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'F.s- _ ,� �.• - z g.;y ^. .^ .+. �,.k. •ix r .� - r t ,, .`� • �a t s+�j .." r y r r �ti* „ 1. z �F - - _ f r ' Application number.. /Cyr d RO PERRI Fee .............. �� .:...:.. OS MAWS, Building Inspectors Initials....:... ...................... s65 Ak APR 0 8 2019 OWN OF BARNSrABLE Date Issued...........i4.!a........... Map/Parcel.... `..Q.G1.�.......: .J TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: (,A) s' n� NUMBER STREET VILLAGE Owner's Name: �I�/llL��C�� 6)a� Phone Number ,SO Email Address: Cell Phone Number Project cost$ Check one Residential_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: s , TYPE OF WORK EA Siding 0 Windows (no header change)# 0 Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review ED Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Ao\ c t*S U36LOM Home Improvement Contractors Registration if applicable) (attach copy) Construction Supervisor's License# S 0��o� (attach copy) Email of Contractor Odz,iki oK1\Q—_—A (_Phone number �;—()00r76 d-s yR ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER ............... *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent-X , . X 9 X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No____,if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COALTELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number 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'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. tr ��,� 'Towle of Barnstable Regulator'y Services r t ,yt _ .- * BARN6TABLE, MAss. 8, Thomas F.`Geiler,Director 'OIEn u•�'�� �, Building Division .Tom Perry;Building.Commissioner 200,Main Street,Hyannis,MA,02601 www.towna arnstable.ma. s Office: 508-8624038 Fax: 508-790-6230 r Property Owner Must Complete and Sign`This Section- _ . If Using A Builder J" L LvAt `"`, e"ubject property y , as Owner of th hereby authorize 1 to act on my behalf, 4 in all matters relative'to work,authorized byahis building permit application for. . IAIwo (Address of Job) a - s tT Signature of Owner ,, ate r , Print Name . If Property Owner is applying for permit please-complete the -Homeowners License Exemption Form on the-reverse side. Q:FORM&OWNERPERMISSION ,' - - Town of]Barnstable • THE tp�� Regulatory Services BARNSfAaLE ; Thomas F.Geiler,'Director MASS 1639• .�� < Building Division HIED a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 wwfv.town.barnstable.ma.us Office: 508-862-4038 A Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code p The current exemption for"homeowners"was extended to include ownef-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) ? `t 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. a Signature of Homeowner 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 caret amend and adopt such a form/certification for use in your community. Q:f0rms:homeexempt The Commonwealth of Massachusetts Department of Industrial Accidents Office"of Investigations ' 600 Washington Street _ . ... Boston,MA 02111 www,mass.gov1d1a Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information ( ( .( Please Print Legibly Naive(Business/Organization/Individual): l " �� Address: MA City/State/Zip:e'' �Ti(1V(Lc.l_ G3, Phone#: SD©" rqo --63 `R Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I. employees(Rill and/or part-time).* have hired the sub-contractors 6. 0 New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. E. ]Remodeling ship and have no employees These sub-contractors have 8. EJ Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance$ 9. ❑Building addition 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 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MOL 12:❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees."[No workers' 13.[J Other ' comp.insurance required:] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $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 thepoUcy andjob 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 MOL 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 n th penalties of perjury that1 .the information provided ab ve is a and correct/1 . ' Si attire: Date: rj 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.EIectrical Inspector 5.Plumbing Inspector. 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. cry person in the service of another under any contract of hire, Pursuant to this statute,an employee is defined as"...ev express or implied, oral or written." An employer is defined as"an individual,partnership,as 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 is 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 an into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to-.your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(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 cun.,]d.vn1-i_have..anv auestions regarding the law or if you are required to obtain a workers compensation policy,please7call-the Department at the number listed below: Self-insured companies shouia enter heir . 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 firture 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number: The COMMOnwean of Massadhusats Department of IudustdaI Accidents face of Investigatlaas 6N Washington Wed Basta,MA 02111 TeL 617-727-4900 ext 406 ar 1-977-MASSAFE Fax#6.17-727-7749 Revised 4-24-07 w-mass.gov/dia Commonwealth of Massachusetts Unrestricted_ Construction Su ®� Division of Professional Licensure less than 3 Bu�ldmgs of pervisor -! Board of Building Regulations and Standards 5,000 cubic feet(991, 991 cuElse b'group which contain Constructs`SiSpervisor meters - space. )of enclosed CS-066582pires 03114l20211 THOMAS C WHITE 415A MAIN STREET " es r. CENTERVILLE MA 02632/ VO7.1S i-ko c Failure to possess State gulldin a current editions 9 Code fs cause- of the Mass For information for revocatio achusetts Call n of this lice Commissioner (617)727CIL .3200 about this license nse. _ _or visit WWW mass.gov/dp► o ons m�erfair&Bui e s fie nation f� ' HOME 1MPR011EMENT CdFJtRACTOR -,Y-PE L-L"C - 6 RPa�s_—=T3f�On ExGi_ it Registration valid for indiwd at use only 11/21J201J Wore the ex iraUon date If found return to ul8tor I „f ' pff ce of Consumer.Affairs and.qusiness 9eg ( ;HOMAS C r FiI-- - +©CO-WORKER LLC. j'Tpart Plaza--tv Suite b170 — -� Bcston;.MA 02115 f1 3`--iC�ib1AS�,.Wr`11rE�- w\ ST 415A MAIN - - — rrENTERVILLE,MA 02632.r lhtder`secretary` Mot va�l wi#rJout slg .3 / Town of Barnstable Building Post This Card So Thatx�tas Visibleafromih`e Str.,eet=rA roved:Plans;Must`be,Reiamedon Job andE#his Gard Mustbe Key t �„ BARSQSYA�S.E. • �,s,. • 6 Posted�Untl°Finallnspection Has Been;Made �% f � .. _. �� : : Permit r� WheraCert�ficate-of Occ�u,panty Required,such B�uildrn�gall Nowt-be 0 p�d unt�l�a Final�lnspnha�sFt�een�made. ; Permit No. B-18-2095 Applicant Name: THOMAS C.WHITE WOODWORKER LLC. Approvals Date Issued: 07 06 2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/06/2019 Foundation: Location: 415 MAIN STREET(CENT.),CENTERVILLE Map/Lot 208 125 Zoning District: SPLIT Sheathing: Owner on Record: WHITE, MILDRED E xr Contractor.N nee„". THOMAS C.WHITE Framing: 1 R ER LL . WOODWO K C Address: 415 MAIN STREET y14 � 2 ". .� ..r F Contractor License: 177283 CENTERVILLE, MA 02632 Chimney: Description: (415 A)Siding, Roof � Est Project Cost: $5,000.00 Insulation: Permit Fee: $35.00 Project Review Req: k � d Fe P Finale ai �a l L a OF, Date 7/6/2018 v Plumbing/Gas - Rough Plumbing: �3 �' l a f A Building Official Final Plumbing: 3 Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. 'm Final Gas: All work authorized by this permit shall conform to the approved application and t-ei p oved construction documents for�which this permit has been granted. All construction,alterations and changes of use of any building and structures shall b m e in with the local zongy lawsand codes. This permit shall be displayed in a location clearly visible from access st r,°reet o "road nd,shall be maintained open,for public nsl -tion for the entire duration of the Electrical work until the completion of the same. w f Service: The Certificate of Occupancy will not be issued until all applicable signatures by'the Swldmgand\Fire®fficial'ssare provided,on this permit. Rough: Minimum of Five Call Inspections Required for All Construction Work: ..� �.' . . s.n 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final' Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application number ..:�.........v......�61;15 ® 3 t .Issued................ .. Building Inspectors Initials..... .. ....:................... JUN 2 8 2018 /Parcel........ ....®�.....�..::...�...................... TOWN O� BARNS'l a�� TOWN O F BARNSTABLE S S EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: AA NUMBER STREET VILLAGE Phone Number ��� Owner's Name: ��L'��� � �`�t� v Email Address: Cell Phone Number r� Project cost$ . nn Check one Residential 1/ Commercial OWNER'S AUTHORIZATION As owner of the`above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 12 Siding El Windows(no header change)# ED Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to ' CONTRACTOR S INFORMATION Contractor's name `K°ttOL"A!S Home Improvement Contractors Registration(if applicable)# ���� (attach copy) Construction Supervisor's License# �S'®��� � (attach copy) Email of Contractor, �i2i2a+�n��Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER,75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN AI1TA rAI I"rr^0W Aonvnve► RIPMRF a PFRM►T CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent(s) will be erected . . Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approvab *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles:front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number 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 APPL ANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Indush ial Accidents Office of Investigations 600 Washington'Street Boston,MA 02111 www.mass.gov/dia Compensation Insurance Affidavit:Builders/ContractorsYIectricians!Plumbers orkers Compens el0ralt L 'b W Pleas A [cant Information Name(Business/Organizatiombdividual): f Address: � LL City/StatelZip• :s VaA D 6 3�• Phone#: Dd v Type of project(required): Are.youan employer?Check the appropriate bog: eneral contractor and! 4. ❑I am a g *'6. ❑New construction 1.❑ I am.a employer with have hired the sub-contractors employees(full and/or part-time).* listed on the attached cheek 7. ❑Remodeling 2. I am a sole proprietor or partner- These sub-contractors have .; g, ❑]demolition ship and have no employees employees and have workers' 9 ❑Building addition working forme is any capacity. comp.;,,�,, e t o workers'comp•insurance . 10.❑Electrical repairs or additions [N 5. ❑ We are a corporation and its required] officers have exercised their 11.❑Plumbing repairs or additions 3,❑ I am a homeowner doing all work right of exemption per MGL 12.19 goof repairs myself,[No workers'comp. - c.152,§1(4),and we have no 13.❑01h� insurance reT*ed.]t employees.[No workers' comp.msurmce required.] #Airy applicant that checks box#1 must also fill oirt the section below showing their workers'compensation policy information. t Homeowner+who submit this affidavit indicating trey are doing all work and then hire offside co�ractors must submit a new aff davit indicating such rou of the slib-contractors ;Contractors that check this box must attacbed an additional p de their he workers' cow policy number. d �or not those entities have employees. If the sub-contracimrs have employees,they p and job slfe I am an employer that is providing workers'compensation insurance for my employees. Below is the olicy . information. Insurance Company Name: Expiration Date: Policy#or Self-ins.Lic.#: City/State/Zip: Job Site Address: the poll number and expiration date). Attach'a copy of the workers' compensation policy declaration page(showing P �` enalties of a d under Section 25A of MG Failureto coverage as required secure c. 152 can lead to the imposition of criminal p foie u to se=e$1,50 .00 and/or ono-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of 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. Ido hereby certify Date. the pains and cities olP�IY that the*fornudion provided abo a is a and correct Si e: �c> D© � o Phone#: .- 93 IM jPlumbbig EE only. Do not write in this area;to be corrrpl�by city or townofficial Perm.itlLicensen•ority(circle one): ectorHealth 2.Building Department 3.City/Town Clerk 4.Electrical Inssp Phone#: rson: Information and Instructions Massachusetts General Laws chapter 152.requires all employers to provide w ers'compensation for their employees. Pursuant to this statute,an employee is deed as"...every person id the s ce of another under any contract of hire, express or impli oral or written." An employer is de ed as"an individual,partnership,association,Corp r . n or other legal entity,or any two or more of the foregoing en d in a joint enterprise,and including the legal sentatives of a deceased employer,or the receiver or trustee of an' dividual,partnership,association or other gal entity,employing employees. However the owner of a dwelling hoes having not more than three apartments d who resides therein,or the occupant of the dwelling house of another o employs persons to-do maintmiin ction or repair work on such dwelling house or on the grounds or buil ' urtenant thereto shall not becaus of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also s that"every state or loca 'censmg agency shall withhold the issuance or renewal of a license or permit to erate a business or to co ct buildings in the commonwealth for any applicant who has not produced a . eptable evidence of co liance with the insurance"'verage'regnired." Additionally,MGL chapter 152,§25 states"Neither the mmonwealth nor any of its political subdivisions shall enter into any contract for the performan a of public work un acceptable evidence of compliance with the insurance requirements of this chapter have been pr ted to the con ' g authority." Applicants Please fill out the workers'compensation affidavi comp] ly,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addres s) d phone number(s)along with their certificates)of ms+ince. Limited Liability Companies(LLC)or L' ' , Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' mpensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affi may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Als be re to sign and date the affidavit The affidavit should be returned to the city or town that the application for p or license is being requested,not the Department of Industrial Accidents. Should you have any questions r ding a law or if you are required to obtain a workers' compensation policy,please call the Department at the her ' 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 printe legibly. The \�n cat has provided a space at the bottom of the affidavit for you to fill out in the event the Offi of Investigati contact you regarding the applicant Please be sure to fill in the pernincense number whi will be used er cenumber. In.addition,an applicant that must submit multiple permit/license applications" any given yea o nit one affidavit indicating current policy information(if necessary)and under"Job Site ss"the ap shoul "all locations in (city or town)."A copy of the affidavit that has been officially ed or mar the city r town may be provided,to the applicant as proof that a valid affidavit is on file for apermits or s. A new davit must be filled out each year.Where a home owner or citizen is obtaining a li e or permit nted to any b ess or commercial venture (i.e.a dog license or permit to bum leaves etc.)said per onis NOT reqo complete davit The Office of Investigations would like to thank you in vance for yoperation and shoul ou have any'questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: 'The Commamw th ofMassachuseM Department of du.strial Amiddnt% fie of estigatiow , 600 Washin Street Bow MA 02111 Tel.#617-727-4M ext 406 or 1- -1 ASSA Revised 4-24-07 Fax#617-727-7749 WWW.mass.gDvldia oF„E Town of Barnstable ti e; Building Department * � Brian Florence,CBO &6,19. ���� 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 p If Using A Builder I1UZ)vx r �(� — hereby authorize �0 ",as Oviner of the subject property .E�('C `. act mY,lbehA ] �� ' to on in aIl matters relative to work authorized by this building permit application for. - -(Address of Job) " **Pool fences and alarms are the tesponsibility of the applicant Pools k are not to be filled or utilized before fence is installed and all final inspections-are-performed and accepted. Signature of Owner° i _ ' ignature of Applicant Print Name Print Name '�116 Dal Q:FORMS.-OWNERPERMISSIONPOOLS Rev:10/17 �r C Co _ R,� 7 s C W C M r • CL w x M w _ m ; /e z n2o ruuer o ��caaac+c� u , ff'cef�G'onsumerQtfa�r Busmessz( gu�ation c HOME IMPROVEMENT CO}+1TRACTOR Registration valid for individilal use only c O ,YPE:LLC t before the expiration date. If found return to: a e Registration Expiration I Office of Consumer Affairs and Business Regulati�i� p` ` 177�So" ' 11/21/2019 10 Par}c Plaza-Suite 5170 a :: , 1 l i;� i Boston,MA 02116 i Cj N .� 'ers.I rNO,, I r-- BCSt .op „. i HOMAS;C R H TiE'WgOODWRKER LLC. Q (D ra:N* ,sf r i ` a w U c s w l�I�.v1ASC.WHIT L m Q 3 N J 41;5A MAIN ST Not valise Without signature' 1 u w tj U Z — ftNTERViLI_E,MA'0 632, %' Undersecreta i O _ w � yam., yamO Ui o 'j w O Q Z J C _ 1® - Town of Barnstable lldin .. °.` - '^ , .c .,F ",r:.. ;` :. , F,, .,.,`,. `'�`'r-...';a"`J ''i", -}/y`'�■. V PostThis.CatlSo That,it;is ble:SFrom the;;Street-Appraved3.Plans,Must beRetarned on Job andµthis Card Must beKept t'* `�-. w E ... • M" Posted�Until„final,Inspection Has-een>WAK,,", �' ' :Where,a Certificate of Occu anc is Re uiretl:such:Buildin shall Notybe Oceu ted until�a Fnal�lns'ectiorr:has-been�made? � Permit Permit No. B-18-2094 Applicant Name: THOMAS C.WHITE WOODWORKER LLC. Approvals Date Issued: 07/06/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 01/06/2019 Foundation: Location: 415 MAIN STREET(CENT.),CENTERVILLE Map/Lot 208 125 Zoning District: SPLIT Sheathing: r -y Owner on Record: WHITE,MILDRED E �. ContractorNarn" e ,..THOMAS C.WHITE Framing: 1 WOODWORKER LLC. Address: 415 MAIN STREET 2 - Contractor License: 177283 CENTERVILLE, MA 02632 Chimney: Description: Siding,roof Est ProieC1 Cost: $2,000.00 Permit Fee: $35.00 Insulation: Project Review Req: A fi , r FeePad: $35.00 Final: Date. 7/6/2018 Plumbing/Gas Rough Plumbing: r � � � Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized bythis permit is commenced within six monthsafte�issuance. All work authorized by this permit shall conform to the approved application and,the approved construction documents for�whicfithls permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shalt be incompliance with the local zon ni g,by laws and codes. a ,,. 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 Electrical work until the completion of the same. . . Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are,providedon this permit. Rough: . �,Minimum of Five Call Inspections Required for All Construction Work: . 4 z - 1.Foundation or Footing Final: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "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 All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ok Application number................................................ DateIssued.......:..... ��. ... ................................ HAM - -Building Inspectors Initials.... ............. . 1 Map/Parcel......: ...... ....................... _ JUN'2 8 2016 TOWN 0� � � � TOWN b� nwNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION JAddress of Project: !�l �A 1� -�l"►� i l �� V 1� 0� NUMBER. STREET VILLAGE Owner's Name: \AA l Lt,4\tq Q R&V-z Phone Number Email Address: Cell Phone Number Project cost$ cam,o0 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in`accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Siding F-1 Windows(noheader change)'# Insulation/Weatherization F-1 Doors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 la of shingles) A Construction Debris will be going to CONTRACTOR'S,INFORMIATION F_ Contractor's name � l Home Improvement Contractors Registration(if applicable) (attach copy) Construction Supervisor's License# (attach copy) 4 y� j Phone number � � 03"®�Y� Email of Contractor U .sait�c�n Cal ftl? -��1 ALL PROPERTIES THAT HAVE STRUCTURES OVER.75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN. ____ _.. ....,.�....T...� .���T ,o►.-'Aoovnve RFCnRF a PFRMlT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper.. Check one: this event is a: for profit non-profit event t. Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES * . Manufacturer# Model%I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number 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'S SIGNATURE Signature r Date d� All permit applications are subject to a building official's approval prior to issuance. The commonwealth of Massachusetts Department of Industrial Accidents - office of Investigations 600 WashhTffin'Street Boston,MA 02111 www.mass.gov/dia Workers, Compensation Insurance Affidavit:Build ers/Contx•actorslEl pctricfaP��umb bs Applicant Information Name(Business/Organization/lndividual). Address: lhk . Phone City/State/Zip d' E, Areyouu an employer?Check the appropriate bog: Type of.project(required): 4. [] I am a general contractor and I 5 New construction 1.❑ I am.a employer with have hired the sub-contractors employees(full and/or part-time).* listed on the attached sheet. `7. ❑Remodeling 2.5J I am a sole proprietor or partner- These sub-contractors have . g. Demolition ship and have no employees employees and have workers ,> 9. Building addition working for me in any capacity. imp.;,;suuce airs or additions o workers'comp•insraance 10.[]Electrical rep [N 5. � We area corporation and its - required.] ;officers have exercised their 11.[]Plumbing repairs or additions 3.❑ I am a homeowner doing all work. right of exemption per MGL 12.g Roof repairs myself[No workers'comp. c.152,§1(4),and.we have no 13.❑Other insurance Tegaa employees.[No workers' comp.insurance rye-] Any applicant that chet3cs box#1 mast also fill out the section hill w and then hire outing their side conhactors must submit a anew affidavit indicating such t Homeowners who submit this affidavit indicating they g the name of the sub-contractors and state whether or not those entities have $Contractors that check this box must attached an additional shed showing their workers'comp.policy number. employees. If the sub-cont�rs have employees,they most P d ob site I am an employer that is providing workers'compensation Insurance for my employees. Below is thep otuy j information. . Insurance Company Name: Expiration Date• Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: the oli number and expiration date). Attach a copy of the workers' compensation policy declaration page can leaag P �' penalties of a Failure to secure coverage as required under Section 25A of MGlr a 152 can lead to the imposition.of criminal 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 to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of of up � Investigations of the DIA for bmnance coverage verification. p ' and ¢sties of perjury that the,information provided , ove is a and correct I do hereby certi Date: Si e: - Phone#: to be co feted by city or town official Official use only. Do not write in this area � PermitlLicense City or Town' # Issuing Authority(circle one): inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.other J Phone#: Contact Person: 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 iri 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 ther legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal repres of a deceased employer,or the receiver or trustee of an in dividual,partnership,association or other legal entity, laying employees. However the owner of a dwelling house having not more than three apartments and who resi therein,or the occupant of the dwelling house of another who employs persons to do maintenance,constructio or repair work on such dwelling house or on the grounds or building urtenant thereto shall not because of such oyment be deemed to be an employer." MGL chapter 1522 §25C(6)also _ s that"every state or local licensing a ency shall withhohd the issuance or renewal of a license or permit operate a business or to constrict burl s in the commonwealth for any applicant who has not produced . eptable evidence of compliance the insurance coverage'required." Additionally,MGL chapter 152, §2 7)states"Neither the commonwe th nor any of its political subdivisions shall enter into any contract for the perform ce of public work until accep a evidence of compliance with the insurance requirements of this chapter have been esented to the contracting ority." Applicants Please fill out the workers'compensation affi vit completely,by hocking the boxes that apply to your situation and,if necessary,supply sub-contractor(s) s es nam e(). ss( )and ph a numb along ' P ers( ) g wrtb then-certificate(s)of humrance. Limited Liability Companies(LLC)or ' ' Liab'dY Partnerships(LLP)with no employees other than the members or partners,are not required to carry work 'comp . 'on insurance. If an LLC or UP does have employees,a policy is required. Be advised that this davit ay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also a re to sign and date the.affidavit The affidavit should be returned to the city or town that the application for the p or license is being requested,not the Department of Industrial Accidents. Should you have any questions re gar ' the law or if you are required to obtain a workers' compensation policy,please call the Department afthe ber.' 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 p ' legibly. Th\abe ent has provided a space at the bottom of the affidavit for you to fill out in the event the 0 of Investigto contact you regarding the applicant. Please be sure to fill in the perniffMcense number w 'ch will be usee ence number. In addition,an applicant that must submit multiple pennit/license applicano in any given yed submit one affidavit indicating current policy information(if necessary)and under"Job Address"the nt sh d write"all locations in (city or town),"A copy of the affidavit that has been off stamped or m by the or town maybe provided,to the applicant as proof that a valid affidavit is on file or future permits oses. A n affidavit must be filled out each year.Where a home owner or citizen is ob ' ' a license or permilated to an business or commercial venture (i.e.a dog license or permit to bum leaves etc said person is NOT d to comple this affidavit.The Office of Investigations would liZce to you in advance for ooperation and ould you have any questions, please do not hesitate to give us a call. The Department's address,telephone d fax number: The fummmw6alth of Massachusetts Department of Industrial Accidents Qfce of Iuvestigatim 600 Washington Street Bosom,MA 02111 Tel.#617-727-4900 ext 406 or 1- -MASSY Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia Town of.Barnstable °� Building Department Brian Florence,CB-0 0 9.r�ss. 1. Building Commissioner 200 Main Street,Hyannis,MA 02601 www town.barnstablema.ns Office 5 08-862-4038 Fax 508-790-6230 Property Owner Must " Complete•and Sign'I'his_Section If Using A Builder - I• �u�2�-_—��C'� as Owner of the subject properip hereby authorize- © �+15 `-tJ��``C�= to act on mp behA in all matters relative to work authorized lip this building permit application for. . . (Address of Job) '*-*Pool a e.res onsibilt• of the applicant Pools fences and alarms are th PP . P t9 are not to be wed-or.ufiltz-ed before fend is installed.and All find inspections'are performed and accepted. Signature of Owner - tote of Applicant �tV \ , ( � � " fir — � �• .. - .: Print Name Print Name - Dar - .. Q:FORMS:OWNERPERM SSIONPOOLS Rev:10/17 m � tier. s oc a� w c " �e zmtoazzue o C� ells .- f ice f�Gronsumerusinessz(`egulation o c HOME IMPRGVEMENT CONTRACTOR Registration valid for individual use only c o i YPE:LLC, before the expiration date. If'found return to: O o t 'r� RQoisfraUon Expiration f ; Office of Consumer Affairs and.Business Regulation r O` 177')20' � 11i21/2019 10 Part,,Plaza-Suite 5170 , k r= Boston,MA 02116 fQ N V1N . .� �p f" ,. THOMAS;C bVHITEWOODWRKER LLC. p C CO Q. i. 0 s w � U c = � w i. T4'0MP,S'C WFiI I� }`, ro�' L LU 00 O 3 I-- 1> 41 FA MAIN ST \>`k i u w u U z '� E CENTERVU E MA 0 632,'^, IsIO# U1�ISj Y111#�IQU#Slgl18#Ure - R o _ —. Undersecretary f v Qa � o _ .. U F=-vU } Town of Barnstable ermit / C e Regulatory Services Fee BABNSTA A Richard V.Scali,Interim Director PERMIT Building Division JUL 13 2015 Tom Perry,CBO,Building Commissioner 200 Main sheet,Hyannis,MA 02601 TOWN OF BARNSTABLE www.town.barnstable.ma.us Office: 5084624038 Fax: 508-790-6230 .EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Vaild without Red X-Press Imprint Map/parcel Number �lz4f Property Address J7' �G c l7lC( Residential Value of Work$ oZ a 0 L-., Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name�C LAAVk'S Uoyl��l' Telephone Number,-�� 81 C(60 Home Improvement Contractor License#(if applicable) f ���� Email- \ "OO-Z) 9 (Z Ca t EN264--, ET Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ta I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken ❑Re-roof Qtupicane nailed)(not stripping. Going over existing layers of roof) a Re-side CZCk W(- ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy oj the Home vement Contractors License&Construction Supervisors License is un SIGNATURE: QAWPFILFSTORMSWuilding permit fortnAWRESS.doc Revised 061313 f L IN The Commonwealth of assuchusetts Department of Industrial Accidewy ' Office of Inivstrgations GOO Washington Street Boston,M4 02111 " wl,vmmas&gav/dia Workers' Compensation Insurance Affidavit: Builders(Ca ns/Phambers Applicant Information Please Print Legibly Name(Businezurganizatianbdividaat). -A V�s `'LJ� L- ( Ad&ess:_�I(�f� ;<t fsti3t ,,,iiL6A G 2 Phone _ Y Are you an employer:'Check the appropriate boa: Type:of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full andlor partfime). * have hired the sub-contractors 6_ ❑New cansfrtnction 2,W I am a sole proprietoror partner- listed on the attached sheet. 7. ❑modeling ship and have no employees These"sob-contractors haze 8. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.Y 9- ❑Building addition. 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 ❑Plumbing repairs or additions 1f o workers' right of exemption per MGL my F 12..�Roo, insurance required.]F c.152, §1(4),and we have no �---, employees.[No workers' 13_RfOther Clo comp-insurance required-] *Any applicant dhnt checks boa#1 tow also fill out the section below showing their workers'compensation policy infnrmafioa. I Homeowners who submit this affulava indicating they are doing all wank and then hue outside contractors orast submit a new affidavit indicating such. tConnactors that check this boa must attached an additional sheet showing the nmne of the suss-cane ctors and state whether or not those entities hwe employees. If the sub-contractors have employees,they must pmvide their workers'romp.policy number. lam an ernpioyer that is praiiding workers'compensation insurance for my emplaf*ees. Below is the policy and job site informadam Iamnance Company Name: Policy 9 or Self-ins.Lic-#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation polio*declaration page(showing the policy number and mpiration date). Failure to secure coverage as required under Section 25A o€MGL c 152 can lead to the imposition of criminal pew of a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and.a fine of up to$250M 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 nd th 'n an alties of perjury that the infotwtation ptmidrd a V is and correct Si tune: Date: Official use only. Do not write in this area,to be completed by city or town o,;(ftaial, City or Town: Permit/I,icense-9 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citylrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 �TME, Town of Barnstable Regulatory Services BAMM MAW Richard V.Scali,Interim Director i639 �� ' oN,pr► Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 508-790-6230 f Property Owner Must Complete and Sign This Section If Using A Builder as Owner of'the subject property hereby authorize^ \ �/�J` C'l�� to act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted' N . sa) � J� Signature of er Signature of Applicant kU Y � \ Print Name Print Name DAL f r Q:FORMS:OWNERPERMISSIONPOOLS 10113 Town of Barnstable Regulatory Services t tof Richard V.S cali Interim e rim Director Building Division BAMSTABIX Tom Perry,Building Commissioner MAss. 200 Main Street, Hyannis,MA 02601 �'°Tec rune+" www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB.LOCATION: number street village 'HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town stat zip code The current exemption for"homeowners" 7\inude owner ccu red dwellings of six units or less and to allow homeowners to engage an individual for hisess a lice, e,provided that the owner acts as supervisor. OF HO OWNER Persons)who owns a parcel of land on which he/s intends o reside,on which there is,or is intended to be, a one or twofamily dwelling,attached or detached structures ach use d/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. uc "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be res onsible all such work performed under the buildingpermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compli ce w the State Building Code and other applicable codes, .bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understan a Town of arnstable Building Department minimum inspection procedures and requirements and that he/she will comply with aid procedures d requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,0 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. H MEOWNER'S EXEMPTION The Code states that: "Any homeowner p rforming work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1. -Licensing of construction Supervisors); provided that.if the homeowner . engages a person(s)for hire to do such work,tha such Homeowner shall act as supervisor." Many homeowners who use this exemp on are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Lic sing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,.particularly whe he homeowner hires unlicensed persons. In this case,our Board cannot. proceed against the unlicensed person as it w uld with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is f ly aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner ce 'fy that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by se eral towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRES doc Revised 061313 Massachtgetts Department of Public Skfety ee oa�vnwrzcv z as Board of 64ilding Regulations and Standards ffice;ofConsumerA,ffa►rs&BusmessRe ulatton.%: g, Constriction Sunertiisor M'E IMPROVEMENT CONTRACTOR License: CS-066582 ;.'` gistratjon 177283 Ty.Pe, xpiraUon 1 /22D1 LLC THOMAS C WHI %. ; �' T i a 415A MAIN ST I , , IF j THOMAS C.W,HITE-WI,'& LC Centerville MA 62632( --- r y�5 ` THOMAS WHINE i 4T5,A MAIN SiT. Expiration " ?Commissioner 03/14/2017 - ERUILCENT LE, MA 02632 Undersecretary, I - I • Unrestricted--Buildings of any use group which contain less than 35,000 cubi I c feet (991m3,of L cenae or reg> tratton and�for and►v1dulruse,only before thexpinattan date fffound return tQ enclosed S ace. Office of Consumer Affairs and Business>Regulation `��' 1O�Park Plaza S'utt�51'�7;0: _ �� B'oston,MA�021-1G_ Failure to possess a current edition of the Massachusetts -- - — --_ State Building Code is cause for revocation of this license. ss.Gov ' of va.id without signature. For DPS Licensing in visit: www.Mass.Gov/DP5/ _ : - t I i �tME r, Town of Barnstable *Permit b wsl �l Expires 6 •f Regulatory Services Fee Richard V.Scali,Interim Director 'T, Building Division T Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 , CC www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number -2 0 Property Address �!f rat l S l Ck' "�UILc. Residential Value of Work$ /moo.o0 Minimum fee of.$35.00 for work under$6000.00 Owner's Name&Address ` ^ Contractor's Name V�1 l Telephone Number so `7 y -© - s qc> Home Improvement Contractor License#(if applicable) p2 o 3 Email:' �o t�OWuCl�: l6C?CZl2�. . r Construction Supervisor's License#(if applicable) S ❑Workman's Compensation Insurance Check one: ( 1 am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-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 ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance.of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A y t Home Im ovement Contractors License&Construction Supervisors License is req ' ed SIGNATURE: QAWPFILES\FORMS ildmg permit formslEXPRESS.doc Revised 061313 .T'he Co837J Mnream o,fm'ussachnsei Deparment of fndtrshirrl Accide Office of Ikmfigations 600 Washington Street Boston,MA 02111 ttmrw.mas&gov/dia Workers' Compensation Insurance Affidavit Builders! ers cant bformation Please Print Name Address: CitylSta `ZL vc«c G3-� Phone& Are you an employer?Check the appropriate bozo Type of project(required): 1.❑ I am a employer with 4: ❑ I am a general contractor and I 6- [-]New eomson employees(full and/or part-time).* have hired The sub-contractors 2.Z I am a sole proprietor orparbxT- listed an the attached sheet, I ❑Remodeling ship and have no employees These svb-contractors have g- ❑Demolition waking for me in any capacity- employees and have workers'[No workers'camp-insurance COMP-MSMMU p Y 9 ❑Budding addition required-] 5. ❑ We are a corporation and its 10-0 Elechical repairs or additions 3.❑ I am a homeowner doing all work offit:ers have exercised their I LE]Phur ag repairs or additions myself[No workers'comp- emu of Mmmption per MOL 12-❑Roof repairs insurance rewired]F c-152,§1(4),and we have no employees-[No workers' 13-0 Other covap_insurance required-j *hayaplflicm 8utchedabox#1nmstalsofilloutthesectionbelowshowingtheirwodmecam policyinti�rtiw. 1&amEowaets who submit this affidm iatluatiag they are doing all wank ad&m bue oaaidecoatscton nmst submit anew affirm t iedi— sadL ICoaooactoest w chadcthis boat mast attached anadditional sheet showmg the mmieof the sub-coauacmts and MM whedw or not those entities hwe uVloyees. Ifthe sub-Cowan have employees,they mnstpmvide 8tdr wailers'comp.Policy number. I ant an elnploysr dietisprm-h f workers'compensadon insurance for my emplof Below is the pobcy and job site irejmemadOIL Insurance.Comparsy Name: . Policy#or Self-ins.Iic_# Fxpiration Date: Job Site Address: citylStafetzip: Attach a co of the workers'compensation declaration sho the policy number and torn ` PY �P�a � P�e3' P�( �g Po�cY �� date)• Far'lnme to secure coverage as required under Section 25A of MM c.152 can lead to the imposition of criminal penalties of a Site up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$230.00 a day against the violator. Be advised that a copy of this statement may be fnrmarded to Sae Office of lavestigati ons of the DTA for insurance coverage verification. I do ht!raby o.fPerfiEry that the vejortrrrdion protRdad a is and eoffftt s' p Date: Phone# Of jicial use only: Do not tt'rtte in arts area,to be completed by aiy or town qffieiaL City or Town: PermitlLicense.9 Issuing Authority(tdrele one): 1.Board of Health 3.Buffing Department 3.City/rottm Clerk d.Electrical Inspector 5.Plumbing hapector 6.Other Contact Person: Phone#• 6 tro,4� Town of Barnstable ' ,. Regulatory Services yMAS $ � Thomas F.Geiler,Director E16- 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Us ing A Builder , `L � t as Owner of the subjectproperty 1 hereby authorize t c `�J� ' to act on my behalf, in all matters relative to work authorized by this binding permit application for. (Address of Job S' ttire o r Da Print Name ' If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q :FO RMS:O WNE"ERMISSION Town. of Barnstable- Regulatory Services Thomas F.Geiler,Director t�nssti �* `rFo '•e Building Division Tom Perry,Building Commissioner ... .. __.. ._ ....._200 Mairi�Street;--Hyannis;MA 026D1 www.town.barnstable-ma.us Office: 50 8-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE. JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: ciWW state zip code The current exemption for"homeowners" extended to in ude owner-occupied dwellings of six units or less and to allow homeowners to engage an individua for hire who d s not possess a license,provided that the owner acts as supervisor. DE ON OF OMEOW1dER Persons)who owns a parcel of land on which h she resid s or intends to reside,on which there is, or is intended to- be, a one or two-family dwelling, attached or de hod s tares accessory to such use and/or farm structures. A person who constructs more than one home in a year eriod shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official a f acceptable to the Building Official,that he/she shall be re onsiMe for all such work performed under the b 5 ff DLrmit (Section 109.1.1) 71ke undersigned"homeowner"assumes responsibility compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned.."homeowner"certifies that-he/she un rs ds the Town of Barnstable,Buildiugbepartment minimum inspection procedures and requirements and at she will comply with said procedures and requirements. 4 Signatzrm of Homeowner Approval of Building Official , Note: Three-family dwellings containing 5,000 cubic feet or ger will be required to comply with the State Building Code Section 127.0 Construction C ntrol. HO WNER'S EXEMPTION The Code states that: "Any homeowner perfonr>n work for which a building is required shall be exempt from the provisions of this section(Section 1 D9.I.1 -Licensing of construction ervisors);provided that if the ho owner engages a persons)for hire to do such work,that such Homeowner shall ad as supervisor." Many homeowners who use this exemption are ware that they are assuming the rmp brlities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors, ection 2.15) 'This lack of awareness results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,o Board cannot proceed against the un icensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is uhimatcly sponsrble. To ensure that the homeowner is fully ewarr of hiAer responsrbrlities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsi'bilities 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 formleertifi ration.for use in your community. Q:forms:homccxcmpt Massachusetts -Department of Public SA'fety _ Board of Buildin Regulations and Standards ,, 9. � Rice oEConsumerAffa &Business"Re ulaho Cone.ruction Supersi.nr .� g. License: CS-066582 ME IMPR01/EMENT;GONTRgCTOR , gistration 1783 ,Type• THOMAS C WHI xPiration r 11[22/2D1 LLC 415A MAIN ST ■ 9r = I �� - Centerville MA U0632 TMOMAS C.WHITE WOODW{�RKE'R LLC. r. 7 . y TH,OMAS WHITE «� Expiration 415A MAIN;ST. Commissioner 03/14/2017 CENTER,IiLLE,�MA 02632 Undersecretary, . r 0 Unrestricted-Buildings of any use group which Contain less tln'35,000 Cubic feet(991m)of Ii►cense or<reg►stratioyn�andmforzindrvtdul use only Y before th��expliatton date; If found returnato ___� enclosed Space. Q.ftice`oftCons.,u er-Affairs and t siness:Regula-tton Y e Y _ 1;Q Park Plaza S—urte 5170 Boston,.1VIA 0.21,1�6- Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. i ass.Gov pps of�adxwitliout signature.� - w.M / 0 or mationvisit: ww — sin information PS Lic ensing en .. D B For Parcel Detail Page 1 of 3 BAtAN5tABLE. 41 IV ,.� s a , Logged In As: Parcel Detail Monday,July 13 2015 Parcel Lookup Parcel Info �. _.�.�_� Developer�; Parcel ID r208-125 I Lot i LOT B Location 1415 MAIN STREET(CENT.) _I Pri Frontage Sec Road sec r�p I Frontage Village IjCENTERVILLE iI Fire District C-o-mm 77771 Town sewer exists at this address I N0 I Road Index Asbuilt Septic Scan: Interactive 208125_1 Map ., Owner Info Owner WHITE, MILDRED EE Co-owner Streetl 1415 MAIN STREET ) Street2 F _ City ICENTERVILLE _ I state WA zip[02632 Country Land Info Acres 0.30 Use iMulti Hses MDL-01 I Zoning�SPLT� Nghbd F0109 Topography Level _ I Road Paved I utilities Public Water,Gas,Septic �I Location Rear Location �) Construction Info Building 1 of 2 Year 1875 "I Roof ablep ( Ext Struct Wall Wood Shingle Built g Living 2474 Roof AC (As 'None _ s r Area I Cover J ph/F GIs/Cm p I TypeBed I Style`Conventional I wall nt PlasteredI Rooms' Bedrooms I �4 t; Model Residential _ I Intpine/Soft Wood I Bath 12 Full-0 Half ) AT Floor Rooms . Heat f_`._._�__._.��,�.._. Total �. _ Grade Luxury Minus I Type lHot Water I �9 Rooms ) , - Rooms Heat Found-i Stories 2 Stories �I- Fuel II �� ation iTypical 1. - Gross 2912 ( . Area Building 2 of 2 Year 1948 __ Roof Gable/Hip Ext,Wood Shingle I Built Struct_ Wall http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14788 7/13/2015 Parcel Detail Page 2 of 3 Living 1120 � Roof�Asph/F GIs/Cmp ( AG None Area Cover= Type Style Cape Cod Int Drywall _� Bede Bedrooms Wall Rooms ;k int Model Residential Floor IH raI dwood �� Rooms Bath Full-1 Half Heat Total Grade Average Type Hot Water Rooms j6 Ro°ms -- stories 1 1/2 Stones Heat Oil ~ Found (Stone Ft s _. _ I Fuel f ation I _.___g Gross Area Permit History Issue Date IPurpose IPermit# IAmount Insp Date IComments Visit History Date Who Purpose 2/13/2014 12:00:00 AM Jeff Rudziak In Office Review 9/10/2009 12:00:00 AM Paul Talbot Cyclical Inspection 9/17/2001 12:00:00 AM Paul Talbot Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 7/5/2002 WHITE, MILDRED E 15339/74 $0 2 7/29/1991 WHITE, EDWARD H&MILDRED E 7627/87 $1 3 8/21/1972 WHITE, MILDRED E&EDWARD H 1707/301 $0 11 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2015 $368,400 $17,100 $13,300 $238,600 $637,400 2 2014 $379,300 $17,800 $14,200 $238,600 $649,900 3 2013 $379,300 $17,800 $14,500 $238,600 $650,200 4 2012 $378,700 $16,500 $11,900 $238,600 $645,700 5 2011 $439,900 $7,000 $4,300 $238,600 $689,800 6 2010 $439,500 $7,000 $4,500 $243,800 $694,800 7 2009 `$484,000 $5,100 $3,000 $350,900 $843,000 8 2008 $459,900 $5,100 $3,000 $358,300 $826,300 10 2007 $484,000 $5,100 $3,000 $358,300 $850,400 11 2006 $437,700 $5,100 ' $3,200 $332,700 $778,700 12 2005 $386,400 $4,800 $3,300 $298,200 $692,700 13. 2004 $317,700 $4,800 $3,400 $165,700 $491,600 1'4 2003 $299,200 $4,800 $3,500 $67,000 $374,500 15 '2002 $301,900 $4,800 $3,100 $67,000 $376,800 16. 2001 $301,900 $5,100 $3,100 $67,000 $377,100 17 2000 $237,000 $5,000 $3,100 $55,300 $300,400 18 1999 $237,000 $5,000 $2,500 $55,400 $299,900 19 1998 $237,000 $5,000 $2,500 $55,400 $299,900 20 1997 $231,400 $0 $0 $52,100 $285,900 http://issgl2/intranet/propdat.a/ParcelDetail.aspx?ID=14788 7/13/2015 Parcel Detail Page 3 of 3 . a R 21 1996 $231,400 $0 $0 $52,100 $285,900 22 1995 $231,400 $0 $0 $52,100 $285,900 23 1994 $231,300 $0 $0 $52,700 $286,600 24 1993 $231,300 $0 $0 $52,700 $286,600 25 1992 $263,200 $0 $0 $59,400 $325,600 26 1991 $267,200 $0 $0 $99,000 $371,700 27 1990 $267,200 $0 $0 $99,000 $371,700 28 1989 $267,200 $0 $0 $99,000 $371,700 29 1988 $179,800 $0 $0 $33,700 $217,500 30 1987 $179,800 $0 $0 $33,700 $217,500 31 1 1986 1 $179,800 $0 $0 $33,7001 $217,500 • Photos w . 7 � w t m http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14788 7/13/2015 i own OII i5a>rnstame Permit: c;2 0/ S Regulatory Services Date: ��`��� Ot Tok Thomas F. Geiler, Director P� tis Building Division Fee: s % RARNSTAISM Tom Perry, Building Commissioner -A jo) 7 9qj t639. ��� NO Main Street, Hyannis,;IviA 02601 Or ptFD hAAI p www.*tow'n.barnstabte.ma.us Office: 508-862-403 8 Fax: 508790-6.ZJ 0 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT , , Owner` Phone: Install at: N `7l � r� � S� _ Village: _�e e.:. old c.•. _r: rr+ Map/Parcel: �11-ID C`�')' Date:, —_ 0 / l Stove / A. New sed" B. Type adia `Circulating C. Manufacturer;. �o,S- ;l.,�e Lab. D. Model No:: Chimney 1 A. New/;Existing; (If existing, please•;note date of last cleaning) no f 4c, 13. Flue Size SX1 __. C. Are other appliances attached to Flue? No D. -Pre-'fab Type and Manufacturer E. ason : Line nlined Z, v1e,4 yr L�LLi S�'eG( 6 �r �� ��`f �S ,;iierfoc1 4 Hearth Ln / A. Materials: &L La 5/e4 � /vh..�� �7ro�zG�'�•� �._ ti� U` �j���u 4 o `i b j B. Sub Floor Construction: Installer Name: G� � ��,1`� (�laar✓i/1 c' CGwC. Address: 62 o �X o �lJ✓lat(, 6, 6`f� Phone: �o �faJ �-6 Location Installation: ��, s�4fi��l �i►-y��c.c-� H.I C`Registration# � / Construction Supervisor:# CSS L /o S 0 OR check_Homeowner Installin , o license required APPLICANTS *dablelo E r APPROVED BY Please-make che the Town o.Barnstable *This constitutes an offcal stove perm it'after. inspection, photographed and approved by the Building Inspector Q:fo:rms:stove Rev 103107 The Commonwealth of Massachusetts Department of Industrial Accidents Office of-Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elects cians/Plumbers APPUcant Information Please Print Legibly Name(Business/Organizatiott/Individuad): �:1 ii e, (��C Address: (L) 1 0- City/State/Zip: (�e��5r 1�^5 ,.✓� t(�, Phone*: 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 employees(full and/or part tithe).* have hired the sub-contractors 6, ❑New.construction 2.0 I am a sole proprietor or partner` listed on the attached sheet: 7. Q Remodeling ship and have no employees These sub-contractors have 8.' Demolition workingfor mein an ..ca aei employees and have workers' Y p h' t 9. F Building addition [No workers'•comp.�incizrance comp.insurance. required.] 5. 0 We are a corporation and its I0.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work = officers have exercised their 11.[]Plumbing.repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required;]:t c. 152,§44),and we have no employees.[No workers': 13F1 Other comp..insurance required:] *Any applicant that checks box#I must also fin out the section below showing their workers'compensation;policy infoAnation.:, t Homeowners who submit this affidavit indicating they,are doing all work and then}tire outside contractors must submit a:new;affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have. If the sub-contractors have a to employees. �rr�, yees,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: -' ►M. `'f(i yy /�(c,5(.fG.•G� o Policy#or Self-ins.Lich#:_ ( .?Q !jf-� OY 7, 3 A 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 tip to S1,500.00"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;nor,ance covM9e'verification I do hereby certify the pains and penalties of perjury that the information provided above is true and correct Si tore: Date: 2 Phone#: Official use.only. Do not write in this area,to be completed by city or to offwid w ,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#: Office of Consumer Affairs&Business Regulation-Mass.Gov 9/24/13 2:06 PP The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) ' s Consumer Affairs and Business Regulation Home Consumer Home Improvement Contracting Home Improvement Contractor Registration Lookup You can search/filter the registration list by any of the criteria below. Search by Registration Number 161642 search Search by Registrant Name Search by City Zip Code Search Registrants) Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Monday, September 23, 2013. Search Results RESPONSIBLE REGISTRATION EXPIRATION REGISTRANT NAME STATUS INDIVIDUAL NUMBER ADDRESS DATE CHIMNEY CARE SMITH, SCOTT 161642 P.O. BOX 202 11/12/2014 Current MARSTONS MILLS, MA 02632 ®2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License: CSSL-105026 SCOTT B SMITH 7 CAPTAIN LUMHERT Centerville MA OWN t Expiration Commissioner 08/12/2015 http://services.oca.state.ma.us/hic/licenseelist.aspx Page 1 of SEP. 24. 2013 2:55PM ASSOCIATED INSURANCE NO, 1398 "P. 1- AC R� CERTIFICATE OF LIABILITY INSURANCE DATE(MM4X MI, kt,.� 09/24/2013 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certilleAte 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 doss not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER 04220-001 CT TW nbrook Insurance Brokerage a.Fm (800)4694604 No. (781)848-6100 400 A Franklin Street Braintree,MA 02184 � RPRIal AtWourpla A.LM.Mutual Insurance Company 33758 IN8uRED - Scott Smith Ctdmney Care of Cape Cod IN P0 Box 202 Marston M14 MA 02948 I COVERAGES CERTIFICATE NUMBER: . 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 YO 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 TYPE OF INSVIRANC6 POLICY NUMMOR P .LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY tFD $ CLAIMS-MADE OCCUR ►AED ExP(Aryonaporson) g i. PERSONAL&ADV W.IURY f GENERAL AGGREGATE S FIA AGGREGATE LIMIT APPLIEe PER PRODUCTS-COMPIOP AGO $ OLICY O- OC - AWOMOeILELIABILITY CCMMNW NINUL9LIM S En acat� ANYAUTO 130OLYINURY(Per Dwsonl $ AUTOS �OESULEO BODLY INJURY(Por amiCen) S HIREDAUTOSED s�ED Aflor $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE g EXCESS LIAR CLAWS MADE AGGREGATE f DED RETENTION$ $ ILL R&AM / �(,� x TOR YMMS OER- A OF P MMZ Vigo G=TIVE' -- ' NIA AWC.W0.70242118-201SA - 4127I2019 4/27/2014 Ek�A_DIOENr t 50010M.00 - 11(Mutdotaryfn n0l► - E L.DISEASE•EA EMPLOYEE $ - 500,000.00 DEBCRIPTIONOFOPEsRAYIONSbelow 61.D -POLICYLPNIT $ 50%000,00 DESCROMON OF OPERATIONS/LOCATIONS IYEHICLES(A�eh ACORD 101,Addidanid R meflu Sahedtdy If MGM IPVA to hgidmd) "Proof of Coverage" Scott B Smith Is covered by the workers compensation policy, CERTIFICATE HOLDER CANCELLATION Scott Smitlry%,Chimney Care of Cape Cod Ro.Box 202 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCM I Bp BEFORE Marstons Wits,MA 02648 THE MMIRA710M DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PR&ISNNYS- AUrHORIIED R@PRE9E3rTaTnrE 019 - ACORD CO TION-All rigntiresomd.ACORD 25(201 CM5) Tha ACORD name and logo are registered marks of ACORD v �1ME,bb� Town of Barnstable Regulatory Services snRxsM a Thomas F.Gdier,Director %6:yq- Buildin.Division Tom;Perry Building:Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstableema:us Office: 508-862-4038 Pax: 508-790-6230 Property Owner Must Complete and Sign This Section fif Using A Builder 0I; 'E Cj , as Owner of the subject property hereby authorize � C� �Wl l^C' to act on my behalf, in all matters relative to.work authorized by this building permit application.for. 41K VAAt (002(S.3 Z (Address.of Job) 'Signature of CKmer Date Print Name If Property, Owner is applying forperinit please"complete the Homeowners License Exemption Form on the,reverse side. _ Q:FORMS:OWNERPERMISSION I �a c, optNe rok Town of Barnstable *Permit# OEvpires 6 to hs furn issue(late y eY Regulatory Services Fee + BARNWCABLE, v� 659_ $ Pe Thomas F. Geiler, Director ©� J Arfp µpt A C t T Building Division® 2008 Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis, MA 02601 �( www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - -RESIDENTIAL ONLY Not Valid without Red X-Press Imprint '4 Map/parcel Number UO Property Address (/Q Residential Value of Work G Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address tLO 4_ Contractor's Name "'��j_ ( � � Telephone Number ! C I Ionic Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 66 S7(l ❑Workman's Compensation Insurance Check one: ZI am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance insurance Company Name` Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to .1b'1V�h} �` ��1 ❑ Re-roof(not stripping. Going over__existing layers of roof) Q Re-side Replacement Windows/doors/sliders. U-Value (maximum .44) *Where required: Issuance ol'this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property vner Letter of Permission. A copy the I� elm vem Contractors License is required. SI-GNATURE: Q: WPFILESTORMS\building permit fonns\EXPRESS.doc Revised 100608 y The Commonwealth of Massachusetts Department of Industrial Accidents Pa. W Office of Investigations 600 Washington Street �< Boston,MA 02111' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Dame (Business/Organization/Individual):7qk Address: t� City/State/Z' l = Phone.#:_, '® Are.you an employer? Check the appropriate-box: :Type of project(required):, . general con and I 1,❑ I am a employer with 4 � I am aeneral con 6. El New construction . employees(full and/or part-time).* have hued the sub-contractors 2. I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, []Demolition employees and have workers' 'working for me in any capacity. 9. []Building [No workers' comp,insurance addition comp, insurance,$ required.] 5. We axe a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work . officers have exercised their l l.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.RJ Roof repairs insurance.required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No workers' comp,insurance required,] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t I3omeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.thepolicy and job site information. Insurance Company Name; Policy#or Self-ins.Lic.#: ' Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as.required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy-of this statement maybe forwarded to the Office of Investi ations of the MA for insurance coverage verificadtion. I do hereby certi n the p and alR'eso. erjury that the information provided a/b�ove ' true and correct. Si mature: Date: /G O 9 _ Phone#' <D Official use only. Do not write in this area, to be completed by city or town official i City or Town: _Permit/L,icense# 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#: 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 ofhiie, express or implied, oral or written." An employer is defined as "an individual,partnership,association,corporation or er legal entity,or any two or more of the foregoing engaged in a joint enterpris' and including the legal representati s of a deceased employer, or the receiver or trustee-of an individual,partners , association or other legal entity, mploying employees. However the owner of a dwelling house having not more tha three apartments and who resi s therein,or the occupant of the dwelling house of another who employs persons do maintenance,constructi or repair work on such dwelling house or on the grounds or building appurtenant thereto ll notbecause of such e loyment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every st to or local licensing a•ency shall withhold the issuance or renewal of a license or permit to'operate a busines r to construct buil gs in the commonwealth for any applicant who has not pro.ducedlacceptable evidenc of compliance wi the insurance coverage required." Additionally,MGL ehapter..152, §25C(7)states'Tleithe the commonwe th nor any of its political subdivisions shall enter into any contract for,the performance of public wor until aceepta e evidence of compl%aace with the insurance requirements of this chapter have been presented'to the co tracting au ority." Applicants Please fill out the workers' compensation affidavit completel b checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and p e number(s) along with their certificate(s)of insurance. Limited Liability Compauies'(LLC) or Limited Liab' 'ty Partnerships(LLP)with no employees other than the mer bers.or partners, are not required to carry workers' compe a'on insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit ay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be re to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pe t.or license is being requested,not the Department of Industrial Accidents. Should you have any questions regar g the law or if you are required to obtain a workers' compensation policy,please call the Department at the ber 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 egibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Offic- of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number w ' h will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications any given year,need y submit one affidavit indicating current policy information(if necessary)and under"Job Sit Address"the applicant siuld write"all locations in (city'or town)."A copy of the affidavit that has been offici y stamped or marked by th city or town maybe provided to the applicant as proof that a valid affidavit is on file f future permits or licenses. new affidavit must be filled out each year.Where a home owner or citizen is obtainin license or permit not related t any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) d person is NOT required to co lete this affidavit. The Office of Investigations would like to tha you in advance for your cooperatio and should you have any questions, please'do not hesitate to give us a call. The Department's address,telephone-and number:. e c4mmmW the of muswhusetts Daparftnimt of ludu�al A.eeidmts MR" of Investigations 600 Wadingtoxi Street Boston,_1A 02111 TeL # f 17-727-400 ext 406 or I-S77-MASSA.FE Fax#617-727r7749 Revised 11-22-06 www.inass.gov/dia THE r Town of Barnstable Regulatory Services wwszAsr.E y Mess. �, Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must " Complete and Sign This Section , If Using A Builder i L , as Owner of the subject property hereby authorize��' -S.t C ( to act on my behalf, in all matters relative to work authorized by this building permit application for: l (Address of Job) 'knature�owner ��� ate Print.Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION Town of Barnstable apt SHE tp�� Regulatory Services ST" Thomas F.Geiler,Director > AS& 03¢ ,�� Building Division rfD AAA't A Tom Perry,Building Commissioner 200 Main-Street, Hyannis,MA 02601 vrww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: I b v O ` JOB LOCATION: v/ (w l f adz ( C J 2 nurA�7ber street village a OMEOWNER": name home phone# work phone# NT MAILING ADDRESS: � �t/I ity/town state zip code The current exemption for"homeown s"was extended to influde owner-occupied dwellings of six units or less and to allow homeowners to engage an indi • ual for hire who a;oes not possess a license,provided that the owner acts as supervisor. EFINITION F HOMEOWNER, j r Person(s)who owns a parcel of land on whic he/she res•des or intends to reside,on which there is, or is intended to be, a one or two-family dwelling,attached or ched s. ctures accessory to such use and/or farm structures. A person who constructs more than one home in a • o-ye r period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official n form acceptable to the Building Official,that he/she shall be responsible for all such work erformed under the b ing permit. (Section 109.1.1) v The undersigned"homeowner"assumes responsibil• compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned-"homeowner"certifies,that he/s 'unders the Town of Barnstable Building,D.epariment- minimum inspection procedures and requiremen and that he/ e will comply with said procedures and requirements, , Signature of Homeowner J Approval of Building Official Note: Three-family dwellings con ining 35,000 cubic feet or 1 ger will be required to comply with the State Building Code Section 127.0 Constru. 'on Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner p orming work for which a building p t is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of cons ction Supervisors);provided that if the omeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor. Many homeowners who use this exemr on are unaware that they are assuming th esponsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction pervisors,Section 2.15) This lack of away- ess often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against a 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 comm ities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the 1 t page of this issue is a form currently used by several towns. You may care t amend and adopt such a fomJcertification-.for use in your comet ity. Q:forrns:homeexempt r q' F kx p 'ac.^__ - ._ -_x sac'.-•..__..+•+v+-.'^a''=sn� - -..v.n�- r✓l��G y x i Boar o m dmg e"gulati san taq ar s �' ? Construction Supervisor License HOME IMPROVEMENT CONTRA ns Licee: CS � 66582 Registrati I 23702- 1', E xp iration 31-28/2009 T tion Expjra 3/14/2009 Tr# 9163 r r:Restnction 00u 'ram ORKER- 's'` A _ t%`LC > Thomas C.White W1OODV,t i THOMAS C WHITES Thomas White 415A MAIN ST \ r��- - �J " 41'5A.Main St. A 2682 a ! t:, e...MA-026-32— Admi. y �S F CENTERVILLE,MA 02632=' Commissioner - entrvill • l i �cense or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and-Standards At One Ashburton I'_lace.]Rm 1301 47 s��`•"::. Boston,Ma,02108 / ' Not valid without signature' —