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4096 MAIN STREET
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' ''..."4'„,"` ' ;" '''''''' '''' , ,,-- , . , . - . , . . ., . , , , 4 , ........„.— , ...,„, _ .......„ . _ _ s Town of Barnstable .2,-di: e- Building C - Post This Carr.dl So That it is Visible From,the Street Approved Plans�,Must be Retained on4Jdb and this Card Must.be Kept 'I`ABL6, • -..� nrxs �Posted Until Final"inspectionHas Been Made 2 , ' - r k - k k Where a Cert fcate of Oc u,pancy is Requ red,such Building shall Not be®ccupied until a F nal lnspectionFhas been made 1" ''' '' Permit Permit No. B-20-857 Applicant Name: Michael Musnick Approvals Date Issued: 03/19/2020 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 09/19/2020 Foundation: Location: 4096 MAIN ST./RTE 6A(BARN.), BARNSTABLE Map/Lot: 336-054 Zoning District: RF-2 Sheathing: Owner on Record: KRAMER,JOYCE&NAGLE,MARCIA I ' Contractor Narne: Framing: 1 Contractor License: Address: 129 RICHARDSON ROAD A ., , 2 CENTERVILLE, MA 02632 k. Est Project Cost: $6,000.00 Chimney: Description: Install two windows flanking one door and re shingle Perrnitj e: $35.00 � i r ,, Insulation: - Fee Paid $35.00 Project Review Req: R308.4.2 Glazing Adjacent to Doors 1 i 4- A. -I Date: 3/19/2020 Final: �� Plumbing/Gas • f ,; Rough Plumbing: Building Official ,. o ..: Final Plumbing: This permit shall be deemed abandoned and invalid unless the work author-kid/by by this permit is commenced within saxmonths after issuance. All work authorized by this permit shall conform to the approved applicatioland;the approved construction documentslor which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures'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 roadtand shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. " F: - 4 '''< r Electrical The Certificate of Occupancy will not be issued until all applicable signaturesby the Building and Fire Officialsare provided onthis,,permit. Minimum of Five Call Inspections Required for All Construction Work:, t i s ,i' , ,* t "� Service: 1.Foundation or Footing a t t t I M 2.Sheathing Inspection *4 4' ' I i u"_ Rough: - 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 Final: 5.Prior to Covering Structural Members(Frame Inspection) - 6.Insulation Low Voltage Rough: r 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department " All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: - .' Town of Barnstable • oaf,:._ `4 , ' - '> . m' . sue. . 11 1 � tPost This Card So That it•is usible'From=theStreet Approvedf Plans Must be�Retained on Job4and this Card Must be��Kept 'osted Until.Fina i spection Has Been Made 1 �;; s ,Where a Certificate'of-Occu pant is Re` wiedA.such Buildm shall Not be£Occu ietlruntiha.-Fln�I Inspectt`on has been;made., Permit No. B-18-1361 Applicant Name: CHRISTOPHER H MITCHELL Approvals Date Issued: 05/24/2018 Current Use: Structure Permit Type: Building-Addition/Alteration-Commercial Expiration Date: 11/24/2018 Foundation: Location: 4096 MAIN ST./RTE 6A(BARN.), BARNSTABLE Map/Lot: 336-054 Zoning District: RF-2 Sheathing:. Owner on Record: KRAMER,JOYCE&NAGLE,MARCIA i ContractorName; CHRISTOPHER H MITCHELL Framing: 1 Address: PO BOX 212 , t ;Contractor License 052112 2 WASHINGTON,VA 22747 ' t Est Pro e'.� � i _ct Cost: $ 12,500.00 Chimney: Description: verizon proposed to mount a wireless antenna on anculary Permit Fee: $213.75 equipment to an existing eversource utility located next to the i ., ; i, Insulation: address of 4096 main street 1 pole#3 v/z 204 ' Fee Paitl '' $213.75 Date ' 5/24/2018 Final: Project Review Req: a - > r � ,' Plumbing/Gas c ,� Rough Plumbing: ' Building Official Final Plumbing: 1 This permit shall be deemed abandoned and invalid unless the work authonzecJ liy this permit is commenced within six months afterissuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documentsaforwhich this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for llie nspection for the entire duration of the work until the completion of the same. i , Electrical — 1 , 4,„ I The Certificate of Occupancy will not be issued until all applicable signatures,by,the�Buildmg and Fire Offcials are provided on this permit. Service: Minimum of Five Call Ins ections Required for All Construction Work: ' '" :,.1 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. 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 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 330 Parcel 6 Application # �� r lL 1 Health Division Rik 0 ®1�4 Date Issued \ .� Conservation Division � � � Application Fee Sa(5 - Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 't Historic - OKH Preservation/ Hyannis Project Street Address u 0 q lQ rOcon fit- 13a rn -a.��- .e. mom- IQ* 3 vie-a b q Village Owner eorX300 ef_ Address Or 10STA‘4, Wa j (.Je3¢-koe �J Telephone '1 g\•y`•( t• 5g6^) Permit Request VertZr o Oropeaea 4-0 y-r iJn4-, wig-cA-c-55 Qft+ernQ. arm, av►ecAla.r t : elJ.1- n Ev V.6C c,c • loca. r)e, 4- am 41-e 4.014.rc,s5 0 `t,ogl2 roc., , -r-cj+- ( Pa Gz,# 3 v ao4. Square feet: 1st floor: existing 111►''c' proposed r)FA 2nd floor: existing-NA(vA proposed r,\cc Total new Yl l 6 Zoning District el(Ps Flood Plain r) Groundwater Overlay Kt(A 60 Project Valuation& la�500' Construction Type Lot Size n(pi Grandfathered: ❑Yes 11 No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) n 1 Pr Age of Existing Structure r Historic House: ❑Yes No On Old King's Highway:,Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other h tom' Basement Finished Area (sq.ft.) n\ Basement Unfinished Area (sq.ft) n j�} Number of Baths: Full: existing n pr. new Half: existing n Pr new Number of Bedrooms: n existing _new Total Room Count (not including baths): existing Nn,for new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other r� �-- Central Air: ❑Yes ,1Ei No Fireplaces: Existing top- New Existing wood/coal stove: ❑Yes *No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size Barn: ❑ existing ❑ new size h i Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size Other: Zoning Board of Appeals Authorization ❑ Appeal # C 1A Recorded ❑ Commercial ❑Yes A No If yes, site plan review# Current Use Lek-tk, (oat. Proposed Use l..c p0 C¢. APPLICANT INFORMATION (BUILDER OR HOMEOWNER) en rn Mod Name crndui5rnal eirmr'ncc.h Telephone Number SIQ'• (0 ly Address 0.Q.don Zoct License# CS- OS'"a f 1 2 (_G�c GVt1k. ,m`Pf O2 L7r Home Improvement Contractor# Email r1(. 112kt.ar g +rrn call '0171- Worker's Compensation # (Ws 733 5?F? ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO G.acns VA.VD t-h" JbG g• W 411'L, 1MC.,:,a 2••1".^1-e - SIGNATURE Cc.,(S DATE "1 V 13 FOR OFFICIAL USE ONLY 4 APPLICATION # DATE ISSUED MAP/ PARCEL NO. } ADDRESS VILLAGE • OWNER • • DATE OF INSPECTION: • FOUNDATION 114 FRAME r - INSULATION . • - -� FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING • • DATE CLOSED OUT ASSOCIATION PLAN NO. I I APPENDIX IV Form 1 APPLICATION AND POLE ATTACHMENT LICENSE Licensee VERIZON WIRELESS Street Address ONE VERIZON WAY,MAIL STOP 4AW100 City,State and Zip BASKING,RIDGE NEW JERSEY 07920 Date 1/12/17 In accordance with the terms and conditions of the Pole Attachment Agreement,application is hereby made for a license to make 1 Antenna attachment(s)to pole#3VZ204located in the municipality of Barnstable in the State of MASSACHUSETTS. This request will be designated Pole Attachment License Application Number BarnstableSC15MA-388931 Attached are my power supply specifications if applicable.The cable's strand size is 0.5 and weight per foot of cable is 0.2. Communication Space Power/Supply Space Licensee's Name(Print)VERIZON WIRELESS By: Name Barbara Kassabian Signature BAti'l a .w NSTAR d/b/a EVERSOURCE Power Company Title Site Acquisition { Tel.No.603-303-8001 Fax No. E-mail bkassabian@trmcom.com For licensor use,do not write below this line Pole Attachment License Application Number is hereby granted to make the attachments described in this application to attachments to JO'poles, attachments to F02 poles, attachments to JU3 poles, Power Supplies and other attachments located in the municipality of , in the State of as indicated on the attached Form 3. Licensor's Name(Print) �J- c Signature (3�___� ' Rt (AGREEMENT ID#) Title Date I 11 Tel.No. The Licensee shall submit an original copy of this application to Verizon New England Inc.and NSTAR Electric Company d/b/a EVERSOURCE ENERGY. Revised 02/23/2015 NSTAR d/b/a EVERSOURCE Form 2 AUTHORIZATION FOR FIELD SURVEY WORK Licensee: Verizon Wireless In accordance with Article III&Appendix I of the Pole Attachment Agreement, following is a summary of the charges which will apply to complete a field survey covering Pole Attachment License Application Number 11,Zi •uEi15 in the municipality of Barnstable in the State of Massachusetts FIELD SURVEY CHARGES Field Survey #Poles Unit Rate Total Field Survey Application Fee 1 pole $139.00 $ 139.00 (includes 1st pole) Field Survey 2-200 Poles $ 13.45 per Pole $ Additional Travel Time* $200.00 per Day $ TOTAL Charges $$139.00 *Based on average of 75 poles surveyed per day,add$200.00 travel time for each additional day required to complete survey. Please note,if you calculated the cost incorrectly,your check will be returned and a new check for the correct amount must be received by this office in order to schedule the survey. If you need assistance,please call the HOTLINE on 800-340-9822. The required field survey covering Pole Attachment License Application# BarnstableSC15MA-388931 is authorized.I am enclosing an advance payment in the amount of$ 139.00. Licensee's Name(Print)Barbara Kassabian Signature Barbara.Kc4 a.>uaw Title Site Acquisition Address 16 Chestnut St, Suite 420,Foxboro,MA 02035 Tel.No. 603-303-8001 Date 1/12/17 4 Revised 03/06/2015 Eversource Energy 1 FORM 3—EVERSOURCE ITEMIZED Pole Make-Ready Work Charges PAGE OF RCE to Complete: Total Poles Surveyed Total Poles Requiring NSTAR Make-Ready Appendix IV Form 3 FLEW SURVEY I..MAKE_READY WORK FORM SURVEYORS: DATE OF SURVEY: CWO #: Verizon MUNIC: Barnstable STATE: MA Exch Code: Munic Code: Licensee Barbara Kassabian LICENSEE NAME: Verizon Wireless LICENSEE APPLICATION#:BarnstableSC15MA-388931 EVERSOURCE ELCO NAME:EVERSOURCE NSTAR APPLICATION # LOCATION POLE* ATT OWNERSHIP CHARGE WORK DESCRIPTION TEL RTE/STREET NAME Tel El F/C J.O. J.U. F.O. YES NO TASK#S / *Height List one pole per line P.S. Tel El Tel El Tel El REMARKS of Att. Rise r 4096 Main Street 3VZ204 N/A ZeriLf 4J • • TOTALS: • Height of Attachment=Height of Licensee Attachment shall be 40"below SLCO MON u eee otherwise noted here by Verizon and EVERSOURCE surveyor. Revised 03/06/2015 ---- • Licensee to complete bold italicized areas only.(Provide ownership information y.known) Revised 03/06/2015 V R .R E - Work Order Application FOR KEN KENDRICK: i r Customer Request In-Service Date: 4(12/17 WO Received Date: Service Address:Street: 4096 Main St Suite:_Town: t3;lrnsillS(c zip: 02668 Customer Of Record: Customer Responsible for Payment of Monthly Electric Bills Name to appear on Monthly Bill: Cellca Partnership DBA—CIO Name: Verizon Wireless Billing Address: P.O:Box=2375,Spokane,WA 99210-2375 Telephone:_Tax ID Number: TBD Existing Account or Meter Number(if applicable): Property Owner Name (if different from above): Owner Address: Owner Phone Number: Party Responsible for Construction costs associated with work order(if different from above) Name:Verizon.Wire ass Address: 118 Flanders Road.3rd'Floor.Westborough.MA 01581 Phone Number: 508-320-2017 Please Note that Articles of Incorporation are required for new commercial EVERSOURCE Customers Type of Service Requested: (Circle Appropriate) X New Service Service Upgrade Service Relocation Temporary Service Pole Relocation Disconnect/Reconnect Service Removal Metering Only OH Service from Pole, Pole#: UG Service from; Riser-Pole#: Padmount#: -. Customer Loading Brief Description of Work Attach (1) antenna. (2) RRH/Cabinet and Type of Load New Connected Load in KVA al meter to the pole. Will require 60 amp Single Phase Three Phase single phase service. Lighting Electric heat / t I Air Conditioning Refrigeration Cooking Electric Dryer Water Heater { Computer - Process Equip. 14.4 Motors/Elevators Miscellaneous Totals 14.4 Number of Meters Required: Residential: Commercial: 1 Public: Main Switch Voltage: Amperage: Phase: Service Voltage: Amperage: Phase: Facility Type(ie:school, hospital): Telecommunications New Building Square Feet: i ALL 480V SERVICES REQUIRE COLD SEQUENCE METERING(DISCONNECT SWITCH ON THE LINE SIDE OF THE METER If more than 1 meter is required, how will meters be labeled?(ie: Unit 1,2, etc, Unit A, B,etc.) l , Additional Equipment: Generator: KW: Phase: Purpose: Motor(S) : Total#: Largest HP: Phase: Locked Rotor AMP: Type of Starting Compensation (choose one): Hard Soft Capacitor VFD *See Article 802 of EVERSOURCE Information and Requirements Book for Maximum LR current and Three Phase Protection * Contact Name (circle appropriate): Customer/Contractor/Consultant: Barbara Kassabian Street Address: 16 Chestnut Street.Suite 420 City, State, Zip: Foxboro, MA 02035 Telephone: Best Time to Call:Monday-Pridav 8 a.m.ro 5 n.m, Pager: Fax: Cell: 603-303-8001 Electrician: TBD License Number: Business Name: Verizon Wireless Street Address: 118Flanders Road,3rd Floor City, State, Zip:Westborough,MA 01581 Telephone: 508-320-2017 Best Time to Call: Pager. Fax: Cell: Please note that by Interconnecting with the EVERSOURCE Distribution System the Customer of Record acknowledges that they have reviewed and are in compliance with the EVERSOURCE Information & Requirements for Electric Service(Blue Book). For New Commercial Services, New Residential Developments, New 13.8 kv Two Line Station Electric Service, please provide (2) copies of City/Town approved site plans that illustrates the new facility location and the proposed location of the new utilities(electric,gas,water,sewer,telecommunications)and a One-Line Diagram. For Service Increases at existing facilities, please submit a One-Line Diagram if available. For New Residential Services where a pole must be set,please provide(2)copies of a site plan that illustrates the proposed location of the new facilities. For Temporary Service Requests, please provide(2)copies of a site plan illustrating service location. You may Fax this Form or mail any additional correspondence to: EVERSOURCE ENERGY Electric and Gas One NSTAR Way Westwood,MA, 02090 Tel: (781)441 —3851 Fax: (781)441-3194 Cell: 339-987-7059 H. Kendrick SW340 FOR NSTAR USE ONLY EVERSOURCE Revenue Allowance: EVERSOURCE Rate: KVA or KW rating of Existing Loads(if applicable): Existing Winter Peak Demand: Month/Date/Year: Existing Summer Peak Demand: Month/Date/Year: 41°42'08.6"N 70°16'22.9"W Google Maps BarnstableSC15MA t ^". ". . " • • -"', ...•_-"--•::••.-,4.........'t?.i...,11•41,e ,,,Z.rtzlr",,• 44,',,t,- ‘71- -. _ ..,+ri. .. a ay,! i• 1y41` ,1".1, x +•*-. ,*. t•Iff ".. k " air , 1 • ., a�``. 3rti r 'r eY L ztVr �I 1 ••:. .tea A le eg ,r 4 Ili 40, j ` t' • +' /r - . � n . • r.- • .• P1 !..-• • 1.. :( ..-ilk.. 1+�a ti 4r -� •" A ,. 1. G r oogle • Imagery©2017 Google,Map data @ 201 7 Google 50 ft•_-_ __... 3 i Goc gie Maps 41°42'08.6"N 70°16'22.9"W BarnstableSC1 5MA usr<.aw e0 0 G..aab c.w. sa.�.we.,0 '0 Google Map data 02017 Google 200 ft , . . . Product Specifications COMMSCPE` POWEGEa OY ANDRE19/, 1 CommScope-Proprietary and Confidential. Preliminary specifications are for illustrative purposes only and will be updated prior to publication. NH360QM-DG-2XR Andrew® Dualband Quasi Omni Metro Cell Antenna,698-896 and 1695-2200 MHz, internal RETs with manual override,internal dlplexer and active GPS Li band antenna 1 u, t ,e 4.j° r Electrical Specifications Frequency Band,MHz 698-806 806-896 1695-1880 1850-1990 1920-2200 Gain,dBi 5.9 7.0 9.7 9.7 9.7 Beamwidth,Horizontal,degrees 360 ' 360 360 360 360 Beamwidth,Vertical,degrees 28.2 25.4 11.6 10.9 10.3 Beam Tilt,degrees 0-20 0-20 . 0-14 0-14 0-14 USLS,dB 13 13 10 13 10 Isolation, dB 25 25 25 25 25 VSWR I Return Loss,dB 1.5 114.0 1.5 114.0 1.5 1 14.0 1.5 1 14.0 1.5 1 14.0 PIM,3rd Order,2 x 20 W,dBc -153 -153 -153 -153 -153 Input Power per Port,maximum,watts 125 125 125 125 125 Polarization *45° f45° f45° *45° f45° Impedance 50 ohm 50 ohm 50 ohm 50 ohm 50 ohm Electrical Specifications, BASTA* Frequency Band,MHz 698-806 806-896 1695-1880 1850-1990 1920-2200 Gain by all Beam Tilts,average,dBi 5.3 6.3 9.2 9.3 9.3 Gain by all Beam Tilts Tolerance,dB t1 *0.9 ±0.6 ±0.7 *0.7 0° 1 5.1 0° 1 6.6 0° 1 9.2 0°1 9.2 0° 1 9.1 Gain by Beam Tilt,average,dBi 10° 15.4 10° 16.5 7° 1 9.2 7°19.6 7° 1 9.7 20° 15.3 20° 1 5,7 14° 1 9.3 14° 1 9.3 14° 19.2 Beamwidth,Vertical Tolerance,degrees *3.2 ±2.3 ±0.7 ±1 *1.1 USLS,dB 14 13 12 12 12 ComrnScope®sripports NGMN recommendoiions on Base Station Antenna Standards(BASTA).To learn more about the benefits of BASTA, download the whftepopar Time to Raise the Bar:on BSAs. General Specifications Antenna Brand Andrew@ Antenna Type Metro Cell Band • Multiband Brand DualPol® Operating Frequency Band 1695-2200 MHz ( 698- 896 MHz r Internal GPS frequency band 1575.42 MHz ' I ( Internal GPS VSWR 2.0 Performance Note Outdoor usage 02015 CommScope,Inc:All rights reserved,All trademarks identified by OO or TM are registered trademarks,respectively,of CommScope. page 1 of 2 All specifications are subject to change without notice See www cemmscope.com for the most current information..Revised:July 20,2015 July 20,2015 ti , . 1 1 Product Specifications COMMSC PEs NH360QM-DG2XR )W t.M • Mechanical Specifications Color Light gray GPS Connector Interface 4.1-9.5 DIN Female GPS Connector Quantity 1 Lightning Protection do Ground Radiator Material Aluminum I Low loss circuit board Radome Material ASA Reflector Material Aluminum RF Connector Interface 7-16 DIN Female RF Connector Location Bottom RF Connector Quantity,total 2 Wind Loading,maximum 225.0 N @ 150 km/h 50.6 lbf @ 150 km/h Wind Speed, maximum 200.0 km/h I 124.3 mph Dimensions Length 982.0 mm I 38.7 in Outer Diameter 305.0 mm I. 12.0 In Net Weight 15.3 kg I 33.7 lb Remote Electrical Tilt(RET) Information Input Voltage 10-30 Vdc Power Consumption,idle state, maximum 2.0 W Power Consumption,normal conditions,maximum 13.0 W r Protocol 3GPP/AISG 2.0 (Multi-RET) RET Interface 8-pin DIN Male 1 RET Interface,quantity 1 male Regulatory Compliance/Certifications Agency Classification RoHS 2011/65/EU Compliant by Exemption China RoHS SJ/T 11364-2006 Above Maximum Concentration Value(MCV) ISO 9001:2008 Designed, manufactured and/or distributed under this quality management system * Footnotes Performance Note Severe environmental conditions may degrade optimum performance @2015 CommScope,Inc.All rights reserved.All trademarks identified by®or TM are registered trademarks,respectively,of CommScope. page 2 of 2 All specifications are subject to change without notice,See wvw commscope,com for the most current information,Revised:July 20,2015 July 20,2015 LUSE EXHIBIT" THIS LEASE IS SCHEMATIC IN NATURE AND IS INTENDED TO PROVIDE ---J / GENERAL INFORMATION REGARDING THE .►.1 LOCATION AND SIZE OF THE PROPOSED J ., WIRELESS COMMUNICATION FACILITY. d / THE SITE LAYOUT WILL BE FINALIZED UPON COMPLETION OF THE SOS S SURVEY AND FACILITY DESIGN. ``nn V STRUCTURAL NOTE ()) - A STRUCTURAL ANALYSIS SHALL F3EIli PERFORMED ON EXISTING UTILITY POLE A, PRIOR TO CONSTRUCTION AND SHALL CH AR L E 5 D I XO N J CC BE THE RESPONSIBILITY OF UTILITY CO. .• PERIMETER LAYOUT LINE T. j (STATE HIGHWAY) INSTALLATION NOTE; li (P) 12 0.0 X 38,.7•H . l` I' \ INSTALL ALL EQUIPMENT, MOUNTING _ . \ N-13600M-DG-2XR � (E; ANTENNA MOUNTED TO BRACKETS AND HARDWARE IN tir/ eft B.DG r (F) UTILITY POI F. ACCORDANCE WITH MANUFACTURER'S P pc,,,,, T.ra. OF (P ��. -� r -���� � RECOMMENDATIONS '( ) U ).(1). ) r•_- >r „_ �� C•ti...x.ERS. do (2(P DELTA ✓""�1 _ G: f ELECTRIC/IL NOTE; fi AC/DC O UERTE RS MOUNTED �--- v 13 NIL GENERAL WIRING DIAGRAM AND (E) t0.(E) UTILITY POLE ..• �. 1 `' L- , --- NOTES TAKEN FROM c-MEMO ETY N. F.:::' . °- _ .-1- i y'4Q' -rJ JAMES F. GVAZDAUSKAS, P.E. " '�`=as DATED JANUARY 12, 2017 • ,.H(DG / �! ) "�'. COORDINATED NOTF• • r•`•�^r�f���c 1 ✓/( 1 '9 5 U'I:TY F OI Ej 3 --ININ. .. s. COORDINATES AND AMSL ELEVATION v .i` (1 t k ///"'- ;g / ,, 204 BASED FROM A FIELD SURVEY ON 1 1_. 14• "'- BASED -• ,`. / 8/1/2016 A METES AND BOUNDS 'x i • / �y�,.. .. SURVEY WAS NOT CONDUCTED • / z 120 ' y _, *. �� ttASWOT HIGHWAY LAYOUT PLAN: y 1 , . .1 Y �Q� . 0 CITY/TOW: BARNSTABLE A �/� A.i �j ° �. ! 1 j k! "•4 \ ' LAYOUT NUMBER: 1252 \\ «! 'e v y r .. 1 - `.. ....:. A im; ,,,:i. 4 t: , !" '• BOARD DATE 1909-07 07 A�.! `' ^" /«Qf 1p SHEET#: 7 a r �✓Y /� . <f I I `� r�� �R"� FROM STATION: 344+67.63 • \ ) C �f (E! ; A L E X `�0�R N. STATION TO: 445+74.36 • LEGEND -. " . ; , _ --- - ,. :d , 1 (F) = FUTURE(B ACX) M� ./...,/o / . 1. . » - B t�4�� 1 ,�. (E) = EXISTING(YE LDW) -« 4i. (P) = PROPOSED(BLACK) APPROX. I OCATION (P) MI[TY PO F TRIX NO m (AGL) = ABOVE GROUND LEVELSUBJECT POLE DOES FALL WITHLN STATE (AMSL) = ABOVE MEAN SE LEVEL NAD 83 LATITUDE: 41' 42' 08.61• /� (-1- SITE PLAN HIGHWAY PERIMETER LAYOUT. N.TS. = NOT TO 4--AI F MAD 63 LONGITUDE: -70' 16' 22.93• MASSDOT I O-IWAY LAYOUT PLAN(MITE) LE-1 SCALE: 1-=50' 0 25' 50' 100' € GROUND ELEVATION: 38.0' AMSL ft1MIIIF LEASE EXHIBIT ! DATE: 02/16/2017 � - '- � BARNSTABLE MA SC15 DRAWN BY: SMB ADVANCED VeIi ftvi.1/e?WS, DRAWING NUMBER REVISION CHECKED BY: SNA ENGINEERING GROUP, P.C. 4096 MAIN STREET Civil En0oeecing-SiteDevelopment VERIZON WIRELESS BARNSTABLE MA SCALE: 1'=50' 4-00 FRIBERG PARKWAY 02668 BARNSTABLE MA SC15 Surveying-Telecommunications WESTBOROUGH, MA 01581 SHEET: 1 OF 6 PROPO D ANTENNA SHALL RE 4'-0'MIN. FROM SECONDARY POWER AND g'-0 M!L FROM PPoMARY POWER (i);PRIMARY POWER LINES E1EV. =33.0'' AGL(770't AMSL) '' TOP OF co UTILITY POLES 3 V/Z 204 ,_�, i!. (P) POWER YYEATHE1tF1EAD ELEY >38 5 TI AGL DI 5't At1St: .i ',. " y (E)POMAR TO (P) METER FROM PROVIDER (E)G!J)`F4 [ '� ���' ElEY. 360'f AGL(740. AMSL)�` 7: b " a T 40 4' RAMS FROM (P) SECONDARY POWER—., ' Oseer WSI) aev. ;aso't AGL'(t3 �usl). (P) 12 0 X 3B.T f r Nt 600M-DG-2XR j I TOP OF(P);4 � ANIENHA MOUNTED TO(E)o(filthy POLE v‘,...// ,r� / aEv. _31.o't ACL(sso't a 014 (P) 2°+,wasocierXDc (P)ANTENNA MOUNTING BRACKET "" / {£) SECONDARY POWER REMOVED ANTENNA MOUM E R - .' ,I._._ �„_ ELEY _. Acl(sas'* P*Stp (� .. - (�moo To(P) RIa1 FROM PROHOEx _�_ °�(Pa . t" -'.. ( ., (P)Yt'COAX CABifS(10fAL OF 2) (1} r. E b,24 3`t 's� t' 1I£T NRI C IN 2-`a-GUARD TO (P)ANfENptik - \ TOP OF(E) FIBER TRUNK *" ,'.. ` .-.��... E1.EY. =2&.0 1 AGL(64.O 2 .) r' '1.s J -iYk -m{ (P)ANTENNA GROUND MARE f (P) FIBER. 2' U-CUARD TO (P) SAR-o ," � x (P) II S(TOTAL QF;"2).'(2)(P}. (P)RRH's (nDul OF z), (2)(P) aPLE1cERs, 4` s 0lPiFXERS, k{zj(P}DELTA joy (2)(P) Data AC/DC coNVEmERs Mown t i tz} TELCA (r) FIBER., ' , . ' To (E)IiTILIIY MOLE ./_ EikY. _ 2a D't AM_(51.0' NAST.) . r 'ac/oc cOrrvERTERs MOUNTED t (E}T>IeO. (P) SAR-0 y. fir:To(E) Uri POLE BOTTOM OF(P) RRH / / I ant, = 20 4't AGL(WY*. AtAil) a 4 ., ELEV. = 13,3' AGL(s1.5'&AMSL) '` / { GUY WIRE a(E}TELCO ' ELEV. _ I9.D't 57.O gt iv acl( waa). � { � 3." ,stir.�_ =2 POLE OI H � ' y ? v c , SWITCH FUSED WITH (3)-20A I ''1 • ° a -, 'CIRCUIT BREAKERS&METER n 6QA-2 POLE DISCONNECT SWITCH FUSED WITH �x r . SOaCE'f a (3)-20A CIRCUIT BREAKERS&METER SOCKET y , (E) 41�5ttN13 -eta y f 3/a4 0EV. 0°±'f L (35:0•± MIST.) PHOTO ELEVATION (P)GROUND ROD- �� \LE- SCALE I'.10' BE LEGEND (F) = E111IIRE(WI) - n�reue�x�: � d N (E) O°s'TMg( ELEVATION INSTALL ALL EQUIPMENT. MOUNTING A STRUCTURALANALYSIS SI+AIL (P) = PRDPO I)(goat) ® BRACKETS AND HARDWARE IN pRioN TO ON EXISTING UTILITY POLE (AQ) ABOVE GR01110 LEWL SCALE 1=10' ACCORDANCE WITH MANUFACTURER'S PRIOR CONSTRUCITON AND SHALL (AM94 = mow BEA LEA 0 5' 10 RECOLMEt10A710N5 BE'NE R oTn�LITY OF U11UTY CO. N.T.S. = NOT TO SCALE '"' BARNSTABLE MA SC15 LEASE EXHIBIT DATA ii/BA16/2017 V�! DRAWN BY:� ��� - 4096MAIN STREETDRAWING NUMBER REVISION CHECKEDBY: ENGINEEE2ING GROUP, P.C. VERIZON WIRELESS BARNSTABLE MA SCALE AS NOTED CivllFngineecing-SiteDevelopment 400 FRIBERG PARKWAY 02668 BARNSTABLE MA SC15 ej Surveying-Telecommunications WESTBOROUGH, MA 01581 SHEET: 2 OF 6 AMU/MAIM' (P) GUY Yf9T9~T (P) 12.011 X 38.7"H INSTALL ALL EQUIPMENT, MOUNTING NH3600M-OG-2XR ANTENNA 1 i - BRACKETS ANO HARDWARE IN MOUNTED TO(E) UTILITY POLE a� I ACCORDANCE WITH MANUFACTURER'S ®� (P)SAR-0 MOUNTED 1D (P) (P)SECONDARY POWERJ1 / (E)3y8.5' UTILITY RECOMMENDATIONS gip,-,o"-"' M PEE �� POLO 3 V/Z 204 rv►"* 4' RADIUS FROM (P) '�a, \�`,. SECONDARY POWER $iRUCNRAL NOTE; (E) OVERHEAD WIRES lYP - -/ _ , - A STRUCTURAL ANALYSIS SHALL BE _ T " PERFORMED ON EXISTING UTILITY POLE (P) 12.0'0 X 38.7'H ' PRIOR TO CONSTRUCTION AND SHALL (E) 38.5' UT ITY NH3600M-DG-2XR BE THE RESPONSIBIUTY OF UTILITY CO. / POLE/ 3 V/Z 204 ANTENNA MOUNTED TO MIN .., ate'" (E)WIRY POLE 2. (P) ANTENNA MOUNTING Alf; BRACKET PER (P) AWS RRH. (P) PCS RRH, (P) MANUFACTURERS SPECS � AC/DC CONVERTER, (2)(P) DELTA f s (E)EDGE OF PAVEMENT _.�_,i Q DIPLDI R5 AC/DC S (NNxECT r �, II SWITCH FUSED WITH(3)-20A CIRCUIT (j)se- BREAKERS O MOUNTED TO�'`�';�„ ANTENNA PLAN ® ANTENNA MOUNTING DETAIL SCALE: 1'=4' SCALE: 1" ' 11j1 1 c1 7.3' = comuscon Nft3s494t-4G-2X'I 117°. 0 y 41, a DIMENSKINS: 12.0'0 x 38.T - WEIGHT: 33.7 LBS F` i.... P__I:4.4 a'Ts as.-. f) ---' .- , 3.2' ®=J rTr 1 } F 1_1sss nE II m _ O1•• aa @•'Il P ^� __ -' , CO.Elo o. aw. t - `�'".'✓ "Oa.C.Ar 2: �E SUX �oa2t�r wog.... t Er 2 / ax T� - - DIMENSIONS: 7:DIIx 7.31V x 3.YD LEGEND / F84tR ME RRH &EQUIPMENT MOUNTING INFORMATION WEIGHT: s,s LBS ( _ (DI AQ) WIT YaL2fT 55:9 WS ITEM: OIWS: HxW:A WBGHT MUM AVIS 90W RRII 25.8"x 11.8" x 7.2' S6.9LBS NOTE MO DIP OF AINT S BACKSIDE BRKT (C) EXISTING( ` 700 RRH 21.6'x 12.0'x 9.0' 57.2LBS (E') � PROPOSED(BLACK} DBL-MPR BRIO' 27.0'x 3.0"x 2.0' 19.0LB5 ( ) .. ABOVE MOUND ANTENNA DETAIL ® RRH DETAIL AWS BRKT 33.0'x 11.0'x 12.0" 16.0LBs fillDIPLEXER DETAIL (ut1�.j = ABOWE U.E1W SEA LEVEL11911SCALE: N.T.S. SCALE: N-TS. PCS/700 BRKT 33.0.x 11.0'x 12.0' 16.0185 SCALE N.T.S. ILLS.< _ NOT DELTA AC/DC CONY. 14.1'x 8.3'x 3.5" 14.1 LB5 DATE: 02/16/2017 ,-'-'-- BARNSTABLE MA SC15 LEASE EXHIBIT DRAWN BY: SMB AADVANCED _ * j � 4096 MAIN STREET DRAWING NUMBER REVISION CHECKED BY: SNA ENGINEERING GROUP, P.C. 1/ERIZON WIRELESS BARNSTABLE MA SCALE: AS NOTED Civil Engineering-Site Development 400 FRIBERG PARKWAY BARNSTABLE MA SC15 5 Surveying-Telceommuaicauam WESTBOROUGH. MA 01581 02668 SHEET: 3 OF 6 PROPOSED ANTENNA a ANTENNA MOUNT/BRACKET ANTENNA GROUNDING (2) 1/2•COAX CABLES& (1) RET- -- ! _ yam) c ON ANTENNA GABLE IN 2• IN RATED U-GUARDS t4 SECONDARY UNES WEAVER HEAD(LEAVE 10' CONDUCTORS FOR UTILITY CO.TIE INS) FIBER FRONTHAUL & BACKHAUL? 77 A FIBER OEMARC ON POLE . 7 t s (2) ER ' WIDER 7 t--• FIBER JUMPERS IN 1-1/2'UV*. ( /2 COAX RATED U-GUARD IF LENGTH - - CABLES EXCEEDS 4' , — F—• RR RCS - (3)/6 AWG WIRE IN FIBER JUMPER (TYP.) RRil t t r 1-1/4'UV RATED PVC DC POWER #2 AWG COPPER GROUND DELTA AC/DC CONVERTER 7. (M) (TYP. OF 2) N---A A---A?- le WEATHER PROOF SQUARE D CAT AC POWER MITE. USE PROVIDED rum NO.: SDSA1175 SECONDARY SURGE MANUFACTURERS WIRING HARNESS ARRESTOR ON 20A 2P CIRCUIT BREAKER /2 AWG COPPER SQUARE D DO-100A,8 SPACE. 16 UR OUTDOOR O- GROUND IN 1/2• MAIN LOAD CENTER WITH COVER. 60A 2P MAIN 4 fff UV-RATED MAC • • CIRCUIT BREAKER WITH (3) 20A, 2P BRANCH CIRCUIT BREAKERS (1 FOR SURGE ARRESTOR & (1) PER RRH) MIUMNK CAT NO.: U2272-RL-518-OL SINGLE LEVER 120/240V, 1.3W 125A MEIER -3/4%10'COPPER CLAD GROUND ROD ) CIRCAL NOTE GENERAL WIRING DIAGRAM AND e GENERAL WRING DIAGRAM NOTES TAXER FROM E-MEMO BY SCALE N.T.S. JAMES F. GVAZDAUSKAS, P.E. DATED JANUARY 12, 2017 ` ,• "'" BARNSTABLE MA SC15 LEASE EXHIBITS oz/16/201� DRAWN BY: SMB - ADVANCED DRAWING NUMBER REVISION CHECKED BY: SNA ENGINEERING GROUP, P.C. 4096 MAIN STREET Civil Engineene -site Develo e� VERIZON WIRELESS BARNSTABLE MA SCALE: AS NOTED g pm 400 FRIBERG PARKWAY 02668 BARNSTABLE MA SC15 5 Surveying-Telecommunications WESTBOROUGH, MA 01581 SHEET: 4 OF 6 4. GENERAL NOTES ELECTRICAL AND GROUNDING NOTES STRUCTURAL NOTES: L ism at RA WOODS t .®draaatA s au iNLME S.120 tl[ L aBM EUENEDI INK W/CCIi AS 0ln ae SO IC ORM L 1 sw.alw AO ROL SANNIRNi Ep .Arf7Fld4 Mlt/ba7.WtYFm-c 1 awn WN=tom imam RS NO or(A moan R 3. 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AL AMER 045.If' RICRAC CARD NO MU E SIAC0524 NM NCR 2 R WIOL BARNSTABLE MA SC15 LEASE EXHIBIT DATE: 02/16/2017 DRAWN BY: SMB L ADVANCED Itfer111104111WirefassDRAWING NUMBER REVISION CHECKED BY: SNA ENGINEERING GROUP, P.C. 4096 MAIN STREET Civil Engineering-Site Development .coo FRIBERRIZON GRPARKWAY BARNSTABLEELESS 0668MA BARNSTABLE MA SC15 5 SCALE: AS NOTED Surveying-Telecommunications WESTBOROUGH, MA 01581 02668 SHEET: 5 OF 6 r es Notes Ti.these 6H.6-Tyska1*mikados 6 Shoulder 1Taet.tb a Roar E eerood.0006 TabA t$-L Seaming 9r Symbols so Typical apvrsdion GraspiaPa Gadaxe: I db•dam,And./be a main..,0:Oher a yr dab a meuvera 4,de a.rpre o)de cAwnrO,B Ern:) .:1 .tee. eaaa, The beeline✓e..nba:e be wrl,,maey.aad ha,e.am,Tete:.s r A,ghn.yaere mt.a n.non w;r-emus►, CMs l..-a..-,s mnCswa.amesa rJnmrsbWdhr.+-a Operes I ..wsa®e-.wow me we sae a) JJaw,. 1 faraescm- ,n ass...rotaxr-ia ca oniiiians-cfn scccay3 u em ..ados,si.Iskee en n6.4.....3 Oetrasiondeinkhh?crhsrohucai&LG*CECr7 rasp to maid • T. oa..>r =j 1memm•Wee 4 lklatikea45gb ee esitm•Mitesnig:yiinm Lis mile ennecryatr C.O ED ...e.rass non. 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W.PAdh a abet ha t' S.posted need Omit,Or oft-pea Ldwepe:cen de d a to e speed pd on sw aeep, het anddpaed it ape 'np speed in ta sir a .:IIIIIIIIII 9=e= 1(5 L=110 FT. g ) ilk.PLACE "" 3AkiiE1S AT irty Jam.. VAX OF THE TAP-Mt LANE ALL CONSTRUCTION SIGNING, DRUMS. BARRICADES. A=500 F( AND OTHER DEVICES SHALL CONFORM WITH PART 6. "TEMPORARY TRAFFIC CONTROL OF TFiE 2009 r 1 I 0 MANUAL ON UNIFORM TRAFFIC CONTROL DEVICES (MUTCO) LATEST REVISION. Typical Application 6 '---- ' — ,.,,.:---''`'' BARNSTABLE MA SC15 LEASE EXHIBIT DATE: 02/16/2017 DRAWN BY: SMB ADVANCED µl 4096 MAIN STREET DRAWING NUMBER REVISION CHECKED BY: SNA ENGINEERING GROUP, P.C. VERIZON WIRELESS BARNSTABLE MA SCALE: AS NOTED Civil Engineering-Site Development 400 FRIBERG PARKWAY Surveying-Telecomwnications WESTBOROUGH, MA 01581 02668 BARNSTABLE MA SC15 5 Telecommunications SHEET: 6 OF 6 of Town of Barnstable,Planning&.Development Department i�w - Old I(. ng's H ghway.Historic-District Committ : ' 01 ''-ttt`� 200 Main:Stieet,:Hyann s,Massachusetts 02601` .e i Phone 508;862:4787 Email erin:lo aii town barnstablema.0 " PLANNING& DEWLOPMENT • : CERTIFICATE OF EXEMPTION - ;Application is hereby made,with foul:0)complete sets,-for the issuance of a cert►ficate"of l a.cmptton underScction 6 and•7 of Chapter .470,Acts and Resolves oflvlassachusctts 1973:as amended,for proposed work as'described below and on plans,drawings,or.photographs •accompanying this'application, ;Date' 1 .Address of Proposed.work, Assessor''s Map and lot# �� V% �© 4 V -.a t, 3ease • Street u'0 "I 1 p • l A to S f f;village . c•A This application is for an exemption of the proposed eonstructionon the tgrounds.that work:`'` -Will not•be visible from any way or public place • Is.within a"category declared exempt by theOld Kings Iiighway:Regional historic District Commission O. .Other: • DeseriptionofProposed:Work:, VPyft2im o eei D rmpofYs- ce, L,J►r-e-1-e5S c rn'enfca. • and •anexika u' 'm n m,‘ an uersnofu. 11. it. t L . NU. 3 V dint-f' is 1 oca+td rt-6/4-`+1) aotdr`e �fO9"o Ma In . . �er�t Ors tns-+ai l a4t cm C s n4 rmr� �ro -via gx m,�Yt tnn. — SlrrCt.il Cd i lt)ireI c• Agent or contractor(please print): or-e k. r6ah4k.k.X Tel.no. jUg"-Coggr ok9UT • •.Address ji Q' "Ch t-rlt:4- St✓ & 42D 0•Xbet U mt7 6a O3 Owner(please print}: PAIYXSO am—el Tel no. 1`q t(-3 S-S.L Owners mailing address: a11A.. 1ti1 t C j (.1)e Kiln 'inn' Oz(.5Qt.1 Signed,Owner/Contractor/AgcnE Checklist. O Four complete.sets of the application and supporting documentation. :$ L 04J 0. Filing Fee(see attached schedule) For Committee Use Only This Certificate is hereby APPROVED/DENIED Date Committee Members'Signatures VED 4'2018 30 in9's awn of$alira trnstatttit�aI Conditions of approval: • t< Committee Y OK!!ExemptionForm 2017 500 North Broadway ' ADVANCED East Providence, RI 02914 Ph:401-354-2403 ENGINEERING GROUP, P.C. Fax:401-633-6354 FAA 2-C SURVEY CERTIFICATION Applicant: Bell Atlantic Mobile of Massachusetts Corporate(d.b.a. Verizon Wireless) 400 Freiberg Parkway Westborough, MA 01581 Site Name: BARNSTABLE MA SC15 Site Address: Utiltiv Pole#3 v/z 204 4096 Main Street Barnstable, MA 02668 Horizontal Datum: ® GPS survey ®Ground survey Vertical Datum: NAVD 1988(AMSL) ®GPS survey ®Ground survey Structure Type: El New Tower ❑Existing Tower ❑Roof Top ❑Water Tank ❑Smoke Stack ®Utility Pole Latitude: N 41°42'08.61" NAD83 Longitude: W-70° 16'22.93" NAD83 Ground Elevation: 0.0' (AGL) 38.0' (AMSL) Top of Existing Utility Pole: 38.5' (AGL) 76.5' (AMSL) Centerline of Prop. Antennas: 29.3' (AGL) 67.3' (AMSL) Overall Height of Proposed Structure, Including Appurtenances: 39.0 ' (AGL) 77.0' (AMSL) Overall Height of Existing Structure, Including Appurtenances: 39.0' (AGL) 77.0' (AMSL) Certification: I certify that the latitude and longitude are accurate to within +/-50 feet horizontally and that the ground elevation is accurate to within +/-20 feet vertically. The horizontal datum (coordinates)are expressed in terms of degrees, minutes, seconds and tenths of seconds. The vertical datum (heights)are expressed in terms of feet. Company: Advanced Engineering Group, PC Professional Engineer: Scott N. Adams, P.E. #46006 Date: 02-16-2017 IP co /STE �tiw yen . onw,reless March 20, 2018 Dear Sir/Madam: Re: Chris Mitchell/Industrial Communications, LLC Please accept this letter as notification that Chris Mitchell working for Industrial Communications, of Marshfield, MA has been engaged to perform research on certain properties and real estate including submitting for zoning approval,building permits,and construction for Verizon Wireless'ongoing network enhancement. Chris Mitchell/Industrial Communications is authorized to act on Verizon Wireless behalf for the purpose of filing and consummating any zoning and/or building permit applications necessary to obtain approval of the applicable jurisdiction for the installation and/or modification of Verizon Wireless' communication Facilities. Should you have any questions regarding any TRM Inc.'s activities on behalf of Verizon Wireless,feel free to contact me at 508-320-2017 or via email at sean.conwav@verizonwireless.com Respectfully, S P,A•tA, Sean Conway Verizon Wireless Project Manager—Real Estate ver170fl wireless March 1,2018 Dear Sir/Madam: RE:TRM Please accept this letter as notification that TRM, Inc. of Foxborough, MA has been engaged to perform research on certain properties and real estate including submitting for zoning approval, building permits, and construction of Verizon Wireless ongoing network enhancement. TRM, Inc., is authorized to act on Verizon Wireless behalf for the purpose of filling and consummating any zoning and/or building permit applications necessary to obtain approval of the applicable jurisdiction for the installation and/or modification of Verizon Wireless communication Facilities. Should you have any questions regarding any TRM, Inc's activities on behalf of Verizon Wireless,feel free to contact me at 508-320-2017 or via email sean.conwav@verizionwireless.com Respectfully, Sean Conway Verizon Wireless Project Manager—Real Estate . . 1 , 119 License to be used for Verizon Barnstable SC11 , SC13 4 SC tit..,,, obOld building permits only. .. 0) --...., g0 p z o c = 0 gu 3 3 corn FA' otx = 0 c 0 'x a „I m ,,. ._,, .", .., ,.. c, _..,.„_ ,.. _. ,., ,-....,........,., 5._. m.. ..,... rr. in 143 61.5 6.) = 0 A re ... .,.. st m - w 1 0 i CO= • • r I L . The Commonwealth of Massachusetts )t_'.I "I Department of Industrial Accidents 0 ttt■l lain" 1 Congress Street,Suite 100 g. stt . ttXI, ji 1111 Boston,MA 02114-2017 'S,....ss,,r'" www mass.gov/dta Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name(Business/Organization/Individual):Industrial Communications LLC Address:40 Lone St. City/State/Zip:Marshfield,MA 02050 Phone#:781-319-1014 Are you an employer?Check the appropriate box: Type of project(required): 1. A I am a employer with 80+- employees(full and/or part-time)! 7. ✓❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition 4.01 am a homeowner and will be hiring contractors to conduct all work on my laoperly. I will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.['Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit 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:United States Fire Insurance Co. .. Policy#or Self-ins.Lin.#:4087330398 Expiration Date:1-1-2019 Job Site Address:3 various locations on telephone poles City/State/Zip:Barnstable,MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statemen ay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certifjtidii the pair r ,Giese erjurjrthat the information provided above is, ue an correct Signature:. . Date: " id Phone#. 7� '-1014 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#: 4 A ® 5 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDI YYY) 3/26/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME CT Ken Christianson The Driscoll Agency PHONE 781-681-6656 FAX, 781-681-6686 93 Longwater CircleaIL.tea) �A(c:Not Norwell MA 02061 'A"RESS.kchristianson@driscollagency.com INSURERS)AFFORDING COVERAGE NAIC q _ INsuRERA:United States Fire Insurance Co 21113 INSURED 2066 INSURER B:The North River Insurance Company 21105 Industrial Communications&Electronics,Inc. INSURER C:Travelers Property Casualty Company of 25674 Industrial Tower&Wireless,LLC industrial Communications,LLC INSURER D: 40 Lone Street INSURER E: _ Marshfield MA 02050-2102 INSURER F: COVERAGES CERTIFICATE NUMBER:1379609215 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. ILA TYPE OF INSURANCE REDaINVD POLICY NUMBER (MMMI POLICY D/YEYYYLtMmiDD/YYvir) LIMITS A x COMMERCIAL GENERAL LIABILITY 5432200173 1/1/2018 1/1/2019 EACH OCCURRENCE $1,000,000 . DAMAGE-TO R. CLAIMS-MADE X OCCUR •PREMISES4Ea'odamence) $300,000 X XCU Included MED EXP.(My one person) $15,000 X Contractual Liab PERSONAL A ADV INJURY: $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE .02,000,000 _ POUCY X JECT- I I LOG PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 1337429349 1/1/2018 1/1/2019 t.JMBBII EO INGLE LIMIT $1,000,000 (Ea -ANY AUTO BODILY INJURY(Per person) $ —AUTOS ONLY X SCHEDULED BODILY INJURY(Per acddent) $ OS HIRED NON-0wNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY -(Per accident) $ $ B X `UMBRELLA UAB X, OCCUR 5811099309 1H/2018 1/1/2019 EACH OCCURRENCE $10,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $20,000,000 DED I RETENTIONS $ X STA A WORKERS COMPENSATION 4087330398 1/1/2018 1/1/2019 ` PER OTH= TUTE ER AND EMPLOYERS'UABILnY • ;ANY PROPRIETOR/PARTNERIEXECUTIVE YI r NI NIA E.L.EACH ACCIDENT $1,000,000 OFRCER/MEMBEREXCLUDED? I I -- - (Mandatory in NH) .E.L.DISEASE-EA EMPLOYEE`$1,000,000 It yes,deaenbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POUCY LIMIT $1,000,000 e Installation Floater QT660221D1260TIL18 1/1/2018 1/1/2019 Job Site $300,000 In Transit $100,000 Temp Location $200,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached U more space Is required) 1 CERTIFICATE HOLDER CANCELLATION 30 - 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Bamstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE ktf „X 4 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD r 1 r Mail Processing Center Aeronautical Study No. ° " Federal Aviation Administration 2018-ANE-2227-OE - as' Southwest Regional Office Obstruction Evaluation Group 10101 Hillwood Parkway Fort Worth, TX 76177 Issued Date: 04/17/2018 Nicole Pelletier TRM 16 Chestnut St. Foxboro, MA 02035 ** DETERMINATION OF NO HAZARD TO AIR NAVIGATION ** The Federal Aviation Administration has conducted an aeronautical study under the provisions of 49 U.S.C., Section 44718 and if applicable Title 14 of the Code of Federal Regulations,part 77, concerning: Structure: Barntable MA SC 15 Location: Barnstable, MA Latitude: 41-42-08.61N NAD 83 Longitude: 70-16-22.93W Heights: 38 feet site elevation(SE) 39 feet above ground level (AGL) 77 feet above mean sea level (AMSL) This aeronautical study revealed that the structure does not exceed obstruction standards and would not be a hazard to air navigation provided the following condition(s), if any, is(are)met: It is required that FAA Form 7460-2,Notice of Actual Construction or Alteration,be e-filed any time the project is abandoned or: At least 10 days prior to start of construction(7460-2, Part 1) X Within 5 days after the construction reaches its greatest height(7460-2, Part 2) Based on this evaluation, marking and lighting are not necessary for aviation safety. However, if marking/ lighting are accomplished on a voluntary basis, we recommend it be installed in accordance with FAA Advisory circular 70/7460-1 L Change 1. This determination expires on 10/17/2019 unless: (a) the construction is started(not necessarily completed) and FAA Form 7460-2,Notice of Actual Construction or Alteration, is received by this office. (b) extended,revised, or terminated by the issuing office. (c) the construction is subject to the licensing authority of the Federal Communications Commission (FCC) and an application for a construction permit has been filed, as required by the FCC, within 6 months of the date of this determination. In such case, the determination expires on the date prescribed by the FCC for completion of construction, or the date the FCC denies the application. Page 1 of 3 NQTE: REQUEST FOR EXTENSION OF THE EFFECTIVE PERIOD OF THIS DETERMINATION MUST BE E-FILED AT LEAST 15 DAYS PRIOR TO THE EXPIRATION DATE. AFTER RE-EVALUATION OF CURRENT OPERATIONS IN THE AREA OF THE STRUCTURE TO IIETERMINE THAT NO SIGNIFICANT AERONAUTICAL CHANGES HAVE OCCURRED, YOUR DETERMINATION MAY BE ELIGIBLE FOR ONE EXTENSION OF THE EFFECTIVE PERIOD. This determination is based, in part, on the foregoing description which includes specific coordinates, heights, frequency(ies) and power. Any changes in coordinates, heights, and frequencies or use of greater power, except those frequencies specified in the Colo Void Clause Coalition; Antenna System Co-Location; Voluntary Best Practices, effective 21 Nov 2007, will void this determination. Any future construction or alteration, including increase to heights,power, or the addition of other transmitters, requires separate notice to the FAA.This determination includes all previously filed frequencies and power for this structure. If construction or alteration is dismantled or destroyed, you must submit notice to the FAA within 5 days after the construction or alteration is dismantled or destroyed. This determination does include temporary construction equipment such as cranes, derricks, etc., which may be used during actual construction of the structure. However, this equipment shall not exceed the overall heights as indicated above. Equipment which has a height greater than the studied structure requires separate notice to the FAA. This determination concerns the effect of this structure on the safe and efficient use of navigable airspace by aircraft and does not relieve the sponsor of compliance responsibilities relating to any law, ordinance, or regulation of any Federal, State, or local government body. A copy of this determination will be forwarded to the Federal Communications Commission(FCC)because the structure is subject to their licensing authority. If we can be of further assistance,please contact our office at(817) 222-5922, or debbie.cardenas@faa.gov. On any future correspondence concerning this matter,please refer to Aeronautical Study Number 2018-ANE-2227- OE. Signature Control No: 360646536-362817444 (DNE) Debbie Cardenas Technician Attachment(s) Frequency Data cc: FCC Page 2 of 3 L Frequency Data for ASN 2018-ANE-2227-OE ,...e 1 . LOW HIGH FREQUENCY ERP FREQUENCY FREQUENCY UNIT ERP UNIT 1710 2130 MHz 460.25 W Page 3 of 3 Town of Barnstable ..,:31: Post This Card&So_That it is Visible From the Street-A ;roved:Plans Must�bejteta ned on7Job andthis°GardaMust be Ke t ` h Epp ; i x � p �6,9. Tf fildSn !Iiinal Inspection Has Been Made f, ,• - ; , ' 1 44 If l � r, r Whe eja Certificate of Occupancyil s Required,such 8u ldmg shall No biOcccdpiecl4nt� F nal Inspectwn has been de V Permit No. B-18-1361 Applicant Name: CHRISTOPHER H MITCHELL Approvals Date Issued: 05/24/2018 Current Use: Structure Permit Type: Building-Addition/Alteration-Commercial Expiration Date: 11/24/2018 Foundation: Location: 4096 MAIN ST./RTE 6A(BARN.), BARNSTABLE Map/Lot: 336-054 Zoning District: RF-2 Sheathing: Owner on Record: KRAMER,JOYCE&NAGLE, MARCIA Contractor Name CHRISTOPHER H MITCHELL Framing: 1 Address: PO BOX 212 - Contractor";License� 052112 2 WASHINGTON VA 22747 '` 500.00��� � Est Project Cost: $ 12, Chimney: Description: verizon proposed to mount a wireless antennaionsanculary ;Permit Fee: $263.75 equipment to an existing eversource utility located next to the Insulation: Fe.e Paid,, S 263.75 address of 4096 main street 1 pole#3 v/z 204 1st Extension to Final: expire 5/24/2019 Date ` 5/24/2018 Project Review Req: r , ` �: � ram.,, - - Plumbing/Gas � '', Rough Plumbing: , _ `r: • -,Building Official . x Final Plumbing: i Rough Gas: Final Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved applicat on and the;approved construction docum nts for which this permit has been granted. Electrical All construction,alterations and changes of use of any building and structures;shall be in compliance with the local zoning by lawsand codes. This permit shall be displayed in a location clearly visible from access street or road and shall"be maintained open forzpublic mspection for the entire duration of the Service: work until the completion of the same. , ,< • f .„ Rough: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Final: 1.Foundation or Footing 2.Sheathing Inspection Low Voltage Rough: 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 Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Health 7.Final Inspection before Occupancy Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Fire Department '"'r Work shall not proceed until the Inspector has approved the various stages of construction. I f" . Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). 4,- 77.A) .11 1 (-.... arr0nnl Nr>kv'rk Snliiiime November 5, 2018 Mr. Brian Florence Town of Barnstable Building Department 200 Main Street, Hyannis, MA. 02601 Subject: Building Permit Extension Barnstable_SC15_MA Dear Mr. Florence, it( 15 di l.Si Verizon Wireless requests to extend an existing building permit(BP# B-18-1361)that was approved on May 24, 2018.The permit allows for the installation of one (1) small cell antenna and ancillary equipment on an existing Eversource utility pole (#3 v/z 204) located near 4096 Main Street. Construction was setback due to a delay in make ready work by the utility company. A six-month extension should provide Verizon and its General Contractor enough time to complete construction.The permit is set to expire on November24, 2018. Should you have any questions or concerns, please do not hesitate to contact me via phone or email. a' Regards, u�. William Perry �o :„ R at Site Acquisition Specialist . Tower Resource Management, Inc. 750 West Center St.Suite 301 West Bridgewater, MA 02379 w Cell: (401) 528-9721 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 Parcel �cy lication 3 LiCR # Health.Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address I/d 9 , atitik, 9-119,4 Village ..,Ie�i4ie,/b/� Owner Z/ee k - 44ei, Address '/CI?[m IA Sired" Telephone Perk mit Request ,n '1 .ff lw v 4n Le,e 'yob ;.T' wcHveet.v,S Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project-Valuation 'ssitkeConstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attaehsupporting doctymentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) c . Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kirig's High ay: O=Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) C'a`uP Number of Baths: Full: existing new Half: existing n'; 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) Dety c eS cTelephone-Ntimber:_. 5TR-- 774 , 2(o (Address Z Marie_ Et-, License-#—_/05-53b ft/la:s it ee, M 14. OZGI/Q Home Improvement Contractor-#_ Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNA5TURE DATE46/fif 3 , - FOR OFFICIAL USE ONLY It APPLICATION# DATE ISSUED -- ' ,f MAP/PARCEL NO. • Y • y+ 11 ADDRESS VILLAGE r .[ OWNER ' DATE OF INSPECTION: f. c ,m_••FOUNDATION ._ . . s 5_, 1 FRAME • INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ;1 PLUMBING: ROUGH FINAL _ GAS: ROUGH FINAL '4 FINAL BUILDING r DATE CLOSED OUT `( • • ASSOCIATION PLAN NO. '.N f The Commonwealth of Massachusetts ns Department ofIndusb�ial Acddeu y_ t t Office of Inve ti atitms 600 Washington Street Boston,MA 02w !Y!f1►.m s.gos WY Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Oxgan tionitn&.v dnai} " ista tZ -.YY?l4 p in A 02104q Phone# 776 o 61124 �.iAre you an employer?Check the appropriate box: Type of project(raper' 1?❑ I am a employer with ,! ❑ I am a general contractor and I G. ❑New won Ioyees(full sudlorpart-time)_* have tined the sub-contractors 2. I am a sole proprietor orpartne - listed untie attached sheet 7. ❑Remodeling ship and have no employees These sub-oontrao:tors have 8. 0 Demolition working for me in any capacity_ employees and have workers' 9_ ❑Building addition IN*workers'comp_insurance Comp_insuranCe.1 required] 5. ❑ We are a corporation and its 10 0 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 insurance required]t C_152,§1(4),and-we have 11D repairs employees.[No workers' 13.0 Other - comp-insurance required] 'Any tpplicnt that checks box#1 nmst also Ea out the sectinnbelowshowing their workers'compensation policy information_ I Hameogvae s litho submit this eft davit ia:"icsting they ire doing savant and then hire outside COcontractors Est submit anew xffictrok indicating soci CCaatxacenrsthar check thisbmx mast attached as additional skeet shosrmg the name of the sub-contactors and state whether ornat those entities Use employees. If the s b-cou nc►orsbase employees,they mastpmvide their warktss'comp.policy number. I run an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy 4 or Self-ins Ile.4: ExpiiationDate: Job Site Address: Ci€y/StatelZtp: Attach a copy of the workers'compensation policy-declaration page(showing the/whey number and expiation date). Failure to secure coverage as required under Section 25A of MGL c. 152.ean lead to the imposition of criminal penalties of a fine up to 31,500-00 and/or one-year imprisonment,as well as civil pr'n elt es in the foffi of a STOP WORK ORDER and a fine of up to$2250.00 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 certi uler the pains andpewalfies ofpetjury that the zfonnt lion provided above istrue and correct tt � Date: 6 f S' tz/ Pliaxintik 577 - 77 6-1/26 Orwiel use ttnlp Do not writs in this area,to be completed by city Grimm affrdat Cady or Town; • Permit/License i Issuing Authority(circle one)e 1"Board of Wealth 2.Barring Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone il: 6 Town of Barnstable Regulatory Services `s sesasr�,srn, $ .. Thomas F.Geller,Director i6;�c►, - Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 •, www.town.barnstafile.ma.us • Office: 508-862-4038 Fax: 508-790-6230 • - Property Owner Must • - Complete and Sign This Section If Using A Builder • OniI, - • /C2 44 V 1C re-- , as Owner of the subject property hereby authorize c 7,4U(d• r(' SPY)I to act on my behalf, 1 in all matters relative to work authorized by this building permit • *4C. n10.1;1 Sfre., -r•rls b(€ (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 ins ,:.: are performed and accepted. tor (IL litipr—Owneri Signature of Applicant • 1101k.—.V4C/C-e. Ka4MeiZ, Print Name Print Name Date ' • • Q:FORMS:OWNERPERMISSIONPOOLS 62012 • > Town of Barnstable � � Regulatory Services �gAgNsTmax ft Thomas F.Geller,Director ‘1,..67:1 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 ROMEO" r • LICENSE EXEMPTION •Please Print DATE: �\.`� • JOB LOCATION: \ nimlber\\ street village "HOMEOWNER": \ name ho•., phone# work phone# • CURRENT MAILING ADDRESS: cik�t,own state zip code The current exemption for"homeowners'was a•a'•ed to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for who ••es not possess a license,provided that the owner acts as supervisor. DEFINTITON OF HOMEOWNER Person(s)who owns a parcel of land on which lie resides or intends to reside,on which there is,or is intended to be, a one or two- ily dwelling,attached or detached structures :'aessory to such use an d/or nd/or farm structures. A person who constructs more than one home in a two-year period chall not be considere,' a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she •. be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes iespo•.ibility for corn,.•ance with the State Building Code and other applicable codes, bylaws,rules and regulations. • The undersigned"homeowner"certifies that h she understands the To>,i of Barnstable Building Department minimum inspection procedures and requirements and that he/she > • comply with said paoce• • -s and requirements. Signature of Homeowner . Approval of Building Official Note: Three-family dwellings c• `I•s g 35,000 cubic feet or Iarger will be requir-• to comply with the State Building.Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION r:. The Code states that: "Any ho,.eowner performing work for which a building pe ' required shall be exempt from the provisions of this section(Sec u on 109.1.1-Licensing of construction Supervisors);prov ed that if the homeowner engages a person(s)for hire to do such ••irk,that such Homeowner shall act as supervisor." • • Many homeowners who use ,' exemption are unaware that they are assuming the responsibiei; s of a supervisor (see Appendix Q,Rules&Regnlatio. for Licensing Construction Supervisors,`Section 2.15) This-lack of a areness often results in serious problems,particul: ,ly when the homeowner hires unlicensed persons. In this case,our Boa ,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 caret amend and adopt such a form/certification for use in your community. C:\Users\decolhIAAppData1LocalthEcrosoft\Windows\Temporary Internet Files\Content Outlook\QRE6ZUBN CPRESS.doe Revised 053012 I!I . • c' 14 ra nA- re,y e s .1 4dt tiStA i-tbts j /led- Z - LX 1-VL 'g g F (za 31 zi,ea x. ..1 ! -)fsott 11 E I I I 1i 1i II JA 1 1 { 5 F t F Fad{ 7 i I. ir- I1 Fii i g � P ! t t I E 1 � 1 I I 1 1 t CsJhe 1`p0421/121.022,cuca//z o`'C (cuodactedea \ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration •170173 Type: Office of Consumer Affairs and Business Regulation xpiration 9/23/2015 DBA. 10 Park Plaza-Suite 5170 Boston,MA 02116 DOVETAIL WOODWORKS _ t; 1 4 1 DAVID SMITH 2 MAPLE ST MASHPEE, MA 02649 Undersecretary Not valid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor - License: CS-105530 A - i. DAVID M SMITH , 2 MAPLE STREET * °MASHPEE MA 1,51649 �.•�,.. .,)1it� Expiration Commissioner 04/05/2016 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 620lC l00 - 7 Map ' Parcel "` d5�7 Application # Health Division / `---6 2,7 Date Issued ePiDesii 0 Conservation Division Application Feel 50 Planning Dept. Permit Fee b Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address "/0 CiC 142.44 Village CsGQ f2l 62,44 i Owner s (r VA-RA/ Address (?•03OK a la . )2_s/ U2 as7L/7 Telephone Permit Request VLPj �� 01-• rt? Square feet: 1st floor:(� existing T7X proposed w—• 2nd floor: existing(�� proposed --0-'Total new — ° Zoning District 1`S Flood Plain Groundwater Overlay Project Valuation 1a,p0— Construction Type Lot Size �� 6 Grandfathered: O'S'es ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family th Two Family ❑ Multi�F milt' (# units) 9 �� Age of Existing Structure og-� Historic House: C94s ❑ No On Old King's Highway: 'Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.fi2 Number of Baths: Full: existingnew Half: existingri newt � ry Number of Bedrooms: existing _new N,., ram, Total Room Count (not incl ing baths): existing -v newer First Floor Roo Count v e. Heat Type and Fuel: Ga ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes No Fireplaces: Existing I New —0 Existing wood/coal stove❑Y s ❑ No Detached garage: ❑ existing U new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Aut rization ❑ Appeal # Recorded ❑ Commercial ❑Yes o If yes, site plan review# Current Use Proposed Use AP NT INFORMATION (BUILDE R HOMEOWNER) o 7% _ iq 27 Name 20 Telephone Number 30 s `/I Address x 300 \e-vt -�'`�� .a License# 4 3 L '( Home Improvement Contractor# I b S( Worker's Compensation # ALL CONSTRUCTIO DEBRIS iTSULTING FROM THIS PROJECT WILL BE TAKEN TO tk tit SIGNATURE DATE —`Q1—/6 t FOR OFFICIAL USE ONLY APPLICATION# i DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE t= • OWNER t ; DATE OF INSPECTION: I ! FOUNDATION } FRAME r C. INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL • GAS: ROUGH FINAL i FINAL BUILDING • ' DATE CLOSED OUT , ASSOCIATION PLAN NO. Y i � k 1 i. The Commonwealth of Massachusetts Department of Industrial Accidents 7 1 ) liAn Office of Investigations IY 600 Washington Street (� l%=1;' Boston, MA 02111 I.` % www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Or anization/individual): e— �" ' "�2' g \)(e.. —• Address: \ 9-- C-0 City/State/Zip: �Zc4 0�;30 Phone #: & =30--. — q /5) Are you an employer? Check the appropriate box: Type bf project(required): 1.❑ I a a employer with 4. ❑ I am a general contractor and 1 6 ❑ Ne construction ployees(full and/or part-time).* have hired the sub contractors listed on the attached sheet. 7. emodeling 2. I am a sole proprietor or partner- ship and have no employees These sub contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp, insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additic 3.❑ I am a homeowner doing all work officers have exercised their 11.1-1 Plumbing repairs or additic myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs • insurance required.] t c. 152, §1(4),and we have no q ] 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 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. 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. 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: Policy#or Self-ins, Lic.#: 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 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 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 Der ins ance coverage verification. �_, of perjury that the information provided above is true and correct. I do hereby certify un� Arr--,F.,,enalties / Signature: ► - Date: J-16-` b 4/Phone.#: &- '3C� / 9 7 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 Massachusetts General Laws chapter 152 requires all employ- s to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every .erson in the service of another under any contract of hire, express or implied, oral or written." An employer is deflaed as"an individual, partnership, .ssociation, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and incl ding the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, assoc.tion or other legal entity,employing employees. However the owner of a dwelling hous&4 aving not more than thre' apartments and who resides therein,or the occupant of the dwelling house of another w'hp employs persons to di maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every .tate or local licensing agency shall withhold the issuance or renewal of a license or permit to opo:te a bus' ess or to construct buildings in the commonwealth for any applicant who has not produced acceptable e idence of compliance with the insurance coverage required." .., 'Additionally, MGL chapter 152, §25C(7)'state• "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance o ,.ublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been preset.ed to the contracting authority." Applicants \ Please fill out the workers' compensatio affidavit c,o*mpletely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)ram,(s), address(A)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limite Liability Partnerships (LLP) with no employees other than the members or partners, are not required {. carry workers' co r ipensation insurance. If an LLC or LLP does have employees, a policy is required. Be acvised that this affidav' may be submitted to the Department of Industrial Accidents for confirmation of insura,ce coverage. Also be s e to sign and date the affidavit.. The affidavit should be returned to the city or town that 'e application for the penni or license is being requested,not the Department of Industrial Accidents. 'Should you .:ve any questions regarding the law or if you are required to obtain a workers' compensation policy, please call tie Department at the number lisle,. below. Self-insured companies should enter their self-insurance license number on d a appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Dep.,tment has provided a space at the bottom of the affidavit for you to fill outin the event the Office of Investigations ha. to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a ref- ence number. In addition,an applicant • that must submit multiple permiblicense applications in any given year, need o submit one affidavit indicating current policy information(if necessary] and under"Job Site Address"the applicant sho ,.d write"all locations in (city or town)."A copy of the affidavit Ihat has been officially stamped or marked by the ci or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new .ffidavit must be filled out each year. Where a home owner or ciitizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to urn leaves etc.) said person is NOT required to complete th. affidavit. ayou in advance foryour cooperation and shoulg ou have any questions, The Office of Investigations would like to thank p please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617.-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia , .1_,------- dAracitagel4 • — --- -'-- vtotRE.IMPROVENI .------*--.1------ - WN Bofrkeoffiii log Registration. • 104514 0 .----'-----4•---' • S--3i N--"• ExPl - - IleaficEINT°C—ONITRACIITBOaRr 14 ',ratio-11c: 7/1:vaidguiagl Tr# GEORGE\N .... " Barnstable,MA 02630 ie. I . _,,-1---.•-.2"-'---fp. \ 130 Redwing LnIP O.Box 2 \ °S. s.-- -- -Administrator 1 ........._ ____ 4",,,,,.tivili,;:t";-: be ognaaoQ t of.itaaoadeaeles . :i. ---;,-;'.,:A.,,3; 'A Board of Building Regulations and Standards , 1 •,,,, Construction Supervisor License . : • 1§-4:4'' License: CS 14344 . _ EkPiretibl::--3/20/2010 Tr# 20063 -10 "Restriction: 00 GEORGE W BLAKELY - -- - 130 REDWING EA/PO:BOX20a -,°-------4— ----- -----" ,-..-- ' • ' • ' BARNSTABLE,MA 02630 oimmissioner ' I -"111111111114111pkim, x REScheck Software Version 4.3.0 Compliance Certificate Energy Code: 2009 IECC Location: Barnstable,Massachusetts Construction Type: Single Family Project Type: Addition/Alteration Heating Degree Days: 6137 Climate Zone: 5 Construction Site: Owner/Agent: Designer/Contractor: Compliance:Passes Compliance: Maximum UA:16 Your UA:16 h S'err E i, • .'.�.r' - ' • Glazing Assembly ' ,e�� orpoorb ..1/4- G Cv1:0, 5 - k t-4,44 Ceiling 1:Flat Ceiling or Scissor Truss 156 30.0 31.0 3 Wall 1:Wood Frame,16"o.c. 71 13.0 14.0 2 Window 1:Wood Frame:Double Pane with Low-E 24 0.450 11 Compliance Statement: The proposed building design described here is consistent with the building plans,specifications,and other calculations submitted with the permit application.The proposed building has been designed to meet the 2009 IECC requirements in REScheck Version 4.3.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. Name-Title Signature Date Project Title: Report date: 02/19/10 Data filename: Untitled.rck Page 1 of 1 • 0,1 r Town of Barns-tab-Ie =.„ Regulatory Services ` qq8 Thomas F. Geiler, Director ��f6sC- h�� Buildingg Division Toni Perry, Building Commissioner, 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508--79( • Property Owter Complete and Sign This Section If Using A Builder • p I, �o�- KY�w��- , as Owner of the subject property hereby authorize csiettott, .+ z ` to act on my behalf, in all matters relative to work authorized by this building permit application for: 401.3-Nett C �. 0 • .. • (Address of Job) (—ha- 0 e of Owner Date c��lr leer Print ame 0 If Property Owner is-applying for permit please complete the Homeowners License Exemption Form on the reverse side. . • Town of Barnstable . , mop Tree r . • 0 Regulatory Services ''• �' • Thomas F, Geller, Director ' aAxxsrwatE, '` Building Division • • 1659 . 1a �PrEO fit, Tom Perry,Building Commissioner. • • 200 Maid.Street, Hyannis,MA 02601 R .towsn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION • Please Print • DATE: JOB LOCATION: village number street • • •_ LIOM$OWNER": name . . home phone II work_pbonc# • CURRENT MAILING ADDRESS: ' city/town state zip code The current exeu.tption 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 BOIY EO\V1'ER • Persons)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.of 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 13ur-lrling 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. . RROMEOWNER'S EXEMPTION • :pc Code states that "Any homeowner performing work for which a building pr.nriit is required shall be cxcmpt from thc provisions of this suction.(Suction 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 sha11 act as supervisor." Many horncowners who use this exemption arc unaware that they are assuring thc responsibilities of a supervisor(sec Appendix Q, Rules &Regulations for Licensing Construction supervisors,Suction 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 thc unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. • To ensure that thc homeowner is fully aware of his/her responsibilities,many communities require,as part of thc permit application, that the homeowner certify that he/she understands thc responsibilities of a Supervisor. On thc last page of this issue is a•form currently used by several towns. 'You may cart t amend and adopt such a form/certification for use in your community. . i y. (-- ,* \THE Tp� Town of Barnstable *Perm O��C C�= e'n ,. c tia Expires ronths in issue Ante ass' °� .tttl�a F Regulatory Services Fec �}�� 9\ M^ 64, � ( )�y� Thomas F. Geller,Director ff-----'V moo;`'w9tlA��' GiJ . rfD OF`10. S , Building DivisiontSTA4j4Tom Perry, CBO, Building Commissioner . 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 Number 3.31 — O S q Prope Address q 0Ct(i2 2;t- Ski, C .z A`C.. Residential Value of Work ( t°CO — Minimum fee of$25.00 for work under$6000.00. Owner's Name &Address ►C'Q W/ L Gt. Contractor's Name 1/4-A-5 \A"'^"1 Telephone Number }b -5(cy e(-7 Home Improvement Contractor License It(if applicable) U4S (`1 Construction Supervisor's License#(if applicable) 1() 3 L1 4 ❑Workman's efmpensation Insurance Che one: , I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to n t1/4t.2 �t" ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-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: Pr perty Owner must sign Property Owner Letter of Permission. copy ofthe Home Improvement Contractors License & Construction Supervisors.License is SIGNATURE: Q:\WPFILE ORMS\building permit forms\EXPRESS.doc Revised 090809 z4 of1HE r Town of Barnstable ,!„, ° Regulatory Services x +?S."RIN,H9BLE'�; Thomas F. Geller,Director �AF0;l,ZiI% 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, S�p` ca., , as Owner of the subject property hereby authorize � A to act on my behalf, in all matters relative to work authorized by this building permit application for. 40 ,2cL S Cu, 2 C L (Address of Job) Signatur of Owner Date -5 Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Fonni on the reverse side. a. ov ram, Town of Barnstable - , io Regulatory Services Thomas F. Geiler,Director Y anxrtsTasr.ej , Tom Perry,Building Commissioner t 200 Main Street, Hya.nnis,MA 02601 { \ www.town.bar s stable.ma.us Office: 508-862-4038 • Fax: 508-790-6230 HOMEOWNER L CENSE EXEMPTION Plese Print DATE: '., , JOB LOCATION: numb r s reef village \ . "HOMEOWNER": • name ome phone# work phone# CURRENT MAILING ADDRESS: ci town state zip code The current exemption for"homeowners" as ex'ended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individua.for hire who does not possess a license,provided that the owner acts as supervisor. • DE r TION OF HOMEOWNER Person(s)who owns a parcel of land on whic e/s'e resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or.etache: structures accessory to such use and/or farm structures. A person who constructs more than one home a two-ye. .eriod shall not be considered a homeowner. Such. "homeowner"shall submit to the Building i f#icial on a fo-s acceptable to the Building Official, that he/she shall be responsible for all such work performed uner the building p: it. (Section 109.1.1) The undersigned"homeowner" assumes responsibility for comp. ce with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies(that he/she understands the To of Barnstable Building Department minimum inspection procedures and requirements and that he/she will corn. with said procedures and requirements. j Signature of Homeowner j i Approval of Building Official Note: Three-family dwelli s 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, II 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:\WPFILES\FORMS\homeexempt.DOC • ! . . . , ia \ The Commonwealth of Massachusetts Department of Industrial Accidents i'a l Office of Investigations 1'_ ,f= 600 Washington Street t. Boston, MA 02111 . -rt / www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationtlndividual): �Q Address: S 6 X G City/State/Zip 2J-L--‘5. C ` c) Phone #: GOY 4.7 l C Are you an employer? Check the appropriate box: Type of project (required): 1.n I a employer with 4. LiI1m a general contractor and I have hired the sub contractors 6. (� New construction mployees (full and/or part-time).* 2. I am a sole proprietor or partner- listed on the attached sheet. 7. n Remodeling ship and have no employees These sub contractors have g. Demolition working for me in any capacity. employees and have workers' 9. C Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. [ We are a corporation and its 10.H Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or addition myself. [No workers' right of exemption per MGL y comp. 12.n Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.n Other comp. insurance required.] *Any applicant that checks box 111 must also fill out the section below showing thcir workers'compensation policy information. I.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 sub-contractors and state whether or not those entities have employees. Cf 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.#: 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 up to$1,500.00 and/ ne-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fin of up to$250.00 a da ag nst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the for . surance coverage verification. • I do hereby cer t a and penalties of perjury that the information provided above is true and correct. Signature: Date: /0'ti ^� 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 Plealth 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 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 lefined as "an individual,partnership, associ . ion, corporation or other legal entity, or any two or more of the foregoing gaged in a joint enterprise, and includin•, he 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 use having not more than three ap,rtments and who resides therein, or the occupant of the dwelling house of anoth r who employs persons to do intenance, constriction or repair work on such dwelling house or on the grounds or buil • g appurtenant thereto shall of because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)al states that"every st•;te or local licensing agency shall withhold the issuance or renewal of a license or permit a operate a busin .s or to construct buildings in the commonwealth for any applicant who has not produced ceptable evid:ace of compliance with the insurance coverage required." • Additionally, MGL chapter 152, §25k 7) states " either the commonwealth nor any of its political subdivisions shall enter into any contract for the performa .e of pu.i is work until acceptable evidence of compliance with the insurance requirements of this chapter have been pre .ented to the contracting authority." . Applicants • Please fill out the workers' compensation affruavit Lompletely,by checking the boxes that apply to your situation and, if • necessary,supply sub-contractor(s) name(s), ,,ddress(-, and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies (LL )or Limit-. Liability Partnerships (LLP)with no employees other than the members or partners, are not required to car workers' co ,sensation insurance. If an LLC or LLP does have employees, a policy is required. Be advise that this affidavit ay be submitted to the Department of Industrial Accidents for confirmation of insurance colverge,: Also be sur: to sign and date the affidavit. The affidavit should be returned to the city or town that the application. for the permit o icense is being requested,not the Department of Industrial Accidents. Should-you have any questions regarding the 1. or if you are required to obtain a workers' compensation policy,please call the Dep Irtment at the number listed b=.ow. Self-insured companies should enter their self-insurance license number on the applopriate line. City or Town Officials i . Please be sure that the affidavit is compete and printed legibly. The Departme't has provided a space at the bottom of the affidavit for you to fill out in thelevent the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitllice �e number which will be used as a.referenc- umber, In addition, an applicant that must submit multiple permit/licene applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should w ;te"all locations in (city or • town)." A copy of the affidavit that hal been officially stamped or marked by the city or own may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new of i.avit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to-bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like tc, thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number:• The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street .. . Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia