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Permit Fee h Date Definitive Plan Approved by Planning Board f Historic - OKH _ Preservation / Hyannis Project Street Address 410 qD yl i 6 Village 2 4 V i 01 Owner `�-F�cl�w (� Address V Y® Telephone r`Z�'- `j $l t L L Permit Request 20Ag_vk G X l(3 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Typez_. Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Ll 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 Fdeat 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 ❑ oxisting ❑ rew Sze_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: w-� NO Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ; Commercial ❑Yes ❑ No If yes, site plan review# I. Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address 9 .1 LIP— License # q 5g.Fr ( 24=s7NHome Improvement Contractor# 1 j Worker's Compensation # !:( p3T 04?6� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 92cur,_%-e—� SIGNATURE ILI= DATE FOR OFFICIAL USE ONLY p APPLICATION# . DATE ISSUED MAP/PARCEL NO. -ADDRESS i VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION 6'� �i �`� Gfl'RI��L �� << t(o FRAME 10 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL i r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL F FINAL BUILDING DATE CLOSED OUT i ASSOCIATION PLAN NO. i ,ter, Town. of Barnstable Regulatory SerAces . Thomas F. Geller, Dixector �y--- °r�d,r,�,� Building Division ((JJ Thomas perry, CBO, Buflffug C011=SSioner 200 Main Street, Hyannis,MA 02601 www.fown.barnsta ble.ma.us Office( 508-862-4038 Fax: 508-790-6230 PLAN REVfEW Owner: �� � Map/Parcel: 1 4. 6 7 ;L 4 Project Address es`f a' kf" Builder: 6-4-S The following items were noted on reviewing: - -7— ► C— P VO tAl -SON 0 7-0 12eviewed by: � Date: C9 Q:Forms:Plnrvw I The Corrtrnonwea�rJt ofIassacr�set>s _Depar�meni of lndustria[Accideneg Office of rrtvesdgalions 600 ?3lashinkton Street Z3osio�r, AM 02111 wwW,rn rrss.gou/did Workers' Compensation Ins arance �dav-it: Builders/Contractors/EIe ctricians/Z'Iulnbers . .Applicant Zn_formatiori Please Print LP_EjbLY �3I17e (Business/Or'ganization/Lndividual : , Adt3ress: City/Slate/Zip: Are you an employer? Check the appropriate boz: Type of project(required): a employer with _ 4. ❑ I am a general contractor and I 6 ❑grw construction employees (full and/or part-time),* bavc hired the,sub-contractors listed on the attached sheet 7, . ❑Rcmodcling 2,❑ I am a•sole proprietor or partner- These sub-contractors have g, Demolition ship and Nava no employees employees and bavc workers' 9. ❑ E��g addition working for me in any capacity, comp. lnsurancc.$ [No workcn,.comp,•imurancc 10,0-Electrical repairs or addition equired] $, ❑ We are a corporation and its r 3,❑ qu a bonaeowncr doing all wort: oificers bavc cxcrcised their I I_[]Pltmibing repairs or addidOl myself, [No workers' comp. right of exemption per lvfGL 12.❑ R.00f repairs c, 152, §1(4), and we have no n insrrranco required.] employees. [No workers' 13.0 O.ther comp, insurance required.] 'Any applicant that chtrb box#1 mud also fill out the section below showing their workers' comp�nsa4on policy informatio . t Homcowntr6 who submit this af[idavit indicating thry are doing all work and than biro outside contraction must submit a new affidavit indicating such. tConiractom that check thin box must atbacbcd an additional sbeot showing the name of the sub-conh-wtrn's and state whcd'cr°T not those entidcs have ernploycrs. I:f'thc sub-contractory have cTnp]oycce,they must pro-vi66 their workcrs'comp. policy number, tarn art empfoyer that is providing,workers'compensaft-on insurance for my employees. Befvty Is the policy artdjab site ittfo rm atian Insurance Company frame: . Expiration Date: Policy'# or Self-ins, Lie. #: C.�C! s: W (b r c '(.�" City/St�tr�Zip;/ c an D Job Site A-ddres " Aitaclt a cope of the workers' compensation policy declaration page (showing the policy number and expLratlon date). Failure to secure cv otragc as requutd under Section 25A of MGL c. 152 can lead to-the imposition of criminal penalties of a find lip to 31,500.00 and/or one-year i�risonrnent, as well as civil penalties in the form of a STOP WORK ORDER and 3 fir stattmcnt maybe forwarded to the Otdice of of.up to $250.D0 a day againsttho violator. Bo advised tbat a copy-of this Investigations of the bIA for msu e vcra c vc ' cation X do hereby certY under pain it pertaLdes of erjury eA&the irrfarmation provided abo e is tYue artd correL>r Datt; ��� Si afore: , Phone �.(�-�, Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License 4 Issuing Authority(circle one); 1. Board of Health 2, Building Department 3, City/Towu Clerk 4. Electrical inspector 5, Plumbing inspector 6, Other instructions Massachusetts Gcneral Laws chapter 152 requires all employers to provide wcckocfsnotb p nation y co tracMlbdiO, Pursuant to this stahrtc,.an emptayee is defined as '...every person in the strut , express or implied, oral or Written-" or-a6on or otherega ll entity, or any two or more rre An eptoyer is defined as ,m individual,partnership, association co rp or the o' cn a cd in a joint enterprise, and including the legal representatives of a deceased employer, of the fort w g g era to e loyccs. However the g g• c lc al enti p Ymg.� o th r h` receiver or tzusteo of m indrvidua], partnership, association or g owner of a dwelling house having not more than three apartmecIIcan onstructi neor rrcpairwo k on such dwelling house dwelling house of another who employs persons to do maintcn or on the grolwds or building appurtLnant tbcrcto shall not because of such employment be deemed to be an employer." MGz chapter 152, §25C(6) also stags that"every state or local licensing agency shall veithhold the issuance or regepf al of a license or permit'to operate a business or to constTuc.tebuildin buildings emm e � �require or�Ln y applicantwho has notproduced•aceeptable evidence of coznpLan �cl AdditzonaIly,MGL ohaptcr 1g §2-5C(7) states 'Neither the conrmonwealth nor any of its political subdivisions shall liznee RZth the in enter•into any contract for,the performance of public work until acceptable evidence of comp urance rc of this cbaptcr have been presented to the contracting authority. quixerncnts Applicants. e workers' tom ensation affidavit completely,by chcc}dng the boxes that.apply to your situation and, if Please fill out th P ncccssaxy, supply sub-contzactor(s)namc(s), address(cs) and phno numbcr(s) along with theix ccztZficatc(s) of LLC) or Limited Liability insurance. Limited Liability Co#anics( lity Paztn san ps If an)LLC or LLP doesebavtc cr than the mambers or partners, are notxcqurrcd to carry workers compensation ins • employees, a policy is required Pc advised that this affidav5tumay o sisub gu nd date the Dzff�da�t:nt of T'he a$dantlshould Accidcztts fox con ation of insurance coverage. Also b bo rctumcd to the city or town that thc'application for the permitthoc h W o ens o arc required to obtain aewfl ccs' o f Industrial Acci.dcnts. Should you have any questions regarding y compensation policy, pleaso call the Depaxtnlcnt at the number hstcd below. Sclf-insured companies should enter their self-imurnn(ro License number on tho apprOprier,Zinc. City or Towp Offlciais Plcaso be sure that tbo affidavit is c:bottom con�plcte and printed legibly. The Department has pro o dtc arding thotapphcaat of rho a£tzdavit for you to fill out in the event the OfEcc o•f Investigations bm to contact y g Plcasn bo surtior� an applicant e to fill in the permit/Jiccnsc numbcx which_will be used n cdconl csirbmit np affdalvit indicating current that must submit p7ultzplc permiV/ ccnse applications in any given y , Y • policy infomoation{if Accessary) and under"lob Site Address" rho applica.at should write"all Iota r tO'Y�m mayb roY rdcd to-(city or town)."A cbpy of the aff ctaYit that has been off ciallystampe crrjaits on ccnsC s A nawy the city oaffidavit must be fiillcd out each applicant as proof that a valid affidavit is on file for fu p ycar.'Whero a home owner or citizen is obtaining a license or permit not related io any business or commercial venttue (i e, a dog license or-percait to burn leaves etc.) said persau is NOT required to complete this affidavit. Tho Office of I.nVcstiga.bons would Uke to thank you in advance for your cooper any questions, ation and should you bavc please do not hesitato to give us a call The Department's address, tcicphone•amd fax nu_mbcr: The Commonwtra-l.th of MassaGh=ltts , D-pUtmeAt Of Iad4gt6 l Accidents Office of luestiptl.ons 600 w �tm St-cict $gstan, MA 02111 Tcl; # 617-727-490.0 ext Q06 Qr 1-877-MASSAFE Fax# 617-7'27-7749 Revised 11-22-06 www.rniSs...gov/d18 oFYHrr Town of Barnstable Regul2tory Services w SLRN TAD LA '1 Thomas F. Geiler, Director rius.s. t679 o Building Division rF µay Tom ferry, Building Commissioner 200 Main Street, T4yannis, MA 02601 www•torvn.barnstah1e.rnn.us Office: 508-86-2-4038- - Fax: 508-790-623 Property ownev Must Cb'Mplcte and Sign This Section Zf'USi-v A Buildef � as Owner of the subject property hereby authorize � � rn to act on my behalf, . in aIl matters relaEvc to work authorized by this building permit application for: YV q V C. 1 (Ad.dtess of Join) Q(10 x 291 Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Rxemption Porn on th•e reverse side. Town 0f Barnstable ��� of 7HE rotyy� Regulatory services Thomas F. Geiler, Director t BARNSTABLE, MASS. -�� i67P Building Dzviszozl Prfo µatA Tom Perry,Building Comrriissionel' , 200 Main Street, Hyannis., MA. 02601 v�rfy)Y,torim.barnstable.ma.us r Fax; 508-790-6230- Office: 508-862-4038 L10ETqSE EXEMPTION Plense Print DATE: JOH LOCATION: strcct yillagc number "1-I0MBOWNLR": home phone 9 work phone# name CURRENT MAILING ADDRESS: slate zip code city/tovm er-occupied ied d� cnin s of six.units or less and: i ended to include own P �' or homeowners. was extended the owner acts as The curYent exemption f --- a e an individual for lure who does not possess a license, rovided that to allow homeowners to eng g suoerYisor. DEI 1NZTION OB Hdn'IEOWNEP P erson(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-fanuly dwelling, attached or detached structures accessory to such tiered and/or homeownex�uSuuchs. A person who constructs-more than one home in a tivo-year period shall not be considered "homeowner" shall submit to the Building Official on.a formeayfpt ai Sectionle to 1il09 l�) responsible for all such work performed u Building official, that he/she shall be . nder the buildan The undersi ned "homeowner" assumes responsibility for compliance with'the State Building Code and other g applicable codes, bylaws, rules.and regulations. Barnstable Biiildin. Department ands the Town Th'e undersigned "homeowner" certifies that he/she d thatthe/shewill comply with said procedures and ements an muaimum inspection pro cedures and requu i requirements, t .,• Signature of Homeowner Approval of Building Official Note; Thrce-family dwellings containing 35,000 cubic feet or largo will be required.to comply with the State Building Code Section 127.0 Construchon Control.ER S Exri KF -ION n a building is required shall be exempt from the provisions The Code states that: "Any homeowner performing work for which g Po of this section(Scc6on 109.),1 -Licensing of construction Superyisors);provided that if the homeowner engages a persons)forhire to do such work, that such Homeowner shall act as supervisor, the cndix , Many homeowners who use thiscexemptionpcsorsr;Sectioaware n 2t 15)y arc as This Jack.of awarenesooften)re'sultsf in serioussproblanspendix Q,particularly Rues &�Rcgulalions for Licensing COnStT] P when the homeowner hires unliccnscd persons. In this case,our Board cannot proceed against the unlicensed person as it would w�[h a license, superyisor. The homeowner acting as supervisor is ultimately responsible, paTi of To ensure that the homeowner is fuaods the rcos is/i c lines ofsi 81uLiCS,a y c the Iutspagc oft this�issue is atform cumc tit yused by that the homeowner ecriify that he/she understands ^ f� n;fieation for use in your community. f b o°, cdA a s'•sYaP f. 4�', `� .NJm°" '' 'n a M .. h���6.MA '�f E STATE !NSURkNCr ;:CCPhPANY 007807;-00 WC 006-37--0908 ---------- -._.------•------------- ._... - L 0 13-66--l OC19-00 ��s - � n'S�' -' i 6���� •�. xs�3iARK:iUV50 .���9BUA�vBT�� f PRO.;ECI MANAr- L.LC 15 LEXINGTON LANE Y.ARNMOUTHIPORT, AA 021b75.-0000 ' EXECUTIVE OFFICES: 70 R14£ STRES~T`, NEW k'ORK, N.Y. 110270 SEE EXTENSION CSC ITEM''I. OF ME INFORMATION PAGE WC990610. I:L�fr� _...«.__.........._-._,..._,..,........._.._._...-......................_AL?,Ci...h.!'.'.=.��......-..._....,.........,...�_..._....-. «._,._..... �' P F F �B'[Et��iaamh��y - �MILL.ER t; MCCART iN iNC 05A DOWLANG E. ONEiL WORKERS COMPENSATiON AMID EMPLOYERS 973 1 YANNOL'GH RD LIABILITY POLICY INFORMATION PAGE PO BOX 1990 i.IM!Tr,D LIABiLiTY COO ANY - NEW OTHE. WORKPLACES NOT Si�CI1�N ABOVE.-u_SEE EX`TENS!CSN OF ITEM 1. OF THE I/4.FCId�MATION PAGE _'ff-v 06'llb.__ T—EM 1 taj[71.'V';' F*L7 12:61 A.M.standard time at the insurr;<t't- mailing address FROM j0/14/09 TO 10/14/it'S 1Fti et 3 R. 4PuorkerK C(stvtp tbsatlon Insur,ace: Parts One of then polio applies to the Workers �^trmpedt;,ait:Ecrn i alau of the states listed - hore: MA S. £I»p(seers l..talziiiryy Insurance: dart i'lnr(a t;r4 the poiir.V applies to the work in each state Its--- in item 5' .R_.,...<...__—accl-n—t ' The. limits pf our liability under mart Two 414'0, 000 �actn acci(4ent EtadilS� asary:�ni kcy .d�ccfcfant $ ..�._..,_� 50U. B4J1 ilv fnlury by IbisQi3n.'i(d policy limit Bodily Injury bV Disease � � _..��a�� each empirayee e C. Other States Insurance,: Part Three of the po)i(ayi Rpplies to this states, if .antf, iisted here; l SEE ENDORSEMENT WC200306A D. This paliry ie3ciudtss-ttse;ma.�_, ..._..__... ._......._.,.-__....._._.._�_..______.._.n_.__..__,._,.�__.___...__..._..._ ......_.— _ .._..._.._.w.._�__.._.. SEE. E)CrENSII:N OF ITEM 3,13, OF THE MFO€3M AAT'ION PAGE - WCSSGS12 �TE M J The pzenflum for skis policy will be dvarrninad hV our Manuals of Ruses, Ci ass ffications, Rates and Rating Narts. i Ail Information required below Is subject to arific.01 on and chaengxs by hudlit. ._._.......,»........_�_..___.._..- -.� ._.._..._...,._.,...._........,......._ ..._........._... �.EstimAfnn TolA..;.... ..Fate Per E.strinateci _ GIasS�eiexltons .. hods Number `�Amuna;ni"?lwn "mot U(t QF Fe• Premium •.__...... .._._...._._..._-__.._._......._.... ___.._..._._____.�....._M_.._...__-..`....�_ �...._._....�..... LAJ Ann,�u4t ,1,3 Year munnration R.nnual El Year i SEE EXTENSION OF ITEM A. OF THE WFE}6k14 ATION, FAGS - VVC7754 TAXES/ASSESSMEMI'L/SIIRF•"iARGES $6 , E15r'FRn a'e....'_GQ?iS7Aitirr(Ei(C£P7 hirP4EidE At%S'f_IC�At7LE BY'a �1 ��,...... .,_...... —_.....,......,e_......_. ..a_...._.�..._._�..� _ A94AlIrtit..UA PREMIUM�.. `_.'C�O Ian TOTAL.ESMMATED?REMS(lAi ���Q ____.,._..._........_,_.r._.._...._._^----_..__...X...L_.._..................__._.__.._..��__.._._. ....ter........_., ___._______..___.._._......_..,....._._. _,.... It IndlCeted teioar, 1?1196�:acijus?mer.:s of pternlurn scell be Mele: Ssrn .w;nnuauy - E CILiarlarty Monthly - DEPMM txOSMIUM - 1 1/13109 A5 S 1.Ga E D RISK 0`6.___..._.. Issue Noe — t; usny�citric; At"horfzd 6iewasentative 4wC r0 0„t 38 V (Rev'd N/N!1) May 1u, lulu 336061 at #34 to 336052 1. .: Z #31 . k ^o xFk 336092 „ p 7- `:. s € 336043 336051 4 S ! ° #4084 3360di #GO 336046 A a� #41 C7 #4044 t 36049001t a r. w� #4070 ' A 336072C-N D #4042 t,3 433604054 # 1- >= 6 is I ti �,,,,'.' �,s "r � c •_ #4022 336047 1 w c #4046 - 1 336027 336039 £ #4073 #3990 g 33&088 #4010 41335028 e 336053 #4053 335053 3-35075 _,.... .• 335031 #4027 3507 >F 335060 #4015 r 1 3 3 r 0(_ 335032 #4011 ems; ; #0 g #4005 S ;LU rz DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal M.P.336 Parcel:07200A Selected Parcel -� N boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:GRANDE,STEPHEN E III Total Assessed Value:$304600 1"=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location:4040 MAIN ST./RTE 6A(BARN.) such as building locations. Buffer f r Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards — Registration;` 155863 One Ashburton Place Rm 1301 Expiration 5/15/2011 Tr# 283151 Boston,Ma.02108 Type LLC ,f , x, t it PROJECT MANAGERS LLC l t WILLIAM PLANINSHEKs ; 15 LEXINGTON ----- YARMOUTHPORT,MA 0267 Administrator N valid w out signature `;� ✓1 e -�anv�:o�Zu�ea/,� o�..��oa�lu�aeCta . . Board of Building Regulations and Standards :w Construction"Supervisor License License��CS 95981' Birthdate -10125/1951 x L � r t r = Tr# 95981 3;. Expiration 10I25j2010 Restriction` WILLIAM PLANINSHEK 15 LEXINGTON LANE �..r,,,TuvnRT MA02675 Commissioner (lb 1 1 ^ `� �a � � -� /. 1c � •1-���-mot- � Iy P 5duA pFTHE r° Town of Barnstable BARNSTABLE. Regulatory Services Building Division pTFD MPy A. n 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection Location �/o/0 &t5/ N Permit Number 70 c' C> Owner Builder P1,4- /AJ tF�, One notice to remain on job site, one notice on file in Building Department. The following items need correcting: / �.<vk f 7- P A) Du Of ,vim o /3 tN CO . CO;04)c Ile C T/g e- C+ 4 L 3 u Y Nu VA Please call: 508-862-46--8-fvr re-inspection. G Inspected b f' ( Date / Q r i Of 1HE Tp� Town of Barnstable �010 ti�P� ti� Expires 6 months from issue date Regulatory Services Fee » BARNSTABLE, : - - �$ MASS Thomas F. Geiler,Director prED ASS PERMITBuilding Division APR 15 2010 ,Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 TOWN OF BARNS-ABLE www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY i Not,Valid without Red X--Press Imprint Map/parcel Number > Property Address {" D C(ffr Residential Value of Work��7 f(� Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address -�C- -�V �!Lu ��✓`�_ n U Contractor's Name 9(10A�c A 411 � Telephone Number ` ( L{ ......... -_... - Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ( l ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ m the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp,Policy# o G 6 1 31 O 0 Copy of Insurance Compliance Certificate must accompany each permit. 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) e-side #of doors ❑ Replacement Windows/doors/sliders,U-Value (maximum .44)#of windows *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 o7th inImproveme tractors License & Construction Supervisors License is requiredSIGNATURE: i The Commonwealth ofMassachiisetts Department of Industrial Accidents ' Office of Investigations 600 PVashington Street 1 Boston, NIA 02111 y° wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep_ibly Name (Business/OrganizationLIndividual): `t/(LQ ^ P C�/l� Address: -� � � VJ _ City/State/Zip: v Phone#: '3 ILC7 6, Are yo"n employer? Check the appropriate box: Type of project(required): I.u�/I am a with employer 4. ❑ I am a general contractor and I � 6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ listed on the attached sheet. 7. ❑Remodeling 2. I am a sole proprietor or partner- ship and have na employees These sub-contractors have g, ❑Demolition workingfor me in an capacity, employees and have workers' Y9. ❑Building addition it [No workers' comp. insurance comp.insurance. required,] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions re 3.❑ I qu a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions Y right of exemption per MGL ❑ p t c. 15f §1(4)No d wei-1 workers' no _ 13.❑ Other�n sue- - m self...[Norworkers._comp, 12. ___Roof.re airs.. h insurance required.] employees. [ comp. insurance required.] L,t,4L,(_ *Any applicant that checks box#1 must also fill oot.the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for'my employees. Below is the policy and job site information. Insurance Company Name: tl ' Policy#or Self-ins. Lic. #: CLOG 0 / ® X Expiration Date: 0 1 d l Job Site Address: L'i _� LI b�' v City/State/Zip: Mi9— 6 " Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certfy under JAe pars t enalties Vperjuthat the information provided above is true and correct. Signature: Date: Phone# '✓ �� I�� Official use only. Do not tivrite in this area, to he completed by city or town official. City or Town: Permit/License# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an eniployee is defined as "...every person in the service of another under any contract of hire, e epress..gr implied, oral or written.". An employ is defined as"an individual,partnership,association;corporation or other legal entity, or any two or more of the foregoin engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee an individual,partnership, association or other legal entity, employing employees.. However the owner of a dwelling h se having not more than three apartments and who resides therein, or the occupant of the dwelling house of anothe ho employs persons to do maintenance, constriction or repair work on such dwelling house or on the grotmds or buildin appurtenant thereto shall not because of such employment be deemed to be an employer." 25C 6 also slates that"ever state or local licensing agency shall withhold the issuance or MGL chapter 152 y g g renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required," Additionally,MGL chapter 152, §25C(h states "Neither the commonwealth nor'any of its political subdivisions shall enter into any contract for the performanc of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been pres ted to the contracting authority." Applicants Please fill out the workers' compensation affidavit corn etely,b checking the boxes that apply to your sihiahon and, �f necessary,supply sub-contractor(s)name(s),address(es)a d pho e number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited L bili Partnerships (LLP)with no employees other than the members or partners,are not required to carry workers' _mi s f,on insurance, If an LLC or LI P does have .employees, a policy is required. Be advised that this affidavit m be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sur t sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pe t or li ``ense is being requested,not the Department of lndustrial Accidents. Should.you have any questions regardi the lawbr if you are required to obtain a workers' compensation policy,please call the Department at the num r listed belo v. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legUy. The Department h provided a space at the bottom of the affidavit for you to fill out in the event the Office of nvestigations has to conta you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference nirm er. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit o e affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"al ocations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town m y'be provided to the f that a valid affidavit is on file for future ermits or licenses. A new affidavit mit be filled out each applicant as proof t P year. Where a home owner or citizen is obtaining a license Qr permit not related to any business or corm ercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. t. The Office of Investigations would like to thank you in adva�ce for your cooperation and should you have any questions, please do not hesitate to give us a call. t TheDepartment's address, telephone and fax number: t I� The Commonwealth oQMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia g`,, :aa a ®a� °�dtd�,t��'�r.'. .'e •e a a 6mGd6.°. �' . GRAi=1`s TE STATE INSURANCE O �€�cla�9 v � .. �,c �:Y , 00��o e, era «t:)-37 310 ---------- .--------------- 01.3-66- 1ccig-oo PROJECT MANAGERS L LC 15 LEXINGTON LANE YARNMOUTHPORT, MA 026750000 EXECUTIVE OFFICES: NINE STREET, NEW YORK, N.Y. 10270 SE''E EXTENSION OF ITEM 3. CIF THE I NFORNIATI N PAGE; VVC990610 MI L.L.ER ta. MCCART iN il4C IDEA rOWLANG t ONE I L WORKERSCOMPENSATkON AND �,1AP L�YERS � 973 IYANNOUGH RO UABILI:TY POLICY INFORMATION PAGE PO BOX 1990 ANN IS, MA 01-0000 INSURED IS Pf4c✓'OLJS POLICYF1UMI;EP 1_I FI I TEE L I AB I L i-1-Y�COMPANY _ _ _ NEW 'O HEn WORKPLACES CES NOT SHOWN ABOVE:,SEE EXTENSION OF ITEM 1. OF THE WfORM A'I•ION PAGE I7.E 2 POLICY PFRl0D 12:61 A.M.Standard time:at the insurte,3,u mailing address _ FROM 10/14/09 TO 10/1 4/10 ITS-W 3 A. Workers Compensation�lInsuranxe: Part One at the policy applies to thy; Workers Compensation Law of the states listen hare: MA A B. l:mptoyers LiabilirV Insurance: Part 1'tnto rat the prslicV Applies to the work in each stpte listedin item 3.A..� m� The. limits of our iia'bility Bander Dart Tavo are: Bodily, arsj;ary by .Accid ant S 00.000 each accident Bodily Injury by Disa3a`.se s.gQ_ Poliev limit Bodily lno ury by Disease $ ._._.._.5L� Ch employee C, father States Insurance: Part 'Shre of theD p llcy applies to the states, if any, iistsJ here: SEE ENDORSEMENT WC 00 OF t � .3 3A _ 39. This policy it3ciutf �theta _., .,._.._.._.._..�.._......_..._.__..... .....�._M_._._.� _:._._.,...._._.__._..._..._......__..__._...:_:._ ..�__,.�._.. es SEE. EXTENSION OF ITEM 3.1). OF THE If+BlaORMATION PAGE - WC990612 The pmrnium for tS is policy will be determined by our I onvai.,s of Rules, Glassifira+si�xns, &8sktez; altc9 Iiatirk MPiati7s. �� w_ Ail Information required below Is subject to vOrif Dion and change by audit. Est matart Tao + mate Per E.strirtaPati �lemur,e nt vn Prsmium Cla:s fircxlrans Gods Number �1 31fDkD OF Pe- I�1 ..�.,..°... _.--- __.......,.._._.......�....�....._..._,.._.,_._._ ..._..._._.m._,_.,.,.. _....... r*,� runerakicfn 6...J rinr�ua! 3 U., A,gnual 3 Year SEE EXTENSION OF ITEM A.. OF THE. INFORMATION PAGE - WC7754 TAXES/ASSE.SSMENI'S/SLJRCiiA.RGES $6 EXPIEPOSE CON57AW(EXCEPT WHERE APPLICABLE f Y STATIE1 _ 1 A MA - 9AMMUPA PREWV1AA __ ff0 MA TOTAL,ESTIMATED PrdEPdAW If u•.atcated.t cw, nisrwi adjuemerts at prarn;wm 5YE11 be made: - Senn;:,Annumuv � Ceuarlarly � Ntontfity DEPOS17 PREtutyUM �1 1/ 13/09 DASS 1 GNED ii i 5K......__._..�. �_..�Y........_ U6..._.............�.�.,._.,W_._._..__ ��...�.. .�....,�,_...�,_._.�.__._._..._,.�.._..�...._ , �iseue Dale. _ - - Ik','Rfsing S:fttIC9,..�.,.p1O•.�.,••'..•..,....•..•.:•••.•.«.. :Authorl,.'4'CI b`Eeprasentative 4Wc.Ga Cal' . 3� 7 (W6er'd R:5/fki} Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only before the expiration date. If found return to: Registra"tion�155863 Board of Building Regulations and Standards Expiration 57,15/2011 Tr# 283151 One Ashburton Place Rm 1301 Type LG Boston,Ma.02108 PROJECT MANAGERS LLC �1 WILLIAM PLANINSHEKI` 15 LEXINGTON LML YARMOUTHPORT, MA 02675 Administrator N valid w out signature `��T � � ;14� ../72C TDL`Y7/l92092lA{P�2 O�i�(�GQA6CLCfLlt6P.�6 j .. ' °e (Board of Building Regulations and Standards %.. Construction Supervisor'License ° LicerisCS 95981' Bkhdate 10/25/1951 � � Ezpaorl} 10 5 2010 Tr# 95981 Restriction` 001 VM E WILLIAM PLANINSHEK ,� I 1 15 LEXINGTON LANES f YARMOUTH PORT MA 02675 Commissioner I ' J .7 C/o ® PM will apply 25 square Maebec Teach Oil Cedar Singles. ® PM will structurally correct only the corner where stump is located. This work is confined to 3ft sill or corner post repair �p either way if necessary. ® PM will install new 6' slider and exterior/ interior trim — materials provided by owner. i bs ® PM will demo, frame and install new deck side window and �n exterior/ interior trim — materials provided by owner. Due to age of home and the clear and present danger of decay of existing exterior walls, sills and trim, Project Managers will v� provide all necessary services to complete project on a per hour 3 payment basis's. All extra, not in written proposal or unforeseen matters. to be agreed upon b Steven Grande and Will g p Y Y Planinshek, before commencement of work. Total Price: $15,775.00 4Reg s, J TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# Health Division f Conservation Division Permit# Tax Collector Date Issued Treasurer - Application Fee Planning Dept. , 4 Permit Fee �,�.� G® ,, Date Definitive Plan Approved by Planning Board �� ql( Historic-OKH Preservation/Hyannis Project Street Address 0 /2/ 6 r / Village Owner _(!7-7:9MtF,Li1 4, a&JD®E Address 6 4/6 27 C_Ge✓nrn @�c�1 Telephone — N e 7UP Permit Request uD C(n t , "i }, CD Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total n Zoning District �y Flood Plain Groundwater Overlay Project Valuation �` Q. °�' Construction Type OLD :° Lot Size�/��1j/® Grandfathered: ❑Yes ❑ No If yes, attach supporting docu entatiorF; 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: O 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 r9'No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name,.4p�J,;;a67_E01,01A)6. Telephone Number Address License# O/q 09 o. nLLV-/ MA lSoM66 Home Improvement Contractor# 6�� Worker's Compensation# (AJ C_g/7& d a y O 5' ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �� r FOR OFFICIAL USE ONLY 1 PERMIT NO. t. DATE ISSUED 1 ; MAP/PARCEL NO. I i' ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION / AV 44 Lb FRAMEcrk �- •• INSULATION FIREPLACE F , ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ' ASSOCIATION PLAN NO. THE DAVENPORT BUILDING COMPANY 20 North Main Street Leftrof South Yarmouth MA, 02664-3143 MWENTOW Site Address:Attomey Stephen E. Grande 111,4040 Rt.6A Cummaquid, Ma 02637 Date: Job No. October19,2006 To:Town of Barnstable Building Department Attention: Main street Jack Labuff,Barnstable Bw1ding hLspector. Hyannis MA Reference: Project:4040 Rt. 6A RE:Grande Garage Stephen E. Grande III 4040 Rt.6A Cummaquid,MA 02601 We Are Sending You: ❑Attached ❑ Under Separate Cover via Hand Delivered the following items: ❑ Prints ❑ Plans ❑Shop Drawings ❑Samples ❑Specification(s) ❑ Letter ❑ Change Order ❑ Corporate Brochures ❑ Proposal Copies Date No. Description: 1 10/19/06 Qri anal Letter addressing Loft usage These Are Transmitted as Checked Below: -'Z �o ❑For Approval ❑ Approved As Submitted ❑ Resubmit 1 copie(s)for AppWval ❑ For Your Use ❑ Approved As Noted ❑Submit_copie(s)for Distrition on, ❑ Returned For Corrections ❑ Return_corrected prints rn Remarks: 11 this meets midi yow- approval, please notify Davenport for xiiien the peanut caii be picked lip. Thaiik you. Signed: Copy To: DBC file Stephen D. General Manager, Davenport Po ompany ��8 —39V— 9X6 o X/5"3 LAW OFFICES OF STEPHEN E. GRANDE, III 60 Union Avenue Suite 1 Sudbury, MA 01776 Telephone (978)443-7881 Facsimile (978)443-7883 Barnstable Building Department Barnstable , Mass. 10/18/2006 Attn: Building Inspector Dear Sir/Madam I have been instucted by my building company (Davenport) to provide you with a letter informing you that the current intended use o the 8-4 loft of the proposed garage at 4040 Main St. (Rt.6jis for stora e o purposes only. --+ Al Thank you for your anticipated cooperation, ORIGINAL /tepZh-en Grande III Town of Barnstable ti Regulatory Services snxNSTnstE. ` Thomas F.Geiler,Director y •ass. �' , i639.� Building Division g Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 wwvv.town.barnstable.ma.us ' )ffice: 508-862-4038 Fax: 508-790-6230 Permit no. 2Q 0 O'3 s`77 Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adj acent to such residence.or building be done by registered centraciors,with certain exceptions,a.�..g with o*?per. requirements. Type of Work: /2��/�/if �� �rlc PLC Estimated Cost . Address of Work: 510e/G /127T 619 6&AIM -4L-113 "TI Owner's Name: _51AE�2i lA► Gi2�'`� �' Date of Application: 16A16 y I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law D*Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a p t as f the owner: l0 0 6 ����i�r� c�R/GDi.cJlr CO. Date Contractor Signature Registration No. OR Date Owner's Signature Q:wpfiles.fomu:homeaff day Rew. 060606 I he commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RC-r Address: g-a City/State/Zip: Phone #: 35'9, Are you an employer?Check the appropriate x:. Type of project(required): t 1.❑ I am a employer with. 4. I am a general contractor and I 6. New construction. _ employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or parmer- listed on the attached sheet $ ❑ Remodeling ship and have employees These sub-contractors have 8. ❑ Demolition- working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition ' [No workers' comp. insurance 5• ❑ We area corporation and its officers have exercised their 10.❑ Electrical repairs of additions required.] 3..El am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions myself. [No workers' comp.. c. 152, §1(4), and we have no 12.❑ R of repairs �� insurance required.] t employees. [No workers' comp. insurance required.] 13.� Other _ .J-,"C *Any applicant-that checks box#1 must also fill out the section below showing their workers'compensation policy information e t Homeowners who submit this affidavit_indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /5WO/-S' ,egjC Policy#or Self-ins.Lic. #: Zy G cPl 6 6 29 o �' Expiration Date: � �a 7 -:Job Site Address: 6 O AVI", City/State/Zip: cam- 3 ? 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 4 fine up to$1500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250 00 a day against the violator. Be advised that a copy of this statement may forwarded to the Office bf Investigations of the DIA for insurance coverage verification. I do hereby certify der t ai alties of perjury that the information provided above is true and correct Si atur : - Date G . Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town.Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions h Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair worknn such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any . applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions`shall enter into any contract for the performance of public work until acceptable'evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation-affidavit completely,by checking the boxes that apply to your situation and,.if _ necessary; supply sub-contractors)name(s), address(es).and phone number(s)along with their certificate(s) of" insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLPj with no employees other than the members or partners;are not required to carry workers' compensation insurance. If an LLC or LLP does have required. Be advised that affidavit may be submitted to the Department of Industrial employees,-a policy is Accidents for confirmation of insurance coverage:.' Also be sure to sign and date the affidavit. The.affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding-the law or if you are required to-obtain a workers' _ compensation policy;please call the Department at the number listed below. Self-insured companies should enter.their _ self-insurance license number on the appropriate line: City or Town Officials Please be sure that the affidavit is complete-and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license-applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit-that has been_-officially stamped or marked by the city or town may be provided to the applicant as proof that avalid affidavit is on file for fiuture permits or licenses. A new affidavit must be filled out each - is obtaining a license or permit not related to any business or commercial venture year.'Where a home owner or citizen (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations;would like to=thank you in advance for your cooperation and should you have any.questions, _ please do not hesitate to give us a call. The Department's address,telephone and fax number: -The Commonwealth of Massachusetts . Depafinent of Industrial:Accidents " Office of Investigations 600 Washington Street " Boston, MA 02111: - Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 _ www.mass.gov/&a i acoRD„ CERTIFICATE OF LIABILITY INSURANCE OP ID P DATE(MM/DD/YYYY) DAVE23-1 09/18/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE The Addis Group, Inc. HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 2500 Renaissance Blvd. Ste 100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. i King of Prussia PA 19406-2772 Phone: 610-279-8550 Fax:610-279-8543 INSURERS AFFORDING COVERAGE NAIC# INSURED 40142 INSURER A. American Zurich Insurance Co D venport Building Co. INSURER B: Zurich American Insurance Cc 16535 c/o Davenport Realty Trust INSURERC: Stephen Aschettino 20 North Main St. INSURERD: South Yarmouth, MA 02664 INSURER E: i COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD POLICYIEFFECTIVE POLICY ATE MM/ DIY EXPIRATION) LIMITS i GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ i GEN L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT B ANY AUTO BAP819625604 03/01/06 03/01/07 (Ea accident) $1,000,000 X ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident) t X 250 Comp PROPERTY DAMAGE X 500 Coll (Par accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ 1 AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ j $ ti DEDUCTIBLE $ RETENTION $ $ TATLIWORKERS COMPENSATION AND X TORY LIMITS JUI ER EMPLOYERS'LIABILITY A ANY PROPRIETORIPAR7NER/EXECUTIVE WC819602409 03/01/06 03/01/07 E.L EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $1,000,OOO If yes,describe under ' SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1 000 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES 117(CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Job Site: Stephen E. Grande III, 4040 Rt 6A, Cummaquid, MA 1 � i i CERTIFICATE HOLDER CANCELLATION HYANNI S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION i DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Hyannis Town Hall NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO SO SHALL Attn: Building Department IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR 367 Main Street Hyannis MA 02601 REPRESENTATIVES. AL�TFj,::TREPR NTATIV ACORD 25(2001108) ©ACORD CORPORATION 1988 i ACORDT. CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDIYYYY) 9/18/2006 PRODUCER (781)826-0123 FAX (781)826-0301 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION THE RIELLY INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Eastern Insurance Group LLC ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 243 Church Street Pembroke MA 02359 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Hartford Casualty Ins 29424 Davenport Building Company Trust INSURERB: Davenport Realty Trust INSURER C: 20. No. Main Street INSURERD: South Yarmouth MA 02664 INSURERE: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER PDATEYMM DDIYYE DATE POLICY EXPIRATION LIMITS LTR INSRD ( ) MM/DDIYY)( ) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE ToRNTE X COMMERCIAL GENERAL LIABILITY PREM SES EaEoccurence $ 300,000 A CLAIMS MADE a OCCUR 08 UUN BW3793 6/1/2006 6/1/2007 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JECOT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATUS OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE$ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Job Site: Stephen E. Grande III, 4040 Rt 6A, Cutmttaquid, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Hyannis Town Hall EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Attn: Building Department 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 367 Main Street FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Hyannis, MA 02601 INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE J Powers Jr./MARSHA ACORD 25(2001/08) ©ACORD CORPORATION 1988 INS025(01o8ym AMS VMP Mortgage Solutions,Inc.(800)327-0545 Page 1 of 2 l Sep 07 06 10: 25a p. 2 Town of%rnstabte . F Reguhitory Services Them F.Gees,Dkw r BWdit Division TM hn7, BWWbv GrteMftdMwr 200 Mda SWOM iiruaait;,MA 02601 Otfiox 5OB462-4038 F.;: SOB-7sa 6�i0 PrOPcM Oww Must Complete and Sign Mis Section If Using A Budder - �•- i PmPuh 6aeby mdko&e in an mscbcas n6tive to xa&aud-.med b da6 btauing P=Rit ePPI"d=for (Adder dJob) /*Mj� v� flamer Date 7 . Print N=w ttxaa+is�vwN�No�s�+ Z d SOO6tZZ l£9 'ON/5l: l l °'1S/9l: l l 900Z Z dWAHl) W084 91?e .0 d Board of Building Regulat ons and Standards N One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement �wntractor Registration --� Registration: 106024 - - ` Type: Trust Expiration: 7/21/2008 DAVENPORT BUILDING COMPANY— Dewitt Davenport 20 North Main Street - - South Yarmouth, MA 02664 :���•' Update Address and return card.Mark reason for change. DPS-Cal e, 50M-05/06-PC8490 Address Renewal ❑ Employment Lost Card �— �'!e -CJanz,xo�tusea� o��/�ac�ivaelZa Board of Building Regulations and Standards License or registration valid for individul use only HOME IMP'2, VEMENT CONTRACTOR before the expiration date. If found return to: f Re i.s_tra`•-on:— Board of BuildingRegulations ulations and Standards - _106024 One Ashburton Place Rm 1301 i y P o_ 7L2� 008 Boston,MEL 02108 pe _Trwtist DAVENPORT BUILbI CaSQMPA, �,TRUST Dewitt Davenport i 20 North Main Street�. South Yarmouth, MA 02664 Deputy Administrator Not valid without signature f , J �= Board offl'uoi/�ldingegula9oents- �an �ars One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement-Ontractor Registration Registration: 106024 Type: Trust p r � Expiration- 7/21/2008 DAVENPORT BUILDING COMPAN`"—;- STR C� aLt � — Dewitt Davenport t = _ x # s 20 North Main Street South Yarmouth, MA 02664 `- - Update Address and return card.Mark reason for change. Address 0 Renewal a Employment Lost Card S-CA1 0 50M-04/05-PC8698 Ej ,p� .IfLC C/IOOYVIl20�ILUlPQ�l1L a��/!/GQ46�tttQ6�6 ----- \U,qBoard of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration;, 106024 One Ashburton Place Rm 1301 E-_ ifation-7/21/2008 c } = Boston,Ma.02108 #Type Trutt rr 4t DAVENPORT BUaLD11JG COMPANY TRUST -- f tit Dewitt Davenport,.—;, ,wcQ- 20-North Main Street W -.° -.-- "J ~ Not valid wit ot siture South Yarmouth,MA 0266$ Deputy Administrator u gna . 1 • • e _�iiT.f�:���.f. �. otYaa�a•�i�'.ne`^���mot"} �-�a�fi:�n- e tit � � as ✓)(.G�O��fer¢�zv�n��.'�!�P;:atfc� = BOARffOF BUILDING REgQ'TJON3 r• License: ..CONSTRUCTLON.SUPERV►Sl9R Numbe 012060 - ' 007 Tr.no: .8967.0 DEINL�T�P DAV =d f! 20 JN WIN ST = ); - � Com..m�ssioner �. r 1 I I. 121.27' h O N O Deck O�5 WO O HO% PO✓ FARM CONDOMINIUM" AREA /N 50. FT. _ J8"020t 16.6' AREA /N ACRES = 0.87 EXIST. FOUND 17.g' O eck 0� o Wp 133. 16 _ Route 6A Main Street DCE #05-200 05-200 garage cpp.dwg THC FOUNDATION PLOT PLAN PREPARED EXCLUSIVELY FOR THE PURPOSE OF OBTAINING A BUILDING PERMIT, NOT FOR ANY OTHER USE LOCATION 4040 ROUTE 6A CUMMAQUID9 MA �b SCALE : 1" = 60' DATE : NOVEMBER 10, 2006 PREPARED FOR: REFERENCE : ASSESSOR'S MAP 336 PARCEL 72 STEPHEN E. GRANDE III PLAN BOOK 381 PAGE 37 & I HEREBY CERTIFY THAT THE STRUCTURE STEPHEN SE PORTER SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. jHOF ss9�ti off 508-362-4541 0 DANIEL Gu, fox 508 362-9880 O A.LA down cape engineering, inc. �.4098 0"CIVIL ENGINEERS �� D6 _ � �L LAND SURVEYORS 79 GA 0 —✓ 939 main st, yarmouth, ma DATE °S SURVEYOR 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 336 Parcel . 072-OOA Permit# �l`� 7 / '-a- -� Health Division o� �y]-r Date Issued `� " 7 `0 f is N bjLG �j Conservation Division -�s R^`�' vn U� > / -e. Application Fee Tax Collector Permit Fee Treasurer 41 Planning Dept. Date Definitive Plan Approved by)YaNffvgWN Historic-OKH Feb. 9, 2001�reservation/Hyannis Project Street Address 4040 Main Street (Rt 6A) Village �uR41 Owner Stephen E. Grande, III Mailing Address60 Union Ave. , Sudbury, MA 07 776 Telephone (978 ) 443-7881 FAX (978) 443-7883 Permit Request The construction of a fence with the height in excess of 6 ft. Fence to be 6 ft from front north corner of house to property line 1% sections of 6 ft running north along line to existing cfarage (See Plan) Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation $5, 000. 00 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 (1,_k41�JD�" BUILDER INFORMATION � �fi/ e ap Fen Telephone Number ( 508 ) 39 G041 (/ Ad&ess-R-� o 6 License# South Yarmouth, 0Home Improvement Contractor# Worker's Compensation# WC819602408 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEWU BY Cape Cod Fence Co. nIGNATUR DATE o�J7 " E FOR OFFICIAL USE ONLY i + 2 i PERMIT NO. • DATE ISSUED f r*. MAP/PARCEL NO. A ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL w FINAL BUILDING r � f DATE•CLOSED OUT ASSOCIATION PLAN NO. l I pp SHE rqy, Town of Barnstable h ' Regulatory Services I saaxsrnsra, Thomas F.Geiler,Director p019. �� Building Division �fD MA'S Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-790-6230 Office: 508-862-4038 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: Pjj2 �_ Estimated Cost v 0 Address of Work:, 40 moo ; N. �� ���o� ,� 6 Owner's Name; Date of Application: I hereby certify tnat: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 []Buj g not owner-occupied caner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. Dat re Name Q:fotms:homeaffidav Town of Barnstable Regulatory Services IV �- ,- .. -:.•..,..:Thgm�s:F;-:�_eiler,Dir•.ec or: : ..'BARNSTABr.E� '' .. v .....- _ ......,..__..__ ....... _. .. ..._ ..... ... NAM 16 ,.• -Building Division TfD MA't :-Tom Perry,B-fiildin 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: S JOB LOCATION: U 6 w C�✓�� L)G Z,�) number street village [� "HOMW 1 I EONER": Q `� name / home phone# work phone# CURRENT MAILING ADDRESS: CU CI/U b city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,thathe/she shall be responsible for all such work performed under the building permit (Section l09.1.1) 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 Tom of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirement . Si atu of meowrier 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 fora/certification for use in your community. Q:forms:homeexerrp t f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street, ;"h Floor Boston,Mass 02111 Workers'Compensation Insurance Affidavit Building/Plumbing/Electrical Contractors Appl�cant..mformatlpn , , ,ta . *PlGfE3 �..,:,.$., ease PI2IlI`le��. ins - name: J /` address: city I/I4� tate: zip: phone# w rk site location full address): l) Aof, N U T- c U (j 1) AA I am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel I am a sole proprietor and have no one working in any capacity. ❑Building Addition d n;t;� ? M1.,.:4 i 's�' �" ..b ,rf- _ -•e� s t4 r .,i .F.S. ❑ I am an employer providing workers' compensation for my employees working on this job. company name: address: city: phone#: insurance co. policy# ...a.::: . :.,t..�,r...z,... .=:a •..`:.::x.y.a..,:,:.,,._ ._...,.�.: .. a....:--...a.� r,:.::� '.;::: ..4;._:m;z.' ..is•-:: ,.,.�:,..n. •:..:.x'ti ..., r..d: u.::.:.-'...� .:'..:�a.:t�rs•�.: ❑ I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone#: insurance co. Dolicy# company name: address: city: phone#: insurance co. policy# �ltfach,add�nonal sheet�f,nece�sarX -a..���J...-�...;3,,Fee �4• � '� w�a <�," + � b � .�q � � � t r: ��I�. �5F m,,•Mr,k"'; .,., is'oX'.F;{,^tiy.L�'Sr ,��i'..,:Mi .a`tit'.J...". °ru.....:;. �,LS.'�o �R"c+k�,�.v.��: Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date z-�Z �J�t� Print name Phone# offi ' use only do not write in this area to be completed by city or town official , city or town: permit/license# ❑Building Department ❑check if immediate response is required ❑Licensing Board ❑Selectmen's Office ❑Health Department contact person: phone# ❑Other (revised Sept.2003) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under.any contract of hire,express or implied,oral or written. . An employer is defined as an individual,partnership, association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having,not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. a„y?R t 7T' P;,��`` '4erir �'�°'f'4:.: y t � x ;k6'- Y�h.R.y,�wh...,�Rb�t�'"h��'uj./}S�,J.s`.ti vt'V 'f.'.r 5�t �l'3, t1 P.y�i. �'••'.t�C' e �,R %L K.'l. #S '�'�':�. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the"law" or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. 1' i �t�,s�.,, City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. � '� a..� �.;. -F." t ,'a } $ rR gfF .ry } - '' � r,i y t } is .rpt The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone #: (617) 727-4900 ext. 406 ) r.-.i ..v<n. ,,...,:v.M -..+.. . ..�,_.. _._^ ._ . .:tisa;z€`'3v...=-ast. 'w .-.•.-,.;��['mi5'��-c ;'qb l`-'�..<. 1 AFFIDAVIT i I, GRACE LIBBY, of Stoney Point Road, Barnstable (Cummaquid)., Ii Barnstable County, P.lassachusetts, being on oath, depose and say; i. ThatI was the o 7.,er of property located on Main Street and Route 6A5 in Barnstable (Cu=aquid) , Barnstable County., i� Massachusetts, consisting of a'-residence :a"t.wo-car- f garage. and- a- 1 - barn, from November 24., 1943 to July 1, 1972, For my title' see deed recorded irY Barnsta'b116`CQunty Registr ry of Deeds in { ; . Book '6,08, Page ::'4 2e That `during each of the last twenty'=(20) years 'of my ovm- ership the ba;rri'°iocated ori' -the -above premises was equipped and I and utilized for residential purposes. Signed under the pains and `penalties' of perjury 'this 30th day of June 1975. s �� y, :.1.' .. ! 1.RJ'.1 . .. (` •.. '�1:, I ��qP :,' 'T .J, I.f.< !} }. X._� _ trace L� Y COMM �EAJH� 'OF TiASSACHUSETTS: Ba.snstab1e dune ..34,p 1975 Then personall 'appeared the abgveNnamed Grace Libby and acknowledged the foregoing statement ,to 'be true to the best of f lied k,A6i4led'ge.,and bel e � me', " i11, E Z L ,y: ' - No ar is IYCo ion/ exp(2r �/7 9 t ] if - _. ,z'v"•"+. .•z:..., �.._-...r '..,.�....... w--«.r. r`-'Iv'-ti.,Wa++,:'` .. s'?'^.-'m,-v=:g'•. - _.c—..•.+-tiC . .._... ..,w .: .. .-,.:.-... .. .... , '._:. .. ..n.:- ..s-._.._.: .e .-... ..r..+.na :....Y "F... ..--,..-.... ...J ... f - .... . ... .. _.... r- .. ..•va::..-....v.Y..*.w i .w.:::..yti .�._. i� AFFIDAVIT I, RICHARD E; HOWE, of Route 6A, Barnstable. (Cummaquid), Barnstable County, Massachusetts, being on oath, depose and say: 1. That, I am the owner of property -locate.d-..on Main Street. 1 and Route 6A, in Barnstable (Cummaquid), Barnstable County, Massachusetts, consisting of a residence, a two-car garage and a i barn, 2. That I have been the owner of said premises since July 11, 19723 and that during the period of my ownership the barn located on the above premises has been equied and utilized for residential purposes each year. Signed under the pains and penalties of per jury thin ,.ri� ; day of 1975. y G- Richard E. Houre COMMOh7 ALTH OF MASSACHUSETTS , ! Barnstable, ss , 1975 Then personally appeared the above named Richard E. . Howe and acknowledged the -foregoing statement to be true to the best 1 of his knowledge and belief, before me, - rJ ary u is o My C:ommiss.ion: expires :l.!'�:C. . r tl a' _ . ._ .. _ i . AFFIDAVIT I, BELLE HOW cf Route 6A, Barnstable (Cummaquid), _ a Barnstable County, Massachusetts, being on oath, depose a_nd say: 1. That I am the owner of property located on Main Street and Route 6A, in Barr-stable (Cummaquid), Barnstable County, Massachusetts, consisting of a residence, a two-car garage and ,a barn. 2. That I have been the owner of said premises since July 11, 1972, and that during the period of my ownership the 1 barn located on the ebove premises has been equiAd and . utilized fl for residential purposes each year. Signed under the pains and penalties of perjury this: day of =�� ,` 1975. 3 e le ,Howe i ' COkEAOYTEALTH OF MASSACHUSETTs 1 �. Bam stable, ss . 1975 Then personally appeared the above named Belle Howe and - 1 acknowledged the foregoing statement to be true to the best of 1 his knowledge and belief, before me, N6tary Pu lic z _ My Commission expires : 4'- .. - ra •..r.e. --__ ._..�.._.". :u _»..x ..;: ..-;. :,,, .:;._„ ,:. .-'r.yn.. _ .-;,? ,7 0 ., .,,.. ...... ...'4 .z_.x. , .,..... _,.. >... .. .....__a-,.v. ......,L.,.„.. __..;:.: .�_...�_,. ,..,...�.:a....� .,.. .., -4sseeor s maps and lot `number ..... ................................. ._� SEPVtC -SY`rTrjjq ~ /I � /' _ (�STALLE) I;� OC a1,.lAl+J,C� , °i Sewage Permit number ..�11. �.. . (� 2'.F2 fit.% �•'I' H z R ,.. + Al r: � .1 I I ��FtT SAi aITAi'?7 CC�L'* �rj} V: .'+NN yF• FTHEt 4 TOWN OFBA-RNST- A- L,,3E Q . i BASH9TODLE, i td, X 9 "39 N BUraLDING INSPECTOR lopMPY a\e�. ^} i yr � :`» rJ .• . ' APPLICATIO141 FOR PERMIT TO.. ....`. .. ...................................... , ..C ?.! ..ate TYPE OF CONSTRUCTION .... , .. ..... ................................ ... . .. ............... i t1' TO THE INSPECTOR OF BUILDINGS: ' The undersigned hereby applies for a permit accordi g to the following information: Location .. ................. .............................................. ................................... ProposedUse ...1/0A..e.............f , .� ...... l'......................................................................... .. ............................ Zoning District ...... .. .... ..................................................Fire District ...156.!"C�3./........................ ............................ Name of Owner ...............Address ... .... ...&1--Ywd'x4�....Ma's--s Name of Builder ..Ji/i.....G� rr?7d..)'` .......................Address .19.�..... 0,ak�.4. .�...^..ya- .Y�a.fhl,t;r�.....pQ�'..!.... / .../.� ....:.Address YL�. �.,( .... 1 Name of Architect ..,(�... 4� '� .................... .�!?.yh. C�q.V. .�.. ..�..G�......cA.................. Numberof Rooms ....fJ........................................................`....Foundation .............................................................................. Exierior .....................................................................................Roofing .................................................................................... Floors .......................................................................................Interior ........................................................... Heating ......... :-'-- ...................:.....................................Plumbing ............................................... Fireplace ...... .......:::.................................................................Approximate Cost ..��`�..�.®...`....� ............................... Definitive Plan Approved by Planning Board ---------------__._-----------19________. Area Nif'.. !�.E�,t�.................. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... (.'..... . .............. Martin, Richard K. d a' yr , 18027 remodel dwelling o Fermitfor Location ............ ........ ................... .......... jj ................ t Owner .Richard K. Martin -. .� ........................................................frame � "�r. �� f�" • • •, � - r'. .V . .. � . Type ofConstruction .......................................... - - r' ... ..... ................................................. Plot ......2 Lot ................. ............ ,' ; j 0 • �� "� '� October 30 � �f • 75 Permit Granted ..1.19 >µ Date of Inspection ...... ........ :....19 - Date Completed ../. ../. .. f7:. . 19 4 ; t- PERMIT REFUSED ..................................................................... 19 ......................................................... .............. ....................`.. . ........ ............/ .. c In �. • .. .� ( �a .• ,, .I t, !N�' , ..'. .......... ... ........................... .......... .. } ............. ........... ... ! t_.._ r•*ti !a' ,i � t, .. ' Approved ................................................ 19t * ni ............. ............................................... .... - 1 �.... ..................... T; I II i -N1 i I � DNS j I ' _ _._ I Y ��I - =o I' R IL Hi C3, - -------- -- Ir I I , _.._.._... =----- 1 LL I , I i ----- j .. 1 I I/4 I-n FRANK WARNER RIE'E A R C I-I I T E C T Sudbury,Massachusetts 01776 978.443.4775 T Ill I — 14V —C ki �. I \6 i I j � it ta v + Lv L F'' ............... I'll,�10 FRANK WARNER RJEPE 4- A R C H I T E C T Sudbury,Massachusetts 01776 POE- is Wll :P n* �'FF.• -� I i I i v- ' I CO p / j y(�� rJ IZ I 4 I I � i I I ' I I I I � I ! I I II 11 II I' 'I I II � p,tII 9J�17�1�(DI2if I fi I ` � i 1 �I �� 9/� K4'x3�h�,.e.•r`�5�8�-�S il' it �y � i. I II —!—_ ,I III TI 11 , it I I Fi, • • ,� li-- '' 'I ___. •� it i; II — Irk I i sVL- ' 1 A �! Six 12�G?_uA� I I I III II �`/�'vrcon�r�'-�(wal✓ I r 1 II ol-T I _.I U _ I FRANK WARNER RIEPEo� I A R C H I T E C T i I � I� Sudbury,Massachusetts Zha'7' 1776 L-At..A-4 IY� �� tea 7 �Q } i } �f i i f MQI/AHAN, GEORLSE E J & MOVAHON, Barnstable Harbor ELEANOR D 25 MAIN 5T S YARM0U7h, MA 02644 S% y 4 t�4'f?" f f 27' LOW Ro�fe 64 �\r co o of/rood Z 0 4 C � 56.7' LOCUS MAP SCALE 1"=2000'f Deck 3 ASSESSORS MAP 336 PARCEL 072 0040 � 37 s, � LOCUS IS WITHIN FE;MA FLOOD ZONE C AS tlnft B. g SHOWN ON COMMUNIITY PANEL #250001 2 Story :h 0001 D DATED JULY! 2, 1992 Dwelling oN Deck y ZONING SUMMARY ZONING DISTRICT: RF-2 RESIDENTIAL DISTRICT 1 i MIN. LOT SIZE 43,560 S.F. TALE'S CIF CAPE COID fNC MIN. LOT FRONTAGE 20' Deck Ram I / BARN�AElL� MA 0?630 41 MIN. LOT WIDTH. 150' MIN. FRONT SETBACK 30 MIN. SIDE 15' V ' I MIN. REAR SSETBAACK 15' V � ' " H0J-- PO✓ FARM CONDOMINIUM' Existing i SITE IS LOCATED WITHIN THE AQUIFER AREA /N SO. FT. = 38,020E Septic Tonk • Old AREA /N ACRES = 0.0 PROTECTION OVERLAY DISTRICT 4r Garage o Proposed lop New Garage r o 15.45' Sri 41- .�YlfalN a 4.00' � i Exst°g � I � OWNE R OF RECORD D—Box Sonotubes for I—_�� I , I STEPHEN E. GRANDE III pergola fdn. P.O. BOX 43 CUMMAQUID, MA 02637 (DEED BOOK 4195 PAGE 86) � I STEPHEN D. PORTER & ExIsting PORTER Leoch Pit cesspool I I O I BOXSE Y 273 CUMMAQUID, MA 02637 Deck � I, �� I I I (DEED BOOK 12303 PAGE 169) 26.1'. •..: I I i 3 REFERENC5.S Deck I I DEED BOOK 4195 PAGE 86 14040 �' i � o DEED BOOK 12303 PAGE 169 Unit A i � y 2 Stony Cesspools\ I PLAN BOOK 381 PAGE 37 Dwelling L i I I I i I I I i x 1 I CERTIFIED PLCT PL A N I FOR THE PU RPOSE SE OF OBT AINING A BUILDING DING PERMIT CO. - j I IN I , i MHB Fnd BARNSTABLE (CUMMAQUID)i MA Back Cent er 133.16,. t S 84'5310 W PREPARED 'FOR 1.45' STEPHEN E. GRANDE III 5-0- aptRouto A & tn ; t y 40 'deb 2 o i� t (19d9 Loy + MHB Fnd o stree (22't Of Pa"ment� Lead Plug STEPHEN D. & LOUISE G. PORTER o ; . Main Tb BND) — DATE: JUNE 150 2006 D ,. (BN N84'50'53 E 165.26 Scale:l"= 20' 0 10 20 30 40 50 FEET MHB Fnd Lead Plug off SOB-382-4541 fax 508-362-98M Z 6 OF p � down cape engln eering, inc. ARNE o q'L,e, CIVIL ENGINEERS Nmze3a8y _ I:AND SURVEYORS Opp C x '"ora' 939 main st. Y armouthP ort, ma 02675 DATE ARNE H. OJALA, P.L.S. LL C:\Land Projects 2004\05-200 GRANDE\dwg\05-200 plot plan.dwg,IS x 24 Site,8/16/200610i05:44 AM, 05.-200 PLOTPLANDWG(AO) c: 'HP_0wner,HP designjet 1050C,Arch C-18 x 24 In.(landscape),1:1