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' .,"" t",.'„., ,.., '. '',. .., -,•, v:,.''',.",. .--`',..' ,.,,,-.:,.t.,''.,,:''','•.,4`,,!...4.':',,r,'i'V'ii,,,.'..1."),,1,.''':.:',.1Z!..?..2'.. '' a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 02 / Parcel D IS Application # '^!s - I e c ok Health Division 'II III_f► N(a `)FE a. Date Issued l le Conservation Division Application Fee JUN 112018 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board TOWN C' �'`'F "JS'll•B_t Historic - OKH _ Preservation / Hyannis Project Street Address a7 0 I fm1/, 4i* Village 74 2 /I-A./5 l Owner Vic) ry/ ,e 1/4its s Address ./� i Telephone 62' 4P ?G z .7 3 3'3 Permit Request ,'jf1 G 77ft T— 9iz of eil /Z ' 7 e ' /4,/4,g Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation '® o c), cConstruction Type JCS 44/4 fjelj 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 l t-llo On Old King's Highway: ❑Yes ITNo Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count 1 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: Cl 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 /f,4 f I /,Js u 1 ft hi€,r 9 Telephone Number ,S-7,a 77 5l z / Address ,% ' Xt4/Lei,t/ G'j4' License # /€ i I yigcn4 , Ph. Home Improvement Contractor# ).5 ? 52-7 Email m1e /fr./P(4p cod/4,,,f,,/477 4 ,/,Worker's Compensation # 4/Ct-'Dd 44-3/ YO 3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO / t415/171. 1,/�v i' SIGNATURE4 70 . DATE Gt�f/ i • FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED -k • MAP/ PARCEL NO. ADDRESS VILLAGE OWNER fa DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL • FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' ::ATE\\ T , • _ _ The Commonwealth of Massachusetts `�: , Department of industrial Accidents • =t"mo= 1 Congress Street, Suite 100 c=��=7 Boston, M.4 42114-2017 �`1::�.: www,mass,gov/die Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers, TO BE FILED WITH THE PERMITTING AUTHORITY, Anollcaat I form_;s_ti_o__n . -_,`.,,,,, Please Print Legibly Name (BusinesslOrganizatiorVIndividual); Cape Cod Insulation Address: 18 Reardon Circle City/State/Zip; South Yarmouth,MA 02664 Phone 4: 508-775-1214 •• Are you en employer?Cheek the appropriate box; Type of project(required): I El i am a employer with 48 employees(tull and/or part•time),' 2.:I am a sole proprietor or partnership and have no employees working for me In/ ' ❑ New construction any oapaoity,(No workers'pomp,insurance required,) $. ❑ Remodeling 3,0 i am a homeowner doing all work myself,.rNo workers'comp.Insuranoe req,uired,'t 9, ID Demolition 4,0 I am a homeowner and will be hiring oontraotors to conduct all work on my p property. I will 10 El Building addition ensure that ill contractors either hive workers'compensation Insumnoe or've sl proprietors with no employees, e 11,❑ Electrical repairs or additions s,❑i am a general oontreotor and I have hired the sub•oontraotora listed on the attaohed sheet, 12,❑P1umbIng repairs or additions These sub•eontraotors have employees and have workers'comp,111311112100 13,❑Roof repairs 6,0 We axe a corporation and its officers have exercised their right of exemption per MOL o, 14,D Other Weatherization 132,11(4),and we hive no employees, (No workers'comp,insurance required,) , 'any applloent that cheeks box#1 must also fill out the section below showing their workers'compensation policy Information.t Homeowners who submit' tlra 6devit indicating they ere doing nil work and then hire outside contraotors must submit a new affidavit Indicating such. ;Contractors that cheek this box must attached an additional sheet showing the name of the sub•oontreotors and state whether or not those entitles have employees, lithe subcontractor'have ern.lo ees,they must provide their workers'comp, ••lioy number, I am an employer that is providing workers'compensation Insurance for my employees, Below Is the policy and fob site 1n orritatlon, Insurance Company Name; Atlantic Charter " , WCE00431902 Policy#or Self ins,Llo,#, . Expiration Date' 08/30/2018 _ Job Site Address;d 94 t: m,,4 la ,si* PAr s7-14 73Le City/State/Zip; ' D ' v Attach'a copy of the workers' compensation policy declaration page(showing the policy number and expiration date), Failure to secure coverage as required under MOL o, 152, §25A is a criminal violation punishable by a fine up to $1,500,00 mci/or onelear imprisonment, as well as olvil penalties in the form of a STOP WORK ORDER and a fine of up to S250,00 a day against the violator,A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verifioation, I do herebyce under --- ----..__--------------.-__----------- t ,p ns and penalties that the information provided above is true and correct. ' si 1,/III .7,,,MYMMrW.,... ...... •,,,A i I \/ 50 . 75-121 Phonel: 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 •S► Plumbing Inspector 6,Other Contact Person; Phone#; ' l • • . -.; - QT./m.1 WC24114/147~-ealg ? t-tisigr ,.;, •,� .. Office of Consumer Affairs and Business Regulation 10Park Plaza - Suite 5170 • Boston, Ma t�iiusetts 02116 • Home Improveme .. .ac �rector Registration Cape Cod insulation, Inc ' � : • v' 9tybrti 1et 63gA7 Corporation 18 Reardon Circle ; ' '�� Expiration; 12/14/2018 So, Yarmouth, MA 02664 �� ' d iikIti, ',w.i Update Address and return card, Mark reason for change, ."A t 4) 20"6/11 • -- -QSt�rdA4bfi.. •, ee Todminonwaal VICA _'.^__. �1+3t11xL.7lj- l pl4'�n7Atlt,.�l•1.c1St.f„t�.l aaaaa/ccr4et6b� ' Office of Consumer Affairs&Business Regulation ° , HOME IMPROVEMENT CONTRACTOR Wit- Registration valid for individual use only ( m I e.1 Corporation before the expiration date, If foun• oi j ,,,At° Office of Consumer Affairs and : as e '�.j='... �x :ration Pk: '',' Z:' � 12/14/201810 Park Plaza• e 8170sa Regulation Cape Cod Insu� f •1E1r1 Boston,MA Henry Cassidy • �,: r 18 Reardon Clro ''= I" So,Yarm M1,� • ' �yr � c�Q .., oulh, ,=r 4� 1410faur ''• Undersecretary IlL �•t al • "hout9l• at • • • W , • • I 1 1 • • • __,.I,' Commonwealth of Massachusetts It'4. Division of Profession's:Lloensure • , ,Board of Building Re uletIons and standards ConsWrn ,it%.U' ,ry Isor • C3.100988 v� AN ' , :••1 1 . shires; 11/11/201.9 HENRY E 0451DY,, / 1 p 8 SHED ROW.", , WEST YARMO>j,T ' 1 �� �� �� ,�;rQCr" n :i; :f Commissioner l/ -• 4-`--- ' , • • r CAPECOD-27 KDOYLE ACCoR Cr DATE(MMIDDIYYYYI `..� CERTIFICATE OF LIABILITY INSURANCE 0E(MMID /YY 4/03/2018 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 pollcy(les)must have ADDITIONAL INSURED provisions or 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 Ileu of such endorsement(s). PRODUCER ACT Rogers&Gray Insurance Agency,Inc. PHONE 434 Rte 134 (A/C,No,Ext): jac,No):(877)816-2156 South Dennis,MA 02660 Mss,mall@rogersgray.com mall@rogersgray.com INSURERS)AFFORDING COVERAGE NAIC 8 INSURER A;Peerless Insurance Company 24198 INSURED INSURER B:Safety Indemnity Insurance Company 33618 Cape Cod Insulation,Inc. INSURER C;Endurance American Specialty Insurance Company 41718 18 Reardon Circle INSURER 0:Atlantic Charter Insurance Company 44326 South Yarmouth,MA 02664 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER IMMIDDIVYWI , „ DIYY l LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS•MADE X OCCUR BKW53328281 04/01/2018 04/01/2019 DAMAGE TO RENTED 100,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY , $ 1,000,000 GEN'L AGGREGATE LIMITR APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY(I JECT I I LOC OTHER: PRODUCTS•COMP/OP AGG $ 2,000,000 B AUTOMOBILE LIABILITY $ ANY AUTO COMBINED SINGLE LIMIT 1 00O 6232707 (Ea accidenp $ 000 _ OWNED NLY X SCHEDULED 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ — IIAUTOS WNEp pBRODILYI7NJUpRY(Peraecidenq $ 1,000,000 X AU S ONLY X. AUTOS ONLY (PeoPERdent)AMAGE $ C UMBRELLA LIAR X OCCUR $ X EXCESS LIAB CLAIMS-MADE R/O EXC10006636002 04/01/2018 04/01/2019 EACH OCCURRENCE $ 2,000,000 DEO I RETENTION$ AGGREGATE $ , Aggregate 2,000,000 D WORKERS COMPENSATION $ AND EMPLOYERS'LIABILITY Y/IN' I PER I I ER" PROPRIETOR/PARTNER/EXECUTIVEANY IR/ EgERUDED? I N I N/A WCE00431903- 06/30/2017 06/30/2018 1,000,000 (Mandatory In NH E.L.EACH ACCIDENT $ It yes,describe under E.L.DISEASE•EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below 1,000,000 E.L,DISEASE•POLICY LIMIT $ • DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101rAddltlonal Remarke Schedule,may be attached If more space Is required) Workers Compensation Includes Officers or Proprietors. Additional insured status Is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. • CERTIFICATE BOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I �, 7/ • ACORD 25(2016/03) ©1988.2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD . Permit Authorization mass save Form Swings through energy efficiency Site ID: 3395226 Customer: Walter Kaess l(& s ,owner of the property located at: (Owner's Name,printed) 2908 MAIN ST BARNSTABLE, MA 02630 (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 b ilding perm' t perform insulation and/or weatherization work on my property. Owner's Signature: Date: )(.- 000000000000000000000000000000a+0e0000000000000000000000aooa0000c0000e FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: GX G— fe3 Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: For Office Use Only Rev. 102015 \,, /-3—/S-Pil a , ,� T Town Of Barnstable .*Permit#66 f510b O/ ` Expires 6 mo fr J e �' •0, �' Regulatory Services Fee i r • BARNBTABLE 1 Richard V.Scali,Director 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 P. RMIT LICATION - RESIDENTIAL ONLY Map/parcel Number Pq11 /9 I Not Valid without Red X-Press Imprint Property Address 33©g Al 5 .1 Q 6, ,v-OA- L C ®Residential Value of-Work$ it•S00-C/r1 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address U-/ (,vPt7t p- 6..5 • , 9® - A l4V 54 .64ai s/4/.64„. Contractor's Name &A, r- vii� Telephone Number S°',7 31795",:- a 0. Home Improvement Contractor License##(if applicable) 6379 ", mail: G 6jf-7- c G.7.-c /,7oef447 Construction Supervisor's License#(if applicable) / a r efiESS �P(� 1O� �a 1�+i1 cZ ❑Workman's Compensation Insurance Check one: OCT Q'g H15 [LI am a sole proprietor TABLE CI I am the Homeowner TOWN O1 BARNS ❑ I have Worker's Compensation Insurance, - UUVV'V Insurance Company Name . ems Workman's Comp.Policy# fitoc • 'Ix- 7o 3 )-Lf0 it -ac/(5-A . Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ckRe-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to l,/,,4-,, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy o he Home Improvement Contractors License&Construction Supervisors License is required! SIGNATURE: Q:\WPFILES\FORMS\buil 'ng pe forms\EXPRESS.doc 1 Revised 040215 The Commonwealth of Massachusetts Departmewt of Industrial Accidents Office of investigations 600 Washington Street Boston,MA 02111 www.mass_gnv/din Workers' Compensation.Insurance Affidavit:BgildersiContractnrsIElectriciansfPlumhers Applicant Information • ' Please Print Legibly Name(Bos sslDrgan anfIntividaai): e F I Biy- ocee.1C .. Address: 2a, 4€%0 1.ic /'z o City/State/Zip: 5 yAvon'td: Phone ,549 3'7QS9,2_ Are you an employer?Checic,the appropriate box: Type ofproject(required): 4. I am ageneral contractor and I I.❑ I aura employer with ❑ 6 New construction employees(full and/or part-time).* have hired the sub-contractors - ❑ 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees. These sub-contractors have g- ❑Demolition working for me in any capacity. employees and have workers' 9. ['Building addition- [No workers' comp.insurance comp.insurance.- g n. required.] 5. ❑ We area corporation and its • 11}❑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 17 ❑Roof repairs insurance required.]I c.152,§1(4),and we have no employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 mast also fill out the section below showing their workers'compensatioapolicy information. i Homeowners who submit this affidavit indicating they are doing all week and then hire outside contractors mast submit a new affidavit indicating such CConttactors that check this box must attached an additional sheet showing the name of the sub-camtractioo-rs and state whether or not those entities have employees.If the sub-contactors have employees,they must provide their workers'comp.policy number. I eta an employer that is providing workers'corrrperrsation insurance for my employees Below is the policy and job site information.Insurance Company Name: 4,,9`rc ' t,-5 G 2.4"-Ge. - Policy#or Self-ins.Lie.#: C — (O . 70.3 l 4(01( . D4715 4 ExpirationDate: 11/3Clite Job Site Address: oZ9619/i A'1 f�� City/Statef t: 8A- .#' 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$1,500,0(1 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fie of up to$250.0O a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify r the pains and penalties ofperfary that the information mationprovided abate is true and correct Simrature: Date: IC 74),7 C f s' Phone#: `70J) .7 9$q 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.fityf£own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information an • i structions Massar_hus- General Laws chapter 152 requires all employs,• to piuvide workers'compensation for their employees. Pal suantto ..,' statute,anemployee is defined as-"_.every p.3r on.in the service of another tinder any contract of hire, e xpi css or rap' ed,oral or written." • An employe-is a-fined as an indivir'na],partnership,also . on,corporation or other legal entity,or any Lwu or more of the fur eguiug a':-. is a joint enterprise,and mclaiTin the legal rcju esentaiives of a clr.. red employer,or the receiver or t nstee o.an individnal,partnership,associatir. or other legal entity,employing employees. However the owner of a dwelling .k.nse having not more than three ap •••eats and who resides therein,or the occupant of the - dwelling house of ano er who employs persons to do wads ce,construction or repair work on such dwelling house or on the groTmrls orb •h": appurtenantthereto shall'•tbecause of such employment be deemed to be an employer." " locallicensing agency shall withhold the issuance or 2 §25C(6) - o y(�that"every - or Pn�¢ g cy MGL chapter 15 , to construct buildm . in the commonwealth for any ' ease or �•,- too operate a bIIsnr—` or t� ofa license renewal peP applicant who has not produ•-• acceptable evide.ce of compTiance with the insurance.coveragerequired?' Additionsy Tl ,M 152, states`Ne ■8 ea-the commonwealth nor ally ofits political subdivisions shall GT chapter .25C(� enter into any contract for the p- '•••••■ce ofpnbli• work until acceptable evidence of complian ce with the insurance. requirements of this chapter have b=a• presented '• the contracting authority_" Applicants Please fill out the workers'compPnmaiio..affida• completely,by check ma the boxes that apply to your sitnafion and,if necessary,supply sub-contractor(s)name( , ad•ress(es)and phone number(s)along with their cei L.ificate(s)of insurance. Limited Liability Companies c C) • Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to -• • 'ricers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised th:.'this affidavit may be submitted to the Department of Industrial Accidents for confnmation of insurance coy- • -. Also be sure to sign and date..the affidavit The affidavit should be r et rne-d to he city or town that the appli - •• at the permit or limn se is being requested,not the Department of IndustrialAccidents. Should you have any• • :•. regarding the law or if you are required to obtain a workers' compensation policy,please call the Deparim.• at■:,: number listed below. Self-insured companies should enter their self-insurance lirrnse number on the appropi line. City or Town.OffiriaT.s t _ Please be sal c that the affidavit is comple and printed lei . The Department has provided a space at the bottom • of the affidavit for you to fill out in the e :,. the Office of In,estigations has to contact you regarding the applicant Please be sure to fill in the permitllicrnce Number which will b: used as a refeLcuce number. In addition, an applicant that must submit multiple permitllirsmse.'.pli'cations in any giv year,need only submit one affidavit indicating current policy information(if necessary)and rm.er"Job Site Arklress"th, applicant should write"all locations in • (city or town)_"A copy of the-affidavit that hay „ officially stamped or••arked by the city or town may be provided to the - applicant as Proof that a valid affidavit on file for tutu.c permits o licenses A new affidavit must be-Filed out each year.Where a home owner or citizen is obi—Ai—fling a license or permit n•t related to any business or commercial venture (ie. a dog license or permit to bum lea•:• etc.) irt person is NOT .A -4 to complete ti,ie affidavit The Office of Investigations would like • t}onle you in advance for your ••.eration and should you have any questions, please do not hesitate to give us a call - The Department's address,telephone ands •n•••er: - - - . The Count on tlh of Massachn setts'' - - Deputinent of lid trial Aocidenta • woe of fvesagatio.>u 6QQ W tQn t Bosto MA&2111. • 617 727 49Q 406 or 1-a77-MASSAFE Fax#617-727 774 Revised 4-24-07 www .R•5 goy/Ea i • r 444790 * r * BARNSTABLE, Town of Barnstable 40 mob Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I H• /tat r f, /� as Owner of the subject property hereby authorize e `�� �e'GUr to act on my behalf, in all matters relative to work authorized by this building permit application for: 63 8 l\NAdte . (Address of Job) Signs e of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. P Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services g r3' ioF1HE Tqy� • Richard V.Scali,Director _r pk , Building Division BARNSTABLE. • Tom Perry,Building Commissioner v� �0� 200 Main Street, Hy nis,MA 02601 '°rEc � www.town.ba-nstable.ma.us _ 0 ice: 508-862-4038 Fax: 508-790-6230 • HOMEOWNER ICENSE EXEMPTION P se Print DATE: JOB LOCATIONit \ number street village "HOMEOWNER": n e home p one# work phone# CURRENT MAILING AD RESS: - city/town state zip code The current exemption for 'a omeowners"was extended a include owner-occupied dwellings of six units or less and to allow homeowners to engage an in•,:vidual for hire who does of possess a license,provided that the owner acts as supervisor. DE I ON OF HOMEOWNER Person(s)who owns a parcel of a d on which he/shes-sides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detac -d structures acce .ory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not :- considered a a.meowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,tha.he/she shall a e responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes res a.nsib' 'ty for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/s ic understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will •la ply with said procedures and requirements. { Signature of Homeowner Approval of Building Official Note: Three-family dwellings con g 35,000 cub'.. feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEO` 'S EXEMPTION The Code states that: "Any home ' l er performing w+ k for which a building permit is required shall be exempt from the provisions of this section(Section 09.1.1-Licensing of Instruction Supervisors); provided that if the homeowner engages a person(s)for hire to do such wor that such Homeowner ',all act as supervisor." Many homeowners who use this ex mption are unaware that th are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for 'censing Construction Supervi Trs,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 uld with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. \� To ensure that the homeowner is full aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner ce that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 040215 ' �ACORD CERTIFICATEDATE(MMlDDIYYYY) OF LIABILITY INSURANCE 0911012015 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 pollcy(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 endorsement(s). PRODUCER 02806-001 DIAME:CT Leonard Insurance Agency (i4/C.No.Est): I ME7� "'C.No.: 683 Main St Ste B Osterville,MA 02655 INSURER(S)AFFORDING COVERAGE NAIC M INSURER A: A.I.M.Mutual Insurance Company 33758 INSURED C & F Remodeling Inc INSURERS: INSURER C: 20 Captain Noyes Road INSURER D: South Yarmouth, MA 02664 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 MA'LBE 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 yyBppYppp PAID ppCLAIMS. � to fit TYPE OF INSURANCE la)A1VD POLICY NUMBER (MNIIDD/YYYY) (MMID6/YYYY) LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PDAMAGE TO RENTED PREMISES occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ —1PouCY PRO- JET -OC AUTOMOBILE LIABILITY • COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS _AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE _AUTOS $ (Per accident) $ UMBRELLA UAB —OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS MADE AGGREGATE $ DED RETENTION $ " RMg APNApT .. X TyOTqiT-S AONNCEppMMRRnppCDDECUTIVEyy���� Dt?RH' $ N/A AWC-400-7032424-2015A 4/30/2015 4/30/2016 E.L EACH ACCIDENT $ 600,000.00 (MandatoryneQ Inb NH) QQ�� E.L.DISEASE-EA EMPLOYEE $ 500,000.00 DESsCRIPTION VgPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space it:required) CERTIFICATE HOLDER CANCELLATION FBO Construction Inc PO Box 285 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE W Hyannisprt,MA 02672 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE �y @ 1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD e- C�i/e cYrwr�aarecaetcl o/C�/ a��ccc/cr�ett License or re istration va;lid for individ�' trite of Consumer Affairs&e Business Regulation • g I ME CONTRACTOR before the expiration date. If found rett, gistration 153792 Type:' Office of Consumer Affairs and Business 1T TO Park Plaza.-Suite 5170 '�, ' iration 1/8I2017 ; DBA. Boston,MA 02116 nODELING •, 1' e E ,yt ;t t ,---' c 't.,,,,,, 4";-j: ly, k iL . }bS FIGUEll OPT t c tie PTAIN.NOYES RD �; to:1=y. _fr �. F2MOUTH,MA 026044 _ Not valid without signature , .. . ,: . ., . tit_ itMassachusetts Department of Public Safety �, Board of Building Regulations and Standards License: CS-104107 Construction Supervisor , , • 1,1 I. ,�� 1 *: .: CARLOS H FIG UEIROA,e;� �c� "� 20 CAPTAIN NOVE pg % ` .r SOUTH YARMOUTH, I .�` - " ixifty, _, . • - .. ... '1 11 1%1,` 1NI,..AA l_n/l__._ Expiration: . Commissioner 08/25/2017 L . J TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ck� Parcel 01,c. Permit# , /0 f Health-Division Date Issued �40.1 ` � Conservation Division - Fee 75 c 5 • CO Tax Collector '. �i /k Treasurer CnF. /0- /?1 , • 4 Planning Dept. Date Definitive Pr<n Approved by Planning Board ' - %e )c c`,4S W•1-h 'Historic-O S#MP 4 (-7)Preservation/Hyannis sC - Project Street Address '1 0 $• M6-1/4 STD il. • _ • : 6 'Village -EP'e2%o5 �� Owner t)P. 1+. w/3LT k 9 E Address •02cc J num Si team.strx/c Telephone 5--A 1 3a)o- — 33 53 Permit Request Rt,pL. o ter- rRcloGliG, CY) Real-- P 4Ol� ri. ,eaoF tW of 04/4 Ilse (Lvbr. C ✓ ledi nos. n 4) 'I/,; S'Q t Square feet: 1st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost #6, 7LiO Zoning District Flood Plain Groundwater Overlay Construction Type ii . ' - Lot Size Grandfathered: ❑Yes XNo If yes, attach supporting documentation. Dwelling Type: Single Family k Two Family ❑ Multi-Family(#units) Age of Existing Structure . Historic House:` Yes No On Old King's Highway: 10Yes ❑No Basement Type: ❑Full O Crawl , ❑Walkout ,0 Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) . Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new I Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas 0 Oil ❑Electric ❑Other • - Central Air: 0 Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes O No , Detached garage:0 existing ❑new size Pool:❑existing ❑new size• Barn:0 existing ❑new size '" Attached garage:0 existing 0 new size Shed:0 existing ❑new size Other: . Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes to If yes,site plan review# . , Current Use Proposed Use BUILDER INFORMATION / Name �/1 1 Z2-1 /'7Z5n1 r AJfl L Telephone Number Z.2 ir` I s7 f Address 16 ci-.r D4 "Dik_(A1 License# CS '7,21 7 /9 COQZCIT th 4 6 3c Home Improvement Contractor# 106 2 VO Worker's Compensation# GJC5'g- 6 6 r/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO . 43 / ice; y#72.6 SIGNATURE jf(4,Q11,1iit.� `'GAFF., DATE _ • /Q /l f/1 y _ c, FOR OFFICIAL USE_ONLY ' _ . • - , . r. PEtMIT NO. - _ - -, DATE ISSUED _ t, -, rr ' - r y" _ -. , . , ) d 4,, t r `vv 1 , _ 5 Tr -$ .1 Ir MAP/PARCEL NO. . + L , .- ADDRESS VILLAGE r . t x Y r: , 7 • • t - k + �. ry, x P , •.ti 1 1 . # . ;� OWNER ' { ... I _ ) :. - _ I. ` sn fa r - DATE OF INSPECTIOI�L '"f FOUNDATION -. — _ ., ( • _ ,' ' _ ' _ q.. s h'r ..-r- y. • FRAME i f r rs • i;t' ; r 7. i , r a M 4 r 'c r e INSULATION, ., . , c `" < • FIREPLACE t ,i,• - :.• 6-, , ELECTRICAL: ROUGH FINAL• ••-.. • ", t r - a - PLUMBING: ROUGH _FINAL - f j ? - - `~ GAS: ROUGH FINAL - 1 • . ` , • . FINAL BUILDING • x 1 - , '' - I, DATE CLOSED OUT ''' - , ASSOCIATION PLAN NO. R : 3 ,j A'', b ; tom• N. f -ti L . 3 s r