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0048 FERNWOOD AVENUE
� � d �� r �'C� z Town of Barnstable *Permit (J�e S Building Department Fee 6mo sfrom issue date Brian Florence,CBO &AMSrAsLE, v M.n g Buildin Commissioner z639. � �0tfo�a 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 Property Address L/ �t Al !4,n ❑Residential Value of Work$ y[TC,c,o Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number 57 f�P 3 G o 0 7 `Y "- Home Improvement Contractor License#(if applicable) /d J 3 d,� Email: Construction Supervisor's License#(if applicable) C © o / 0 ❑Workman's Compensation Insurance Check one: APR 10 2018 ❑ I am a sole proprietor ❑ I am the Homeowner TOWN O 8ARNS 1 C BLE. W have Worker's Compensation Insurance { I►}D Insurance Company Name A %(Ni A4 U✓ Workman's Comp.Policy# A ty `/ 6 0 ? 2 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) U.-Re--roof(hurricane nailed){stripping old shingles) All construction debris will be taken to , /7�Ae�a ❑Re-roof(hurricane nailed)(not stripping. Going over` existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAWPFILESTORMSTXPRESS2017 f k ?hie Comrnomveakh ofMassadrusetYs Departmerrt rr,f lrirdusiriat Accidents - - Office ofimw igations 600 Washington Street Boston,MA 02HI mmv massgov1dta Markers' CampensationInsurance Affidavit BuilderslCuntractursMec dcians/Plmmbers Applicant Infdrmati kn Please Print Legffily lr a=M..i' a / `L O h (�/ A &ess City/stabef .y / Phi 4' Z 8C, GO Are you an employer?Checkthe appropriate bom ' Type of project(required): I.pI am a employer wi . 4 ❑I am a general conixaciur and I 6- ❑New consbracti(m employees{fall andfor part-time)_* have hired the sub-contmcfars 2.❑ I am a sale praidetar or pastaer- listed on the attached sheet. ?- ❑Remodeling ship and have so-employees These smb-condractow have g_.❑Demolition woLidngr for me in any capacity- employees and have wo6ne ' 9. ❑Building addition [No wpdm S'Camp.imsmance coanp-mcurmom- r -j 5. El We area corporation and its 1�❑Electrical repairs or a d�tions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbingrepaim or additions. myselL of ememption per MGL + c[e re l woilmrs'�_ rightc.152,§1(4�aadwe have no IZ�Roafrepairs . employees_[No woib s' 13_0 Other comp_ir=aace required_] ;$ayWffcza dmtdmdsboaP1 alsoMouttheswfi=b9awshMdng&drwc&es'ca®pessatimtpahcyinf3MM9 _ Mmevwm=who subagttdaisaf8daeiti gthey mmdaingRU vat andd=bimautd&canoe=smnstsubmita new affidaestiadicetmornrR ZConLmcio6 d=ehea this bu mast wed as additti®sl sheet shoumg theaaxae of std}coam�ctcra�d stye�rhethec ar not rlwse emitiesha�e emplapes.Iftbesab-caatzamks eeopiayea%the}'amstPmui&&ek warxexs'cmmP°palkFnumbeL I am an arltpIoy�crr flerrt;is providing workers'co�per>•srrfiarr iaszirar�ca,for trcJ'earP`F°l�eex .SeFoav it tTia prrficy�arm jafa�s inforraatfon. Insurance CompanyNMM: 7c) M /-Yt uTvaG 4- /,.� Policy,4*'or Self-ins Lie_ ,C�i.i C �/ 6 6 7 6 a % 3 01 074 74 Expiration Date: Job life Addre= ly 0 ►ti&,,o d v l" City StatetTp: LI 14aA,A,., 0 d.6 Of Attach a.copy of the workers'compensatiolrpolicy-declaration page(showing�policy a�b •aad expiration safe). Failure to secure coverage as requiredunder Section 25A of MGL c�15,can lead to the impositioa of criminal penalties of a fine up to$1,50Q 00 aad for one-yearimpaisaamen,as we11 as cied peualb s.in the fona of a STOP WORK ORDEItand a fine of up to$250-DO a day against the violator- Be advised dint a copy of this statemerd maybe forwarded to the Office of Immst gations of the DIA for ms coverage y t sm Arlo hemby c wander thepains aad penahhes afparjuty&&the informadwipmidedahmv fs bare and correct Sim: Phone lk S�SY C e a 7 AY o O,�xciaf uss a�rrly. Da not rrrlta is tl�s tea,fo be cmnplete�d by czfp ortotcn a,f,�reiat My or Town: PerraitMicense ff Issuing Authority(ci de one): L Board of Health 2.Building Department 3.CityfFown Clerk 4.Electrical Inspector g.Plumbbag Inspector 6.Other Contact Person: Phone#: — -- - 6 laformation, and Mstructions iM�c�easiace#fs Geheaal Laws cTiapfrr ISZ regales all employees to provide workEas'compensation for$ieii employees_ ° pm-s tr this Vie,an En?kgme is defned as."_.evmy person in the service of der und=acLy contract oflife, egress ar hl3plied,oral or wrrit=f Art er V&TM,is dmfoied as"an mdiVidnal,paifnersbip,assoCiEfion coipora#ion or offer legal en[iiy,or any tFvo or more of Liam foregoing eiagaged m a Joint mtmpnse,and mclndmg the legal rsp.L entat ves of a deceased employer,or the receiver or trust=of an individual,parinez3bip,association or other legal entity,employing employees- However the owner of a dym mg house having not more than tbree aparfineuts and who resides therein,or the occupant of the - dw-eging house of another who employs persons t D do maini=Laace,constcucti.on or repair work on such dwelling house or on the grormds or bmZdmg appurtenantthereto shallnotbecanse of such employment be,deemed to be an employer-" MGL chapter 152,§25C(6)also sf s 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 btuildiags in the commonwealth for any. applicant who has not produced acceptable eyideace of cump&ance wish the insurance.coverage required-" Additionally,MGL chaptrr 152, §25C(7)slates¢Nejth=the commonwealth nor any of its political subdivisions shall eM r into any contract fortbm perf=zace ofpchho work miff acceptable evidence of compliancewith the mm,M,ce. re tints of this chapt Ex have been presented to the contacting v anfhoufy." Appric Please fill obt the workers'compensation affidavit completely;by chi-m-king the boxes mat apply to your situation and,if necessary,supply sub-contracfnr(s)name(s), addresses)andghonennmber(s)alongwiLtheircer da-cat*)of insurance L-jc e LiabMty Companies(LLC)orLlmitedLiabfity-Pazfneiships(LLP)withno employees othe�.thanthe members or pmtaeas,are not regrired to cauy workers'compensation insarxacx If an LLC or LLP does have employees,-a policy is re ic±md. Be a.dvisecllhdthis affidayitmaybe snbmittr-d to the Depa-tment of Industdal Accidents for confnmation of ice coverage: Also be sure to sign and date the aidavit. The affidavit should be-retrnned to he city or town that the,application for the permit or license is being requested,not the Department of . Tndastrial Accidents_ Should you.have any gnesthons regarding the law or if you are regaled to obtain a workers' =Mpeasation policy,please call the Department at ffie immber listed below. Selfri smred companies should eater their self-fi+sarance license number on the appropriate Ime. City or Town Officials t Please be sore that the affidavit is complete and printed legibly. The Department has provided a space at the:bottom of the affidavit for you to fM out in the event the Office ofInvestigat i=has to comact youarding reg the applicant Please be stn a to fill in the pennitllicease mmnber which will be used as a refere aw number_ In.addition,an.applicant that must submit multiple peEMtlIicense applications i a any given year,need only submit one affidavit indicating curr-ent policy infb=ation(if necessary).and raider`Job Site Address"the applicant should write"all locations i aor ( ' town)-".A-copy of the•affidavit that has been officially stamped or madced by the city or town may be provided to the " appEcant as proof that a valid affidavit is on f Ie for fature'permits or licenses Anew affidavit must be filled ovt earh year.VVhere a home owner or citizen is obtaining a license or pexmit not related tQ any bn sinus or commercial venio= (L e. a dog license or pennit to bran leaves eft_)said person is NOT retomred tD complete this affidavit: The Of 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,DepFr =fs address,telephone and fax number- The CG=I aTMI*of 1 nseft-, ' Departmmtc&ldd�iakAocident% �iC�e of� izo>� ��ashin�an B ()�111 Ta 4 617-727-49W ext 4.06 car i-M MA SSA Fax#617-727'749 Revised 4-24-07 vsnag��t M ass ac tusetts[?epart�nent,of Public Safety Board:of,8dilding Regulaf#onsiand Standardss:. License; CS-040124 Coristrpction Supervisor 'r LIBERO J MOLINARI 11 SHEEP PASTURE;WAY� EAST SANDWICH MAJ 02537 k PfSKl •k ' Expiration: CoPY1.►J11`SsiO erg s 03%29/2019 ' �o Uaomzirlaortaxcr,��u��aaaac�ueefYri _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR j Registration: T 2322 Type: ' Expiration m 7/112I148� DBA MOLINARIROOFINGI } i x a I t Libero Molinari 11 SHEEP PASTURE EAST SANDWICH,MA 02537 Undersecretary \ Construction Spe�sr , . » . . . . \ \ | R i : { . < } Urslicted-Bukh of any use group which contain \ I s¥an35$dombc%k(991cbicmkEGof i | enclosed space. ; Failure to sessa.__te edition ¢eM_scu_A ( \ ® : State Building Code a cause for revocation @thsline . } v■Licensing information vs: WWW2ASSGOv@PS | . . .. ! , j . . /z Cr . SOT ?)S T)O J Page Nc. 1 of 1Pages. i i 93 THORtffON DWE )` "YANNSSr i'drAaS;{.CxLs=T;S 0260< `0SAL ! Ftait(rl Zit (308) SM3750 Sandwi.ssPROP pions:/fax(W) 7771"52656 ;Hyannis 1 } i I PHONE -508-790-SS07 �JATE TO JOANNA CALLLAHAN JOB NAME r LOCAT:ON ! 48 FERNWOOD 4-�k i HYANNIS MA 02601 , r JOB NUMBER JOB PHONE I We hereby submit specifications and estimates for: RE--ROOF ENTIRE ROOF ' AREA ( MAIN HOUSE AND GAR/,GE ) #1 STRIP OFF EXISTING ROOF" _ f #2 INSTALL METAL DRIP EDGE #3 INSTALL NEW VENT PIC'F_.- FL...ASHINGj is i tt4 CHIMNEY CHEC: ALL FLASHING AND COUTER FLASH WHERE�.iH�.RE ij i #S INSTALL ICE AND WATER SHIELD AND SHINGLE UNDER LAYMI= i f r f #b INSTALL CERTAINTIED SHINGLES COLOR • }i #7 • THOROUGH CLEAN UP OF ALL DEBRIS RELATING TO THE A80',JE WORK ; I i ij ii I' LIMITED LIFE TIME WARRANTY ON SI-ANGLES * FULLY INSURED WORKNIENS COMPENS?,)T I.ON AND LIr`;BILITY INSURAh4,C, F'. 1 i ii We ,Rrapl &hereby to furnish material and labor—complete in accordance with the above specifications,for the sum of: {1 1 TWELVE THOUSAND EIGHT . H-)_CDED--------------------- dollars o.�a_s is Payment to be made as follows: - ONE HALF TO BE PAID UPON COMMENCEMENT OF THE ABOVE WORK , THE BALr-aNCE TO BE PAID UPON COMPLETION . }! All material is guaranteed to be as specified. All work to be completed in a professional j manner according to standard practices. Any alteration or deviation from above specifica• Authorized j tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate. AD agreements contingent upon strikes,accidents or � delays beyond our control. Owner to carry fire,tomado,and other necessary insurance.Our Note: s proposal may be DAYS workers are fully covered by Worker's Compensation Insurance. 3 C A I S withdrawn by us!! net accepted 'thin days. ®ccc alptemas aT Rm1peaml —The above prices, specifications \ and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment wil be made as outlined abcve. Signature Date of Acceptance: i ® DATE(MM/DD/YYYY) ACAOR" CERTIFICATE OF LIABILITY INSURANCE 05/19/2017 I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF.INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to. the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Lori Wong OXFORD INSURANCE AGENCY INC a�"No,E 508 987-0333 a No: iE MAIL ADDRESS: lwong@oxfordinsurance.com 300 MAIN ST INSURERS AFFORDING COVERAGE NAIC# OXFORD MA 01540 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: L BERO MOLINARI INSURERC: 00LINARI HOME IMPROVEMENT INSURERD: 11 SHEEP PASTURE WAY INSURER E: EAST SANDWICH MA 02537 INSURER F: COVERAGES CERTIFICATE NUMBER: 156280 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE itagn ADDL wvn POLICY NUMBER MM/DDPOLICY EFF IPOLICYD/EXP LIMITS L.TR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F—IOCCUR DAMAGE O RENTED Ii PREMISES Ea occurrence $ } MED EXP(Any one person) $ f N/A PERSONAL&ADV INJURY $ HGEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ — PRO- �i POLICY❑JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT $ ��AUTOMOBILE LIABILITY I I Ea accident $ I 'ANY AUTO BODILY INJURY(Pei person) 4 ' ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PRO acci PER DAMAGE $ HIRED AUTOS AUTOS { Per dent UMBRELLA LIAR TO CC UR AT. EACH OCCURRENCE $ EXCESS UAB LAIMS-MADE N/A„ AGGREGATE $ _ DED F I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBER EXCLUDED? I WA WA WA AWC40070081132017A 05/21/2017 05/21/2018 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Y yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 i N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/Workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Yarmouth 1146 Route 28 AUTHORIZED REPRESENTATIVE !" .f, South Yarmouth MA 02664 L "A: � Daniel M.Crotwr y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD r .'a&E suspect nabbed while shaving... Hyannis News Page 1 of 5 �1 r , Hnnis News t. Your Life, Your Liberty, Your Pursuit of Happiness B&E suspect nabbed while shaving. . . Rd ~a i hi 4 I 0 Hyannis Shortly after 2pm a man came home to an unwelcomed guest inside his house... ... he chased him off and called police. http://hyannisnews.com/?p=5397 11/25/2013 ,_,;§&E suspect nabbed while shaving... I Hyannis News Page 2 of 5 A description was put out as multiple Barnstable police units responded to the area of Fernwood Ave and began searching the surrounding streets. Nearby, an alert police detail officer noticed the suspect fleeing on a bike... ... another police detail officer also ran over to assist. (Despite criticism, police details do often assist on-duty officers... but that's another topic for another day) A manhunt developed as officers converged on the area... Patrolman "Gino" Desruisseaux had a hunch and questioned a nearby landscaping crew... ... Desruisseaux's hunch paid off as multiple officers, including a detail officer in his private vehicle, zeroed in on an address on Orrs Ave, several blocks away from the initial scene on Fernwood Ave. As officers confronted the individual in the top photo he was busy shaving... perhaps attempting to alter his appearance... perhaps just cleaning himself up for the mugshot. Regardless, the suspect police were searching for originally had some facial hair... ... police weren't fooled. Officer Brian Morrison drove the victim over to identify the suspect. An arrest was made based on evidence connecting the suspect back to the Breaking and Entering on Fernwood Ave... However, police weren't quite finished yet. While police were busy pursuing the now cleanly shaven B&E suspect, other officers discovered a recent B&E nearby on Oak Hill Avenue... Coincidence? Police don't think so... For nearly two hours crime scene investigators were busy at both scenes, Fernwood Ave and Oak Hill Ave... The suspect under arrest in the above photo is the lead suspect in both B&Es... and quite possibly other local crimes as well. Police were still working on the report while this was being written... http://hyannisnews.com/?p=5397 11/25/2013 TOWN OFBARNSTABLE BUILDING PERMIT_APPLICATION Map g y Parcel' 96 Application # �� Health Division Date Issued 'V Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis r Project Street.Address Village 0.ylWlS v � /n�Owner _ t U-YVI,na Cat_I,Wi azn Address `t6 (,jm c �e Telephone Permit Request 1?00F g'Ec-tio�t,►s� S�.DEw�ze. , 13Eci ip aYx (� ` �3u 9e.�r F4 r/aN G— C 1Yi.�C--Ci J+CC�dK 01Jf4Z On) 15 1* 'r N& I"::'-9U A/h 47/0A.) . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings;Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq. Cn Number of Baths: Full: existing new Half: existing new , < cry Number of Bedrooms: existing _new , _?71 Total Room Count (not including baths): existing new First Floor Room Count W Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑Other .c Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1r) Arlm +Telephone Number Y. Address qS � ���IJ k License # - 5 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY AR;PLICATION# DATE ISSUED ' MAP/PARCEL NO. ADDRESS F VILLAGE r OWNER ' DATE OF INSPECTION: FOUNDATION 1 ' FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING h DATE CLOSED OUT ASSOCIATION.PLAN NO. L4 'F W N h �-( cz) _ 'I El n n ° ty Gbh vEE rn 7 0 � ° n 8 �� �. y r r o - � o n tJ ro C r* a tp v � n 1� o nv o o CDP- o n rc CD m o rr o n O r o < 7 n CD ZX ° y ° El ElC CID �l O n, _^ Yi. o ci 0 o O Cl n ET' r0`_i P° w 0 Q-.` yticwt c� C7, C) tom, - F' Y n 0-VQ p Di �.� r�7 O H i..l O n 1 fi C7 -ni `� *.7• I •i S G• 'cJ c� �°J v q- P'r n (�- 6q p i. no P-. O oo 0 n '' �n n o ,p ry s� n O C➢ CT7 Ffi Cv R, ,� �, ,- 411 � n �• Fes` R, � p r,- �, cu � r O ,n l7 Vl 4-t C CY. R ° lC VJ -1 Fj-, 10 CV ILI It10 ° c ° o P, ti b+ O U7 J El LJ 0 El L�J I� � CP G o p d ca o o n o. O a Q R o• PO O n 0 O m d Massachusetts General Laws chapter I�)rcquucs a_u empiuycrs iupiuYJUI YYULJ��. ✓ Pursuant to this ,tatutc, an err'PCOyee is defined as "...every person in the serYicc of another under any contract of hire cxpress or implied, oral or written_" An employer is dcd=d as "an u?dlndu4 partacrship, association, corporation or other legal entity, or any two or Marc Of the foregoing cagagcd in a joint cntcrprisc, 'and including the legal representatives of a dcccascd c aploycr, or the ceeciver oz trustee of an individual,paitnerSEP, association or other legal entity, employing emPloyees. 13owevcr the owner of a dwelling house having not more thin three apartments and who resides thcrcin, or the occupant of the IWcUiag laousc of.a.notbcr who employs persons to do maintenance, construction or repair Work❑n such dwelling house ar on th.c grounds or building appurtenant tbcrcto shall not bccaust of such employment be dccmcd to be an employer." vIGL chapter 152, §25C(6) also states that "every sLate: or local licensing agency shall withhold the issuance or ,r.UC ;;I of a license or permii to operate a business or to construct buildings in the c0rzLwouIvea_1th for any applicant who bas notprodueed"acceptable cvidmce of compliance with the.insurance coverage required." �dditio.,, ly, MGL ohapter 152, §25C(7) states `Neither dsc commonwealth nor any of its polikical subdivisions shall cater iatD any contTa-ct for.thc performancc of public work until acccpt�lc evidence of couq�lizncc�xth the m`�naT�cc equiremcnts' of this chapter have bmnprescatcd to the contracting authority." ,.pplicants lease fill oixt the wozkcrs' conxpensation afCdavif CDMPlctcly, by checking the boxes that apply to.your situation and, i# ccessazy, supply s ib--�oriizaetor(s)name(s), address(cs) and pbouc n'umber(s) along with their certL5c;&tc(s) of uriranec. Limitz<d Liability Companics.(LLC) or Limited Liability Partocrships (LLP)with no employece other than the Lcmbcrs or partum., arc not rcq=cd to carry worker-s' compensation inscrrancc. If an LLC or) LP does have Dployces, a po)iry is rcquircd. Dc advised that thu amdrrvit may be submitted to the DcparLmcnt of Industrial ceidcats for cou5rmztioa of.iwuzancc covcrago. Also be sure to sign and date the Lf5daviL The aEcdiv;it should returned to the city or timm that the application for the perz¢it or license is bring requested, not tho Dcpaxtment of AuRb al Aeci.dcats. Should you havc any qun&-lions regarding the law or if you are rcquixeri to obdrin a workLrs' ,zxzpensa.tion policy, plcaso call the Dcpartmcni a.t:the nurgber listed below. SeJ1 insuzed companies should enter their Jf banirJnGa liccmo number on the appmpraatc line. j ity or Tow-P Ofcisils cast be sure that tho affidavit is complete juad printed]cgibly, The Dcpafto Grit has provided a space at the bottom fficaffidavit vat for yov to fill out in the cvcat l:Zi.e Office of)uvcs tigations ha`t to coatnct you rcgarding i.hc applicant caso be sU.rc to 511 in the perms/hcensC rm ni, bcr which will be LLScd U a reference nuznbcr.. In addition, s applicant it roust submit nTLatiplc pczmM ccnsc applications in o-oy given.year, nocd only submit oap a$dl+vit indicating cu�cnt lacy inforxnat ou(if necessary) and under:"Job Sit,Address" the applicant should writ "all TDGatiDnS in (city or *m),"A ctrpyoftbe affidavit that has been.officially starupcd or marked by the city or town may be provided to the plicant as proof that a valid affic avit is on 51c for future permits or licenses. A pew a$tda� ,mistbe filled out each ir.Whcrc a home owner or citizen is obtaining El J_iccnsc or.permif not related to any business or conrmcrcial venture a dog Eceosc orpcuoit to birrn leaves ctc.).said person is NOT reguucd to eomplctx this aflxdavaL o Office of Investigations would LIcc to tha..nl,:you in advan.cc for your cooperatim and should you havc any qucsLiow, asp do nothcsitn.te to give us a call Dcpartmmt's address, telephone"and fax uumbcr T o, C6mmmwQ l.th of Ma sAchusct Doplutm.eat of Industiat1 Ac-cid�nts ©face at'T��es{��atons 6DO 'Washiugtan Street Bos'tcm, MA 02111 Tel. # 617-727-4300 ext 406 ar 1-S77-MASSAF'E Fax # 617-727-7749 11-22-06 �wur.m asS.go��/di a YHe own of Barnstable of rp� 'd Regulatory Services Thomas F. Geiler, Director sAFwsrAmx. 1679. Building Division �� AT�DIa Tom ferry,Building Comnussioner 200 Main Street, Hyannis, MA 02601 ))-mY,town,barnstable.ma.us Office: 508-862-4038 Fax: 5.08-790-6230 x0)jtOWn1ETz LICENSE EXEMPTION Please Print DATE:_ U 10B LOCATION: �L/2!T/GCiBNlS number ,.n /sstr`eeett village "HOMEOWNER":--- � V "t/`--_ 1�.( Y!l(�y s0 work hoot# name home phone# ,• P CURRENT MAILING AllDRESS: GC9 f�ry,yl city/town -t---- sate �— 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, rp ovided that the owner acts as supervisor. DEFINITION OF FI011�EOWNER 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 or detached structures accessory to such use and/or faun 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 'ihe 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 be/she understands the Town of Barnstable Building Department rniztimum inspection procedures and requirements and that he/she will comply with said procedures and req i ements, SignaCinrc Homeowner V` Approval of Building Official Note: Threc-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 homcowncr perforating work for which a building permit is required shall be exempt from the provisions of this section(Section lo9.i I -bci -nsing of construction Supervisors);provided that if thc homeowner engages a pc son(s)for hire to dosuch work, that such Homeowner shall act as supervisor." Many homeowners who use this exemption arc unaware That they arc assuming the responsibilities of a supervisor(see Appendix Q, Rules &Regulations for Licensing Construction Supervisors,Section 2,15) Ibis 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 Aith a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communiucs 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 cuT en tly used by several towns. You may Carr t amend and adopt such a forn/crrtification for use in your community. . o¢VEt Town of Barnstable Regulatory Services STAaz�, Thomas I', Geiler, Director -v hrAss. � Eo Building Division Tom .Perry, l3ixilding Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4-038 Fax: 508-790-6230 Pfoperty Owner Must Complete at-.d Sign This Section If Using A Buiidet Z Owner of the subject properly hereby authorize _ to act on my behalf, in.all.inatters relative to work authorized by s build pttn-,it application for: OfjOj s� SiLmature of Owner Date Print Naze If Property Owner is applying for permit please complete the Homeowxiers License Exemption Foixn on tEc reverse side. Town of Barnstable *Permit# 76 cA i Expires 6 months from issue date ll Regulatory Services Fee C�CJ Thomas F.Geiler,Director Building Division Tom 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 28`?-Q/ Property Address rCQ �f��N - S ><tesidential Value of Work �� _ Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address V o �iUst¢ �iY /9-f �f�/ Lo Contractor's Name ----It)/ Telephone Number �6 Ii' lrl!— 7701 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor X-PRESS PERMIT I am the Homeowner ❑ I have Worker's Compensation Insurance AUG 21 2007 Insurance Company Name Tr.W N nr_- B A R NSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders. U-Value `- (max1tium:44).:. /fNV'1`1_ i�i'rSSte!C 'Where required: issuance of this permit does not exempt'com�ryancr with other town department regulations,i.e.Historic,Conservation,etc. 5 i . !," ' '1,1p C. P,1` z ***Note: Property Owner must sign Propel t Owner Letter of P0. ii sion. copy of the Home Imovement ;pr oniraetm License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 s ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance.Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: �7 - City/State/Zip: �4� <S . 41� Phone.#: rJO�-�?J�- 770 / Are you an employer? Check the appropriate bog: Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I . employees (full and/or part-time).* have hired the stab-contractors 6. El New construction . 2.❑ I am a'sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' co insurance.$' 9. Building addition [No workers comp.insurance �• ' e uired. 5. We are a corporation and ❑its 10. Electrical repairs or additions officers have exercised their '3. aq ]m a homeowner doing all work 11.❑Plumbing repairs or additions + right df exemption per MGL myself [No workers camp. lion P p 12.0 Roof repairs insurance required.]t c, 152, §1(4),and we have no employees. [No workers' 13.❑ 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. $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 worker'comp.policy number. lam 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.#: 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/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do he u r Wpains, nd penalties ofperjury that the information provided above is true and correct Si ature: Date: pv v _ Phone#: Official use only. Do not write in this area,tb be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Informnation and Instructions L Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two.or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee-of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the' dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." McjL 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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'The affidavit should be returned to the city or town that the application for the-permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workeis' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insmange'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 number which will be used as a reference number. In addition,an applicant e t/license numb P Please be sure,to fill in the p rmi cense applications in an ear,need onlysubmit one affidavit indicating current that must submit multiple permit/license pp y given gi y . policy information(if necessary) and under"Job Site Address"the applicant should wiite"all-locations in (city-or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves-etc.)said person is NOT required to complete this affidavit. .T11e Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number:: The Commonwealth of Massachusetts Department.of Industrial Acoideuts Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617-727-7749 Revised 11-22,06 www.mass.gov/dia I I __ oF1HE r Town of Barnstable Regulatory Services cgs rsres , : Thomas F. Geiler,Director pr i6 9 A��� Building Division Foy Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: :;-)( /©� JOB LOCATION: U &M(')tJ(-)6 o� number RrreetQ —7 village /1 "HOMEOWNER": IA"vva- (/�v�t � l �� JyJ�U name home phone N work phone# CURRENT MAILING ADDRESS: r�(/�1,--)C)0 �IJ/I n� l+`-� V 1 69y/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws, rules and regulations. The 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 r it ents. � Sig ature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109,1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. �-� Town of Barnstable *Permit# 5 Expires 6 months from issue date snnrtsrne�, g �' Re ulato Services Fee • KAM i639. �� Thomas F.Geiler,Director Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 0260lw � Office: 508-862-4038 �`o� qy� Fax. 508-790-6230 �v �0 EXPRESS PERNUT APPLICATION eq Dy Not Valid without Red X-Press Imprint Map/parcel Number Property Address v &-Otv1UD d C7✓e- A jo K)/11 aResidential OR ❑Commercial Value of Work w- Owner's Name&Address (Y1Q5 l O�Qr/Y1GL i(1(, rG�( ( � a✓1 'G� /lLck�ic� Ave, 14-4 C!l n l C Contractor's Name�'�I l ttt:l1l _—r/VI D Q.aSl1T Telephone Number L ( Home Improvement Contractor License#(if applicable) 4t 100 7 q U Construction Supervisor's License#(if applicable) C 5 0`7 d-]q F�Workman's Compensation Insurance Check one: I am a sole proprietor Larn the Homeowner I have Worker's Compensation Insurance Insurance Company Name a_)e,l C NY 9-c i C a n Workman's Comp.Policy# (_ C 3 I - o? -7- Cl Yl- 0 0 Permit Request(check box) Re-roof(stripping old shingles) Re-roof(not stripping. Going over existing layers of roof) , Re-side replacement Windows. U-Value (maximum.44) Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc- Signature L_&121�1� LZ &Aexpmtrg V• CAPIZZI HOME IMPROVEM ENT INC. SPECIFICATIONS AND ESTIMATES PAGE 1 OF 3 _'z pBU. aV� l�Io� CAPIZZI HOME IMPROVEMENT Established 1976 , Serving the Cape for 24 Years PROPOSAL 1645 Newtown Road Cotuit , MA 02635 508-428-9518 1-800-262-5060 Fax 508-428-1547 I Date: � //l0o ( Name: ((A 4 Jo Address : b Address: �� f-e� w M.00a 4 1/ City: i Town: l� YGihrj:� Home Phone: Other Phone: �77;_ 7 70 / -7 76 - 7 J75 Estimator: Job No. We hereby submit specifications and estimates to furnish and install �3 solid vinyl white replacement windows with 7/8" insulated glass , 1/2 screens , using the Harvey Tech 2000 welded sash window. Double hung - Picture unit Single casement - Double casement Triple casement - 2-lite glider 3-lite glider LABOR & MATERIALS $ �6 f 3 a. OR same as above except using the Harvey Classic vinyl replacement window. LABOR & MATERIALS $ [r— b. OR same as above except using the 7/8" Thermopane Slimline replacement window. LABOR & MATERIALS $ OPTIONS : a. Low E glass b. Low E & argon gas $ C. Trim coverage on same exterior sills & casings 6�G�� $ �aa n d. Colonial grilles f"ne $ �aaa c No touch-up painting included. w TTe4s,r T ._inc 2 O ff rho 1 Qf`'1 p y e ' L� DC Some touch-up may be required on interior and Cx/"teErior casings . In some cases window shades and curtains do not fit after new windows are installed and customer may need to purchase appropriate size. ACCEPTED BY THIS PAGE IS 4PRT OF AND IN CONFORMANCE WITHDPROP#Ag— / TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION- Map Parcel Permit# K Health Division ti Date Issuedgt.;d Conservation Division' Fee �� Tax Collector -7 1 (� TreasurerCS Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis ; Project Street Address ` ' Village �S ` Owner Address _.5cGyh f Telephone a Permit Request 1'1.31 c �G�� Ut�s l/L � /aL, /il/�UE+�� • Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 71•aD Zoning District` Flood Plain Groundwater Overlay Construction Type LA Size Grandfathered: O Yes W*6,If yes, attach supporting documentation. Dwelling Type: Single Family Two Family Cl Multi-Family(#units) ' Age of Existing Structure Historic House: ❑Yes 0 On Old King's Highway: ❑Yes 2110 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 U If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Qelephone Number ��''Ql Address AL License# _ d 2-7 � y 3_5 Home Improvement Contractor# Worker's Compensation# GJ /0 st ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE _ -7 ZZ Zl�� _ r 3 -FOR OFFICIAL USE ONLY - 1 tWIT NO. ' DATE ISSUED ° � MAP/PARCEL NO. ADDRESS .: VILLAGE OWNER : `` = I , . _ • _• ` r _ t _ ,' - '.,fir _ -, ------------- 6 DATE OF INSPECTION FOUNDATION r� FRAME ■ • i � . ..- f ; ' e e a i 1- • � - .. «. III - INSULATION _ t FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL. GAS: ROUGH FINAL r ; � FINAL BUILDING• •_ '�' .' _ ''.' � 1 .-. r •' • •4• j' . ,t DATE CLOD OUT , ASSOCIATION PLAN NO. 4 :-- -:— The Commonwealth of Massachusetts Department of Industrial Accidents 01frce atlnyestigatinns lid 600 Washington Street Boston,Mass. 02111 Workers' Comiensation Insurance davit ZOMM name: location: city hone# 7S�—2241 ❑ I am a hon6bwnier performfng all work myself. ❑ 1 am a sole orovrietor and have no one working in any ca achy %/ %%/%/ /%% %%%/%/////%%//%/%%%%/%%%%%%%%%%/%%%%%%%%%%%/%/%%%%%%%%%%%%%%%%/%//////%/.:',� (JQ I am an employer providing workers' compensation for my employees working on this job. comonnv name: Nplu_ , HSwE =*vl&Vir—INJ91ALr llo l�lt*ly�is��A/ address: # city 0 n,(/ )' bdL 3S phone.. insurance co. {�,?)� Cftlld r;e�f+�-S noiiev# tic ///////w/m/m/m/m///////////i////////%//////////i%//////////%///,1--1//////////////%//////%///////////%////////%///// ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the follo«ing workers' compensation polices: company name• . .. ....... .:...... address: city: phone#- insarnnce co. ohcv# comnanv name- ....:.......... address: phone#r ....:.:... insurance co. olii v# ..... ......... . / / %// Failure to secure coverage as required under Section 15A of MGL M can lead to the imposition of criminal penalties of a ane up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the 0111ce of Investigations of the DIA for coverage verification. I do hereby certify render the pains anddppen/allies perjury that the information provided above it tru and earreeY Sigmturee-�—' G/ d — Date C r� Print name rg eb cgi eK It. R A S C H IZ F0A- f Phone# -'/eJ g' /s 1 S Ccontactperson: use only do not write in this area to be completed by city or town official own: permitilicense q ❑Building Department ❑Licensing Board 'ifimmediate response is required ❑Selectmen's OtSce ❑Health Department phone#; ❑Other (Mmud*95 PIA) The Town of Barnstable BARNSTABLL 9�A Department of Health Safety and Environmental Services rE r Building Division n Ma. g 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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. 'q )Type of Work: 8 , 317- 0 W ��®�' Estimated Cos Address of Work: Owner's Name: y Date of Application: ? ✓ �g —�� I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law []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 permit as the agent of the owner: 106 Date Contractor Name �O2 G�APiLZi jbmE X,tegistration No OR Date — Owner's Name q:forms:Affidav om „ ivaelld 1 t ` MOMS`IMPROVEMENT -- n 'r.r GJ�ie P �na � �'` Re9."- %a.tI., CONTRACTOR' + TYPe 100740 ' j BOARD OF B.UILDING''REfaUL,ATIONS , t. PRIVATE CORPORA TI' 7"`� License CQNSTRUCTIQN SUPERVISOR Expirat DN ion 06/23/00 ,�,�,5 lii Number CS 057032 j CAP IZZI HOME:IMP r Tr:,no, 5742' RO NE ,a, t ; �-v��-�- as VE NT,1;iNC �k� ,° {� ` EzPir@s ;Q9/26l�p01 z, , 1�,, ADMINISTRATOR 1o`fJ Wt0 Reg�tricte +TO::-UO ,I Ne COCU1t MA 02b35 : { THOMAS X CAPIZI JR (.i x +;` I 280 FERCIVAL DR 4'a W BARNSTABLE, MA 02668 Adml�istrator 1; Ii ;7 92 Co!`arrv�noiuueci z;a� ,l/l�aveac�i�ute�ld 1+ DEP,RRTNENT 6f POBIIC SAFETY' �r DEPARTMENT OF'PUBaIC Sfi.FETY 7<: ONSTRUTION SUPERVISOR LICENSE C •, �k r CONSTRUCTION SUPERVISOR LICENSE Number Ezpir:es @@ Restricted l� � � ', �,roM►'�!S':►�'!°,'.� S�ONA��=O'Aglr,�r FREDERIE V RgSCH III 1@60 BOURNE:RO s COTUIT; NA 02635 PLYMOUTH, NA @2360 I Town of Barnstable emit: Regulatory Services ate: Thomas F.Geiler,Director �� 41 MAS& : Building Division Fee: 039.p�� Tom Perry, Building Commissioner 'RaD� `/ p 7 1�p 200 Main Street, Hyannis,MA 02601 `� D www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: J �1viez� Q'e-Llati Qv1 Phone: Install at: qY re wrn _Village: CeYt✓l 15 Map/Parcel: o��Fcl 0 q('0 Date: l o/ Z 7/C) � Stove A. ew Used B. Type: adiant/Circulating C. Manufacturer: /`-/6jfw7-k"-S7.0A Lab.No. D. Model No.: 4ev-1 ; Chimney a A. New/Existing (If existing,.please note date of last cleaning)B. Flue Size ` C. Are other appliances attached to Flue? IJ D. Pre-fab Type and Manufacturer E. Masonry: /ti t; Lined/Unlined Hearth A. Materials: r 6 o r —rl l&-.. - -7,Wc_Q-1 CCkV1 B. Sub Floor Construction: e- vA.c re•--C- Installer Name-.- Address: Phone: 76 Location of Installation: APPROVED BY: R�— Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 122801