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0262 LAKESIDE DRIVE WEST
i Town of Barnstable N RECEIPT 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-4070 Date Recieved: 11/24/2017 Job Location: 262 LAKESIDE DRIVE WEST,CENTERVILLE Permit For: Building-Insulation-Residential Contractor's Name: JONATHAN N WHIPPLE State Lic. No: CS-078683 Address: Webster, MA 01570 Applicant Phone: (508) 279-1110. (Home)Owner's Name: THEODOR,LAURA J Phone: (774)487-4412 (Home)Owner's Address: 262 LAKESIDE DRIVE WEST, CENTERVILLE,MA 02632 Work Description: Insulate attic. Insulate Walls. - t Total Value Of Work To Be Performed: $5,000.60 t� Structure Size: 0.00 0.00 0.00--, -Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter.568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Jonathan Whipple 11/24/2017 (508)279-1110 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $5,000.00 Date Paid i Amount Paid 1 Check#or CC# I Pay Type Total Permit Fee: $85.00 11/24/2017 $35 00 Paypal Paypal Total Permit Fee Paid: $85.00 11/24/2017 ' $50.00 Paypal Paypal 67 .,.�.,;dWun�; .,u. �,.. ,..,,.d✓a� .3-dF�`.„...N..k aw ..b�,�,"�".....«.a..., �, ....,�».wr�2__. .x 1►-710 it Town of Barnstable C>?��O ti Permit,#.# L:.rpires 6 iuoit r Regulatory Services Fee �s"er'°`r '"' B.ARVSrABLE, � y aASS. 61q� �m Thomas F. Geiler, Director PERMIT 1h MA A ,- . Building Division 10� .t Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 'O\NN OF BARNSTABLE www.town.Barnstable,ma.us Office: 508-862-4038 EXPRESSPERMIT APPLICATION - RESIDENTIAL ONLY ax: 508-790-6230 Not 11aiir(rvithotr(Red X-Press Imprint Map/parcel NurnberC;?13)L 7,3 Property Address'L �C (�� A.� -. 2l ' `� "'E.�r'.d'I✓/ (f Residential Value of Work_ Minimum fee of$35,00 for work under$6000.00 Owner's Nam e & Address Q /y ' ?rrZ Contractor's Narne___�� Telephone Number Home Improvement Contractor License# if applicable)_ ?�'llAra Construction Supervisor's License#(if applicable)_ Q3?. ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner [have Worker's Compensation Insurance Insurance.Company Name Lj, Iry Workman's Comp,Policy#__ Copy of Insurance Compliance Certificate must accompany each permit, Permit Request (check box) 511*R"e-roof(hurricane nailed) (stripping old-shingles). All construction debris w'ill be to ❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of rood Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows *where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, A copy of the H e I provement Contractors License & Construction Supervisors License is eq wired ///I / a0�/E•lf 10/29/2010 15:56 5083932273 NORTHWOOD INSURANCE PAGE 01 OP ID:TO DATE IMMIDOIYYYYI ,�. CERTIFICATE OF LIABILITY INSURANCE 10/29/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER$ 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 pollcy(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 endorsements. COW PRooUCER 508-771.1632 NAME T Northwood Ins.Agency,Inc. 508_393-Z965 PWONE E FMARX Ne $40 Main Street,Suite 9 Hyannis,MA 02601 •STANL-1 INGURMISt AFFORDING COVER"15 NAIC N INaUpEp Dean Stanley Building INSURER A:Liberty Mutual Insurance CO. r Contractor,Inc. INSURER e 359 Capt.Lijahs Road INSURER c Centerville,MA 02632 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CFRTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L TYPE OF INSURANCE POLICY NUMBER MMIDD/Y MM EXP Lmrr$ GENERAL LIMBJTY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY _ERRM&ttJEa acaurerroa $ CLAIMS-MADE 7.00CUR MED EXP(Any om pwson) S PERSONAL R ADV INJURY S G@NERALAGGREGATE 3 GEN'L AGGREGATE LIMIT APPLIES PER: PROPMTS-COMPIOP AGG 3 POLICY PRO• LOG 3 AUTOMOBILE LUA!'iILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Par pwwn) S ALL OWNED AUTOS DODILY INJURY(Per accident) 3 SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXOE98 LIAR kd CLAIMS-MADE AGGREGATE ; DEDUCTIOLE $ RETENTION 3 $ WORKERS COMPENSATION WC C13133743140110 08131/10 08131/11 E.L.EACH ACCIDENT STATU- OTH• AND EMPLOYERS'LIABILITY YIN1 ER A ANY PROPRIETOWARTNERIEXECUTIVE 3 100.0 OFFICERIMEMBER EXCLUDED? NIA 9OO OO (Mande wy In NN) E.L.O18EABE-EA EMPLOYE ! I it yes,descxlbe under OEBCRIPTION OF OPER N 9W E.L.DISEASE-POt,IOY tnMIT $ 500,00 JJ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Mirth ACORD 101;Addt lunal Remarks Schedule,B mor*space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dean.Stanley Building ACCORDANCE WITH THE POLICY PROVMIONS. Contractor,Inc. 369 Capt.Lijahs Road AUTHORIZED REPRESENTATIVE Centerville, MA 02632 0 1986-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD i The Corr mollwea-Illy oflAfnssacliusells ---- Depapfinenf of IndusfrialAccidellts Office of 171vesfgalio7ls 600 Was11inglou Sfreel _ Bo$J.t?77 I, 4 02111 11.11M1110..ss.go i i✓dl a Workers' Compensation Zusu-mace Affidavit: Builders/Con:tractors/Illectriciaus/Plumbers Applicani Inform.a6o:n Please Print Legibly Nance. (BusinesstOrganization,Individual): Address: -T 159o7- lzr j� 40 1:,�'-,g4, r;�" City/Statel ip:�F.�-r /rc[� .�� ozG Phone Are q an employer?,'heck the appropriate box.: [13.00ther fproject(required): [3. I am a employer with 2. 4. ❑ I Win a gen-rai contractor and etx�ployees(fu.11 and/or part=titue).* have hit-ed.the sub-contractorsNewconstruction❑ I am a sole proprietor orp:artner- listed ov:the a't.tached sheet. Remodelingshi and have no"emt io'rees These sob-contractors hat ep p I emolitionworking :forme in any capacity. employees and liTve workers'. uildrng addition[No workers' comp,inswunce comp_ insui'auce..zequired_] 5. ❑ We are.a corporation.and.itslectrical repairs ora.dditionstafl3cers have exercised their❑ :I am a hont"eotivraei doing all work lumbing repairs or sdclitions myself. [No workers'comp. right of exemptioii per iMGLafrepairs insura,ice:required.] ? c- 152, §1�4), and.we have no employees. [No workers' her cotvp.:insurance requu-e.d.] y'Any appticaut thatchecks box#1.nuLst also filloui&-e section below showing their workers'coarpensation policy info=tiam- f Hanleo#wners who submit this.afiidsiat indicating they are doing all'work and then hire oirtsid'e rontraciurs inul attbdnit.a]7ew affidavit indicating such_ yCoatuc.tnrs that check this box vtust attached an additional:she.et sh'owit>c the'osm:e of"ihe saeb•ernrtrscAnrs sn.d stare whether or not those entities have employers. Ifthe sub-contractors:have emplDyus,.ihey.must provide their wurkers''cowp.policy-number_ I alit an employer thatis provNding urorkers'.:conrperisahart insurance for RV elttpZgy•eas. Delowr,is ilk q polic -rand job szte 11�OrNfaitlOd6 Insurance Company Name: G// 7z13� i!/rl/14L Policy#or.Self--ins.Lic.#: ��/!j/ ���1���/OGC® Expiration Date: 3( Job Site Address: Z f&4-3-Iae Attach a copy of the i`•orke.rs' compeit'sation policy declaratiom page(s;hoi«ng the policy number and expo-at on i14te). Failure to secure coverage as required under Section 25.A of lulGL c. 152 can lead to the imposition of criminal penalties of-a Buie up to SI.,500..00 andfor one-year iMpn*so=ent,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 fbm arded to the Once of Investigations of the D.IA f&insurance coverage vetzfcation. I do 11.Mby c,ert' der thapahy a)r1 � hies o perjury that the n:rfortnation providad abotra is trua.and correct. S.i tore: Date: // 6(, / Phone#: Fuse onll'• Do not tirke in this area,to be comphrted by citt or toms.ofcial Tomm: Perm"it/License# Auth on ty(circle one): i �pp THE), v� Y i + BARNSTABLE. • jF, MASS. Town of Barn stable ' �pIFD MA'S A Regulatory Services Thomas F. Geilcr, Director Building.Division Thomas Perry, 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 4 as Owner of the subject property hereby authorize /UPIy! ' G �Z�� to act on m behalf � Y in all matters relative to work authorized by this btulding permit application for: (Address of Job) j Signature of Owner Date Lwga A h,eo&r Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. P�oIHE Town of Barnstable ' Regulatory ,Services jaAj�srABLE, Thomas F. Ceiler, Director JASS. $ ' �.o '639' A,� Building Division Tom Perry, Building Commissione 200 Main Street, Hyannis, MA 026 I. www.town.ba rns to ble.ma.u Office: 518-862-4038 Fax: 508-790-6230 H MEOWNER LICENSE EXE PTION Please Print DATE: JOB LOCATION: number st et village "I-IOME'OWNER" name hom phone N work phone H CURRENT MAILNG ADDRESS: city/town state zip code The current exemption for"homeowners" was extended to inc de ow er-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not pos ss a I' ense, provided that the owner acts as'supervisor. DEFINITIO OF f MEOwNER Person(s) Who owns a parcel of land on which he/she resides or i ten s to reside, on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such us and/or farm,structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. h "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be res onsible r all such work performed under the building permit. (Section 109.1.0 The undersigned"homeowner"assumes responsibility for complia ce ith the State Building Code and other applicable codes, bylaws, rules and regulations. 'The undersigned"homeowner"certifies that he/she understands t e Town o Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with sai procedures And requirements. . Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubi feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOW ER'S EXEMPTION The Code states that: "Any homeowner performing work for whic a building permit is required shall be exempt from the provisions of this section(Section 109.1.I -Licensing ofconstruction Supervisors);provided that if the homeow er 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 the .are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack ofawareness often results in seriousproblems,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 caret amend and adopt such a form/certification for use in your community. Mass ichusetts- Deportment of Public Safety Board of Buildin!- Regulations:ind Standards Construction Supervisor License_ License: CS 35037 Restricted to: 00 c I. DEAN F STANLEY` 359 CAPTAIN,LIJAH.R D CENTERVILLE, MA 02632 c-- �"�- 'x�t Expiration: 1/19/2012 (bmiilissiuner' Tr#: 12334 ' Board of Buei1d g Regu► ods and Sta` HOME IMPRO`✓EME NT CONTRgCTOR License or registration valid for individul use o Registration 132149 ~ before the expiration date. only Exp►rat+on Board ofB lffound return to. = 11/28/2010 wilding Regulations and Standards T Tr# 2780E6. One Ashburton Place Rm 1301 -Pe -Individual j DEAN F. STANLE� r Boston,Ma.02108 DEAN STANLEY`A V 359 CAPT.LIJAH RD,�� x CENTERVILLE, .. MA 02632 _ n i -` Admi strat - Not va - lid With signa ur -- , . a r Town of Barnstable VE'O'yti° Regulatory Services .� Thomas F.Geiler,Director • ansxsrnBLFE 9�. M�: � Building Division '°rEa MA't s Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PERMIT# I FEE: $ CID SHED REGISTRATION / 12/0 square fleet or less (Q �/ G✓`� T I ? �9 Location of shed(address) Village. Property owner's name Telephone number Size of Shed Map/Parcel# 4ne� Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? ,6'6 Fjz�¢Yl Conservation Commission(signature required) / 'JS � 4AI PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE ptJ1S COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. al��°Y PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV A 21901 r ` f _ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 01-6 Parcel 07 Permit# zl ,5,0 Health Division ft!, &2 1ou iA- 13h2N1ay 3 Date Issued �0�- Conservation Division i ffi 1 I"2�. Application Fee Tax Collector - Permit Fee �. Treasurer SEPTIC SYSTEM MUST ep Planning Dept. INSTALLED IN COMPLIANCE Date Definitive Plan Approved by Planning Board IMTH TITLE 5 Historic-OKH Preservation/Hyannis ENVIRONMENTAL DE AND TO TiONS Project Street Address / S i le, 0 rVyt_ (VFs t Village a'a 4,ry I !�� Owner PLt.(.(JC, 5�1- 6 Ces Address �e )0 Telephone _ SQY g 3 l —f,q"3 3 Permit Request CO fnVm,� SXtS_ ——' ,r 4 C Q u,e, Square feet: 1 st floor: existing 1449 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size 4 Ch Grandfathered: ❑Yes BAo If yes, attach supporting documentation. Dwelling Type: Single Family 0/ Two Family ❑ Multi-Family(#units) Age of Existing Structure 4 > Historic House: ❑Yes 04b' On Old King's Highway: ❑Yes 3-f10 Basement Type: D Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 0 Basement Unfinished Area(sq.ft) /✓� � Number of Baths: Full: existing c - new Half:existing new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fu I: Cas ❑Oil ❑Electric ❑Other Central Air: 6�Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No p 9 9 Detached garage:❑ex isting Elnew size Pool: El existing ❑new size Barn:❑existing ❑new size Attached garage: ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authnization ❑ Appeal# Recorded❑ Commercial ❑Yes If P ,es site Ian review# y Current Use o s vax,2�d-(_ Proposed Use 122:4 "[LIA_1 rao BUILDER INFORMATION Name �S Telephone Number �7�?✓� = �c � Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEB IS RESULTING FROM THIS PROJECT WILL BETAKEN TO SI( 4TURE DATE /%//Q�- FOR OFFICIAL USE ONLY PERMIT.NO. 9 DXfE ISSUED MAP/PARCEL NO. ADDRESS- VILLAGE OWNER , DATE OF INSPECTION: FOUNDATION FRAME INSULATION , F FIREPLACE ELECTRICAL: ROUGH ell FINAL ffn N PLUMBING: ROUGH Q Q FINAL GAS: ROUGH tN tj� FINAL ; r 5 { FINAL BUILDINGS Ha To�%gk4' ASP g m j'r')aGTo6 c(ac +G =trrooQ M t MN DATE CLOSED OUT G ' ASSOCIATION PLAN NO. t ' -The Commonwealth of Massachusetts _ Department of Industrial Accidents' 600 Washington Street - Boston, Mass. 02111 workers'.Coin ensation.Insurance Affidavit-General Businesses L v v address: work site location full address : I am.a sole proprietor and have no one Business Type: 0 Retail❑Restaurant/Barffl;Yng Establishment working in any capacity. Office[� S es('including Real Estate,Autos etc.)' ❑I am an em to er with . em ko ees full& art time . then %%% Royer providing workers com � I am an empensation for my employees working on this job. coin in',name:. ; . ;,: /,• +':.:i..: '. .: �8i'lressi' :t s. +' •• �.� ., .a }.. .•,.t, :�r, •r� hone:.#.:: !. ansurin ce.CU O NI am a sole proprietor and-have hired the independent contractors listed belowwho have th l e foil workers' compensation polices: co in an na 1riY..�'. f� m i.t� ::�f. '•i � .\:t- i^•r f�'� r i {:: .)y::•' _'t♦ ! ;inY••. ,,:'.. !S.�Z:,;'.rl• 'rlj.•'.t. r:f�^:!`:',1i•• 1::•' .. • , - :.••' .;.r. . .)' �.z.: %%////////////////%_ insurance CO. - / / .rl• _.i•• '{: gar_*.q ? :::��,:`:•?''• ^' 01 coin en• as'uie.. ;: _ acdresse. insurance so: �•:' Fagure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years,imprisonment as we civil penalties in the fdim of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that g copy of this statement may f rded to the Office of Investigations of the DIA for coverage verification. I do hereby certify er a' a penalties of perjury that the information provided above is true and-c ecL Sigoature Date Print name Phone official use only do not write in this area to be completed by city or town official city or town: permft(heeuse# ❑Building Department []Licensing Board []Selectmen's Office [3 check if immediate response is required Health Department contact person: phone#; ❑other (revised Sept 20 3) Information and Instructions Massachusetts Geoeral Laws chgpter�152 section 25•requires all employers to provide workers' compensation for'their. employees: As quoted from the law', an employee is.defined as'every person in an service of another under arty 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 mare 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 bf- another who.employs•persoris to do.maWenance, construction or repair work on such dwelling fiouse 6r on the grounds or building.app urtenant thereto shall not because of such•employment be deemed to be an employer. MGL chapter 152 section 25 also•staies that every. state'or legal 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 is the worker's' eoupensafm affidavit completely,by checking the box that applies to your sitdation..Please supply company name, address and phone numbers along with a certificate of in m insurance as all affidavits ay be submitted ccidents•for confirmation of insurance coverage. Also be sure to sign and date the to the Department-of industrial A 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. City or Towns . Please be sure that the affidavit is complete andprinted 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 wii l be used as a reference number. The.affidavits maybe returned to the Department bymail or FAX,unless other•ariangements have been made. The Office of Investigations would like to thank ybu 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 emce of Wesffeatlens 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 nhnns-#- (6171777.4900 ext:406 Er Town of Barnstable o� Regulatory Services r t asT i,E,$ Thomas F.Geiler,Director 16g9. Building Division. �''lFD MP•l k Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 permit no. Date 3 �� AFMAVIT 1101yE IMPROVEMENT CONTRACTOR LAW SUppjy,MENT TO PERMIT APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernize io u ied ion, •improvement,removal,demolition,or construction of an addition to any pre-existing wnoc p b g containnig 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. �� �� Estimated Cost 'Type of Work-_Tt-2/�'t Address of Work: n owner's Name Date of Application: I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law [Dlob Under S 1,000 []g ' dung not owner-occupied er pulling own permit Notice i5 hereby given that: T OR DEALING WITH UNREGISTERED OWNERS PULLING THEIR OWN LE�ME IMPROVEMENT WOp Do NOT HA.YE CONTRACTORS FOR APPLICAB ACCESS TO THE ARBITRATION PRO GRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDERPENALTIES OF PERJURY I hereby apply for a permit as the ageut of the owner: Contractor Name Registration l�Io. Date OR Owner's Name RESIDENTIAL BUILDING PERIM FEES APPLICATION FEE New Buildings,Additions Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE square feet x$96/sq.foot x.0031= plus from below(if applicable) ALTERATIONSMENOVATIONS OF EXISTING SPACE G} -square feet x$64/sq.foot= x.0031= � plus from below(if applicable) -._ , -- GARAGES(attached&detached) ` square feet x$32/sq.fft: _ -... __ _ x.0031= - �:_.._ STRUC-T.URE->120:sq.;ft. >120 sf-500 sf $-35.00 >500 sf'-750 sf >750 sf- 1000 sf 75.00 -->1000 sf-1500 sf >1500-sf=Same as new building permit: : ' _ y square feet x$96/sq foot= - x.0031= _ STAND ALONE PERMrrS open'Po ch x$30 00 - (number) -" Deck r- - . _ -----x$30 00 �:, _ ,.. ~(number) - FirepIacelChimney. x-$25 00— w (number)= _. - - • _. Inground Swimming Pool _ $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) �/-1 © 1 Permit Fee projcost Town of Barnstable oFIHME , ' do Regulatory Services BAMSTABM ; Thomas F.Geiler,Director 9 MAss. �p 039• .• Building Division tEp �1,44 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION /� Please Print DATE: -? ///O`- JOB LOCATION: r�b oL L��Q�,cs Ctp_ ►_�L�AU-p �S' r �F,{/� ,➢` (// li(•SL . number /� j r- street village a "HOMEOWNER": R L IS l�l.l��J j�S S d 6�j 4-W- "3c?,a sa 0G.w 7 q%&S name /� home phone# work phone# CURRENT MAILING ADDRESS: ato a__ 9L414 OVA— /�I 0,� 6 3 A city/town state zip code The current exemption for"homeowners"was extended to include-owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned" eowner"certifies that he/she understands the Town of Barnstable Building Department W ro d s and requirements and that he/she will comply with said procedures and 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. Q:forms:homeexempt : - i IS e - _ 1 ,p F� i I I 11 �• .. ice. .... , r"' t : I i i I' f i : I i i , I , i. I , I i , P`OFTHErp�� The Town of Barnstable O� BARN LE. Department of Health Safety and Environmental Services Y MASS O °rEOMpy> Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW � R> O.wner7 S' - � P Map/Parcel: Project Address:2. 7 �r SA Builder: C)u-) ts�y The following items were noted on reviewing: �' S �• � lrn e �-e � n Reviewed by: Date: ti J q:building:forms:review 12 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map3 Parcel U -7 3 - Permit# Health Division Date Issued Conservation Division Fee _�57.CCU Tax Collector /� XTreasurer �C��44 Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address o o a)- LQ 12-&-S t Vic: 0 /2, T- � Village C lzv r^� Owner oeAl jl� 16- r_ApJ 7-6a�ljfe Address r- A_5 A�%� / Telephone 17,S - q cfl� / - i Permit Request ^' �l✓� ( '� ��� 1 u i 1�aQ0 w 1 TH A,enras�a 3.1 2 c/ r y 1 i-v ,n f) CA A — /��/<<►�s ; f P,`T�� 3 . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cod P.b Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: .❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family X Two Family'❑• Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes 9 No On Old King's Highway: ❑Yes XNo 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 A feat 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:'14 existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes X No If yes, site plan review# Current Use Proposed Use � BUILDER INFORMATION Name 4!�,//O/o / vc.N�S� [ Telephone Number 7 7/ eo7 �l L/ Address - Ao7ei-lam E... i4V License# 65�8 `761 174 Home Improvement Contractor# Worker's Compensation# °--" - ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Dc of P ), IGNATURE DATE FOR OFFICIAL USE ONLY yr PERMIT NO.` DATE ISSUED MAP/PARCEL NO. t m r v N ADDRESS VILLAGE , OWNER DATE OF INSPECTION: r: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - - GAS: ROUGH FINAL s FINAL BUILDING. ' DATE CLOSED OUT ASSOCIATION PLAN NO. a The Commonwealth of Massachusats _.._ Department of Industrial Accidents n 600 Washington Street -_ Boston,Mass. 02111 ' Workers' Com ensation Insurance davit 0000 narne location: r ` �T/,U city phone# -77/•-,-� �-1�Qi ❑ I am a homeowner Performing all work myself~ I am a sole etor and have no one woddug in anv M % em 1 workers compensation for my employees worlang on this job.::::;:;;}:.}}:.:;{,:,T:.:}:.7}}:<.}}}}:{{.;};};;:;::;:::;::; I am as p PrO° ........................ ......:.::.::.:::..........:..:::::..:. . m ;m n,.::::......,..........................................................::.....::.}.....::....:.:::.;.. . . ............... .................:.r.................,.......rt..{...:... ................ ......... 4.:. .r ...w. :a....:,....:..v..•rr..... v:: ..:•.,.:{..r{.,::::::.,t,•::•::•:: .... .. ............................, :....... ............. ........... •:::v::}:{y:n;:rv.vY:r.•Y{•:•Y{•.:i::.y.:::.y{{i:r{:.yr•::-:::: :. dress:::::.... ...............................::....:.,...:::x::v::v:.v„ .....:v}.• .......v....;},.}r!4:....v.x.•..•...............x....•"•'v:m •x.v::nv.. 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O :.................. Failure to seeure coveeate d required order Setitloa 2SA of MGL 152 can lead to the imposition of ahnioai penaWa of a tbu up to Si,S00.00 and/or one yam,�prisomamt as weII as eivII penalties in the[orm of a S?OP WORK ORDER amd a Me o[5100.00 a day aLainst me. I uader:t:nd that a copy of this atatemmt may be forwarded to the Olsee of huesdZutiom of the DIA for covers=e verisrMdOM 1 de hereby certify under th p ' and p o perjury that the information provided above is truce and coned Si t n ;{ Print name " 'C,J4A F--L) r• i ucG � 7� ��� ! t write in this area to be completed by city or town omcial offldal use only do not prated city or town: permitAteeme 1! Q LLD epartmeat Board ❑che&if immediate response is regmred Osaectutews OIDce ❑HnM Deparnment • - a contact person: - phone#, Ins .31111111111111 (m uad 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",an employee is defined as every person in the service of another under any coffi--,:- 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 recerier 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 an the grounds or building appurtenant thereto shall not because of such employment be deemed to be as employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: 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,neid=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 corrttacting authority. /% Applicants Please fill in the workers' compensation affidavit completely,by checldng the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Indwaial Accident for co on of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be rca=aed to the city or town that the application for the permit or license is have the"law"or if you being requested,not the Department of Industuiai Accident. Should you any questions regarding are required to obtain a workers' compensatich 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 fM out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pe llicense number which will be used as a reference number. The affidavits.may be returned io the Department by mail or FAX unless other arraagemeats 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 0mce of Invesduadons 600 Washington street • Boston,.Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat 406, 409 or 375 Department of Health Safety and Environmental Services seT¢ ,• Building Division " 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 BuiIding'Commissioae 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. Type of work: cvLAfy Estimated Cos DUU of Address of Work:��.� ,!I►�E S (Z. t s� Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law E]Job Under$1,000 Building not owner-occupied E30wner pulling own permit _ Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME MOROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav '�� g� w:J �✓/�O TOOfJVIKOI��lGN6[II�O�i �. HOME-IMPROVEMENT CONTRACTOR Registration 4ilO833 ` L Type ' INDIVIDUAL ' 3 q Expiration 411/09/00 r tx# RICHARD P-DUCHESNEY ARD P.:DUCHESNEY ADMINISTRATOR 1 PATRIOT yNAY "' ,t ," ,3 `CENTERVILLE MA 02632 a , Assessor's offioe (1st floor),, s s Assessor's map-'and lot number `TNETo�f Board of Health (3rd floor): SEPTIC SYSTEM MUST Q w� �LSewage Permit number ............t. :... "'SST gg ee,, l►� /� �® lA,g 7 r • �6.`ED �N C®MP(,.BAN MARBSTAXLE, - , AOa Engineering Department (3rd floor):' M6 9� House number ................ .. :............ r . CODE . °°,° 39 a� WITH TITl:E 5 . f. ENVIRONMENTAL OD AR �YPY APPLICATIONS PROCESSED 8:30 9 30 A.M. and, 1:00-2:00"P.M. only' TOWN REGULATIONS f` r � /rX TOWN :`OF -BARN:STABLE BU1rLDIN't INSPECTOR ! ' APPLICATION FOR PERMIT TO ........ =T�/J...add, O ,,: ,,,, .. .............................. ' TYPE OF CONSTRUCTION ........61 ................................. :.........................................:............................... ` `..........,97 TO•THE INSP CTOR OF BUILDINGS: The undersigi geqby ap/plies jTfo �permit ccorrdding .to the following informat n: yj/f Location ... ....�. .........�'�......... .. ../✓ ....! .. ........ ..... :./,,:.'.(�' �, ...�, ProposedUse .............. a .....................................................................•.............. ... Zoning District ......... .................... ` ... .... ....................F...ti.....................,....Fire District ..:.. �� �� S-4 a We i Nameof Owner ...................... ...........................::..Address ...1............ .............................................. .......... Name of Builder .. '� ........................:Address ...... Srb !e 4- -r1e�.t... .. ....... ' ........ .. Name of Architect ... .................. �...... . ............................Address ... . ...... ........................ Number.of Rooms .,Foundation .................... Exlerior !: ....:.......................... *..... . .....Roofing . ....... . . f Floors '...:.... ... Interior .. ................... ................ .................. ....... Heating / ......................:.......:.......:................................Plumbing ........... .............................................................. Fireplace ...........f/0:...........................................................:Approximate Cost . Definitive Plan Approved b• Planning,Board .. J c pP Y ---------- ---------------------19 - ----- • Area .../../....r� ....:.................. Diagram of-Lot-,and Building with Dimensions Fee ,... SUBJECT TO APPROVAL OF BOARD .OF HEALTH p © �e-S J G-TRrt5s r 4Gr • • , - /W60 1 1'IQ�) 4" ` OCCUPANCY,PERMITS REQUIRED FOR NEW DWELLINGS jCtStri0 V)ee- , I'hereby agree to confo to all the R les•and Regulations of he Town of_Barnstable rega ding the }above construction. Name ....... ..................... ...... ....... ........ .. Construction Supervisor's. License ..................................... { _ LE,VINE, PAUL R. No 30523 SPe�mit for ..Build Addit..�,gn.•Single' FamilY...Dwel:ing.......... r s Location . ...•.elide„Drive- We.�t enterville............................ Owner r ...:Paul R. Levin ................ Type of Construction Frame PIOt ......................jLot" ... s _ r. , a.<«•. z - .. ..;{ ,� Permit Gran*ed MarGh .1�. 19 87 9-7 Date of Inspection'...... ...ig�.....19 Date Completed ..... .. . ...... 19 r " - .. �.�' °'Z ;�': '�ti ^ � � '� -. ,� .��=' {�. .i^. .. �'' tea✓ !" ,+; .A •� � � -, �' z 'S".F,M` t w _ - .w - �t .'r' . "•� alp .. S. • f''_. � �r1,!. 'w�• v t� • ,?�. ' ' }.. ^. '� •, r f T ..`(�.i. � , •' ••r, „ t�M a-•� ' e " - • ` ... t t' � 3 • 'Sf W •.. • �.� ,/, mil_ .. ./! _ �Y' _ , ... kL� .��.� ° i^ yj _ V iJ' • /i7 � I, '.a� h' f s _ _ r PJ• !,."� II - Assessor's offioe (1st floor)'. At, offHEj� Assessor's map and lot number .i........................................... , - d�Q� `♦� Board of Health (3rd floor): D 1 Ks Sewage Permit number ........................................................ Z BAHasT&BLE. S Engineering Department (3rd floor): moo, "639 0� House number `° ' s� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00--P.M only a TOWN OF BARNSTABLE BUILDING INSPECTOR " ' APPLICATION FOR PERMIT TO ....... `; - TYPE OF CONSTRUCTION .........................................19 i TO THE INSPECTOR OF BUILDINGS: The undersie��h�e eby appliesrforala permit according to the following information: Location .. '...1. :1 �.........!c' . .......................................................... :./..:.�(?y '�.. �- T....�� \ ProposedUse :...:........:r`:`" .�............. ...................... ..................................... Zoning District ............A... ...................... ,............. :Fide District ........... ........ .......... .... ` ... Name of Owner � ' " . ......... .... ....................,.... .......................'......Address Name of Builder .......................... ?.............. ..........................Address .:.....*:3 56..... � ham, ....... ... �. ...... s� Name of Architect .�............................Address ....... .................... ...................................... ........ Numberof Rooms ............. .................................................Foundation .:.. ................................ . ......... Exterior ....... ..v...... ....... ............ Roofing.t +° .... ................... ...... Floors ... ` . Interior ......':. I G Heating ......... -.................:...........................................................Plumbing .......................... " Fireplace ........... .Y..0..............................................................Approximate Cost ........ r91.. ..................................... Definitive Plan Approved by Planning Board ________________________________19________ . Area .../.... Y........................... Diagram of Lot and. Building with Dimensions Fee v SUBJECT TO APPROVAL OF BOARD OF HEALTHLj Fvo i - - r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to confor:'m\to all the Rules and Regulations of the Town of Barnstable regarding the above construction. II VjeU) o� fig ► �' Name .......... .................... ........ ... .. . 5J �. Construction Supervisor's License .................................... I,EVZ0E, PAIJL R. A=232-073 ` . ` . 30523 B�zil�l �dditio� No -----' Permit �v ------------ _ Single Family Dwelling ._ -----' ------------' C�P&a Lakeside Drive Wes-, , Location .'���-----------------.. ' ~' ~ . ` Centerville - ~~`---------'---------------. ' Paul R. Levine . Owner .................................................................. Frame Type of Construction ........................................... . / ________________. �) _______� ` � ^ Plot b� ---------� ------' ' . Mazolz 17 " 87 Permit Gronne6 -------------]V ' - ~ Date of Inspection ------------lP ^ Done Completed ------------]9 ' - ` ~' ' L � - . � ^ , ' _ ' ' ' ' . ' ' ` I - MAP LOT 23 ;r • 'j WATER ELEVATION= 14.9 2Ox3 HYDRANT. of / �0 , � t POSED DOUBLE HAYBALE _ (LIMIT 8 SILTATION / EXIS TING 2p/ FOUNDATION p r 38 , LOT 16 # DECK I �•��� } 19X3 y _ 2Ox4 0 20x 7 I 1 f �0,00eos�� LOT 15 20 18,657 S F. 20.2 L q K�sID DRY 20x2 pg ON PLAN `APR 1 0 �.98 PLAN OF LAND IN CENTERVI; [ s FOR �f'AllL R. LEVINE SCALE P' 20'- APR 4.