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Home My WebLink About3760 MAIN STREET f a i y V fli y , 33 f II : . t ., . . ., 4 �� d a r r, Town of Barnstable Building^�. •^' ;v,� .aF.�. :, :..i�'"�:;. e:,.� �^.fie,:' �v. kI�'�• .,�'' �..., � •�.,� <. ,+�, , *.:, MARNW PostThr :Card So That�t is Visible Fromthe.S.treet-Approved Plans_Must be Retained,on`io6 and this Card Must be Kept ' sBaaeP shed Until Final'InspectonHas Been"11/lades e R Where a Certificate of Occupancy is Regouired,such Bu�ldgshall Not be Occupied until a final Inspection hags been mady Permit Permit No. B-17-3587 Applicant Name: COLONIAL RESTORATIONS LLC Approvals Date issued: 10/30/2017 Current Use: Structure r Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/30/2018 foundation: Residential Map/Lot: 317-028-001 Zoning District: RF-2 Sheathing: Location: 3760 MAIN ST./RTE 6A(BARN.), BARNSTABLE Contractor Name: COLONIAL RESTORATIONS LLC Framing: 0 Owner on Record: LEHMAN, MATTHEW C&FORT, ELIZABETH ' Contractor License: 108470 2 Address: ATTN:ESCROW REPTG MC DFW 4-3 fi �=v Est. Project Cost: $ 10,885.00 Chimney: WESTLAKE,TX 76262 � y Permit.-Fee: $ 105.51 Description: Replace Joists in area measuring 14x8 w 7x4x8 oak joists Insulation: Fee Paid: $ 105.51 Project Review Req: Date: 10/30/2017 Final: Plumbing/Gas Rough Plumbing: -_ "- Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by�th s permit is commenced within six.months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which,this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structur s shall be in compliance with the local zoning by=laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public-inspection for the entire duration of the final Gas: work until the completion of the same. I s ��Y Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are.provided on fhispermit. E� Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or Footing 2.Sheathing Inspection ar p a u Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT loft TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION, ARN Map Parcel . - , A1140 STABLE Application Health Division f. }t `j ? A Date Issued �� 3a IQ" Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board .r .1 Historic - OKH - Preservation/ Hyannis �L Project Street Address 2 710 Village �� Owner /o �' �� z r-} Address A o Telephone r t O, r Permit Request �e l&u ;d S ;„ a-ea x� 7 8 L Ou� �Ois TS Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation y I r7�T?S•©o 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 ❑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 ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J C' ee Telephone.Number Address 7 Y -0 P, License# LS U 7 8`-1 0 Pdl I.J., AAA Home Improvement Contractor# 1 0 y 70 ( 1 Email ( I., �r o 60 c r C o ^1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S a'� e ✓c-S oS C SIGNATURE DATE 7 Ida f 7 _ - FOR OFFICIAL USE ONLY * APPLICATION # DATE ISSUED MAP/PARCEL NO. e ADDRESS VILLAGE - OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 4GAS: ROUGH FINAL --FINAL BUILDING DATE CLOSED OUT i s ASSOCIATION PLAN NO. � 1 t .lip Commarnrealth-of-4&ssadiusetts. O Ce OfInw-lrgatEahs t �. r 1590 WasArngtoxtStreet ! J Warlmrs' Camp ensiUm Inmn-mc 1Aff-rd zyib$,m"lder7s/C�unfradursMec�s/Phnnhers App1fcan1 Info=bun Please lint F HIV City1` fatig �`t-� d r s a l Phone:g Areyou as employer?Che:ckthe appropriate bor_.. • T ' I am a general confractor-and I 1�cf project(required): L❑ I am a employer wi fi 6. ❑New cemsfructim ,�, employ.ee3(fall an&orpart-ime,* iiavehned-fhe mb-contmdars 2-Lam"I am a sole gmVrietc r orpastuer lisfed oaiime attached sheet. 7 ❑Remodeasng ship and haves no employees These m b-cantractom base • 8..❑Dem.DIE= w ing fornm in any capacity. employees and.hare wadmr* �- El Building sdd�iuu [Na ty es' camp.iusumace comp-insnraQt L$ recF&ed_] 5- ❑ We are a cotporafion.and ifs 10.0 EleoZical repairs or ad€Stioas officers haveexe�edtheir 1L Ph=bin. re aim or additions 3 ❑ I am a hameowher doing alt world ❑ lr P mysdf[No W09mrs'camp_ tigb-t of caemprfion per M-GL ❑Rnof'r .c . insurancee gied [ ae.m Fl°ggeeIs-[Naon�dvwoe.ehrasve no . . / rr`� comp_tusks required.]I ` `�YaPFfi��stcbed-�5ax�ltaastaLsaffia�thesectfoaheTa�sTsurong�ie¢wo�ced�prasatinapoyepin�rmsamL . Snmeovraeis�ebo sabot iris�6da<<u ia�caimg shay axatiaia�affcaa�c au�.tbenha2 oatsdecoa��+*�nmtt sn5mitaaezv�d�-eat�^��<sacTi F fCa�xsetos3�ehedcthrisbmcm�stzt�rhe3�mtad�fiansls3�tsI�nticiagtleeaua�ofll�esu7s-c�dxsrto-s�dstatetxheti�etarnot•r�nseeatitiesba� .. emp3oJ2es.TfthesnTo-toadt�es7u�eempIo�ffieg�stgmvidtt]Lit unrkffi'�amp.pali�aumbct - I am art irmirmica fbr my emFIglrem Mow is Aepa-M7 ad jab zFta in-fcrmafian Ins=MceCompanyNatne: Poficy or Self-ms Lid_ �pirafm Date: Job Slea Addre= Cifylstafd4p: Afla-ch a copy of the workers!compensationpolicydeclaratidm page(showing the polacy namher and e=piz-atbn date). Failure to secure coverage as requiredunder Section 25A o€MCL m 152 can lead fo the impositba of rAminai penaHies of a t up I a I,Saa UU and'or ane-year implisa eu as well as civil penalties.in the fo=of a STOP WORK ORDER and a$ne of up to$M DO a dap aaaind the violator. Be adtised ffvat a copy of this tat mzy be f xvmded fn the Office of Investigations of the DFA far insurance coverage-mific alion. I da hereby eRrh f3�r;au�x tics pains !f]5�tftatths hz brmafim1 rm-idzd aborg is bars an d carrect Simature_ Date /-�L 1 t Phone �� • �3 - 9�o 0,0EdaI uss MI�V DDo ctnt errata ift tidS Arai,tfr be-crrfcsgl'eted bg diy artair�ti njOaeuri City or Town: Permiff1cense# Is g kutlmrffy(ca cIe ane): L Board of Health r.llnffAing Deparft eat 3.Myffown.Clerk 4.Electrical hmpectar S.Pfumbiag hivector 6.Other Contact Person: Phone it: —-- — —- 6 nf orm�atron all has hfassa,h=etfs Geese rg Laws chaps 152 reqcdres all®pIoy=to provide workeas'coarpensatton.for$sir M[3pI0Yees- PnrsQantin this sue,an Inyee is defined as.¢:Cvmypersanm the service of antler u.d=amy C°ffra r-t°f hil� empress c r implied,.O ai or b." oraf m or other legal e�y or any two or more " An�Ivyer is d�fined as¢era iildrvidztal,par(nersh�,asso�iior�cc � I er,or$ie of D fbregoiig engaged is a joint 'and inalndmg the Iegal reFSenf�iy=of a deceased emp.oy or twee;of an mdrvidoal,par�sh�, assoGiaiion or other Iegad entity,�y�°�Ioy�- However the MORMnc�x a dwrMag hmse hag not mcae thm three'aparimeEs and�vho resides therein,or the occupant of the- nse of anot r who employs Persons to do mai�aace,Conch .Fi off,or repay woad as such dweIlmg howD � .nar¢fheretn gnnnatbecanse of such mcploymedbe deem bean enxplay�" or on tiie g}otmds or bmldmg app MGL cT�apterk,§25CC6) sfaiL-or local l CMS1 M agency sTaal[ - old die issuance err a]so sfafrs� e°ve1[�erg to o erate a J�usiuess or to construct bmldings' e co on�ealt3i for any a prental of Pa_pplicantwbrodnc ed acceptable evidence of compHancewith stance coyeragerequ>z - irr I52,§25C(7)stairs'Tei thZr the nor jay of its political snbrTv%sions shall eniEr inkny a coaiiac for the pew cd ofpvbliGoa uitr1 Ie cvidnce of compliances die i�s��c •. raT3iM=[EG offhis fErhavelieenprnseatedin the s ozdy." �P Iicanfs . Phase BIL o� the wo]�S eusaiion affidavit co ,by cog -ac boxes�apply to your enation and,if sab-co s)nane(s), address( andphoneruxmber(s) alangwithe cecte(s)of necessary,sngply s v1itllno Iflyees other than the inmxra:aCe Liab�y awes(MC)or Lisb7ityP��IP (LLP) �P members orparin=y,are,not ' fo cagy Co=T eosaf ion ir-c a ce- If an LLC or LLP does have T ees a policy is adyisedfhat a$dayitmaybe sohml ed to the Depaifineat of rndastiad �-oy P cY - Accideds for confumafion of . ce cove Also be sure to sign and date e afrEdavrt The affidavit should bez>;inzaed fn$e city or town fhst �appIi for the putt or license is being requested,not file D epar[m enf of Ir�Sixial 1Lscid - Sbonldyon have 'ons g the Ian or ifyon are rued to obiaia awork s' r their camp ensafionP olicy,PI ease call D eat at the number listed belov�: Self-insured co�anzes sTianld en� self-in��ncelicensenmberonthe lira. LIty or Town C MM dzls - r Please be sore that the is comp lete - leg ib,. The Deparimenthas provided a space at tTie botiam has to co» .yoaregardmgthe applicant of the affida�for you to o�i a the event tit ce ofInv an licant Please:besUtetnf171in peamitllicensemtnber VMbc�edasareferencen�b -Inaddbion, aPP currmt �must submit nzul$xple PMmitUcense applic�i is any given year',need only sohmit one affidavit Indira g and under"Tob Ste T_r_ ess�the applica�shouldwrite aa.Ulocatibms in (Grit'or - p olio in�COPY hoCif dfa e:d or marked by$ie city or town maybe provided to$ie ibwn) A copy of the affidavitt3iathas bed officially applic�t as proo f f3�at a valid affidavit is an file z6r A permits or licenses A new affidavit�st be filled o ea Gh a Iioease r ennrtnot r$7atrd to may bminms or com mm-c ial year.-Where a home ovine-or Chi=is obfa�g P to��this affidavit (ie.a dug license orpeunitfn b=lea4es etc.)saidpe�son " O1 reqjred The Office oflnyeSdg?fl= vldLketntla:okyonmadyance your coC`PMzt nand sbouldyonhave myqc�ons, phase do nothcsfafe to gimm a c�M The geparim eut*s address,trlephone and fax m3 bm: �` 1 f:z)-nMjaaVe8jt3E of Masa.Gh ' �Q11nd�cialA � ' El f?3]=MA 02111 Fax gevised¢24-)7 - g —AP fa Colonial Restorations.LLB Bam House ! Leaning 0 a fad Grm- SOB?35-3�0{1 1 *t s ti 981.WM Tom Gran $Nww.Gf1981xvin 4 Massachusetts Department of Public Safety i �J/c1 r,r rx rzufealllr o � j. �arlr�eft '' * Board of Building Regulations and Standards t Office of Consumer Affairs&Bus ess Regulation ` License: CS-078132 HOME IMPROVEMENT CONTRACTOR � Construction Supervisor — Registration '4.08470 Type: - Expiration $t1w0-18 Partnership YT BRAD FORD GREEN i 74 DUG HILL R® ,+ COLONIAL RESTOI�AT S L HOLLAND MA 04621 Thomas Green I 74 DUG HILL RD. - = ,Ix_ .- h HOLLAND,NIA 01521 Undersecretary ' ,rv� lJr Expiration: 1 commissioner 08122/2018 - y TOME 1WROVEMENT CONTRACTOR COLONIAL RESTORATIONS'LLC 74 DUG HILL RD HOLLAND,MA 01521 31lG� LIC.!REG NO. EFFECTIVE EXPIRES HIC.0646928 U/-30/2016 . _ 39 017 ... .... — ...... CD -------------------- 5 J p a 4G S e J e l"2 a l a c e rLz J Town of Barnstable Building Department Services d Brian Florence,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, �l ,as Owner of the subject property hereby authorize C raD—. to act on my behal& in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections e performed and accepted. S' tur of Own Signature of Applicant Print k=e Print Name Date Q:FORMS:OWNERPERMISSIONPOOIS Rev:08/16/17 • Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 srmHsrn1= iA www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: n street village "HOMEOWNER": t name _ - home pho #g work phone# CURRENT MAILING ADDRESS: cityho state zip code The current exemption for"homeowners" exten to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire .o es not possess a license,provided that the owner acts as supervisor. DEFINMON OF HOMEOWNER Persons)who owns a parcel of land on which h sh esides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structure access to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be consid d a home er. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/s shall be re ble for all such work performed under the buildin ermit. (Section 109.1.1) The undersigned"homeowner"assumes sponsibility for complian with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that h she will comply with said proved s and requirements. Signature of Homeowner Approval of Building Official Mote: Three-family dwellings ontaining 35,000 cubic fie, or larger will be required to comply with the State Building Code Section'127.0 Construction Control S OWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fomtc\EXPRESS.doc 08/16/17 l Town of Barnstable � . . t Building � —�. ' ' � -�. � So�That rt's Yi'sible:'From�the%Street A roomed'Plans Must.be Reiained o`n�'Job andathis Gard Must�be Ke t PostTh�s Card pp � f p Permit • R = �� _. a ccu'ied until a.fn�al°ns ectrori has been-made.° 1 el mit ' ems ,: ',here Certificate of Occupancy;�s Required,�suctrBu�ld�ng shall Not�be 0, p p , Permit No. B-17-1813 Applicant Name: COLONIAL RESTORATIONS LLC Approvals Date Issued: 07/24/2017 Current Use: Structure i Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 01/24/2018 Foundation: Residential Map/Lot 317 028-001 Zoning District: RF-2 Sheathing: Location: 3760 MAIN ST./RTE 6A(BARN.),.BARNSTABLE �y Y . Contractor Name COLONIAL RESTORATIONS Framing: 1 Owner on Record: LEHMAN,MATTHEW C&FORT,ELIZABETH E �� , � �� LLC 2 Address: ATTN:ESCROW REPTG MC DFW 4-3— � - .Coritror License 108470 Chimney: WESTLAKE,TX 76262 E ProfEctCost: $ 15,37U.00 Description: Replace 71/2 x 8x12'Beam(in kind w/new oak beamn cellar, Permt Fee: $ 128.39 Insulation: replace 8x8x14 ft and 8x8x10 ft. Beams(in kind with new oak beam in final: �/s /��Ick cellar fee Paid: $ 128.39 D to 7/24/2017 Project Review Req: Replace 71/2 x 8x12'Beam (in kind w%new oak"beamVn cellar, Plumbing/Gas replace 8x8x14 ft and 8x8x10 ft. Beam s;(tn ki d w�thynew oa Rough Plumbing: beam in cellars ,... .' Final Plumbing: Building Official Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six,months after'ssuance. g � � All work authorized by this permit shall conform to the approved application and the approved construction documents for which•: this: permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structu es shall be incompliance with the local zon rig by laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open or public inspect+on for the entire duration of the work until the completion of the same. Electrical Service: ®r The Certificate of Occupancy will not be issued until all applicable signatures byhe 8uildingantl Fire Offic ials-are providedonthis permit. Minimum of Five Call Inspections Required for All ConstructioJWR n Work: 35 Rough: 1.Foundation or Footing °~~ ~ � ��' 2.Sheathing Inspection final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame inspection) 6.Insulation Low Voltage final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site. Final: AII:Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma 3 I� Parcel : r p a cel Application # Health Division D Date Issued 7 � Conservation Division LU Application Fee Planning Dept. (D 0 Permit Fee �a 3q . co Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyanfi�, ' CD 0 Project Street Address 76 C Aar E�- Village bas s�{0i10 Owner !w�� w 4 j Le. �,MG n Address 7 E® Al r Telephone Permit Request _��nl��e 7 1; Y x �� b�►, �,�� , , ��.�� a�I� �a,�� c� �IQ� p , i �� I��B D°� x )4 ` x r ( a b�u..,s C; �✓� /L¢_Q., CIA Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation I�;,370.Qo Construction TypeT 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 ❑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 ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number 7Y S-- 9 It C o Address 7 y :� I-I II Q _ License#_ C.S r 0 7 Fr 1.3� P S I CJ . a Home Improvement Contractor# 10 9 1 7 Email o I) c r 19 1 . c G .Y, Worker's Compensation # ZIA ,�,s s ALL CONSTRUCTION DEBRIS RESULTING FROM lTHIS PROJECT WILL BE TAKEN TO - SIGNATURE DATE 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. II - . TTi�Co>Rzrr�arrfs�ealttlt�jf?�`rrssr€�trisetts Department afTririrrsfazalAct:tderrts M- t Of C.0 oflUmfigadmis . 600 Waslifirgton&reet y Bastion,ATA 02111 fvivi-n,biasrggovldirr NFarkers' Ca mpensaffa n Iusai-ance Affidavit:Bn ldex-slContradursMect icians/Phmihers Applicant Inf nmatinn Please Print Le Name L C Address: `7 `� citylstatelzip: W�4 � /M Areyou an employer?Checlstheapprapriatebom ' T . eof ( �rect j re am a general contractor and I g*10yew(RAl an p L❑ I am a employer with I b❑ �. ❑New cansfzmrtia4 d(orpart�time * 1 avehiredthe sub-conractors 2. I am a sole proprietor orpartner- Usted on.the.attached sheet. 7. ❑RemodeHn!? These sub-contractors have ship and have no employees $_ ❑I]emolitiort woddng for in any capacity. employees and.have Wolkas' 9. ❑Building additioa [NO WP63ZrS' txfmp,insurance Caine.insumnml required] $- ❑ Mite are acorporation and its 10:[]Eleetacal repairs or additions 3.❑ I am a homeowner doing all work officers have•exercised their 1L❑Plumbingrepairs or additions. myself(No workers'comp- might of exemption per MGL 12_0 Roofrepairs i*+m ce required]1 c.1.52,§1(4k andwe have no employees.[No wo&ess' 13.[lOtluer tee.p—r S cone.insurance required_), •6.ajr qT icmtdhat checks box R mat Rlsa M outthe sectimbeLav sUusiag i ie"s�ieis'compeasatiaupoTIcg irdormsEiun TM, meoanemwho submit d"sisiffLda[,rinduating they are.doins2Uvral=4&eahirea•utsidecontnctorsamstmbmitanewarffidavitindirginarnrR fCag=ctors ff=t checlrihis boa must attached m.additional dma s1mwfng theaam.�e of the sub-comirsrkra and state whether arnat those entitieshav ewiuyees.if the sabtantactarshiceemployee%theymrstpmvidetheir worken'romp,paricynumber- I arrr are employer er that;is pm direg,warkers'campvLsrdio-n himirimcefor ary anrpla},e¢s $elope is Agpo-M7 curd joh xix informs dom Insurance Company Name: 'Policy 44 or Self-ins-LicAl 5 pitadonDate: Job Rte Address: City/Stater : Attach a copy of the war hers'con pensationpoliry-doclaration page(showing the p^Iicy number and,empiration Fate). Failure to securer coverage as requiredunder Section 25A of MGL c- 152 can lead to the imposition.of ct imi nal penalties of a fine up to$U.00.00 andfor one-yearimlxisoran—f as we-11 as civil peualties•in the form of a STOP WORK ORDERand a rme of up to$250-00 a day against the violatur. Be adiised ffiat a copy of this statement maybe forwarded to the Office of Investigations of the DIA far insurance coverage yeriffcadon.- 'I'da lieraeby=dfj,u.PuLar tlrsprarrs information-prai.-i €d a6ove is t rua and carrect Signature_ Date: r a S Phone lk SF - 73 S-= ys y c/ Dfjacird use icily. Do rrat o-rrrta rrr fFafs axeQ,tv be coltsplete�d b}city+�i-ta pr n o; rerat City or To-nu: PermitfLicense:9 Issuing Authority(drele one): L Board•of Healffr 2F.Building Department 3.City1rown Clem 4.Electrical Inspector S.Plumbing Inspector 6.Oth-er Contact Person: Phone#: — -- — — 6 � ormatian an(I fas efions ifassachzzsetts Genezal Laves chapter 152 regmres all employes to ProvideworkCrs'compensation for their employees_ Pm this St&t$,an rm'PIayae is detmed as-k_.evecyperson M the service of another under any corlrart Of hire,. Mpress or implied,Ord arvi" err�Ioyerefined as"an mcfividnal,Parfne ,associAn ation corpazaiion or other legal etclity,or any fv�o of more. r m a oint andmclndmg e l g�lrEgres�fi=6f a deceased empIoyer,or,the. of the fnregojog Aged 3 Vie,. o to ees_, Hovzeves the receiver or trastee;� an individual,paztae6hzp, association or o Iegal entity,�empl yng crap y owner r a tmste:dvmu ?g a having not more than.tI=apmime and�o resides therein,or the occapant of the- dvPelIinghorse of ono er who employs pesons to do m - ce;consfractian or repair ve°dc on suc7i dweIlmg 1ioIIs�e or on the grozmds or apPurfenaatthereto Shan tbec a of saah emplcymentbe deemedto be as e3ployer_ MCrL cbapter 152,§25c(6) sfafes t ¢every sfa_ia or Io Rcemi L9 agency shall TifhTiold$ie issaance ar renewal of a license ar Pe \ to operate a business or to nsfruct braldmgs is the coznmozrePealth for arrp applicantvQho Jlas notprodnced acceptable evidence of mpliancetvifh the insuragce coverage required. u AdditionaIly.MCrL cbaptrx 152V!=C�M]'c sues aldeithcr comma awe;alft nor amy ofzts political subdivisions shall meter min any contract for ihepofpablic acceptable evidence of compliancevrrth the mom .. r_ Cure of_d i chapter have.l eeenpreseniEdto thO c ting.aailiozity." Applican-is - the boxes that apply to your sitnafion.and,if Please fol oi± the wozlrers'compensahon affidavit co letely,by rherlg aPP s of nerressaiy,supply -contracfnr(s)name(s)° address( )andphonenumber(s) aIongwith their cerlifrcate() ffi=7ance_ Lim f d Liability Compaoies�(LLC)or L- LiabilityFarfneiships(LI P)�erthno employees other tban the members or parfnep,are not r-bqz 6d.to ®cagy ve orlr 'compensation insm mc,_ if an LLC or LLP does have employees,a policy is required. Be adyised�ihat - affidavit maybe submitted to the Department of Industrial Accidents for confirmation of i mn-;m coverage Also be sure to sign and date Jne affidavit The affidavit should bez•etnmed to$e city or town that the application o'the permit or license is being requested,not the D epartmeat of ' fife Iavr or if n are, to obtain a workars' dial A ecid= . Shouldyon haYo'aay g yo req ed axes&Iionld eaater.thea Corapensationpofiey,Please ca Ith6l) p 'dbelov. Self-iosmedmp self-fil rn ice License number on the appro • Lie City or Town Officials r - Please be sore that tb:o affidavit is coMplete d legibly. The Depadmeathas provided a space at the bottom of the affidavit for youth frIl out in the eve the Office ffnvesdgaiinns has to coufactyou.regardmg the applicant Please be sure to t17]in the penitllicense number which be used as a reference number.In addition.an applicant that must sobmit multiplepemihMcense Rlitahons is green year,need only sabmit one affidavit indiratmg dent policy mforsaation(ifnecmmy)and '7,ob Site Ad&r ' "the applicant shouldwate"aII Iocatiuns m (�Y or town).-A copy of-the,.affidavitt3iat has officially strn2 or maticed by Ahe city or town may b e provided to the applicant as proof that a valid affidavit is �n.fle for futare'p or licenses- A n6w affidavit zm st be fIled oirt each year.Where a home owner or citizen is ottaining a license or p not related in any business or commercial van e dn.)said p - (ie.EL dog license or pemut to bwn Ieav erson is 1�T sd to con l2lete this affidavit n - The Off m of Tnvesti gaiioas would]Jke to 13�ank you m advance fo!your cooperafian and sbovld yo have miy 9 ons, ' plcese do nothesifaIe to&eys a caIL The Deparrtmwfa address,iElephone faxn�bez: 1 �am�asxealiir ofchntts Dent of�d�ria�A�d�nts. .. floe ref�t.�e�g�tio--�; • ��an Sizes � ,, a-i-t27-4qoo i�Lxt 446 or 1-977 MA MAC Rai6.7727 M R.evised4-24-07 W W masE�gq,ddia , I �TKE ToWn of Barnstable Regulatory Services F RLRNNSMARTM Richard V.Scali,Director 6;m�� Building Division Paul Roma,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 t If Using A Builder I, Q� 1��Y' `'v� , as Owner of the subject property hereby authorize 3 rA -1ee-1 A, 1 o,:u( 4123 14:d-^I to act on.my beh4 in all matters relative to work'authorized by this building permit application for. � � a S � (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature o Owner S' e of Applicant Print Name Print Name Date i I�I QYORMS:OWNERPERMISSIONPOOLS Town of Barnstable =' Regulatory Services tME r° , Richard V.Scali,Director ti Building Division s°vszwst.E. Paul Roma,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862'>4038 Fax: 508-790-6230 \ HOMEOWNER LICENSE EXEMPTION Please Print DATE: �) JOB LOCATION: number street / village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 9 city/to state zip code The current exemption for"homeowners" as extended to include ownerkccupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a lice e;provided that the owner acts as supervisor. DEFINITION OF HOoWNER Persons)who owns a parcel of land on which /she resides or intendto reside,on,which there is,or is intended to be,a one or two- family dwelling,attached or detached structures cessory to such us and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered homeowner. Sup h'"homeowner"shall submit to the Building Official on a form. acceptable to the Building Official,that he/she shall a res onsible or all such work Rerformed under the buildin ermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility fo oni°liance with the State Building Code and other applicable codes, bylaws,rules and regulations. o` The undersigned"homeowner"certifies that he/she unders� ds a Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply //sai rocedures and requirements. Signature of Homeowner f �,f Approval of Building Official Note: Three-family dwellings containing /5,0,00 cubic feet or large will be required to comply with the State Building Code Section 127.0 Construction Control. p H MEOWNER'S EXEMPTI " The Code states that: "Any homeowner p9rforming work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1€ Licensing of construction upervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exe ption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Libensing Construction Supervisors,Sectii,n 2.15)xThis lack:of awareness often results in serious problems,particularly when the homeowner hires unlicensed person . In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The hom owner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many co munities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilitie of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt sue a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 0.1 ; Colonial Restorations,LLC Sarre a� House Sills ° Leaning ° Sagging IPOTTED 'Grad Careen 5 08-735-9900 7p'n r3 wwwxr1981.com o@cr1981.com r Massachusetts Department of Public Safety Board of Building Regulations and Standards /„n rir7�no�rttecr��/q//i?114csicic�ra all° e Office of Consumer Affairs&Busi'uess Regulation License: CS-078132 -- HOME IMPROVEMENT CONTRACTOR Construction Supervisor - Registration 108470 Type: Expiration 8/18/2018 Partnership T BRADFORD GREEN 74 DUG 14ILLRD COLONIAL RESTORATIQNSLCC HOLLAND MA 01529 Thomas Green 74 DUG HILL RD. HOLLAND,MA 01521 Undersecretary Expiration: '� Commissioner 08122/2018 W u moo. o -_ HOME 1mpROVEMENT CONTRACTOR COLONIAL RESTORATIONS LLC r 74 DUG HILL RD HOLLAND,MA 01521 � :4 L4C.i REG NO. EFFECTIVE EXPIRES U" 1 HIC.0646928 11/30/2016 ate SIGN �_- 1 CP 106 to/z // -Z it �2 V%x Ir e � c t .. III �R4 � � • � From: Mckechnie, Robert Robert.McKechnie@town.barnstable.ma.us Subject: permit application 3760 Main Street, Barnstable Date: Jun 23, 2017, 8:37:31 AM To: <info@cr1981.com> info@cr1981.com Good morning, I will need a drawing showing the location of the work you have proposed for the subject property. Also show the elevation and the bearing points with a description. I will need this information before the permit can be issued. Thank you, Robert McKechnie Local Inspector Building Department Town of Barnstable 200 Main Street Hyannis, MA 02601 508-862-4033 _ G /�Gr/ �t"�,�w. Town of Barnstable *Permit# tres 6 months from issue date ' Regulatory Services Fee y MASS.IEg Richard V.Scali,Director i639 ♦0 k iOtE� 6 V"l R Building Division �) rk � n ra , �PaubRom�;"adding Commissioner (PM 20am Street,Hyannis,MA 02601 NOV 3 ZQ�'town.barnstable.ma.us C� Office: 508-862-4038 Fax: 508-790-6230 EXPRES'S1,NEiRNIIPLICiAaTION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 3 T�� / "t�� Syr GQ /'tS �l Pr 67� `Residential Value of Work$ 6'�0, Minimum fee of$35.00 for work under$6000.00 Owner's Name&AddressC�r :37K'0 rl", KjA Contractor's Name Z/,�e i /V X-l'i-u S k14vTelephone Number — y' 6ff®,9 Home Improvement Contractor License#(if applicable) 2 7�—"G Email:_Yh*tP,& �cod lI c 4-t_a w-@,Wf A-�o. co,-, Construction Supervisor's License#(if applicable) �orkman's Compensation Insurance Che one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance �. Insurance Company Name /J Workman's Comp.Policy# W ��® �/ ?�7e— nee Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ t(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken toY,1"r_e-,0u ❑ 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 O r must si operty Owner Letter of Permission. A copy of a Home I r vement Contractors License&Construction Supervisors License is r aired. SIGNATURE: Q:\WPFILES\FORMS\buil " permit s oc 06/20/16 Ilia-Commomvealth ra,f Massradiusetts Dgprarkmeat a,fly s&hd Acdderdg 600 F{raShhrgtort Street -- Boston,MA 02111 -- kv�vt�m��av�dia WGr.leers' CumpensaGan Insu=ce Affidzv&BmlderslCuntx acknm/Elec&mmus/Phmibers AppHcan#1ufkm tiGu / Please Prm FAY .Name Add�es 2°-� 6'Ce-"' CiWSla.& 0t5?� i-`t fS; Phone 44r: 09 Are you an employer?(Meck the appropriate bar: Z of project r I.❑ I am a 1 with 4 ❑I am a general contractor and I Type Pal (required): rn }: ayees(andfor part-time)-* have Nredthe sulr-contractors 6. ❑1�Te�ooflsirocFiozx 2.EVI am a sole propdetaa orpartuer- Tisted oathe attached sheet 7. ❑Remodeligg sbip and have no emplayees These sub-contractors have g ❑Demolitioa wodang for me in any capacity. employees and bare wogs' 9..Q Building addition [No jy odM&comp_hum ance COLap.insuranim 1 required-] 5. ❑ We area-corparation and its 10-❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1L❑Plumbiagrepairs or additions myself[No workers'camp- right G§I{ ffido�e have no I-❑Roofrepairs. insurance required]1 c. employees.[Nowotkers' 13_❑Other co=p_msuraace required-] 'Anyapp&csv�a 'cbedsb=#1nmstaLsafiIloucthesectiaaheTow iheirsvodces'campeasafiaapnIicgi�o¢msaoa #I .ea<uaea 3 submit d is zffidaea im&rztmg they chin;sll w sad then bile aatside urat� +�umst submit a new a�da�C such- employees.If thesub-caatmctashave employees,dieyn=stpmvidethe1r sradm&c mp.pali-y numbM I am ara eliip7r�cr flint is prauiduig�vorkets'comperlsr��n i�isuranes�or xc}�¢mp£uJ�ees $etobv is fJ�e�pulicy�aruI job si��e hcfot�urrtiart ,/� Insurance Company-Name: Tolicy A*,or f-iM I.ic_ ��J �3b 7 l T o F�pifaEzoaDateL Job Site Address: 3 o ce yyp l -SA /�(�+'r Citpl5tztel�.tp: Attach a-copy of the workers'compensationr.policy declaration page(showing the poficy number rind expiration dafe). Failure to secure coverage as required undcr Se chon 25A of MO-c.157 can lead to the imposifion of criminal penalties of a fire up to$L50D OQ iu dror oiie yearimprisaunen,as well as civil penalties in the form of a STOP WORK ORDERand a fine of upto$250.00 a day against the violator. Be ad;tised'that a copy of this statement maybe forwarded to the Of of Investigations ofthe DIA,for- urance coverage verification I era tieMO eerAry, �dsr pins and per�aIfies a.�Fer ry f7�atflra aifar�rafiarrprot rIed abai�a f�€tGr�u� :d correct Sit3tafure: Date: Pone lk 6 Ojok at um only, Do not write in this oma,to be crrrnpleted by city ortovivi rr,#j`aciat City or Town: PeruddlT;cense g Issuing AUf harity(Carle cunt): L Board of Health 12 Buff De%mr-h eut 3.C yrrown Qerk 4.Electrical Inspector S.Plumbing hispextor 6.Other Con act Person: Phone it: ilia-Vw P94S�� Mo— 4�1- _ q�xzj P�aaotjdaja}�p-e s�aa�$dam atjy • I -jam E sn ad�o�a;Epsatj+oa ap asEajd nob F� radoaa mo�zn}aa�agzaxodg}o�a�xjpjnoa�smaenI�°aor�FO a�Z sao�sanb a�q pin� • '4*b DTE s.1U a;-9jdmoo(4 Paanb=J-OX si ao= PPS('a}a sa�aj amq o7 rad io asaaatj f op E aZJ oa m ss==q�(4 pa�Iax-.oa mad io _ �mm�ga sr o ra�o amazj E axa '�a� an�aab j�,�'• - ' 1 ? o PaILg a, ��.izpr�A1zu V sasaaaij m s;I[IDad I ajg as sz y"--Op1 P E ooid se}�rjddE a-q o4 papjA a aacq m Am a�Aq P�nz so padags _ o�q��EPg'a�Io JSdoa V,:(�°4 io ) tcc sa. I IIB� PIa°zC�tidci�a�}Kam- S 9.°Is.-wpm Pus(Sm-sx�u-c�u°r4�os�iID?Io d �2= � �p aao ozgns�jaa T=u`- L=Aff d� -saa tjdda as¢aat d ajffi}jnar qns � jlddEae`aotupPE-nI cgaaaaat�xa�a�ssspasnagjLtai Zagn�stnasaaa �ada�}�j�°�amsagasaaId qBE_]IIadE a2mp�gai °? 58LI ?�A�° �0 �II2aa QT� °I1�°�no�SQ} EP�aL�} ° uaoRogatj} aasds E papa sFgs=�daQata Xj� �dPum a}ajdmoa sr a ate }a3IIs agasEaja atp as xagqu asrraaij=URMSII�RjOS sate r.4�a PIn°qs sajae�o. aS ' P ?I�' IE� �(j uq seaId`6�tdodao esmdama suo saab sx�aai E�qo aq pammbai 2m-aciSp 1 aq} .M aaBq not pjnogs 1 2:01mm:�McT:6QotR3°u` ffopgsI so _ dad}snlaogEagddEatA }t�a}io oatp o�pau�a=aq �TAvr��T a ne airs a a o a.9exaa.oa=rrvmsm a ao�aoo=oI s�aaPPOV PInO� "r�E ate eP CEP P g a SL odE`saa�ojdtra In srq q go;.aaux}mdaQ ag}u} qns oq EP$s sFa;sq: P-PE a d so sraq u= abagsaapd' m=uvJI 0=1su- . J o�� 4pammbar� m sgumda o Ljfi4s?'IPq?�I -�rrp,,, a-q}ae�=R;o s=Sgd= ou-g}ra3-(d"j)s -md� Pam! ' go(s)zpR3rUq, =_uQglrpla&op (s)-mqu as (sa)ssatpp'e `(s}aa (s):E% ,Sjddns°dress as c`jiaE aozs snod o��jddE sa�oq a dq °aEp t<oes�adtaoa �sra�oaa a q} °jLg aId • �, - s�aijdd-� =mgTn=atp t u g �aauggdoma jo a_uapua ajge; .1�:3 fM&o?I o d'm�aae�a�radatgia} }aoa �� Ilogs saoT.sujpq°s jmpjpds��o km mu ai.�aN (L)DSZ§`75I ' I��I`�IIEao? PPS' � IInT]aS 2�E adO�27�?P mcm a�Ip3•am dt�aoa JO mumpiaa aI chaos paanpo-1d;nit sZj o'Ta a=ijdde dire iaj:tF}Ieamzat=oa ate.rn s mp�q oa o}so ssaa<snq E a rada o4 t uad za aszraaij E o j aquas .za atg.PI°1II-j-vgs j-eaol.1a Gr4SSJada„PZR oqu(9)DSZ§`ZSI.4alrp'Is W radold=aE oq(4Pam=P aq��°Iffim go asa-eaaq;cTaH p o4=rjt 2mn)Lmq io sgrma-�atp.ao so ° o `r op at snsad rgaae�o asuo 2a asnoj 2mUa p tas tm•-voi mdw m uo- sdlamp -q m a ax�}aoraZaa a a � z2IIaMPEata3o ag}�abaa3og -saa6ojdma dojd�`d�i;ua jaaj=Tpo m MogenossE`cngsrattuEd ne�a�a�sn�inrmT a m msold=posEaaap ego s�?;e�sa�j Iagaj u amt¢m aa4. =m`63�=F29j.rag}o so uoT.�Mo'±'M`ao'. enossE q=up:Ed "FuE„se .sz lay d= a� - � ID ISO`Par[d�.xo ssaE�a °aaCj�o ma 6ne saptM MqN aego=U=ata ulaaSTaddsad8 9 ss paagaP sr,aa�fv?�ae`ads S?qg ap= -=La ojd=satp.-vu Boz;Es=d®o s=a•cFrh ai =&Idh=ire==ba=m=Aq'S&2-IT==0 s4v=T-M� suo �n-4suq p -c uo :um. o 4 y 1c o onsu eAa airs (dVuiness e u anon - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement gontractor Registration Registration: 172476 ,$? Type: Supplement Card Expiration: 7/2/2018 BEL ISLANDS HOME IMPROVEMEN IVAN IVANINSHENKO 204 CINDERELLA TER. ` " - MARSTONS MILLS, MA 02648 Update Address and return card.Mark reason f, scA co zorw-osm Address (—� Renewal Employment f ��e tpci.�iasizai�tieirl(�n/�'/��rJ;lrrcf�r:;clfJ j frice of Consumer Affairs&Business Regulation ? License or registration vali for ndividual use only ` ME IMPROVEMENT CONTRACTOR before the expiration date If f and return to: j Office of Consumer Affa' s a d Business Regulation egistration 172476 Type: ! 10 Park Plaza-Suite 5 0 =: z Expiration 7/2/2fgt „ Supplement Card Boston,MA 02116 BEL ISLANDS HOME g-P-12 ENIENT IVAN IVANINSHENKO; ``M^ 204 CINDERELLA TERu r tho s' MARSTONS MILLS,MA 02648 Undersecretary of vali w e i f a 1 1 i MAssachusetts Department of$`utolic S�set Board of Building Regulations and Standards: License: CS-105964 NAN 1/NANIUSHENKO 174 UPPER COUNTY ROAD'APT I 144 DENNIS PORT MA 02$—U Expi-ration: ivc7 m+ssi4 ter 0110112018 i i i i i ! . I 2/25/2016 10:42:06 AM PST (GMT-8) FROM: 100005-TO: 15087901414 Page: 2 of 2 ACC> CERTIFICATE OF LIABILITY INSURANCE DA 2 /2o s 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 endorsemen s. PRODUCER BRYDEN 8r SULLIVAN INS NCONTACT AME, 88 FALMOUTH RD PHONE FAIc HYANNIS, MA02601 EMAIL ADDRESS: INSUR 3 AFFORDING COVERAGE NAIC# INSURE RA: LM Insurance Co ration 33600 INSURED INSURER B: ANDREI YARMALOVICH DBA BEL ISLAND HOME IMPROVEMENT INSURERC: 204 CINDERELLA TERRACE INSURERD: MARSTONS MILLS MA 02648 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 28713782 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. ILTR TYPE OF INSURANCE ADDO WvD SUER POLICY NUMBER MAD EFF MMIDDY�II IJIHn3 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMCLAIMS-MADE OCCUR0 RENTED A S c $ MED EXP(Any one icon) $ PERSONAL&ADVINJURY $ GEN1-AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PERK LOC PRODUCTS-COMP/OPAGG $ OTHER-- AUTOMOBILE LIABILITY COMBINE[)SINGLE LI I $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DIED i I RETENTION S A WORKERS CoMPENSAnoN WC5-31 S-384176-026 2/25/2016 2125/2017 S�TRATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRI:TORIPARTNERIEXECUTWE YIN N E L.EACH ACCIDENT $ 100000 OFFICERIMEMBER EXCLUDED? N N I A (Mandatory in NH) E L.DISEASE-EA EMPLOYE $ 100000 IF yes,downbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. ANDREI YARMOLOVICH IS COVERED BY THE WORKERS'COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1116 RT 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN SOUTH YARMOUTH MA 02661 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATNE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 28713782 1-384176 16-17 WC Ashish eorgaonkar 2/25/2016 1:38:27 P14 (EST) Page 1 of 1 7 , Town of Barnstable Regulatory Services 8AKAM Richard V.Scali,Director Nua►` Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, l f YJ'L C Fbi 1 , as Owner of the subject property hereby authorize 3 dF--t>��As to act on ray behal f in all matters relative to work authorized by this building permit application for. ��C�0 �i� CSC-• `��ns ; ��- (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installe d all final inspections are performed and accepted. Ole S' a of of t Print Name Print Name Dat Q:FORMS:OWNERPERMISSIONPW S Town of Barnstable Regulatory Services H ptr Richard V.Scali,Director ' r Building Division t Paul Roma,Building Commissioner% KAM 1639. A� 200 Main Street, Hyannis,MA 026 1 OTC www.town.barnstable.ma.0 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXE ON Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name ft me phone# work phone# CURRENT MAILING ADDRESS: city/town X0FM]E0VtWER te zip code The current exemption for"homeowners"was extended to incoccu ied dwellings of six units or less.and to allow homeowners to engage an individual for hire who does not posse,provided that the owner acts as supervisor. DEFINITTOOWNER Person(s)who.owns a parcel of land on which he/she resides o reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to sor farm structures.'A person who constructs more than one home in a two-year period shall not be considered a homeowno eowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be re onssuc work Derformed under the building ermit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for com 'ance with the Sta a Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understan the Town of Barnstab Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and req ements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,/00clubic feet or larger will be required to co ly with the State Building Code Section 127.0 Construction Control. 9 . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is re uired shall be exempt from the provisions of this section Section 109.1.1`-Licensing of construction Supervisors);provided hat if the homeowner P ( i engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." i 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFIL.ES\FORMS\building permit forms\EXPRESS.doc 06/20/16 Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee KAM �' Thomas F.Geller,Director A s63g6 Building Division Tom Perry,CBO, Building Commission 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �I 7 �®�Vot Valid without Red X-Press Imprint Map/parcel Number 3 J -�- I tl Property Address .� . 0 11(ft in 1� e`-t .6&4,5 fill D t f 6 [residential Value of Work$ , t]00. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address L! 6_, Eg jlTe a elf Contractor's Name K161 Ae �SPT Telephone Number 5-DY-^36 Home Improvement Contractor License#(if applicable) Email: WA (4 �eN�� •we Construction Supervisor's License#(if applicable) q q o6 opp.SSMIT ❑Workman's Compensation Insurance Check one: SEP IS 2013, ❑'1 am a sole proprietor ❑ I am the Homeowner ❑ I.have Worker's Compensation Insurance MVIA OF BARNSTABLE Insurance Company Name 'I 1 6 4 Q� L mIl o f Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) // �� A /% &ie-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to A,! ,CQ f?� // ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\FMRESS.doc Revised 060513 ; r Massachusetts -'D?partment of Public Safety ,Board of Building Regulations and Standar Construction Supervisor Specia!s)- License: CSSL-099406 TAM WRASSE TT 3775 MAIN SMET,, CUMMAQI3 MA";0263 �••�•- i�3'�" .. Expiration Commissioner, 12/1212013: �; v �. �e 1parirmesneaec�`C�a�C�/�ua:rtcc�euaeGr3 Offite of Consume;Afl"airs&Business Regulation `.� .i ME IMPROVEMENT CONTRACTOR N' el9 istration: T59706 Type: piration: :, &ik(1* Individual KIM M BASSETT14 KIM BASSETT 3775 MAIN ST 4y �� q CUMMAQUID,MA 02637 Undersecretary License or registration valid for individul use:on] before=the-expiration date.—Iffound return to:, Office of Consumer Affairs and Business Regulation rI 10 Park Plaza Suite 5170 1 Boston,MA 02116 Not valid without signature i e X �nr I V 27m Camnromvaallh ofMassachuseM Dgwhn=t vf 1ndrastrcal AccideniY Off-we ofimfffigad-ins 6#0 ffiwkingfon feel Boston,MA 02M tmn.anas&govldia Workers' Compensation Insurance Affidavit BuiIders/Contractors/Electricians/Plumbers APPEcant Information Please Print Legibly Name Musmess/Osga �mUffividnao:T 1� r'►1 fl :i P Ir Ad&e .3775 _IIdul ST- (rimoi AQui,6 MA OA63`7 city/stat r./p: ale t g -30-4 Aire you su employer?Check the_ appropriate box: Type of project(required): L❑ I am a employer with 4. ❑I sin a general coubmator and I 6. ❑New constuxion loyees(fall and1orpart4ime).* have hired the sub-contractors 2: am a sole proprietor or partner- listed on the attached sheet y- ❑Remodeling ship and bate no employees These sob-contractors have g- ❑Demolition working for me in any capacity. employees and have wodcers 9. ❑Build-mg addition [No workers'comp.i=zm=e Comp.mcnranoe 1 Vie-] 5. ❑ ate are a corporation and its MCI Electrical repairs or additions. 3.❑ I am a homeowner doing all work officers have exercised their 11-0 Plumbing repairs or additions myself[No worlmrs'gyp- right.of exemption per MGL 12.❑Roof repairs insurance required.]I c-152,§1(4} and we have no- employees [No workers' 13.0 Other comp,insurance require -J sgplicaat that checks boa#1 tmrsi also fill out the section below showing&&woikerk rouTens t on policy'in t�tion. �Homeowners who sabmit this sfEdsvi t indcatiag they are doing allwc*and&en hare outside contractors mast s;dU=a new affidavit inrH1r-,fl— mrh. rCont mctors that check this boa mast attached m additional sheet showing the name of Bra sob-canttaators and state wbether ornat chase¢miCies have eroplvyees. If the sob-coat mctan bsve employees,they tmut provide their worker'comp.policy number. .Inman employer thatispratMYjg te,orkers'cotnpamatian inmrance for trzy anq;loyees. Beio*v is die poHo7 and job silo infonnadoiL Insurance CompauyName: Polky;9 or Self-ins Lic.#: Expiration Date: Job Site Address: City/Statelzip: Attach a copy of the workers'compensation policy declaration page(showing the policy,number and expiration date). Failure to secure coverage as regairedunder Section 25A o€MGL c, 152 can lead to the imposition of criminal penalties of a fine up to 31,500.00 and/or one-year imprisonment,as well as civil penalties in the form of it STOP WORK ORDIR and a fire of up to$250-00 a day against the violator- Be advised that a copy of this statement maybe forwarded to the OfSce of harestigations of t1le DIA£or insurance.coverage veriffcation- I do hereby clerhfy under thaprans andpenatUes afpedwy that the informa&n pravi&d above is hue and correct Signature Date: C7' %-7/ 3 Phone#: O;}kial use only. Do Trot irrite in this area,to be completed by city or town official City or Town: PermmitUcense it Lisuing Authority(circle one): L Board of Health 2.Budding Department 3.CityNdwn Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,an=Tloyee 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 "an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an indi partnership,association or other legal entity,employing employees. However the owner of a dwelling house ha ' not more than three apartments and who resides therein,or the occupant of the dwelling house of another who loys persons to do maintenance,construction or repair work on such dwelling house or on the grounds or budding app ant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)1 also states th "every state or to licensing agency shall withhold the issuance or renewal of a license or permit to operate business or to nstract buildings in the commonwealth for any applicant who has not produced acceptable vidence of mpliance with the insurance,coverage required." Additionally,MGL chapter 152, §25C(7)states either a commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpub .c wo until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to contracting authority." Applicants Please fill out the workers'compensatioJda.v i complete by checking the boxes that apply to your situation and; if necessary,supply sub-contractors)namss(es)and ph a numbers)along with their certificate(s)of insurance. Limited Liability CompaniesLimited Liabtlt Partnerships(LLP)with no employees other than the members or partners,are not required to rkers'compensati ilis rance. If an LLC or LLP does have - employees,apolicy is required Be advithis affidavit maybe bmitted to the Department of Industrial Accidents for confirmation of inctnance . .AIso be sere to si d date the affidavit The affidavit should be relmuned to the city or town that the ap for the permit or livens being requested,not the Department of Industrial Accidents. Should you have aons regarding the law or ou are required to obtain a workers' compensation policy,please call tine Depat the ntmiber listed below. Ifinsured companies should enter their self-insurance license number on the appline. City or Town Officials Please be sure that the affidavit is complet and printed legibly. The Department\aa ided a space at the bottom of the affidavit for you to fill out in the ev at the Office of Investigations has to cou regarding the applicant Please be sure to.fill in the pennit/license umber which will be used as a referenc , In addition,an applicant that must submit multiple permitlliceme plications in any given year,need only on affidavit indicating current policy information(if necessary)and 9 er"Job Site Address"the applicant shou "all cations in (city or town)."A copy of the affidavit that has een officially stamped or marked by the own m be provided to the applicant as proof that a valid affidavi is on file for future permits or licenses. A davit m be filled out each ear,Where a home owner or citizen i� o y btamnmg a hcense or permit not related tosiness or c ercial venture (i.e.a dog license or permit to bum Ieaves etc.)said person is NOT required to cohis 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 anh fax number. t ° The Commonwealth of Massachusetts Depaitmmt of Industrial Accidents Office of kvestigatiaxts 600 Washington Sit Boston,IAA 02111 TcL 617-727-4900 wa 406 or 1-977-MASSAFE Revised 4-24-07 Fax#617-`�27- 49 www.massgov/dia �IKE Town of Barnstable Regulatory Services �: � s�uvsrnsrs, • MASS. �, Thomas F.Geller,Director P. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 _._ www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, ,as Owner of the subject property hereby authorize X*I 611"'t to act on my behalf, in all matters relative to work authorized by this building permit 4 V (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOL•S 6/2012 Town of Barnstable -_ Regulatory Services � Thomas F.Geiler,Director �F 19. Building Division ' Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-86274038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street d age "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS:• city/town state zip code The current exemption for"homeowners"was ext ded to include owner-occupid dwellings of six units or less and to allow homeowners to engage an individual for hue who do not possess a license, ro 'ded that the owner acts as supervisor. D ON OF HOMEO R Person(s)who owns a parcel of land on which he/she re 'des or intends to rVch ,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accesso to such use and/ structures. A person who constructs more than one home in a two-year period shall not be considered a homeo er. Such"honer"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be res o ible for all sork performed under the building pen-nit-(Section 109.1.1) The undersigned"homeowner"assumes responsibility for comp ce th the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the wn of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said o ures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cub c feet or larger wil a required to comply with the State Building Code ' Section 127.0 Construction Control. HOMEO MR'S EXEMPTION The Code states that: "Any homeowner performing work for which a bu'ding permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supe 'sors);provided that if the homeowner engages a person(s)for hire to do such work,that such omeowner shall act as supe isor." Many homeowners who use this exemption are unaware that they are assumin the responsibilities of a supervisor (see Appendix Q,Rules&ReguIations for Licensing Construction Supervisors,Section 2. 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: t 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. I C:\Users\dccolldc\AppData\Local\Microsoft\wmdows\Temponuy Intemet Files\ContentOutlook\QRE6ZUBYMRFSS.doc Revised 053012 t i rs; ; - � TTown of Barnstable *Permit# ^ ��- ,�1 Expires 6 months from issue date ., Regulatory Services.2 4Zo 08 homas F.Geiler,Director RJ _ TOWN OF 13ARNSTABLJ �`— Building Division Tom Perry,CBO, Building Commissioner k 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY 317 0 1)Oi q� Not Valid without Red X-Press Imprint . Map/parcel Number Property Address41 W/Residential Vale of Work_Z y5-d61- Qe Minimum fee of$25.00 for work under$6000.00 , Owner's Name&Address - e - ,37�6 T>-d 614125A4 4119 �Q36 Contractor's Name //� /-}�� Telephone Number Home Improvement Contractor License#.(if applicable) 49 70� Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Che k one: El"I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company NameP � Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to (Q Re-roof(not stripping. Going over . existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum,44) .'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 of the Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 s Nlass,ichusetts- Department t►f Public Safct�- 8o;trd of Buildin�ff Rc�gulatitins and Standards Construction Su ervisor Specialty pecia Ity License License: CS SL 99406 Restricted to: RF,WS,DM KIM BASSETT 3775 MAIN STREET CUMMAQUID, MA 02637 Expiration: 12/12/2011 ('ununissiuncr Tr#: 99406 • i 1 __ � ✓ite i�omvrno�I2u�e� o��aC,�u6e�6 ' _ _ _,_.._ -- \ Board of Building Regulations anti Standards License or registration valid for individul use only i HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ifi Board of Building Regulations and Standards Registration j 159706 Expiration 5119l2010 Tr# 268660 One Ashburton Place Rm 1301 -,Fr Boston,Ma.02108 {'IT.ype Individual KIM M BASSE71- KIM BASSETT 3775 MAIN ST �'- J'l ,Jv�!r✓" CUMMAQUID,MA 02637-- Administrator F Not valid without signature O ) ' The Commonwealth of Massachusetts Department of IndustrUd Accidents Office of Investigations a ' • 600 Washington Street Boston,MA 02111' wtiOw.mass.gov/dia ' Workers"Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/Organizationffndividual): Address: � ' - City/State/Zip: h,-t S Phone.#: Are you an employer?Check the appropriate bog: :Type of project(required):. 1.❑ I am a employer with 4. [] I am a general contractor and I *, have.hired the sub-contractors 6. ❑New construction . employees(full and/or part time).2.& I am a'sole proprietor or partner Remodelinglisted on the-attached sheet. 7• ❑ ship and have no employees . These sub-contractors have 8. Demolition employeep and have workers' avorking for me in any capacity. $. 9. ❑Building addition [No workers' comp.insurance comp.insurance. 5. [] We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11. Plumbing repairs or additions '3.❑ I am a homeowner doing all�work . � . g p • myself.[No workers' comp. right bf 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 anew affidavit indicating'such. tcontractors 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. ff the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.P Expiration Date: Job Site Address: City/State/Zip- -Attach a copy of the workers'compensation policy declaration page'(showing the policy number and expiration date). Failure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the-Office of Investigations of the DIA for insurance coverage verification. — I do hereby certify under the pains•and penalties of perjury that the information provided above ' tr an'd co rect Si attire: Date: _ Phone#: Official use only. Do not write in this area, tb be completed by,city or town,official City or Town: ' Permit/License# Issuing Authority(circle one): J.Board of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: A Town of Barnstable Regulatory Services yHARNSTAB� s . E� Thomas F.Geiler,Director �A 16;q. �m lFo,3u.. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must .Complete and Sign This Section If Using A Builder I, , as Owner of the subject property hereby authorize �i(1'a�,o to act on my behalf, in all matters relative to work authorized by this building permit application for: 76?6 c.,[ 1 . (Address of Job) Signature of Ov6er Date trtY Suva C-- Re Q Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION 'THE Town of Barnstable Op Tp� " Regulatory Services BARNSTABLE, Thomas F.Geiler,Director 9 MASS. 1619• .� Building Division TfD �s 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 Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code P The current exemption for"homeowners"was extended to include 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 undersigned"homeowner certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions, of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors;Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Town of Barnstable *Permit#6 a00 �Saa X-PRESS PERMIT Expires 6 montiis from issue date PERMIT Regulatory Services Fee o?�, D� NOV 2 7 2007 Thomas F.Geiler,Director Building Division SOWN OF BAF3NST � o� ABLE Tom Per ry,CBO, Building Comm oissioner / 200 Main Street,Hyannis,MA 02601 www.town.barnstable,ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Numbe " Property Address GU ICI tNh c� 4,b k £ Rl� esidential Value of Work , a��'f° -� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address J� t��4 .l M G Contractor's Name ' �G v�' Telephone Number 9 V7 G�oe� Home Improvement Contractor License#(if applicable) G � Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 7 . 9 to "t Z 7 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *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 copypFffie Home Improvement Contractors License is required. SIGNATURE: Q:Fonns:expmtrg Revise061306 t� f" 14 � s :P� s. r,'.l � `"�5?• .`�` � :",""'a .1, _____�_r.._..�..__._._._..__._.._�..-1 .ISSUE DATE 09,104/2007. RODUCFf? THIS C-ERTIFICATL IS ISSUED AS A MATTER OF E FORNIATiON ONLY AND filler McCartin CONFI RS NO RIGHTS UPON THE.CERTIFICATE HOLDER.THIS CERTIFICATE � ba Dowling&O'Neil Ins Agcy DOES'10T AMEND,EXTEND OR A.L.TER THE COVERAGE AFFORDED BY THE POLIO cS BELOW. { 22 West Main Street �—.._.�..- __ ...._._.��_..—.....�__.�W �_-------__—_-, Hyannis,NIA 02601 COMPANIES AFFORDING COVERAGE � IN5l_'RED ------- — -- —__— — _ William W Croston ! �1ba William W Croston BuildingConractor COMP..NY A,A.I.M. Muraal Insurance Co, rII U Box 138 I1.T'T'T :R 0sterville,MA 02'655 gi .-.. r a yrrfsrarx�r^. R„ a L � . 'ri"' 7xnT�1 I✓ Ja" ZI1t LJi a a., r` THIS IS TO f E RT)FY 111A f THE PGL)C IES OF INSL RAft L LISTED 81 l 3Vi HAVE N�.LI,ISSUED TO THE-PNSUU.D NAMED ABOVE FOR THE POLICY ' PT-,RIOD INDICATED,NOTVJITIISTANDING A`)'RI:QJIP,ME:U f,TEilt 0R CONmrIJN Or ANY CON TACT OR OTHER DOCUMENT WITH RESPECT � J TO WHICH THIS CERTIFICATE MAY HE ISSUED Ok 1v1A1'"PERTAIN, 1 li INSURANCE AFFORDED BY TH ,.POLICIES DESCRIBED HEREIN IS SUBILC"i' 1 'i O ALL'rHl:TERMS; U EXC-L. 3IZ)NS AND CONI)I iONS OF SUCH POLICES, LIMITS st'IO1�WN_!MA�'HAVE 14>N REDUCED BY PAID CLAIMS. CO TYPE O£INSUkANF POLICY'VLhIBER j POLICY FFF.0 1YE POLICY EJCPI"TION .1 LTBI DATE M1DD/YY) DA'I F.(MM1pD/yY'j LIMIT'S a I GFNLRAL LIABILITY i l GENERAL AGGREGATE -- 1 1•---1�, - °Rt)UUC`rS-CU>tHP;GP AEG. _......_.__._•.— OMMER.'FAI.GENEk.Lt LiADiL(T'1 I ��-'—"�—•— —_----�—w— �—,__�� i PERSONA!,&A.)t'.;NJURY_—' li I�=CLAIM3 A(AlaE=,tCCJR .� I EACH OCCURRENCE f S --i =OWNER'S&CONTRACTOR'SPA01. i I 1------ --- _,—'•--`! IFIRE DAMAGE(Anyone lirej --�---- MED.EXPENSE(Anyre:c P..) -. AUTOMOBILE LIABILITY !+ COMBINED SINGLE � MIT l ANY AUTO i ALL.OWNED AUTOS 33 BODILY INJURY SCHEDULED ALTOS I �.... HIRED At+Tos ( ----- - ---- ----- ----•-•7 "ION-ONNED AUTOS BL'OILY INJURY I .,ARAGE LIABILITY 1(Pa'ncadan) Y - 1 PRr-<N'Eary DAtoeAGE -E%EBBS LIABILITY — _�— �--EACH OCCURRENCE -- - _---7' L'MERELLA FORM j ! +—'— - + AGGREGATE i � OJ-HERTHAN UMBRELLA FORM WORKERS C'OMPE!YSATION A�?db�----'--_--- —. TA'fC!'rpR.Y LIMITS EMPLOYERS LIABILITY t I!� X N f a mopiuf:rORI 1 r A ) I;I.:EACH ACCIDENT 1,000,000 AYt.NFrtS1EkF.r:UrIVE I � 1fPICIERS ARE- 1 701 1419022007 I MCL r�E}:CL rg/0:i2007 00r08/2008 Et.D(S£hsE-• E:POC'z L:IMrr'�[ i 0pq,p(}aEL DI.-SE-ASE-EACH } -�--� (" FMPLAYw — �1,000,(%DU c ONIMENT'S/DESCRIPTION OF OPERATIONS OR LOCATIONS: �VILLIAM W CROSTON IS NOT COVERED BY 111E WORItER.4'CONIPE.iSAT'IO'N POLICY. I i i i 1 Rin rKOL'LD A,14 OF rHF.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE Yf � HFREOF, 'HE ISSLiING C'OMPANl'GVILI..ENI)F.AVOR TO MAIL&)&!PI'rrEN NOTICL-,TO TNG CFRTIFlCA Ti P ` LD£4t PI lMLD TO,THL GRIT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE.NO OELIGATK N I R I IABIL rY OF ANY KNO CPCytM1 1'HE COMPANY,ITS AGENTS OR REPRESENTATIVES. I L ILTHORI; E D R£PRL:Sr:'NT'A'C1Vc. . � ✓!ze Poar�nzo�,zcuecz�C! o��/�aclauoe�4_;`-__—.------- — ____. k B4 frd 0!,PujIding#egulatiuns and Staudai d ' - E 'PROVEMENT CONTRACTOR i Ltcetise or regtstrattt t valt�i for mdty dul use on v . Re tration y a betorc.1"o expiration hate. [f:foq *ftfurt to. 700023 Boarf(of Building Regulations astd S III nd.tt ds Exp�rafton 6/82008 One Ashburton Place Rm 13p.j v :Type Boston,Ala.02108" .' BILL C ( TON B.UILD(N_G CQNTRACTOR e'vI LLfA�t- ROSTON �U0Wf /`a B fD 1-F' s {L l NNI�J SY'n�VGUU9 r-.F"'i.� P ::d 1.t �p :u •n�.rrl I � rt-Y v,ry,� 'E �.. j'Ili., � YV ActmsltIItR ---— -- '� r �. a i �%A I it I%itltopt,t sigtt typq ;z ,1 ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' wrvw.mass.gov/dia ' Workers}Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. rV1166W z/0 Address: �', ! Sv City/State/Zip: P/6 '�'"�`��` '"'�` a' r' Phone.#: Arr-e,you an employer?Check the appropriate bog: :Type of project(required) 1,Ir t am a employer 4. [] I am a general contractor and I 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• Ej Demolition workingfor me in an capacity. employees and have workers' Y P t9 9. ❑Budding addition [No workers' comp.insurance comp.insurance,$' required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work . officers have exercised their 11.0 Plumbing repairs or additions ' myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance.required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp,insurance required,] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infom,ation. t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating'such. ornotthose entities have 1Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whetherh employees. If the subcontractors have employees,they must providb their workers'comp.policy number. I ani an employer that isproviding workers'compensation insurance for my employees. Below is.thepolicy and job site, information. Insurance Company Name: hs Policy#or Self-ins.Lic. Expiration Date: Job.Site Address: e& 1Wfi 113,r,,,vs/44 " M I- City/State/Zip: Attach a copy of the workers'compensation policy declaration pa;e'(shovring the policy number and expiration date). Failure,to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the.Office of InvestiL7ations of the WA for insiaanee coverage verification. ' I do hereby cetWfyq4er the p ' I. nd penal ' s of perjury that the information provided above is true and correct Si afore Date: 4�7 Phone 4: Official use onTY7 Do not write in this area, to be completed by city or town:official City or Town: ' Permit/License# Issuing Authority(circle one): J.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: i °Ft►,Er�,, Town of Barnstable Regulatory Services HAABL SSS. E Thomas F.Geiler,Director i639• ��'� .1 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize &O1 C— VW'514,P1, to act on my behalf, in all matters relative to work authorized by this building permit application for: 13260 17 /C / 114 k (Address of Job) Signature of caner Date 9 �71 Y St-f o o-T Print Name If Property Owner is applying.for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION �oFtr+e rq�� Town of Barnstable Regulatory Services * BARNSTABLE, Thomas F.Geiler,Director 9 MASS. �,, i63q• A.0 Building Division JEv � 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 EXE PTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name hom hone# work phone# CURRENT MAILING ADDRESS: cya state zip code The current exemption for"homeows ext ded to include owner-occupied dwellings of six units or less and to allow homeowners to engage an infor ire who does not possess a license,provided that the owner acts as ' su erp visor. F ITION OF HOMEOWNER Persons)who owns a parcel of land e/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attetached structures accessory to such use and/or farm structures. A person who constructs more than onetwo-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Buiic' 1 on a form acceptable tothe Building Official, that he/she shall be res onsible for all such work erform th buildin ermit. (Section 109.1.1) The undersigned"homeowner"assumes/Iresponsibil for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she and rstands the Town of Barnstable Building Department minimum inspection procedures andgequirements and th the/she will comply with said procedures and r requirements. e' a Signature of Homeowner r` Approval of Building Official Note: Three-family dwellings containing 35,000 cubic f t or larger will be required to comply with the State Building Code Section' 127.0 Construction Control. HOMEOWNER'S EXEMP ION The Code states that: "Any homeowner performing work for which a buil yang permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that tif the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assumin •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. Q:foiTns:homeexempt Town of Barnstable *Permit# :3 — ,4�OFt tof�,y Expires 6 months from issue date - - Regulatory Services Fee * XAM $ Thomas F. Geiler,Director 9 t63D. �ArEc ru't" Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 X-PRESS. PERMIT Office: 508-862-4038 APR 3 0 2004 Fax: 508 790-6230 �,�� n Y EXPRESS PERNIIT APPLICATION - RESIDE ,t ARNSTABLE Not Valid without Red X Press Imprcnt Map/parcel Number 70 a �� Property Address . .Value of Work [gResideutial owner's Name&Address Contractor's Name JS Telephone Number Home Improvement Contractor License#(if applicable) 2- R f onstruction Supervisor's License#(if applicable) -OctO ❑Workman's Compensation Insurance Check one: C- [�] I am a sole proprietor : (� I am the Homeowner Q ;--6 I have Worker's Compensation Insurance < _ — w En co U0 a Insurance Company Name cn Q,rorknian's Comp.Policy# x• O Z O f• co r- rn Permit Request(check box) ❑'Re-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) ® Re-side' [] Replacement Windows. U-Value (maximum A4) *Where required: Issuance of this permit does not exempt compliance vrith other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. H e Improvement Contractors License is required. Signature Q:F0rms:expmis8 v.,,..ansann3 of Teti Town of Barnstable Regulatory Services S 8 L ' Thomas F.Gefler,Director 1619• BuildingDivision - Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-8624Q38 Fax: 508 790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I _:w....:-...,.�:_.;as.,Ownet..ofthe.subjectpropetEy ..........._ •. - - hereby authorize ct on tay..behalf,. in all mattets relative to work authoiized•by this building.perit•applicat ontfor, ikA-4 2 (Address of Job) 1 o V Signature of ex Date Print Name r Results Page 1 of 1 Home Improvement Contractor Look Up Enter Search terms separated by spaces. Search terms can be Town/City,Name, or License number Select Search type: AND r OR Search, r._{ Search Results Reg. No. 11 Applicant Street City State Zip Name Title Expiration PO Box 102149 JOHN 118 160 W' MA 02668 Johnson, Construction 6/30/2004 JOHNSON Church St Barnstable John Supervisor Total of 1 Records matched. Back to Home Page BBRS Privacy Statement http://db.state.ma.us/bbrs/hic.pl 5/4/2004