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HomeMy WebLinkAbout0017 OUTPOST LANE ID TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION i q Map 7 Parcel d Application# �� I Health Division Conservation Division Permit# Tax Collector Date Issued —7 Z Treasurer Application Fee 60 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 71i2lo d"11-1 i T Historic-OKH Preservation/Hyannis Project Street Address 1 7 60'r(3�6 S Village V_ U Owner . S c---- A Av- S Address !`7 Telephone 7 7 - Permit Requester Square feet: 1 st floor:existing D s proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ID)WO Construction Type W60 Lot Size /1 4 i/3 S'47 i—f Grandfathered: ❑Yes No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes A No On Old King's Highway: ❑Yes `1 No Basement Type: -�Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) 0 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_Eount �=a Ln Heat Type and Fuel: gGaS ❑Oil ❑Electric ❑Other Central Air: ❑Yes VNo Fireplaces: Existing New Existing wood/coal s ove: LkYes No cry Detached garage:❑existing ew size Pool:❑existing ❑new size Barn:❑exist. g ❑new siFoi Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial 0 Yes ' 14 No -If yes,site plan review-#--- Current Use Proposed Use BUILDER INFORMATION &' 3(o 7<::::;D V-x Telephone Number � Address -s J Q License# ®7- Q zS� t, Home Improvement Contractor# 7 ) ©D�__76 Worker's Compensation# Csy /7 t�-S 6` 7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Y� !v►�ci fi/ ��-, SIGNATU -- DATE 0/_0 t' FOR OFFICIAL USE ONLY , PERMIT NO. DATE ISSUED MAP/PARCEL NO. s ADDRESS VILLAGE OWNER t DATE OF INSPECTION: t FOUNDATION o FRAME INSULATION — FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT . ASSOCIATION PLAN NO. � Y The Commonwealth of Massachusetts Department of Industrial Accidents € Office of Investigations ~d 600 Washington Street Boston,MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information `` Please Print Legibly Name(Business/Organizationdndividual): . 1 t, a C Pn lJ.✓ Address: t— City/State/Zip: S'1' CZ).„JA", 5 Phone*: s� 9 `740 4)6 Are on an employer?Check the appropriate box: Type of project(required):. LKI am a employer with 4. ❑ I am a general contractor and I ma employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction . 2AIy. I am a'sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling //' ship and have no employees These sub-contractors have g. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• $. 91'❑Building addition [No workers' comp.insurance comp.insurance.t' Electrical re airs or additions required.] 5. ❑ We are a corporation and its ❑ P officers have exercised their 3.❑ I am a homeowner doing all work ,. 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no; employees. [No workers' .13.❑ 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.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: 60 / 7 e VS-6 7 Expiration Date: J 3 O Job Site Address: /� B�'J��o S9' �B��J z— City/State/Zip: Attach a copy of the workers' compensation policy declaration page•(showing the policy number and expiration date). Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereb uncle s and penalties of perjury that the information provided above 's tru' and correct Si afore. Date: 4 ' Phone#: �s e 7 4 Q d / V6 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: l Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation o other legal entity,or any two.or more of the foregoing engaged in a joint enterprise,and including the legal representa'ves of a deceased employer,or the receiver or,trustee of an individual,partnership, association or other legal entity employing employees. However the owner of welling house having not more than three apartments and who resi es therein,or the occupant of the dwelling hous oPanother who employs persons to do maintenance,constructi or repair work on such dwelling house or on the groan or building appurtenant thereto shall not because of such a loyment be deemed to bean employer." MGL chapter 152, §, 5C(6)also states that"every state or local licensing a eney shall withhold the issuance or renewal of a license o permit to'operate a business or to construct buil ngs in the commonwealth for any applicant who has not foduced.acceptable evidence of compliance wit the insurance coverage required." Additionally,MGL ehapte 152, §25C(7 )states"Neither the commonweal nor any of its political subdivisions shall enter into any contract for.the.,performance of public work until acceptabl evidence of compliance with the insurance requirements of this chapter have been presented'to the contracting autho -ty," Applicants Please fill out the workers'compens 'on affidavit completely,b checking the boxes that apply to your situation and,if necessary,supply sub-contiactor(s)n e(s),address(es)and ph a number(s)along with their certificate(s)of insurance. Limited Liability Companies LC)or Limited L' ility Partnerships(LLP)with no employees other than the members or partners,are not required to c workers' co ensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised at this affid t may be submitted to the Departr<ient of Industrial Accidents for confirmation of insurance cover a'e. Also a sure to sign and date the affidavit. -The affidavit should be returned to the city or town that the applicatio for permit or license is being requested,not the Department of Industrial Accidents. Should you have any questio garding the law or if you are required to obtain a workers' compensation policy,please call the Department at number listed below. Self-insured companies should enter their self-insurance license number on the appropriate lin . City or Town Officials Please be sure that the af)ee is complete* ted legibl The Department has provided a space at the bottom of the affidavit for you tot in the event th Office of Inves i ations has to contact you regarding the applicant. Please be sure to fill in thit/license num er which will be us as a reference number. In addition, an applicant that must submit multiplit/license app ' ations in any given ye ,need only submit one affidavit indicating current policy information(if ney)and under Job Site Address"the app ' ant should write"all locations in (city or town)."A copy of the af that has b n officially stamped or marke by the city or town may be provided to the applicant as proof that a ffidavit' on file for future permits or licens . A new affidavit must be filled out each year.where a home ownitize obtaining a license or permit not rela d to any business or commercial venture (i.e. a dog license or per ' eaves-etc.)said person is NOT required to omplete this affidavit. The Office of Investigatiuld like to thank you in advance for your cooperate and should you have any questions, please do not hesitate tos a call. The Department's addre s,telephone-and fax number:. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washingtoxi Street Boston, MA 42111 Tel.#617-727-4.904 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.go-vldia El° Town-of Barnstable R.egullatory Services sAxrisrAB Thomas F.Geller,Director 9 MASS. fb p� M � B1iRding Division MA Tom Perry,Building Commissioner 200 Main Street, Hyannis,Na 02601 Office; 509-862-4038 Fax: 508-790-6230 Permit no. Date ' AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: A—) e w Estimated Cost ,kddress of Work: Owner's Name; 6 Date of Application: ` 0)- 6 I hereby certify that' Registration is not required for the following reason(s): ❑Work excluded by law ❑lob Under$1,000 QBuildmg not owner-occupied ❑Owner pulling ownpermit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS T'O THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES.OF PERJURY I hereby apply r a permit as the agent of the owe. Date Contractor Name Registration No. OR Date Owner's Name Q:f=ms:homeLffidav 3 - �64�►ss� .L.Qr 39 jb._�o► �-� _ J I i- 3-7 14 , t . i (�u T P C�5T L hN' CERTIFIED PLOT PLAIN , al L07#3� L)u T POaT LIZNE CJ_N1rx�tVf4LFw cONBTRucTION ONLY : # .SOP 91�..FOUNDATION IS'7,G FEET IN W. LOW POINT OF ADJACENT Is ' A •` SCALE_ DATE_Feb ty ' �NQIII�V�'ERIN� CO.IN S 4�t 1 CERTIFY THAT THE ,. CLIENTS SHOWN ON THIS PLAN IS LOCATE 51 RSTEREO . 4' JOB NO. 9oa4 ON THE GROUND AS INDICAM, O # f�. LAND CONFORMS TO THE 20"ING uNEW Al' MEE $URYEYOR DR:BYi ., `.D� OF BARNSTJABL , MSS e.y i A 4 '. = ��Tt'e �lAtNST. COO.by, _. ._ l•7 f - , .- j - � ASS,. SHEET O.F� RV. #! - --. ' d SV�rd , - ns an Board of Building R ervisor License ConstructionSuCS 74205 License,, 311195ro Tr# g128 ~`��3112008 AG Expt rat►o�n 1�, L, Re$t-ict►on,, __... L DADMUN ,�' DApDOND STREET `_{r^, Commissioner. 51 WEST DENNIS,MA 02670...- ✓/ze �omvnwouueczll� o�../�aoaczctivaella Board of Building.Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 128718 One Ashburton Place Rm 1301 Expiration' 5/9/2009 Tr# 129197 Boston,Ma.02108 Type: DBA, D.L. DADMUN-CUSTOM BUILDERS DAVID DADMUN 51 POND ST Not valid without signature W. DENNIS,MA 02670 Administrator o CERTIFICATECP j� �+ w � � OF LIABILI iT Y INSURANCECD DATE(MM/ODIYYTY) auceR 04/12/2007 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION slack&tone Insurance& FinamcW Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 79 Water Street HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Worcester, MA 01604 ALTER THE COVERAGE AFFORnE®!BY THE POLICIES S LOW. INSURED INSURER3 AFFORDING COVERAGE NAIC 0 ` WSURER A, AIG DL. Dadmun Custom Builders 191A Main Street INSURER a: West Dennis,MA 02670 INSURER C: INSURER D: I.NSURF.R E: COVERAGES THE POLICIES OF INSJP,ANCL LISTED BELOW HAVE BEEN 1$$UEO TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W MAY BE ISSUED OR MAY ITH RESPECT TO WHICH THIS CERTIFICATE PERTAIN, HE INSURANCE ApFORDEp BY 7Hts pOLlCIE8 DESCRIBED HEREIN 3 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITION$OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED SY PAID CLAIMS. LTR INe�p TYPE OF INSURANCE POLICY NUMBER DA E IY iGENERAL LIABILITY A E ! LIMITS COMMERCIAL,GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE ® OCCUR I - PPEM E r� G a •Utg ICI S MED EXP(Any one persar,) g j PERSONAL A ADV INJURY S uEM L AGGREGATE LIMIT APPLIFg PER: GENERAL AGGREGATE $ Y POLICY 17PROJECTEILOd. PROCUCTS-COMPIOPAGG $ AUTOMOBILE LIABILITY ANY AUTO I COMOINED SINGLE LIMIT I(Ee Aa�1t!ent} $ ALL OWNEC AUTOS SCHEDULEOALITOS BODILY INJURY �— (Per person) $ HIRED AUTOS NON-OWNED AUTOS BODILY INJURY 'Peraftdmot) _ PROPERTY DAMAGE (Per acwdent? GARAGE LIABILITY ANY AUTO AUTO ONLY.A Ar,CIDENT a OTHER THAN EA ACC $ ExcES'i/UM9RElL4 LIABILITYAUTO ONLY: AGO S OCCUR ❑ CLAIMS MADE EACH OCCURR.9,NCE S AGGREGATE g DEDUCTIBLE S pETENTiON S S MANDKQRS COMPENSATo $ OYErlS'LIABILITY ✓ TORT LIMU-Ts Ea ER- A ANY PROPRIETOR/PARTNERIEXECUTIVE WC1764567 12/1212006 12/1+21;eOU' - OyyFggFICERIMEMSEREXCLUDED? El 5 t0U,000 SPF_e�iA�LPROVISOrN9Delbx JZ-�121ESEAft ASE•Fa,EMPLC'fEF 3 100.000 OTHER E POLICY uMI7 3 .00106 v CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE EXPIRATION 200 Main Street DATE T.EREOP,THE ISSUING INSURER WILL ENDEAVOR TO N.AIL TJ GAYS WRITTEN Hyannis, PJIH 02601 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE UFr,BUT FAILURE 70 Do SO$HALL IMPOSE NO OBLIGAtigN OR LIABILITY OF ANY KIND URoN THE;INSURER,ITS AGENTS OR REPRESENTATIVES, AUTNORIiEO REPREBENTAfIVE AC ORD 26(2001=) r 1 W)ACORD CORPORATION 1988 From: 08/22/2007 09:18 #235 P.001/001 bep iy ub Ub:uip p. 1 Town of Barnstable. t Regulatory Services Thou It.comer,n reefer is"' Building Division* ToinTaTy, 8mlding Caamrds*aer 200 Mda Street Hyaoais,M&02601 wwvr ta�n.barastabkxuLus Office: Sog-8624038 XRX: SOS 790-4230 " Property Owner Must Complete and Sign,This Section If Using A Builder I, •._, O N Q CN AVE S ,as'Owner of the subject PmPcmy he=bya=ha6w AVM NhA4 L/Aj to ect 0a=aybehalf, in all =Iz&e to work aui&wized by this building P=ak ap*ation for. . 17 CcITD`1ST LANE• -&-yTfieVial (Address of job) —Z," b ofCNMJ Daix Prim N&= �.� a )-r- L SO Wa o Pala JL Jam1- z<10 �r IN Li 1f tH rr *.I-J f��r vT V d mod{ I "t uu.. y 1 ? { i 1 i f,U. . - I.\I I b ai r! `R$3't lst l Y YR + , Z 1 (,4 J,R Y r - - j-, d # F a r- S ?l v a _ .t r 34,, 1§ �1 rat r{Rk ti i d r t'' .�^ t� `y1 ' l. ll f r1. i �' • xc i v 5 kli5 slYii -- Yd_ r + 9 7 t :.1 1 I S(yy,� 5 .''W""" 1,.��" f 1'k [ �h�'p Y}g '4 5 _ t t `t - .i. y j rf S'`a,. ' _,I O•r , "' 1 ',• , )2 f - v _.�..:4i�I..,,��,. w r /p� s . I Iq".�;3..,I'\I_I �i',�.�"�":1.- ItI ��' ��+ ►�6µ45, i i 1 h T !i ii e `it i . - - r R 1. d r� ., e ! t " -I 4 r "'O �' 1'I + /1 ^. /. 3 j h e l ` b ., f a � i f - ,b IR } iF f1 d �f ! H. f Rl. R7 y ry, Z Rt d >1 t #�„-f s �,� t ti - t .4. f r, t �Yl �. e "� v ,"'I `+Sk4t+..ryfe nS * r,, { xi + �.w `i 3 - + L �i r :1 4 1 y } 1 �+ '9�5y S $ r `� L r' 1. T ' t@ do d ��;. 1 M+ A e r I— - 7-i- _ e i,', r dl t,fi S15 �- .`..3 t�.lt t - 2 ;: Y r;t , �F r .� rf-7 a 1 i _ _ ° i i � J-y A : f k - 111��' b t� t4 y r - .'rP F .4 tilt D �1 '' i dl h }} j" S > ; l '. kr p K ' Z I .I r .,,. 4 l - a c 1 f . i l a !� } ft {�� q.J V A; - R' fjt }tt a C Sf rj.i - :. '-: { IJ _ n' 3, ", . — . (�° '* ®�r '�� F'R s 4 r a 4 of � - $ 1, 1 T � ? - ! a a 1 P 1 5 � x 1 , T i 4 u_', k r + I n ' .. 3 h CERTIFIED PLOT PLA s�� �43y� 4 IRL r H f, } l!t _- t 4 }1 +w La 3� r ��N tiay� r ryas '[ !►CTION ONLY t '. IN -- -+I . � JI ,tMUNDAT10N° IS J p FEET t I ` ,,i*X POINT OF ADJACENT' SAigh,81AA + ` As o +', J ^ DATE= k++ : .. SCALE= =30 dab lY: A A.' ),. .ki Yt, CLI ' E` RlNO :lJfl I CERTIFY THAT THEr , 4 - ENT b, SHOVIN ON THIS PLAN IS 040 w��V' 141�. :. 090TERED roams ON. T!!E 6RO D A 19!' w -"-. "'.'f s r: .�YL A ND. - �- - C OPFESR a8 TO T ME _::Z�R6Q _ �� a ETOR DR.8Y9 � ._ pF :e�ARNST t$L 4 �Il ,:'.. � $� $HiE�T...t,. � ©ATr..:, g, .F � a r '' v_ a e �n fir t:.. k v a k r. - �a `.: ° L,, L i,; ih y.-r.. �. .'�N '{Lt tr '�'rtt t'i A` ( Y {Y ��. a r.A::.1ti .# _: � 4 Town of Barnstable *Permit#�1 9 O °4 Fxpires 6 months from issue date egulatory Services .:.. :.Fee-.: ?=R.5 Tliomas:F.Geiler,Director, ....—.-Building Division- .,I - � ��M T • .. . -• "-' -'• ''•Tom Perry, Buckling Commissioner X.p a " .200 Main•Street,• Hyannis,Na 02601--•-• MAY 1 7 2005 Office: 508-862-4038 _ ....... . . . .. Fax:'508-79'0-6236 _, �T.� B,ARi�1STi4BLE _ -• -EXPSSER1GI[T. '1�T;IC•A:'TTON = RESID�NTL�tL� Not VaUd withoutRed X Press Imprint Mapiparcel Number l property Address 1 �� tial Value of Work " en Mincmum fee of$25.00 for work under$6000.00 Owner's Name&Address ,�C `{� � Y �J if\ � Contractor's Name U 7Telephone Numbe Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkman'8 C mpensationInsurance e one: 1 am a sole proprietor, �] I ar`gthe Homeowner o Worker's Compensation-Insurance --}' Insurance Company Name ` e' � `A••s 4-0(1 Workman s Comp.Policy# rn Copy of Insurance Compliance Certcficate must be on file. Ln Permit Request(check box) e-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof] 0.Re-side Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town.departrnent regulations,i.e.historic,Conservation,etc. ***Note: property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature Q:Forums:expmtrg Revise063004 • a •-- The Commonwealth of Massachusetts - Department of Industrial Accidents Office oflnuesugatlons 600 Washington Street, e Floor -- s Boston,Mass. 02111 Workers'Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors 3e # • C name: U VA IYUSIVU dMA address sty �QWICX/t� state: zip• ghone# JLJO � work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I'am a sole proprietor and have no one working in any capacity. � ❑Building Addition ❑ I am an em toyer prov4 LworkerscompSns4iqn for my employees working on this job. t.. s b •<yw $ .r• tp s. `�<4 'C.Q�'it.Y..��ln i'..a'�,.[ a�.�1.u..>•c7P'1'i.!"'[rd..< �� a.t°•:5°;'risTf�}'�.k:ii.w d ). a•- r s h ?`.i~'. '�;'• < ;t�. y:ti' t#'!' ar;, 's aut' ,� t e y+. ,.,. � �...�}R J �- •4 f(.pz'�'r,,Sv�a4.'���ws�daastx'�t, .e'�`g �-!� ? '�1+��i"cN� �..i�+'dl,{.r y�'t ti:4 Pr't5'. ��y# �i.. S , sf r r� � �i� ..4 ' q. k'� a }i b.. y yb, a x,a•:-L"��' P''.' G i ,�"y•-f EiY - v12�$M''.tr w't } r� F'� +�}a?k = 'r, t :a`ddFess � ti�-E to-.<•,� ��s x .�};trr M y a > ,a'. :e r t v t <''.:,x r. Y 2- i.G +Z�"k 4''jaYt 'itY. 3�'•+,"�'f"r;' t}r .I t 4:' MJ.ef,G._' f�e•A ) „�+4`.. A u5' 4'+'r .LM�•. F -•FP pv'.,� jg :!r �?t�l„��r q`�`''�,1 c=ck"�c �: �e �y��.", s•. �,i' '�4' P + A:'tLdfi'��r'`ua"+i 'rr r r� ,'�' fi o _ sr � t %o. e1z +v'• o.'i '�b S`�tPr bF'y 4F•T'+Ys',ktt" k�¢ 3'IK �F�f3'r D '.+d lc ro!ieti• y 0. t e ^ `nx;,�, ♦ 'r(sE!",g. `,' a "+K.�s`rr�4 •ui'tri�f•3Y3.a 4yf#, 7 ,t;-p VK : �.(.'sFh�'_• .a4e4�'S", r.•f+ ,. t "f":X<, ,.M:.k�\s_ -^• .�. t i. _ am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have e following workers' compensation polices: _ •.. ...... .... :.... .:...x,..,r...:•.::..n -:...: .,.. ..i..r .ea,•....,'H'.._. }. .::_ wr' y:;:. ,,•ns 4.Ry� <n•+ ":a. .'tG'l'<+''.rlTini:"��,{^!:'if'•#'7`d'>,�?!?.uM1^.T�3��;h .,�F y�.�'!'- �, }>� } , e`} tr '4. 'v'.�s.'�{' _•'.., i g G �� �3 gCF.M- ant tl$7n8« ei r / ✓.'_ f:7ny'4A address.. _ ;t"l6 � A � r +•'t r ey 'r1 d" f'a"Y:.. �.�. .r tr f ' +. ..4.e..•.::' .t. ..v. ..: ...:. • ...! :.:..::..:..:.Y:i'i•'v: A:: Qlleh#i'. artsuratireeCore. ...:s:.. :..�.., .we�:x;'. ss«•,_...[ <as,;`'.�:,.. ',r.,,`lt.,a ,....[�r..>�.....,.: Q�C tt<:r " s ,;, 5+ - i+. 3 r s r . ?R •3 t.•1 ctSmuBnv'nii�rt'e. - — r l Y'•u .. �� � .f •: r �� � � '�G 1 j ! s• t 2 � � F+,.: e,sl a Ihl one;#.:: - h .� a: ✓ ti- ]ti'Sltl'anCg'e0 ,�. , e Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civic penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA'for coverage verification. I do h cerhjy un r t pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name ' Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license#� (]Building Department' CILicensing Board: ❑check if immediate response is required y ❑Selectmen's Office c C3Healtb Department contact person: phone#; ❑Other (revised Sept 3003) - - Information and In tructions Massachusetts General Laws chapter 152 section 25 requires all a loyers to provide workers'compensation for their employees. As quoted from the"law", an employee is defined as a ery person in the service of another under any contract of hire,express or implied,oral or written. An e ployer is defined as an individual,partnership,association,c rporation or other legal entity,or any two or more of the for going engaged in a joint enterprise, and including the legal epresentatives of a deceased employer,or the receiver or truste of an individual,partnership,association or other legal e tity,employing employees. However the owner of a . dwelling h use having not more than three apartments and who re ides therein,or the occupant of the dwelling house of another who loys persons to do maintenance,construction or epair work on such dwelling house or on the grounds or building app nant thereto shall not because of such emplo ent be deemed to be an employer. MGL chapter 152 sec 'on 25 also states that every state or loc licensing agency shall withhold the issuance or renewal of a license or ermit to operate a business or to c struct buildings in the commonwealth for any applicant who has not p duced acceptable evidence of co pliance with the insurance coverage required. Additionally,neither the co onwealth nor any of its politic subdivisions shall enter into any contract for the performance of public work '1 acceptable evidence of co pliance with the insurance requirements of this chapter have been presented to the contractin uthority. Applicants Please fill in the workers' compensation affid 't com letely,by checking the box that applies to your situation. Please supply company name,address and phone numbe al ng with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents or confirmation of insurance-coverage. Also be sure to sign and date the affidavit. The affidavit should be returne to a city or town that the application for the permit or license is being requested,not the Department of Industrial ccide Should you have any questions regarding the"law"or if you are required to obtain a workers' compensatio policy, ase call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete d printed legibly. The Xcoct rovided a space at the bottom of the affidavit for you to fill out in the event e Office of Investigationu regarding the applicant. Please be sure to fill in the permit/license numbe which will be used as a rehe affidavits may be returned to the Department by mail or FAX unless oer arrangements have beenThe Office of Investigations would like to thank you in advance for yd shoul you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number:. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406 Board of Building Regula 'ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 134313 Type: DBA Expiration: 10/24/2005 DAVID SAWYER CONSTRUCTION DAVID SAWYER' _ 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. Address [:] Renewal Employment r,i Lost Card 71. �o�x�xo�uuect��a if/ a¢c/tcaek2 _ Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 134313 One Ashburton place Rm 1301 Y Expiration: i0124=5 Boston,Ma.02108 Type: DBA DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. �„ , ui _ SANDWICH.MA 02563 Administrator Not v witV6ut signature i WORKERS COMPENSATION AND 101FRI" EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-801 4A88-A-04) RENEWAL OF (6KUB-8014A88-A-03) INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1. INSURED: PRODUCER: SAWYER, DAVID R KERRY INS AGCY INC 318 MEIGGS BACKUS ROAD PO BOX 1945 SANDWICH MA 02563 NORTH EASTHAM MA 02651 Insured is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-28-04 to 08-28-05 12;.01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 i= l� D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy Aill:be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 08-27-04 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: KERRY INS AGCY INC 28SHB ooaae5 ` David Sawyer Construction 318 Meiggs Backus Road Sandwich, MA 02563 (508)-539-1992 Proposal Submitted To: Work Place: 4-11-05 Steve Garcia 17 outpost Ln Centerville, ma02632 ------- ----------------------------------------- ---------------------------------- Strip, Remove, and Haul Away all old roof shingles. SUPPLY&INSTALL: Landmark 30yr"AR"Architect Shingle Color: fANT- )4 ??? Renail plywood as needed White aluminum Drip Edge Ice & Water Barrier on all edges of roof GAF Shinglemate Underlaynment Paper Sysytem GAF Cobra Ridge Vent New Pipe Flange CLEANc' REMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLETED. ALL DEBRIS TO LANDFILL. TOTAL INVESTMENT FOR MATERIAL&LABOR$ 5,075.00 All material is guaranteed to be as specified, and the above work to be performed in accordance with the specifications submitted for the above work and completed in a substantial workmanlike manner. Payment as follows % now& %na,completion. Any alteration or deviation from the work specifications involving extra costs will be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. 10YEAR LABOR WARRANTY/PLUS MANUFACTURES SHINGLE WARRANTY. NOTE-This proposal may be withdrawn by us if not accepted with 30 days. Respectfully submitted David R Sawver ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. Date Signature TOWN OF BARNSTABLE BUILDING'PERMIT APPLICATION' ITIP Map �� Parcel .]< � �J S, INSTALLED,IN �'Bf�PLI `emit# WITH TITLES Health Division ENVIRONMENTAL CODE Abtee)lssued Conservation Division Nee ;00 Tax Collector �..5'c Y, Treasurer Planning Dept: �. r Date Definitive Plan Approved by Planning Board 4 Historic-OKH' Preservation/Hyannis (vary= I �Rssd �t G/a3 �/1 i . t a Project Street Address 0 CCU7 L. �. :-10 38 ) F�f • Y Village Owner l✓ tA AgjSUress - 1,��j 11Vb4' W00� ? Iv"` Telephone Permit Request �'��LL;w � ✓ �"�/�-v�c�r' 4 1=12Uvi,{ t Square feet: 1 st floor:existing proposed 2nd floor:existing proposed' Total new Estimated Project Cost 7 Zoning District Flood Plain Groundwater Overlay ' Construction Type ' Lot'Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House' O Yes O No r . On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) t Basement Unfinished Area(sq.ft) Number of Baths: Full: existing -new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count ,Heat Type and Fuel: ❑Gas O Oil ❑ Electric ❑Other Central Air: '❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:' ❑Yes ..❑No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing- ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes' ❑No If yes,site plan review# :Current Use Proposed Use BUILDER INFORMATION i c Name C 4 F/I.>7 h Telephone Number -?) 70 G-OG 937 Address �Z 1Z\vim Si License# ° b� 7- 1 Home Improvement Contractor# 1 2 q FS 7 ' Worker's Compensation# ` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6�A WA1 Sa SIGNATURE . A d DATE BUD I - -FOR OFFICIAL-USE ONLY PERMIT NO. - DATE ISSUED .. MAP/PARCEL NO. ADDRESS . ' •4 VIL•'LAGE a _- OWNER _ I t DATE OF INSPECTION;: FOUNDATION - FRAME t INSULATION • r ` .,. -- FIREPLACE',. ELECTRICAL: t ROUGH FINAL PLUMBING: ROUGH •FINAL ` GAS: f ROUGH •FINAL FINAL BUILDING; DATE CLOSED OUT ASSOCIATION PLAN NO. s p TOWN OF BARNSTABLE Permit No. ---------- Building Inspector Cash 10 �Yl fie• ---------------------- 1619. 6 YPYk. OCCUPANCY PERMIT Bond ----__ ------- No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ...................................................... 19...... _ ........................................................................................................._ Building Inspector Assessor's map, and lot number ... ............................... THE Sewage Permit number ....... .. .........4.....................I............... SEPTIC SYSTEM M �7 INSTALLED IN COMP .................................................... House number ......11.14. WITH TITLE 5 1639. ENVIRONMENTAL CODE �EOYaYa TOWN 'OF BARNSTVftLpf,',II.ATIOP,,',C; . BVILDING , INSPECTOR C- APPLICATION FOR PERMIT TO ......... el............... TYPE OF CONSTRUCTION ........ f.......... ...................................................................... TO THE INSPECTOR OF BUILDINGS: The undersignedh7eeby applies for a permit according to the ;allowing information: Location .)........WzV...............It .". . ........................I � '0 00 ...........Proposed Use ... 11'eu. 40�-V-.C,01.................................................................................................. Zoning District ..........X— ................................................Fire'District .................... Nameof Owner .4.................. 4..........Address .......................................... Name of Builder .. ... .... . ...... ..... ......... . .................Address ........... ...... 472*'qS�., Name of Architect ........ .. ........Address .................. Number of Rooms ............. ..............................................Foundation ........ Exleriormxl�/,e�.6a ........ ......Roofing ............................ Floors k.4141i�:.414-e ........................Interior VA -o"4'r .. ............ ;00, Heating ........ ............................................Plumbing .... ........... Fireplace Cost ..........................................y -Approximate C( ..... Definitive Plan Approved by Planning Board ------- -----------19--------- - Area ............. ..... .. ... .... Diagram of Lot and Building with Dimensions Fee p ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH J G X1 :A Ito . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the ab ve construction. Name ............ ... .. ..... ............ MOE, MR. & MRS . a ,A.. No 22$ 4 • Permit for ..Q.ae...$.tw y..... Single Family Dwelling Location Lot ,#_38�:13 Outpost Lane M ,. Centerville } -u ' ................s. ..................... , ....................... , ........ Owner Mr.'....&..Mrs......Moe....:..... t r ' Type of Construction ..Frame........................... A f � r .. .. ........................................................... ......... ; Plot .......................... Lot ................................ r Permit Granted ..,.,,,March 2, 19 81 , Date of Inspection / 4.:... )9 j Date Completed ... ...;.;. PERMIT REFUSED .. . ... z. .................................... 19 t ? M > .. - ........ .��.f?1i. .................................................... ....... . .� ............................................. 4' , a •i ApproveedS ........................................:..... 19 - - .. , r tr ..r...�.e..��af �`� t s z b ti It / t t /,. I.'tZf" �jz r f \r r 4 e - +e _'ll� J+�./- «_ i v 1 , i i�t t ��rL ' .rt, l+ _a�}� , ri ti. s arsc r I.�i , r .j_I j t,. 1. -' d- xi_ -., .:}ir''�s an,, r x` . r•$j k;Pt' ""*^.. � ' jr�+ y."'e t l,ir."* - - ...�"t . } "r ,, I. 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