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TOWN OF BA ABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 6 �c� C � NUMBERR STREET- VILLAGE Owner's Name: C t Phone Number Email Address: Cell Phone Number 6l�. M0 6 Project cost$ Check one Residential �_ Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize �t,e to make application for a building permit in accordance with 780 CMR Owner Signature: --Date: ? l 1,p ( S TYPE OF WORK ❑ Siding ❑ Windows (no header change)# Insulation/Weatherization ❑ 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 C N(d CONTRACTOR'S INFORMATION Mike McCarthy Construction Contractor's name PO Box 5 West°Dennis, MA 02670 Home Improvement Contractors.Registration(if applicable)#• ` opy) CSL-58633 HIC-169393 Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY11S 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 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-d:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. t 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 43��PgANTtS SIGNATURE Signature Date /3-/ f All permit applic ons are subject to a building official's approval prior to issuance. coif g'62 00a1 Permit Authorization mass save Form 84, e 3D enerW ciTkioncy Site ID: 3815849 Customer: Carol Broadhurst ro the of property owner located at: P (Owner's Name,printed) 88 Stoney Cliff Rd Centerville, MA 02632 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: V I 1 a0000aoaouaoo+aco+a000aa�a��ar�ar�so�ao�,�aooaa�s�ats�+e�a���aaoarroa+���a���as�� FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participate g Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: Page 1 of 1 ForOfficeUseOnfy Permit Authorization as save Form cc-t I-Z0o Ste` G 10 �-3�- Site ID: 3843760 Customer: Trudy Sinn i I, I ('1)A„ S j A. ,owner of the property located at: (Owner's Name,primed) 161 Kettle Hole Road West Barnstable,.MA 02668 (Property.Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor.listed'. below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Dates atsQ+<aaoac��+aes�o���oa�srs�soc�oaooa�a�cooaaa�ao�ao+�oao��aoao�s�a+�rs��►�000ara�a FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating.Contractor Date; Name: RISE Engineering Phone: 401-784-3760 Email Page.1 of 1 For Office'Usz Only. �� • � .J�Pi C��/iY���?iL'C%�P�CI"G�����,/���G2��,v�C�i�L'Gc�P�� Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Individual MICHAEL MCCARTHY `} Registration: 169393 P.O.BOX 52 Expiration: 06/15/2021 WEST DENNIS,MA 02670 ' l :t Y - L - Update Address and Return Card. SCA 1 is 200M--05/11177 /lP.. U'O/J%1J24/21lJPO,/,C11.OJZ✓ZIJOJiO,C/UGSP��.J . Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Reaistation Expiration Office of Consumer Affairs and Business Regulation 6993= 06/15/2021 1000 Washington Street -.Suite 710 MICHAEL MCGARTI-5 Boston,MA,0211.8 ,� J 5= I ; • � t MICHAEL F.MCCgRT1� — 6RANGLEYLN. , ' � �•lf SOUTH DENNIS,MA 02860 Undersecretary : Not valtdv+iithout signature =- rhrtaonweaith of Me ssac wsetts i)I f Buil of Professional Licensure Board of Bwifdinge9!llatlons and Sfandards Michael� by y Co>nslifo!>t Canslerty; ,vir CS:=p88633=064. ` '0et~dills Q�GM11 Fiber' � I Mae t 3lF�d tarofAkmad 2041 M CH/�i.J C*k PO ROX42 VMS DENNIS 04�elOtet->ldsa ; :� NATIONAL F18BR Mot tgl�tdastembwad •..-wc.�.rw.......... wim- - iAlCommissioner A OSHA 00�.55712 U.&Department of tabor Oawpation0tatey am Heallh"AdmUdstratim M. lchael McCarthy. :.. .. : ' !gas,at+�ooeesfi�yceteeaio+auroea,psttonarsatcry��ite�rii �'+ �S ;aG� �� ' Poll Ttahiktg C6u�e fn Cetus@ -�� " &Health. 32tiwtsbft�t6ne�eluursofgel��ti� k ' The Commonwealth ofMassaehusetts _ Department of Indzistrial.Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Mrorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMr=G AUTHORITY. Applicant Information Please Print Le ibly Name{Business/Organizadon/lndividual): Nfichnel McCarthv. Address: PO Box 52 026 City/State/Zip: �es� rpnii� Are you an employer?Check the appropriate box: Type of project(iequired)' 1.Q I am a employer with I-- employees(full and/orpan-time).+ 7. D New construction 2.❑I am a.tole proprietor of partnership and have no employees working for mein S. Remodeling any capacity.[No workers'comp.insurance required.]. 3.�I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. ❑Demolition 10 0 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.O 1 am,a general contractor and I have hired the subcontractors listed on the attached sheet. 13❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t . p 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other ::r✓,),j),Jk•1 152,§1(4).and we have no 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 Homeowners 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 subcontractors and state whether or not those entities have ' employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that isprovidingiporkers'compensation insurance for my employees. Below is the policy andjob site information: 11 Insurance Company Name: ` `ST►'on� i....i cI ;1 i 4, k Tr c Policy#or Self-ins.Lie.#: Expiration Date:_ 1'.)- ►��I�j 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 MGL c.152,§25A is a criminal violation punishabla by•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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and t e ins enaldes of perjury that the information provided above is true and correct. Signature: Date: I�-��f�I F Phone#: St k) TC b 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 Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,Map % Parcel Application #2,01 Health Division Date Issued Conservation Division Application Fee 1 5-0 VOV Planning Dept. Permit Fee •�� Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Addresses Village_ c ��,� Owner Address Telephone Permit Request ��.�.-�...�� Z a�: r,•.� '. 1 •- la•.c`lt, y-►» s.- x ,� �L.� E.- �r�. U,• v► �. C 1=�.` y L O SE Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation .moo no Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, aftach4!s pportin documentation. Dwelling Type: Single Family 9 Two Family ❑ Multi-Family (# units) �•. Age of Existing Structure \mice-A Historic House: ❑Yes ❑ No On Old King'&Highway. ❑Ye's ❑ No r Y Basement Type: Jtull ❑ Crawl ❑Walkout ❑ Other , Y Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Fri Number of Baths: Full: existing Z new Half: existing new Number of Bedrooms: 3 existing —new Total Room Count (not including baths): existing -4 new First Floor Room Count Heat Type and Fuel: C�"Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number so% - Address License ## Home Improvement Contractor# \A\ zs-k Email Worker's Compensation # �o Z ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE C/" '`�J� DATE � d FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER ' DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f Board Hush n Resguiatiotns'ard$tan araix: ctitmrurtiott, 0"r pil. tt� t ass•CSSL,-102778 �. CONOR D m SUSictox ,SA6AM 6 �pn t goner OW19t2tN8';. . OfTiee of Consbmer AfTairs&FBnsiness R gulst oo��l� License or registradon valid for individul use only` ME IMPROVEMENT CONTRACTO before the expiration"date If found return to: SLN sMftn: 171251 Type: Office of Consumer Affairs and Buslness Regulation ws� xp; iration: :'31112t)i6.:,. Rart flip= 1Q Park Ftaza-;Suite 57t}: Boston,MA 02t1b CON-SERVE ENERGY CON.O MCINERNEY 376 ROUTE 130 SUITE G SANDWfCH,MA 02563 ` unckrsec itsry - Not valid without signature 1: 1. l i ti s# is Kcr=.wM i a IIYC Wn rwuu&&CK arlu I nc.lim ILu-IL s 1 G'nuLUMK: ._.. .. . .... .. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.If.SUBROGATION IS WAIVED,subject to the terms and cbndidons'of the policy,certain policies may require an-endorsement.A.statement on this Certificate does not confer rights to the tertificate holder In lieu of such endorsements .. PRODUCER CONTACT NAME..:. CSBSIWORKCOMPONE PHONE FAx AIC,No,Exl: AM,No); - PO BOX 946580 EMAIL nooREss: Maitland,FL 32784-6680 INSURERS AFFORDING COVERAGE NAIC 1.877-724 2669 Continental.Casuap_,�Com n 20443 1, INSURER A: � pa Y INSURED INSURER 8: CONSERVISION ENERGY INSURER Cc 376 ROUTE 130 INSURER D SUITE C INSURER:Et SANDWICH,MA 02663 INSURER F>. 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 L;POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OFL ANY CONTRACT OR rOTHER DOCUMENT WITH RESPECT TO :WHICH:THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE :AFFORDED BY THE POL'CIESr DESCRIBED HEREIN IS. SUBJECT TO ALL THE TERMS, . EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAIMS; a18R DDL JMR POLICY EFF "POLICY EXP - -- LTR TYPE OF INSURANCE' RaR POUCY NUMBE MIDO M/D LIMITS.. ..: A Y' 6611:316335, 03l11 H 5 03111/16 GENERAL LIABILITY EACH OCCURRENCE : 1'QQQ QQQ . 'r)AMADETORENTED - COMMERCIAL GENERAL LIABILITY ;,SOO OOO vREdlses IEe'ocaoenm: CLAIMS-MADE OCCUR MED EXP(Airy Ma pe$a� _ 1O OOO PERSONAL A AOV INJURY $ 1000 OOO GENERAL AGGREGATE _ 2.000.000 . GENT AGGREGATE LIMIT APPLIES PER: kODUCTS-CCMPIOP AGO E:1.000 000 POLICY JEECCT 1^1:LOC 11 cOMeIEOSINGLELIMIT A AUTOMOBILE LIABILITY 3 11 311/16 (Ea aWdent);, 3 1,00000 ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTOS AUTOS: BODILY UVJIIRY(PeraWdant) ..: . `, .. .. NON owNED PROPERTY`DAMAGE HIRED AUTOS /� AUTOS (Per acddeM) q UMBRELLA LULB X occuR 601131636 : 03191/16 03/11l,16. . EACH OCCURRENCE Z 000 000 EXCESS CLAIMS-MADE AGGREGATE _ OLIO QOO DEIDIXI RETENTION$Ill,060WOFUMM _ A. ERLv+sumN Yrt+ 60.11316349 03111/15 03/11/16 X TaRYuiurrs ER ANY PROPRETORIPARTNER1E)SOU IVE .(FflCERA EMBER EXCLUDED?- ,.NIA . �El.EACH ACCIDENT $ 500 o00:.. �011andatoryInNH) :.ELDI5EASE-EAE6IPI.OYEE $�500000< DyesESCRtI desate under POLIY 500 OOOs. DESCRIPTION OF OPERATIONS tielow `. _ _ ` El.DISEASE`- C OMIT OTHER J TORY LIMITS ER E.L.EACH ACCIDENT . - .El:.DISEASE EA EMPLOYEE . _. . ..... ... El.DISEASE=POLICYLIMIT . Dime Certificate Holder Is added as an addltionaQinsured'as Ord ided in the blanket additlonal Insured;endorsement as it pertains to work being.performed by named insured:under wrRten:contra INCLUDES PRIMARY AND:NON-CONRIB TUTORY CERTIFICATE HOLDER CANCELLATION Rise EnBlneeRng SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE' WILL BE :08-PMRM IN 1341`Elmwood Ave ACCORDANCE WITH THEPOLICY PROVISIONS; Cranston,R102910REPRESE P 1488-2010 ACORD CORPORATION.All rigfits reserved. ACORR 25(2010105) The ACORD name and In go.are registered.marks<of ACORD `�� :�, ?'he Com 'orrwealth ajMassachusetts • Pepanment of Induslrfal Acddkti .} 0,�9ce of l�t►►estgad©nt 6 0 Washington Street oston,MA:02111 >vww.massgov/dio Workers' Compensation Insaraace davit: Balders/Contr_actors/Electficians/Plnmbers A lac n fo do PI sts Print L bty Name(Hysinf� 0rPniMdoW1ndivit : Cons rVlsion Energy Inc Address: 378 Route 130 city/state/Zip: SAndwich, MA 02563 Phone. #. .: 508-833-8384 Are you awe Chest the appropr[ate Im s I.Q 1 am a employer with 6 4j t am a general contractor and[ Type°f pr°ject(regnlrcd) errtployeea(Rill and/or part-time).' ve hired the sub-contracto�y 6 .0 New construction 2.❑ I'am a sole proprietor or;partner 1' on tlm attbed sheet. 7. Reatodeling ship and have no employees sub-coattactot9 have 8. ❑Ikrnotiti0 wortcin9 for me is any capacity: loyees and have workers' [No worker'co 9. Buildin comp. insurance c mp.inwanee.i' [� g addudon required:) 5; [� a are a corporation And:;its 18.❑ Et�trtcal rep or:addttions 3.❑ [am a homeowner doing all"work o sera have exercised their I l. Plumb mg repo Puadditiony myself.(No workers'comp. . ti t of eaempdon per M.OL 12. . Roof insurance required.]t c.:154§1(4),and we have no � 1a.❑ t am a homeowner acting`as a :` a dye [No workers' 13.Q Other WeatherizatOn genets!contractor(refer to#4) Amp.insurance:tequ"'+ed J �Y appHtant t4atchecta boa NI muu oleo Rat out the secoiaa be showing their woritas oompwaticaSotieY i6formati� t`Homoownm who n+batit this A idavitindieating they ate doing work and dtea bite outside egnotactas;mnu iContraeooss that check Ws box must adwhw waddiaow sheet sutnnit a stew aflidaviCutdiceting such empioyoar, If the °O*oy�.tbry'mmt vi Y name of toe sand sate ortat dtoae eatuia love zmb�oontractan have Pro Mx*wmtet»'sop.Peiiey:rmmf�r ; on►an crnployrr Neat provPdLrg moochers'canape A lnstrrwnce or lnforon. : I m3'.elOyt , Below b the pods}►and job site Insurance Company Name. CSBSIWORKCOMP NE Policy.0 or Self mL Lie,It 601'1316349 Bxpiratton Date: 3-11-2016 Job Site Address: City/State/Zlp:; Attach a copy of the woriten'compenlattoo policy oa page(Showing the poticyr number and eipUatioo date). Failure ro secure coverage as required under Section 25 of MGL c. l52 can tend to the im itton of criminal fine up to 31,500.00 and/or one- sonmenE,as ell as civil penalties of a of up ro$250.E a day, the violator. Penalties in he form of a STOP WORK ORDER and a fine t a copy of this State-Ink"may be forvmrdsd to the ij.:,A of Investigations of h fo insurance: lion - I do km boy under fp bl an na/tlm o that the�foraeadaw prm�tdtd above is A►r[e and c'ontl+cl.. Phone k F6. eo feted P guy of Totpn. PermlAathofHestl2.Bnlldtag Department:3 CI own Ctertc 4 EfeeMcat inspcetor:SPtnmblog anr >Z Pena0: l Phone!ts i j` q i OWNER AUTHORIZATION FORM owner of property located at hereby auftdze ConserVis on Energy,to act on my behalf to obtain a building permit to perform work on any property. �ate4-za - s� V1, THE TOWN OF BARNSTABLE BARNSTABLE, NAM 1639*ON BUILDING INSPECT- OR APPLICATION FOR PERMIT TO . ............ . ... .. ... ...................... ..... .................. ........... TYPEOF CONSTRUCTION ...... . ............. .... ............ . . . ......... ................................................................. . .. .!" .....................19...6.. ...... .. TO THE INSPECTOR OF BUILDINGS: The undersigned here� ,applies for a per I ac -r g fall in motion . . .. Location ... ......c," . ...... . ....... ............................................ ProposedUse ..... . . ........... ....... ......... .... ............................................................................................................................. Zoning District ........ . ....... .... .... ..... .. ....... ...............Fire District ....................................... . ..... .. .. . ............. Name of Owner .................. .... ... .. .. ........Address .....9..�7............. . ..... . ........................ Nameof Builder ............... ...................................................Address ...................................... ................ Nameof Architect ................... . I . . ... .......................Address ................... ... ........... . ........................................... Number of Rooms /...... ...................................Foundation ..... .. .. ..... .. .................... 440............. .... .... .... Exterior .......... . .. ...... .. ....... .. ............................Roofing ....... .. . ........... ....... ............................................ Floors ....... . .... .... ............. ........ .........................................interior ... ........................... . ................................................. Heating .......... .....................................................................Plumbing .... .... .......... ............................................................ Fireplace ....... ......... .......................................... .......................Approximate- Cost ........ .... . ........4?a 0............................. Difinitive Plan Approved by Planning Board --------------------------------19 Diagram of Lot and Building 'with, Dimensions rri tZ7 0 0 2 (n Vj X -U rT, 0 ter ' t, o 37 ' rri > 0 V11 I hereby agree to conform to all the Rules and Regulations of the Tow B r stab re di g/ bov construction. Name .... ... ..................... .... ........................... ............ 'I Pelchat, Richard I No ,.126lo. Permit for .....add to single ` family dwellin .........................................g �!�IK..................................... Location 88 Stoney Cliff Road Bvc-k ...................... Centerville ............................................................................... Owner Richard Pelchat .................................... ......................... Type of Construction frame ......��: .3: .... Plot Lot ......... ................ Permit Granted t September 8 19 69 Date of Inspection T4.119�� Date Completed 19 ✓ r 5 � PERMIT REFUSED �` + ............................................................................... �,,,��"^'..""",.,.,.__^""^" .................................................................. .......... ............................................................................... ............................................................................... ` 1 pb Approved ................................................ 19 .................... ......................................................... Al'4*s, t1G, �u . 61&3� Town of Barnstable *Permit oY Expires 6 mo hs from iss�ate "(+ Regulatory Services Fee BnRMABM nuea.1639. Thomas F.Geiler,Director �� e H-P PERMIT Building Division 9J1.7 Tom Perry,CBO, Building Commissioner J U N 10 2 0 1 3 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARKOWAKSPERMIT APPLICATION - RESIDENTIAL ONLY �G fj y Map/parcel Number Not Valid without Red X-Press Imprint , l y V`C. Property Address T©vl fL. Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address frzwr i t d ( as� of-6 dd/t y r S Contractor's Name Ci Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) s Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I -the Homeowner have Worker's Comp nsation Insurance Insurance Company Name J Workman's Comp.Policy# �'�(7� (7 7 j 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) ❑ side placement Windows/doors/sliders.U-Value (maximum.35)#of windows /a #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. copy of the Home Improve ontractors License&..Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 060513 1 000�lom0 CARE REE omes Inc. . 239 Huttleston Avenue Fairhaven,Mass 02710 Telephone 508-997-1111 Fax 508-997-1297 Website:www.carefreehome'scompany.com To the Town of Job Address: `t City, State, Zip: owner of the home at the above Customer name location, authorize Care Free Homes;Inc: as my agent to obtain all necessary permits and to perform all home improvements to my home as stated in the accompanying contract and application. Customers name Date The Coannaonwealth of Massachusetts Department of Industrial Accidents r Office of Investigations Con Tess Street Suite 100 Bostota, IAA 02114-2017 www.mass.gov/dia " Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers r AP licant Information - Please Print Leuibly Name(Business/organization/Individual): (dRE•RM HOMES 1K 3 . Address: Fp{N VEN, MA 02719 City/State/Zip: Phone#: Are yo an employer?Check t appropriate box: e� Type of project(required): 1.Are a employer with 4N 4. ❑ I am a general contractor and I ..:. employees(full and/or part-time).* have hired the sub-contractors 6 ❑Ne onstruction .. . 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 emodeling ship and have no employees These sub-contractors have g. 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 officers have exercised their 3.❑ I am a homeowner doing all work 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152 1(4),and we have no 12.0 Roof repairs q ] , § 13.❑ Other employees. [No workers' comp. insurance required.] "Mv applicant that checks box 41 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 i employees. If the sub-contractors have employees,they must provide their workers'comp. p.policy number. I I am an employer that is providing workers compensation insurance far my er1zployees. Below is the policy and job site information. Insurance Company Name: I Policy#or Self-ins.Lic.#: CAI dC 3519 -7 Expiration Date - Job Job Site Add .:. C City/State/Zip: Attach a copy of the workers' comp sation 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 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$250.00 aoyygainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations 26e 91A for insurance coverag tion. I do hereby cer r the and a lt' er jur t/zat the irzfornzatian provided above is true and correct. ;:.. Signature: Date. �:,..... Phone Official use only. Do not write-in this area, to be completed by city or town official City or Town: Permit/License# ' Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other :_ Contact Person: Phone#: _ I Client#:33723 CAREF. .$CORD, CERTIFICATE OF LIABILITY INSURANCE DATE (A o1W Y' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO FLIGHTS UPON.THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMP TANT:K the prtIficate holder Is an ADDITIONALINS ,the pollcy(Iss)must be endorse d.If BUSNO-GATION IS WAIVED,subject to es m the terms and conditions of the policy,certain policiay require an endorsement.A statement on this certificate don not confer rights to the certificate holder in I eu of`such andoree e). PRODUCER Herlihy Insurance Group Inc. NAM: 51 Pullman StreetH E No •508 756-5159 N.); 508.751.5747 Worcester,MA 01606 A°°REas Soo 768-5155 CUST171�R o r DISU s AFFORDING COVERAGE NAIC0 INsuRED INSURER A:Peerless Ins.Comp. Care Free Homes Inc 239 Huttleston Avenue nNIURERe:InterQuard Insurance Company Fairhaven,MA 02719 INSURERc:Safety Indemnity Insurance Comp - INsupac a INSURER E: INSURER F 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 TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCEMIL POLICY NUMBER HbfDD UMITS A GENERAL LIABILITY CEPS929704 /01/2012 09101/201 EACH OCCURRENCE s7 000 000 X COMMERCIAL GENERAL LIABILITY PREl4SES occurrence s100 000 CLAIM9-MADE �OCCUR MED EXP(Any one mom)_ $1 S 000 X Bl1PD Ded:250 PERSONAL&ADV INJURY $1000 000 GENERAL AGGREGATE s2,000 000 GENL AGGREGATE UMIT APPLIES PER: PRODUCTS-COMpwAm 52,000,000 POLICY PRO- LOC. S C AUTOMOBILE LIABILITY 62139 7/07/2012 07ro11201 COMBINED SINGLE LIMIT ANY AUTO 11000,000 ALL OWNED AUTOS BODILY INJURY(Per person) S BODILY INJURY(Per aodderd) S 1 X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PereoddanU i X NON-OWNED AUTOS S UMBRELLA LU4B OCCUR. EACH OCCURRENCE S DICESS LlAB CLAIMS-MADE AGGREGATE :. DEDUCTIBLE S RETENTION a. B woRKEJas COMPENSATN7N CAWC359478 9/01120f 2 09ro11201 X WC STATU. H. AM EMPLOYERS'LIABILITY Y/N 3TORY LIMITS OFRCERIMEl BER EXCLU 7���N NIA E.L.EACH AccroENT $1 000 000 (Myyppnd.roy b nd E.L.DISEASE-EA EMPLOYEE S 1 000,000 DESCRIP��OFOPE low E.L DISEASE-POLICY LIMIT s1400000 DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schadala.N mom space Is required) CERTIFICATE HOLDER CANCELLATION 30 Da for Non-P ent SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE'EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Of Bamstebl@, ACCORDANCE WITH THE POLICY PROVISIONS. Building Department 367 Main Street AVTH0MMDREPREBENPATW. Barnstable,MA 02601 z. 0 988.2009 ORD CORPORATION.Alt rights reserved. ACORD 25(2009/09) 1 oi.1 The ACORD name and Ingo are registered marks of ACORD #55�018/M58619 PS2 b 0 n � N rZ r, ,a _ •1 34`, .d.� t p Y �W .; a , N � ....-r .rim• •. . ,. ` �J�.r*,t, � -�-`"""�" .. -! - - t ' Tinse or rep stration.valid for md!vidul use'.only< before the expiration dad ' Office of Consumer 9'--Jf found re'.i j Affairs and Busi 'rn to 10 Park n Plaza:-SUMG 51.70 ess r'cVulatio►� � Boston . ,]VI 71 A 02: IfG � Not alid,witliout sigma e 1 INS Massachusetts -Department of Publ:ie Safety . Board:of.Buldirng Reguiatioas;and:Startdards Construction,Super-i - r7� S License:CS-095228 . AANA J PICK 19 HAMLFTST ! Fairhaven M 02719 °J�,.p. a� aa�a Expiration Comrriissione 03/22/2014 ' �a�panvmomca o�Cda�uaeCt� ffice £ConsumerAffaers&Business Rs`gulatiom 71ME IMP ROVEMENT"CONTRACTOR egistration: _1 5b3::= TYPII Expiration: 6/19/2014 Supplement Lill CARE FREE HOMES_='rNC ;i DANA PICKUP JR 239-Hutfleston ave — � - FaU,haven, MA 027,19 Ui'dersecretary s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Maps Parcel Permit# /9:2 9,1 3 TO�'JN C:� f�R ��ifaSLE lealth Division G3 Date Issued Conservation Divisionl � ' —t� � f j; o Application Fee c Tax Collector Permit Fee Treasurer �-E i l V I S J Off SEPTIC'SYSTEM! MUST aE _ Planning Dept INSTALLE®.IN CONIPLIAF� . t WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRW FAENTAL Mr)—`- AN[ T0V!.'i� P7C 1 �..':. Historic-OKH Preservation/Hyannis Project Street Address 51yo x n���CTT ®CL Village I� Owner ! . , Address Telephone (�� Permit Request 1 n ews mac— lv Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 14 Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes Lq No On Old King's Highway: ❑Yes ANo Basement Type: .Q Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) dU _ Number of Baths: Full: existing c new _ Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: IQ Gas ❑Oil ❑Electric ❑Other "4 �— Central Air: ❑Yes A No Fireplaces: Existing _ New. Existing wood/coal stove: ❑Yes V 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 Nto� If yes,site plan review# Current Use &A I de6T, Proposed Use s BUILDER INFORMATION - -Name G - Telephone Number, I:�V'?-5--775 c30'97—' Address License# ez 3 Home Improvement Contractor# Worker's Compensation# 9 � ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PRO ECT WILL BETAKEN TO S t(A / c..,-Zc-11)r SIGNATURE DATE FOR OFFICIAL USE ONLY ,PERMIT NO. DATE ISSUED MAP/PARCEL NO. - • ADDRESS VILLAGE OWNER DATE OF INSPECTION: Ile - FOUNDATION FRAME INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL`" { GAS: ROUGH FINAL 0 1 FINAL BUILDING DATE CLOSED OUT _ ,• ASSOCIATION PLAN NO. The.Commonwealth of Massachusetts Department of Industrial Accidents Office offnyesliff-00es i - 600 Washington Street x Boston,Mass. 02111 Workers' Compensationdrisurance Affidavit i#gen name r—A&dzc r - e location: V tY— sG3rtll /e, /¢ e - �J phone# ci I am-a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity [� I am an employer providing workers compensation for my employees working on thiqs-job x yA e ••.+T('F }fir - YLL 7 : a i7iyr. .•�- rg--•s r �, "'p--sa-a,.x�� S">r"�icryar^,�" �;�•si urx 5K3t z. E�- -r'h -'rz t ,�c'j' :.c .a ,.t 5_t, z T.* 4,�xn�. i' •�.' ..r''x zv -,x, A +^ft't y3 a{ t it k t'd�s- s r y.- �- ' x;: ``,yr` "�.�5]5� :�t :'�c •s' �t �4t��F;�F .-�•r �� �-`�,d'tX A Py¢•: �rk-y s + ;cY a r r ,Lri`i1 r,,� Y t �r'°a a r:!' � m%.t CzOm an.game tit r f S Y u.r r n} a Y A s a wr r k� . u ^%`t;.S, vo,}.� �,k-ic' "{+yr,„'� i"'+.Yr +.�::G' fi�:t�'<P'R`.F'F•kV ^T v'a'.� "'` rr.:..�c� '`....t�I q R^ i?:Et ft' i S t x l 'r•".. 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N't� •5'-.t s' +��.r^�''f ma'(' c:tn "�. Yil 1_.l r �..V �a�;}r, ��^.2�1 S f.fY1 4 � - At�.+6.:t6�,��"�r°-:5xn� 5�{W .f �x '� r 4� 1 n:er a g� lc I r � -, r 'T •d'�" a 1 f tr t i rrt xY� "�' �i y^ c'�r.k."ta3'�., aty -,,s t+ n...+}t �c -.jr•.+,a S#3H v ,� r -- 1�tb f�.c�Et {�' .r [] I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices 'IM '+4s �cayr r -r,«K-- a'T�"y'+ter r'M+_' ""fs"i X,/' s.t`m.%r' +��y '�:'Sy'q .{ �L s -r .mac• ,+3. .. t -41� P .,r,,�. 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Cti�.w`_,,,a'�,4y r�m.} - s�+3i t � � x iy�r��-r'�s�.F,� ia� yu�f t�;,,F f�y"'r�.'.��'.�,�a v ;er.k.A Nab, k i ai x� � 4r {rh•... 7 =.. � F .1� 4tg`+``5 ..rr��-..rc�'x"�'4--✓y.. r-y'r. .ans '�` t� x•¢".('r'kt7 .+} - ,+ g r s r t+' .�•+^. _-,ti r� stnsurance co 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 andlor one years'imprisonment as well as civil 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 hereby certify under the pains and penal 'es of perjury t t the information provided above is true and correct �y / Date v Signature P ' t name I�����(� - ��D�' �reu- Phon # �� 7 7✓�`� official use only do not write in this area to be completed by city or town official city or town: permit/license# MBuilding Department []Licensing Board n check if immediate response is required ❑Selectmen's Office []Health Department contact person: phone#; rl0ther (revised 9195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants ' compensation affidavit completely, b checking the box that applies to our situation and Please fill m the workers co p p y, Y g PP Y supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out.in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, Please do not hesitate to give us a call. Ift The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406 �NE Town of Barnstable T°w� . . Regulatory Services ' saaxszAB Thomas F.Geller,Director asnss• 019. � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 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 exc lions, along with oth requirements. aU�g � �� Type.of Work: ) v v Estimated Cost Address of Work: Owner's Name:(Sl Date of Applicatio I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑lob Under$1,000 Building not owner-occupied ]Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME UYIPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. 3 to Owner's ame The Town of Barnstable Regulatory Services Thomas F. Geiler, Director Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:JOB LOCA N: 4i , vt11p number stare/et^ village "HOMEOWNER": name home phone# work phone# CURRENT MA=G ADDRESS: • G� city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel,of land on which he/she resides or intends to reside, on which there is, or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be resRonsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and . other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection proced es and requirements and that he/she will comply with said proce es and require e - 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 persons)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed-Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community.