Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0168 STONEY CLIFF ROAD
��� bSfOrJ ���� ,. � - , . ., � �F ;, 6 } n II '�'. . � _ .. V L r R�1� Town of Barnstable *Permit 6 SGS PEF-pVAjonthsftom 'sue to * Regulatory Services * snxxsTABLK A lMASS& �' ] 2®13 Thomas F.Geiler,Director x T tED MA Building Division 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 �e-;;, Not Valid without Red X-Press Imprint Map/parcel Number r (� Property Address I l/0 9- J�O Vi r=:e4 C La kn � R09-d, , Ce-tAe--Zl,, (�ey. �'�(� ca 3 Z Residential Value of Work$ ZC)CO. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address M 124 F-a TU h Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ m a sole proprietor m 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) ❑, a-side [Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows S #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 co oft ome Improvement Contractors License&Construction Supervisors License is ui SIGNATURE: 0 ( / 13 Q:\WPFILES\FORMS\building p it fo \EXPRESS.doc Revised 060513 5 1 Town of Barnstable Regulatory Services snxr ABS. Thomas F.Geiler,Director �Eo 39- 16 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 HOMEOWNER LICENSE EXEMPTION DATE: O 7 1 f73 l 13 Please Print ' JOB LOCATION: 16 �T0 Mkt CC; V e 20a ` Cif/✓�(� numb ��� v7D6err street p -!7 C3 village "HOMEOWNER": Maq _ ? — 3o S- _50E- E(S q 2-1 name // home phone# work phone# CURRENT MAILING ADDRESS: 1p a�q C(c Kd city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The un rsi "homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection p o e an quirements and that he/she will comply with said procedures and requirements. ID7orneo*ner 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." r 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. & # C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContenLOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 °F�►+E r Town of Barnstable * °* Regulatory Services s"MST`'$ Thomas F.Geiler,Director A 1639• aTEn n►A� Building Di vision 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 /er' Complete and Sign Thon If Usin A Buil I, , as Owner of the subject property hereby authorize Z to act on my behalf, in all matters relative to work authorize this building permit. (Ad ess of Job) **Pool fences and ala are the responsibility o he applicant. Pools are not to be filled or u ' 'zed before fence is installed d all final inspections are perform d and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMSSIONPOOLS 62012 the Commonprealth of Massachusetts Department of Industkial.Accidtnrts Office of luvestigations 600 Washington Street Boston,M,4 02111 wow mass.govIdia Workers' Compensation Insurance Affidavit: BuildersjComtractnrs/ElectriciansiPlumbers App icant Information -- r Please Print Leidbly Name Musiumtorga a on&dividwl): M a Address: (�e(g 9�O vx e- C[. P Q ocz� City/Sta,&Zip: ��; L le (til �3Zphor SO ? - 8 if . Ct L 2- Are you an employer?G6eck the appropriatie bqa: Type of project(required): L❑ I am a employer with 4- I sin s l txmtractat and I 6- ❑New construction employees(fall and#opact-timE).* hnmhived.the sub-contractors r listed on the.attached sheet 7- ❑Remodeling 2.❑ I am a sole proprietor or partner h Tese sob-contractors have ship and have no employees 8. ❑Demolition working for mein any capacsty. employees and have workns'. 9 Budding addition [No workers'comp insurance comp. I 5. ❑ We are a corporation and its 10_0 Electrical repairs or additions required]3. I am a homeowner doing all work officers have exercised their 11-❑Plumbing repairs or additions ❑ right of exemption per MGL myself.[No workers'comp. light ❑�oaf r epaics insurance mod] c.152, §1(4),and we hati�e no employees.[Noo workers' s' 13• ' Other U�i n Gld l.�� comp-insurance required-] "Airy applicant that checks boa#1 •also fill out the section below showing their wodteta'compensad-Policy information. I Hotneo WUM who submit dus afftdsm m&ca=g they an doing all wak soil the brte outside comuactors ntnst submit a new affidavit indicating such. tcom mcmrs diat cheet this box must attached an additional sheet showing the name of Ste sub-emtracton and state whether or not those entities have employees. If the sub-coatmauts bane employees,they'moat paovide their wod em'comp.policy number- I am an employer that isprovidiag workers'compensation insurance for my employe" Belau is the policy and job.site information. LA Insurance Company Name: Policy#or Self-ins..l lie.#: Fxpisatian Date: ? 3 ( � L 3 r 'n Ci (State,+ :Ct% .t/�► e rJ 2�3Z Jab Site Address: (?J�o Y12., t C/�� (U. - tY Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as rewired under`Section.25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500-00 an&or one-year imIxisonment,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 OfDIA for insurance coverage verification- I do hereby pains andpenalttes ofperjury.that,the informatian,prov ded above is bue and correct e: Date: Phone 0: Off iciffl use on y: Do not write in this area,to be completed by city or town.official. City or Town: PermitUcense# 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#: 6 • 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/Electricians/Plumbers Applicant Information 4Please Print Legibly Naive(Business/Organization/Individual)'� P- Address: //�� City/State/Zip: �f� /`A Gt Phone ,,7 v Aweou an emplo er?Check the appropriate box: Type of project(required): 1. am a employer with ' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. %&modeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 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 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: �' `+� �L Policy#or Self-ins.Lic.#:_ 7 6 J6_�*y W`�` Xpiration Date: Job Site Address: �/`L C /� �oid City/State/Zip:�l Attach a copy of the workers' compensation policy declaration page(showing the"policy number and expiration date).. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce fy undqrthhepairs and enalti perjury that the information provided above is true and correct. Signature: Date: Phone#: M CP ?-_7i 2 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 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or.other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work'on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance,with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if numbers along with their certificates of - necessary,supply sub-contractors)name(s),address(es)and phone ( ) g ( ) 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 d you have an questions regarding the law or if you are required to obtain a workers 'dents. Should g g Industrial Accidents. Y Y q compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each _ year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. _The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 - Tel.#_-617-727=4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 _, www.mass.gov/dia i ACOORO® CERTIFICATE OF LIABILITY INSURANCE DAT0/12°201 10/12/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT NAME: OLDE CAPE COD INSURANCE PHONE FAX 29G WINTER STREET A/C,No,Ext: (A/C,No): E-MAIL ADDRESS: HYANNIS MA 02601 78DBW INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURED INSURER B: WARREN, WALTER DBA NORTHSIDE INSURERC: HOME IMPROVEMENT 40 ALEXANDER DRIVE INSURERD: YARMOUTHPORT MA 02675 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WV D POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ C DAMAGE TO RENTED OM PREMISES GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE DOCCUR MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS—COMP/OP AGG POLICY PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO �CUFYEDULED BODILY INJURY Per person) $ ALL OWNED NON-OWNED BODILY INJURY Per accident $ AUTOS AUTOS PROPERTY DAMAGE HIRED AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ IDED1 IRETENTION $ $ WORKERS COMPENSATION WC STATU- I OTH- A AND EMPLOYERS'LIABILITY (7PJUB-5658064-5—1 2) 09-01—12 09-01—13 X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? Y/N E.L.EACH ACCIDENT $ 500,000 (Mandatory in NH) NIA Y E.L.DISEASE—EA EMPLOYEEI$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE—POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREFO,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF BARNSTABLE AUTHORIZED REPRESENTATIVE 230 SOUTH STREET HYANNIS MA 02601 ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/06) The ACORD name and logo are registered marks of ACORD TRAVELERS TRAVELERS - RMD P.O. BOX 3556 ORLANDO FL 32802-3556 TOWN OF BARNSTABLE 230 SOUTH STREET HYANNIS MA 02601 N- 0 o 0 a_ N ACORD CERTIFICATE OF INSURANCE (On Reverse) 002597 � ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# � Health Division 62, Yel 04A.06 Date Issued �{- �Conservation Division N3 164 Ok Application Fee Tax Collector Permit Fee 04 Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 11(9 Village `' ICJ Owner We,,mY,, ,71AAddress Telephone Permit Request' la _,1 I', 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 ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑Full ❑Crawl -El Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ 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 Q.Yes ❑No If yes,site plan review# Current Use Proposed Use, BUILDER INFORMATION Nameb19117eK-7mot. Telephone Number �' l 7s Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �' FOR OFFICIAL USE ONLY Ilf,'RMIT NO. '.DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE y ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN.NO. The Commonwealth of Massachusetts Department of Industrial Accidents' 600•Washington Street _ - Boston,Mass. . 02111 `sa Workers'.Com ensation...............Usurance Affidavit-General Businesses ` state 110 work site location full address El I aai•a sole�roprietor•andhaveno one ' $psiness 7[ype; []Retail❑RestaurauiBai/ tiing ' ablishmeat working le any capacity El Office El S (incladin Real-Estate,Antos etc.)' �. I am an em 10 with ein to ees full& art time): Other //%////%/%NI/m, // %///%� % , .y/%/ low%/e/s worlan on this job.. . �I am an'employer providinrg v,Workers cemvensation for my p ,y g , �' .i• '. t :r,.. i' •r• '�:' :,: :fir'- `l•;}:•�i .. fi L� t(:tt•t •�,.r...l: lLy.� .'t!r'j••`5•..•s ,.•{ti. ,.L1 '•_. •f• .�.• .rr .. .li. ''..J' ..•♦<`:r? COrl1 8II roil' ir: ;t' .�;:i .t}:'s,r:.t t3 t•a i1:'•.•i' ..ti Y`:•l j�. :'t,,':(t�,i:;:. '?i7'"�' •,i :r: ... S. �,r'l,,`` „y.,:» i.�r•fS;,,:4 :�' .,.,i4.•,•::I::.cat;i'.,.li;' .'...r.ji:., :�;.+?,;3:... r....•::t..<a :Ir :•:C' h•t,..:�•..., .y !�"' Al: $tlaICSSC' r' i., ;t..:.• .F.,- .' i,: ', , t"' ''^{'Sl1{1': :ti{ ' ' 'iC' •, ... ;,�: •n _5. t�•:.k�,:L:}y.. , rr •' ''%C v'�!�ct:' •d-:••', { •':•. .•,.:t• •...' {. ••a ,:hi.•y � L Ct..•t t. - .L. :7•.;. :�e�•t^t'''r •i•' 'i,?'.i: 'r { ..i:.• 't•::•'t',. .1�'•:4 •` ;it':. i.• .:�. ,l •t ,'r 1: '�'t:4.6•�.: i•: ,,i•{ a•`:i:',.. O11C. •' •.r.::.`;1'e•: ., fAS11r81iCe.CO:tr. {o:..l^ •L:•hv. !. .. I// ' I'am a sole proprietor and'h�ve hired the independent contractors listed below•who have the following workers' .compensation polices: :. .:... 'i ;; :•. • .; . . �. :L" a i:i't,.:;y}:'. �'•i:��4,tra?ti1+'t.`':r eE�^^`}•= • ..ii:•.!•t: it:'Lit''{'^�.^,i' .l. ''s\5i:' f°''i'r. :., t:,�• .c ,f. •r '��.::•:"r••Y• t y, .ta Co 9II name: !.•L :•a' rt-°:°''' :t!• :P.r. f. �� r•ryr. i.!,� .:r•;+•::•,, •.e- �t..:"r,•.a:�i •' _ ,{!,a' il.r fe t�.. •t., . :r•::t4,•., , r'y'•t.• .t• ,4:.'i:i.'}f :�, d• ••j J ?i y. , .;. ..i V:- ,t''k• address:. .t• 'r:�`t,•: '!•.L` "3 t• ci t.•' a fY .r,l';'. -i''t 1'rt%r. ��., .1-•:r, ', :1�•.•.5:.'t•'a:oi• r�:4 4t• :i: f• = .r! • .ti: - `•hl. .�t ..,�: �',,: Ali• �. � `fi'diie'�fs. ;�. '.� •"• '':•�- '":r•.,. Wit: '• •1 :. .• . •.• ••'•_ • i'tiJi l.::: •.A:r•'':,"• '•• •• •�•• ,tr:'�-'• ' • •;1•.•' CI� ti,: 's.#•. .-.• ,r• :��.�'•;:y ,"•.St�."iu;' it:;�^.��'' r'�+'' •1: 'r s,•:i'�s`j,.:ti.ritt:=',jt�.�q:.'��;. •',.9Y^ �,1: _,•p•'•ry :C:'•'*7i'•w�''':•Y:�• •''•.';ft• ,;..P"• -LM1 `•�i�r•:•; .'tL• .rUlIC e#+ in'sursnce co. :i::• .:�•r.{ :'6j•J•'t••rtit .:a•�:.'�• ••c•f,?,1.n..tipty,!`r:•y .Pta �r. :'f.j F,o:� 'ti• 's•• �a"S'i••t'•.C• '�• ''•'LY-�,�:C:: t' ',`l.'t^f: 't •'.0 '•yt:•!Y�'.i•� 'a. 't '•t' .A,`i }r:.r.!'i: coin'gu nande•--------------- ,vac ••_*:• .;r'""' �dy . .; ;+ r =:t�,�':, . .+ `. ti '� .rS.. .tv. "i'i.:,+,y'L "t 1'• ,r: 't�:rj,:=J.•'{.tw , ,�.`: _ L'{;,.j•' •Cl •f'•• .i •.i.r ••t.<•: '•1,•'},••n, ••pi •i••' 1q •t•:.i:• ,.'.7',. •Tuj<<.g• •t.• :1•.`•t: :{L�• .'1.: •!'••1 • .f: .ti,t,', ': -'�a:' •,r:t': �'�:�•: s: .:hL'`•. 4, •4t• ! i 1:� s: i"• '4''•e'' 'o'�Cb:""t r.l1''r:;'�•, •'f;:''.it:• •:p,'Z,.•• ;,.y,r...tt!:rj {.; f.S;:tn•-!.t'. '0'IICt':�• •���insifrsiic.. '+" Failure to secure coverage as required penaltiesnder tion 25A of the form of STOP WORK ORDERGL 15i can lead to andnd a fine ofsition 0, �0l).00 a day against�me�I understand that I to$1,500.00 L one years'imprisonment as well as civffp to copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification I do hereby certi unde the pains an alties of rjury that the inform ation provided above is true a co ect Date Signature Phone# Print name official we only do not write in thL6- ea i be c leted by city or town officW permit/license# []Building Department city or town: []Licensing Board ❑Selectmen's Office [}check if immediate response is required ❑Health Department , contact person• phone#; []Other (revised Sept 2003) L Information and Instructions- _7viassachusetts General L'aws'chg Ater 152 section 2.5 regwires all employers to provide workers' compensation for their•. e�ioyees 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 defimd as an individual,partnership, association, corporation or other legal entity, or any two or mqr a of the foregoing engaged-in a�joint enferprise,and including the legal representatives of a deceased,employer, or the-receiver or trustee of an individual,parhaership�association or other legal entity, employing employees. 'However.the owher of a not more than three apartments and-who resides therein, or the,occupant dwelling house�!' �bf the:dwelling house bf to'do maintenance, construction or repair work on such dwelliong house'or on the grounds or anOther who emplbysgersbris bugling applutenant thereto shall not because of suchemployment.be deemed to be an employer, MGL chapter 152 section 25 also'states that'every state-or local licensing-agency shall withhold the issuance dr renewal of a license or permit to operate a business or to construct buildings in the.commonwealth for any applicant who has not produced ace eptable'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 unti acceptable evidence of compliance with tpe insurance requirements of this chapter have been presented to the contracting . authority: Applicants Please 0 in the workers''eonpmsafm affidavit completely,by checking the box that applies to your situation.. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Departznent•of industrial Accidents-for confirmation of insurance coverage. Also�be sure to sign and date the affidavit. The davit should be returned to the city or town that the application for the permit or license is being udustrial Accidents. Should you have any questions regardirip the'"law"or if you are requested, not the Department of`I required to obtain a:workers.'-compensation pplicy,pl.ease call the Department at the number listed below. City or Towns . Please be sure that the affidavit is cbmplete andprinted legibly. The Department has provided a space at the bottom!of the affidavit for you to'fill out in:'the event the Office of Investigations has to contact you regarding the applicant Please allidi a to fillipthe pernnt/hcense number which wi`(.1 be used as a reference number. The.affidavits,may.be returned to, be-suthe Departmentm or FAX unless othei••ariangementshavebeenmade. d like to thank y'ou in advance for you cooperation and should you have any questions, The Office of Investigations woul Please do not hesitate to give us a call. hone and fax number: . . ess tel r t s addr ep artmen The Dep • • - •• . . ' The Commonwealth Of 11�tassachusetts• Department.of Industrial Accidents on of wesuptions 600 Washington Street ' Boston,Ma. 02111 fax#: (617)727-7749 .. Jr_ ii-drrc rrft.r.Innn _..._L 'Ane - 1 a { f 2 ^�, v �� � 4 / n �, i V { S f 1 � �� �� \ J � .l j } � � v � � � � � Z- Z2 � � � } 9 J UAe C1V-C �g /3 9 U i � N � C fiv � II c f 1 �gv - � Z � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map - C) Parcel Le - -3 Permit# r�e� Health Division 900 fv���� Date Issued Conservation Division o LS Application Fee —(1 o Tax Collector Permit Fed a Treasurer ' Planning'Dept SEPTIC SYSTEM MUST BF Date Definitive Plan Approved by Planning Board 94STA LE T ;,CQ�P�" VATITI-E 5 Historic-OKH Preservation/Hyannis E"oROMMENTAL CODE ANO TOWN Project Street Address D •ry w — Village Owner � � er.v,Q SY�C�QQ Y_� I � Address S oallp__ Telephone ff Permit Request J� -Q_ I O✓1 .!t. c- h-a�� POyrn 0511ir, hl t&42 S he a .'A till Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay r�eow�dlaf�eeQ�ct Project Valuation� (F)0® Construction Type eq O iy Lot Size e e/ Gi( Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes XNo On Old King's Highway: ❑Yes ,4 No Basement Type: A-Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) _ Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new — Total Room Count(not including baths): existing new_� First Floor Room Count Heat Type and Fuel: )4Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes 0 No . Fireplaces: Existing New Existing wood/coal stove: ❑Yes 14 No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:X_existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes gNo If yes,site plan review# Current Use (Gi`6wa-W Proposed Use r r BUILDER INFORMATION Q Ce[t Name V (! Telephone Number Address crnnur License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��ll/les�' ,A Skill A SIGNATURE DATE �'� - FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED _Y MAP/PARCEL NO. ADDRESS ' VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION FRAME _/b INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH _ r FINAL -GAS: ROUGH :-' F� FR9AL FINAL BUILDING 1r ;� , � DATE CLOSED OUT r' , ASSOCIATION PLAN NO. i r Town of Barnstable Regulatory Services Thomas F.Geiler,Director MASS 039. .,01 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 r 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 Estimated Cost d Address of Work: Owner's Name: ' Date of Application: 15 Y10 Z - I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 RBuilding not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent o wner: .a 0 o Date Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Massachusetts �-...: Department of Industrial Accidents Office 01/ose508fioos _ 600 Washington Street -= Boston,Mass. 02111 -- Workers' Compensation Insurance davit name: � location: /l C l.JY p D city hone# ❑ I am affi6meowner performing all work myself. I am a sole rietor and have no one worlds in ca achy I am an em to roviding workers'compensation for my empltryees working on this job. X.::::::: :::::::::::::::::::::::::::::: :: : ..::::::.::..::.....::::::.:::.::.:.::::::.::.......:..::::::::.:..:::::::.:..::.:...... eomnanvwna ................................. ::;:::::::::::..:::......................... . :;::>:: ': :: ....... hone:#.:. ....:.p ;... .:: c1tV' ? 'till nsuran ------------ am sole proprietor eneral contractor,or homeowner(circle one)and have hired the contractors listed below who have the followin workers' compensation polices; g ..................................................................................................... ...........................::.::::.:::.::::.,.::,.:::.::::::. co an name:> :.... idle .::....�:.::..::...........:...::.:..::.:..................::::vn....::::.:...........:..::.......... :w::...�:................:::.............::.::.........:...........................:::.......v .. .(---- v.{•: X. k; . ........ ::;i<:j iii`;':;?:}: ;:;RS:{:}:•;;:;:yti:;:;:;isj:ii;r::;:;i j:$> ':?}:si :»:Eion 1•.:. 'd#y: , <'n .•. hlnranceco:::;:;:.::;:.:.::.:;:;:;,;::.::.;:.;::,:..::::.:.; :... .....:,....:. .,...:.....:...... ... . o .c sa ,.......:. >. h ............•:::::..:..::::.:::..;•.:..:..:::.::.:..:.:::::::::::..::.:.:.::.::::.:::.:..:........::::: l lLi w � ... rFF nsuran Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of crbninal penalties of a fine up to$1,500.00 and/or one years'imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against ma 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 pe of perj t the information provided above is hw.and correct Signature Date Print name � /L' /T 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 ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department contact person phone#; ❑Other (devised 9/95 PJA) t 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,neitherthe 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. or Applicants a I Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and hone numbers along with a certificate of insurance as all affidavits may be supp Ym8 mP Y p submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and +d- 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 permitllicense number which will be used as a reference number. The affidavits may be returned t_ the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imlesdgailons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET F NEW LIVING SPACE square feet x$96/sq.foot x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EMSTING SPACE 23 square feet x$64/sq.foot= lot x.0031= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq.ft, >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf-1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch _x$30.00= (number) Deck _x$30.00= (number Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) permit Fees projcost •no cMA Appendix 1 Table dS-Z-1b(continued) prneriptive Packages for One and Tna-Family Residential Buildup Heated vit6 Fossil Fueiz MINIMUM MAMUM XI Heating/cooling Gj�ng Glazing Ceiling Well Floor $asc w.0 Stab eter Equipment Eflicicncy' Arm'(Y.) U-value= R-valuej R-value' R-values! R-value I �ue Package 5701 to 6500 Heating Degree Days' Normal 13 19 10 6 Q I2'/. 0.40 3S 6 Normal R 12'/. OS2 30 19 19 10 13 19 10 6 8S AFUE • g 12/. 0.50 38 NIA Narraal T 15% 0.36 38 13 NIA 6 Normal U 15% 0.46 38 19 19 10 NIA 85 AFUE t` 0.44 38 13 ZS _N/A NIA AFUE 6 15% Q.s2 30 19 14 10 NIA Normal X IS% 032 38 13 25 N/A NIA Narrnal y 13% 0.42 38 19 2S 1 6 90 AFUE Z 19% 0.42 38 .13 19 10 6 90 AFUE AA 18% 030 70 19 14 IO 1. ADDRESS OF PROPERTY: (cd o - )` 06K26" S 2. SQUARE FOOTAGE OF ALL EXTERIOR WALL / 3. SQUARE FOOTAGE OF ALL GLAZING: L 4, %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q.-AA-see chart above): NOTE: OTHER MORE INVOLVED METHOD A DETERMINING ORGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORM BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f980303a 780 CMR Appendix J Footnotes to Table A2.Ib: d Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall area, expressed as a percentage. Up to 1%.of the total glazing area may be excluded from the U-value requirement. For example,3 f of decorative glass may be excluded from a building design with 300 fl of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented bythe manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units: center-of-glass U-values cannot be used. 3 The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation.thickness over the exterior walls without compression, R 30 insulation may be substituted for R-38 d for R-49 insulation. Ceiling R-values represent the sum of cavity insulation and R-38 insulation may be substitute insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 4 Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing,and interior drywall. For example, an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. a The floor requirements apply to floors over unconditioned spaces (such as unconditioned crawispaces,basements, or garages).Floors over outside air must meet the ceiling requirements. f The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must mczt the same R-value requirement as above-grade `walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes elebtric resistance heating use compliance approach 3;4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see-Table J5.2.la NOTES: a) Glazing areas and U-values are maximum acceptable levels.Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b) Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value ' in Table J 1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall, floor,basement wall,slab-edge, or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 1ME ram, Town of Barnstable P ~O Regulatory Services BAMSTABLEv Mass. Thomas Thomas F.Geiler,Director 1639. �ATFOMA'�A`� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, -e— �i as Owner of the subject property *J hereby authorize i�t� `IJ(/I to act on my behalf, in all matters relative to work authorized by this building permit application for: `'c. (Ad ess of Job) Signature of Owner Date Print Name Q:FORM&OWNERPERMISSION BOARD OF BUILDING REGULATIONS License .CONSTRUCTION SUPERVISOR Number CrS 078687 Bir�fidsate` 05/291*960 a� V y EPtres� O6/�9/2004 Tr.no: 78687 Restricted BRUCEP MILLS' HYANNFS, MA 02601 Adminisfrafor OTle TDovn�na�tcuea`C/ Board of Building Regulations and Standards HOME INEARO�VEMENT CONTRACTOR Req' t tFan =36003 4 Zir ttan 10/04 C , :�ividual BRUCE P.MILL BRUCE MILLS ` 16 CROOKED POIVCTFt HYANNIS,MA 0260.1 Administrator r ' Y • ro � i THE The Town of Barnstable o� NVA OMAS& G� Department of Health Safety and Environmental Services ASS. Om Building Division 367 Main Street,Hyannis,MA 02601 ;08-862-4038 ` ;08-790-6230 PLAN REVIEW r 7wner: a Map/Parcel: 96 Q�� 'roject Address: Builder:�Y��� /��1 ��� C • Che following items were noted on reviewing: \r 2_ U U l.L �J P rreA 62.OVIAS 9 I eviewed by: ate: w au WI(t _ffQF-t-�ry�-f- Ok War I�H l --- ---- So I j , 1 -EKV.l. `n�; �Oqo <c, ian o. e f: I i f i LP I n � o n `n r ' 6 � P .a r � i � I i I i i G I 6 I i f