owner ......+7.=e.5... ,....S...T.gi h....................... Type of Construction ...F.raMe.......................... ................................................................................ r Plot ............................. Lot ................................ a - Permit Granted December 15, 19 80 ........ ...................... Date of Inspection ... ................................19 Date Completed ......................................19 E PER IT REFUSED .................................... ....... 19 .......... .. .. . . � �. .�. -�.................. ............ ....... .�. A.......... I j.y.................. Approved ................................................ 19 . ............................................................................... ............................................................................... SMOKE DETECTORS REVIEWED f UILIGD T. DAE U FIR E _N T - . DATE. 60TN SIGNATURES A URES ARE REQUIRED FOR PERA91TT1NG 6� l� Barnstable Bldg#leg t• ^ roved by' APp #: -/3ZZ Permit ,✓ i. �, ,, U Cl .: - ` 017 Yk qA �1.LL./ f Ry Neu 32x 1 G" W A7E1Z to r ti/o 00 GLe'G 01R rti1 5 L O M 1� l�cD r �d o o c-1 d PEN t /\,j cT- 5T",4 FpxM A S)awn-lh lnsvlafiah ka C 2i o-LWbl1 S Xis iH C,imc� ' 3 I. E7Csnkcdd' 1'pQ>1�r1 Y'�At-L,1 i 4Z ADD 3 �NDE�saa Nper ►. L,NC JN �r�n�loWs �e41-Ace W�yCltn d�w s . 7 ��� OS�3 VYA��'(��OARI� ON�XI'rVG,th�^qI �.�"� �AC�u�:�.\� .ET._��N �.����- Scw�� ��-l� 'fneP�Pe�==--F���s�,—'u-�'��J�t� �h,,,�►e� }� 'NlA-rc1� Aj� C ksE2�o2y,la1�s -rD 13 I . ... . - s'�oS // Ts fr�oU3�c E�C I ST1 N r— J el4kvzVu 3z" prewny QH.d ear b � f �JZ - - - - - - - - - - ` J ADO 3 ANuE2so4 NAu-w, LiNtf DH Winclows. �eP 1Ace W/win owS . ��F{" OSr3�NA��'lZ13onRD oN�K��'v�¢.m�^Q) Sfcv< w�tli TAePi°oe✓'_-_ F��„s1,--�-/---W-�=��`�"' �h,�eies �o �ATcla