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HomeMy WebLinkAbout0120 HARBOR BLUFFS ROAD '�I i Town of Barnstable *Permit Building Department Services Expires 6moPeefromismedoe NAB& « Brian Florence,CBO Fee 1 ' Building Commissioner o * � 61 '0a Mxt" 200 Main Street,Hyannis,MA 0 I www.town.barnstable.ma.us Office: 508-862-4038 NOV 2.0 2u.,ax: 508-790-6230 TOWN O. bAMS1ABD EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address Ido L jAL ) t' b l l oIJ esidential Value of Work$ /0/d u u Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Ro IQ Telephone Number Sa if '7 16 rj'73a Home Improvement Contractor License#(if applicable) Email: 1-ol C• CvA 4D Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner (� I have Worker's Compensation Insurance Insurance Company Name 1, 'V vl k/► A FYI CA Workman's Comp.Policy# wC C- 5 f3 O�V 1-7 y SZ- Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value ' (maximum.32)#of windows 7 #of doors: J *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 r quired. SIGNATURE: - QAWPFILESIFORN[Mbuilding permit forms\EXPRESS.doc 08/16/17 3lie Commomveai'th of Massachusetts Department ofrudwtzialAccidm& - Office ofhnrwtigations y : 600 Washington,S`tmet _ Boston,MA 02111 mmumamgm1dia Workers' Campensaf lanInsurance Affidavit BuildersICantractor&TlecEr cianslPlumhers Ap t Information Please Print 1.egl�tlY Name aaaQatiti4a/Fnciiv nai}= 11 Ct l(�frl S�Y U C�1t ��vr-� CityrSta,WZip: `7 Z` -ci 5 3 Are you an employer?Check the appropriate box: ' Type of project{rewired}- emP YU 4. I am a contractor and I 6_ ❑I+Ie cx:ns[raiciion I_ I am a to 'With ❑ t� employees(fall.a€�dfor timed* have hired.the sob-coatF.at� 2.❑ I am a sale proprietor orpaituae- listed onthe attached sheet 7. ❑Remodeling ship and have no-employees These sub-contractors have 8., Demolition �P. � atidhavewo�s' ❑ wading for me in any capacity. employees 9. ❑Building addition [No workers'camp.insurance camp_msuranmi required-] 5_ ❑ We are a corpomtion and its 10'.❑Electrical repairs or additions of�wAxs have examised dair 3.❑ I am a homeotivner doing all work 1 L❑Plumbing repairs or additions myself[No workers'oomp rigbt of exemption per MGL 12.❑Roof repairs. i zur nce required-]F c.152,§1(4h andwe have no exrployees.(No vtorJess' 13.❑Other cow-insurance required-] •Anya;9Hcaut&atcbetcsbos9lems#also fiIlrnrt the sKionbelaw showing ibeirmdcerecompenmdonparkyinfamt2 i= I Homem mess who submit dos affidngl inTcadag they axe chin;all wat and,ffim brie autd&conhxctms—st submit anew affida'a indicating sudJL fConttactgm ff t cbea this boot nest attached sa additi— sheet slwdng the name of 19ie m&-comas nail state whether or not(hose entities hzee employees.If The snb-caatractoeshaceemplayee%they mustpmvuUtheir tisark—'comp.policynumber- lam an eiizployerfliatisprnid&gwarkers"conqmmad47iiinniratzceforiufejtrplolces. $e1ovv is flteptri<icy a d jab site infomatiom Insurance CompanyNatne: h�v� 'Policy 4 or Self-ins-Lin-4 VJ"50 0!(0 Q1/(L Expiration Date: q10 Z-bw f- n Job Site Addresw _iJ-t0 L tf ��f l'� CitgfStaW2l p: Attach a cop} of the workers'compensationpolicp 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 fide up to$1,50D OD andf'or one-year imprisonment as Buell as cif pena%es.in the faun 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 Iuvesrdgations of'1he DIA for insurance coverage verfficatism I do h. ruder the paints and periaMer o fpatury fhatthe info rwad=prvP 'dabm a is bare amid correct Si Date- l'Z t! -,)-Jb 7 Phone i€ tl,Q'Md use anly Do not write in ddis area,tar be completed by city ar tomn o ffr" City or Town: PermitMicense A Issuing Antharity(circle one): L Board of Health Z.Building Department 3.Citp Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 laformatiou and Tnstrxctions Massachusetts G emeral Laves chaps=152 regamw all emplaym-S to provide woaeas'compensation fur their employees. FM-Saw this atafe,an.ernplvyee is defined as."_.every person in the service of another under any contract ofhire, express or jmphed,oral or�erifiun." An e"pkyer is defined as"an individual,partnership,association,corporation or other legal entiy,or any two or more of the foregoing engaged is a joint enterprise,and including the legal represer atives of a deceased employer,or the receim 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 apaitments and vvho resides therein,or the occupant oftha dwmMagc house of another who employs persons fn do mafitman ce,construction or repay work on such dwelling house or on the grounds or building appmttnait thmrAD shall not bmanse of such employment be deemed to be an employer." MOL chapter 152,§25C(6)also stew 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 comm arrwealth for any. applicant who has not produced acceptable evidence of cdmpliance with the hmm ance coverage required-" Additionally,MOL chapter 152,§25C( )states'Neither the coffinanwealth nor ray of its political subdivisions shall enter into any contract for the performance ofpnblic work until ac u ptable evidence of compliance with the inmuance._ regL�m eats of this chspt cr have item presented to the enter�authoz ity." : Applicants Please fill out the wo&s'compensation affidavit completely,by chwldng the boxes that apply to your situation and,if necessary,supply sub-confractor(s)name(s), address(es)and phone Tnr- er(s)along with their=tifica te(s)of insurance. Limited Liability Compames(LLC)or Limited Liability Partnerships(LI.P)with no employees other.than the membms or partaeas,are not required to eauy woikms'compensation ice. If an LTC or 112 does have employees,a policy is regnired. Be advised that this affidayitmaybe submitted to the Department of Indusfiial Accidents for continuation of insm-anm coverage. Also be sure to sign and date the affidavit: The affidavit should be-retinned to the city or town thatthe application for the permit or license is being requested,not the Department of Leh,. a Accid�is. Shouldyon have any questions regarding file law or ffyon are requfird to obtain a workers' compensation policy,Please call the Departmezit at the number listed below. Self-insured companies should enter their self-fi su ce license number cm fhe appmpr iefn line. City or Town Officials r _ Please be sure that the affidavit is complete:and primed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Iuvestigations has to cord-act you regarding the applicant Please be sine to fill in the penmitMcense mumbes which will be used as a reference number: In addition,an.applicant that must submit i ai iple peanitllicense applications is any given year,need only submit one affidavit in catia cuirm t policv i afb=ation(if•necessaiy)and under`Job Site Addmse the applicant should write,"all locations in (city or town)."A copy of the•atedavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for fntnre'pcm#s or licenses A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or pea nk not related to any bu rims or commercial venture (Le. a dog license or permit to bum leaves etc.)said person.is NOT reqaired to complete this affidavit The Of of kvtSfigatiOnS would like to th— you m advance for your cooperation and should you have any questions, please do not hesitate to give rrs a call. The Department's address,telephone and fax number. 'I�Le Coate �Wmjft of MassachuseM �. DeparEm�afla&isftzakAooident� _ Office of lnve&g do-pti 6w WaWMzG, s c E�IIF . Tf,-L 4 617-727-4900 cxt4€6err14R-MAMAC Fax 4 617'27'749 Revised 4-24-07 WwW gog/dia 1 1 Town of Barnstable Building Department Services i R�p1N?P1Ri ,Y i ' Brian Florence,CBO 63¢ ►`� Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us . j Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I E / �-- ,as Owner of the subject property hereby authorize�VOIL ( to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner SigTatulre of Applicant 1 Print Name �' Print Name Date QTORMS:OWNERPERMISSIONPOOIS Rev:08/16/17 Town of Barnstable Building Department Services Brian Florence,CBO _ k Building Commissioner 200 Main Street,,Hyannis,MA 02601 _, , K"L �, www.town.barnstable.ma.us a Office: 508-862-4038f . P Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# i work phone# CURRENT MAILING ADDRESS: . �a • city/umn state zip lode 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 4 e a el of land on which he/she resides or intends reside, n which there P rson s who owns arc to r o w ere is•.or is intended to be a one or () P �, 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 buildingnermit. (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 E 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 "a , 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 areassuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often t; 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. F To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. QAWPFII.ES\FORMS\building permit forms\MRESS.aoc r 08/16/17 { ESTIMATE Rolfe Construction Inc 4 16)1 Eileen 141 Bog Rd Marstonsmills, Ma 02648 Phone: (508) 776-9932 Estimate # 000026 Email: rolfe.construction@comcast.net Date 09/27/2017 Description Quantity Windows 1.0 Replace three large windows in front and remove over hang anderson 400 series azeck trim exterior new interior one picture unit 2 double hung Replace kitchen window over sink casement anderson also replace trim exterior azeck new interior Replace two anderson double hung in living area 400 series anderson exterior trim azeck new interior-also remove over hang Replace side door new fiber classic door 9 light Remove replace peice of baseboard in bedroom Permit fee 125.00 Material cost 5200.00 Paint labor 1175.00 Carpentry labor 4160.00 Subtotal $10,660.00 Total $10,660.00 Notes: The three front windows are not exactly same size a few inches smaller due to not having those existing sizes available any longer can have made but cost is through the roof will look the same . Paint labor can be done by others if you choose Thanks Mike Rolfe Mike Rolfe Eileen Page 1 of 1 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 policyges)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, 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 Neu of such endorseme s. PRODUCER License#1780862 AW.m nee.certificates@hubinternationai.com HUB International New England PNo :( )945-0446 FAX :508 945-9136 265 Orleans Road North Chatham,MA 02650 INSURERS AFFORDING COVERAGE NAiC i INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER 8:Associated Industries of Msssaehusetts Mutual klonm a Cm"a°33758 Rolfe Construction Inc. INSURER C 141 Bog Road INSURER D: Marston Mills,MA 02648 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 CLAIMSa1AADE OCCUR S22g2$30 04103/2017 04/0=18 DAMAGE TO RENTED 100,000 MEDEXP(Any am 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 2,OW,WO X POLICY❑jECT El LOC PRODUCTS-COMP/OP AGG 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO BODILY INJURY Per n $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY BODILY INJURY Per accident $ AUTOS ONLY AUTO ONLY PROP AMAGE $ UMBRELLA LJAB d OCCUR EACH OCCURRENCE EXCESS UAS CLAIMS-MADE AGGREGATE DED I I RETENTION$ $ B WORKERS COMPENSATION PERTUT, OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N WCC5005017452 0HIO2R017 OSN2/2016 TA ER E.L.EACH ACCIDENT $ 500,000 QFFICE 19%w EXCLUDED? N N/A l� EL DISEASE-EA EMPLOYE � 00 0,0 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 1M,Additional Remarks Sctwdule,may be attached it more Is required) Certificate holder is listed as Additional Insured for General Liability when required by written centrac CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Brewster THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN. ACCORDANCE WITH THE POLICY PROVISIONS. 2198 Main Stred Brewster,MA 02631 AUTHORIZED REPRESENTATIVE ACORD 2S(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved.. The ACORD name and logo are registered marks of ACORD Llcen'se: CS-MB55 r s s t ' ,Construction Supervisor ; Y, TMtBaEtto ,aaHuntBERx n s 05 08 14 N9NE; S58200354 MICHAEL ROLFE f ` t t mm 3 ooe � f I BOG ROAo i. °tea , O,A� 9-2. » '04�29197'1 P, . � f� MARSTONS MILLS MA 02648 - ' # - , '" +ssFx M` t6GT S f0 t' q �AS�J� NE AVIOR 4f8aGROAD. LL�� MARSTONS MILLS MA 92648 p Expfratgan, w, sr •� r _ v F„i c ,; �; z 0a12912018 i rr �1 ;s 000s rse osiotevor tsm1 o9 Commissioner i. Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 , Home ImprovemenCGontractor Registration Type: Corporation ^+ — Z Registration: 128174 Rolfe Construction Inc M r Expiration: 03/04/2019 141 Bog Rd. a Marstons Mills, MA 02648 l�. c f q SIB - Update Address and return card. Mark reason for change. SCA 1 t'i 20M-05/11 r— a n �u.t.tece•ern office of Consumer Affairs&Business Regulation; HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: 1 Office of Consumer Affairs and Business Regulation Reotstration Ex i ion 10 Park Plaza-Suite 5170 i1_-28_471 03/04/2019 Boston,MA 02116 Rolfe Constructidn_lnca , MICHAEL --- 141.Bog Rd '-W; r i Marston Mills,MA`02648;?` Undersecretary Not valid without signature -iovM01barnstawe M Building Department Complafi4nquiry Report Date: �j - Rec'd br. ?L:= Assessor's No.;�'�vr/O a Complaint Name: Location �a G Address: -.. lie Originator Naine• Sheet: State: Zap: Telephone: D/E Complaint . Description: wz ZZ- . 1(2 1�1 lilGLL Inquiry Dcscripdon: For Office Use Only Inspcctor's Action/Commcnts Date: Inspector. / Follow-up / Action Additional Info. Attached Engineering Dept. (3rd floor) Map `� c� � Parcel I(} � � Permit# �7 _ House# Date Iss ed P� S 3rd floor) 15 --9:30/1:00-4:30 SGj r--JJ Fee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) cif 4-,-, Planning Dept.(1st floor/School Admin. Bldg.) THE►q;_ Defi ' lan Approved by Planning Board 19 RE.;` . TOWN OF BARNSTABLE Building Permit Application 4Projiectre�t Address l oA,_C7 LOT- Village . ' Y�71✓�/S Owner /f�. ,L/j�� Address _if �ir3s�/ot1 �i,�t✓iJ�/r?v'� Telephone ;2,47- 4242 G/7 _Z 2 f G 9�' Permit Request /c*`1-7Z'11,4, 0� / , !0,612g4 / First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family �^ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes IUo ` On Old King's Highway ❑Yes 91 o 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 No. 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 'No If yes, site plan review# Current Use Proposed Use Builder Information Name.�i C�;,�' / ?�/ Telephone Number— A/d�dress«����y(�p �✓ fl d-z-Z41- License# A6'D32 ZZ/ ��`�7E,�yy��i,�a�/�1sr�Pl" Home Improvement Contractor# 1207f D Worker's Compensation# Q�,Al" lg / NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. v y DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 'd-� ✓f22 lJ �/�'GCZQGGUC��'I,QP.�6 I f a XOME IMPROVEMENT CONTRACTORS REGISTRATION �. % Board of Building Regulations and Standards ,•One Ashburton Place - Room 1301 :Boston, Massachusetts 02106 - I • I _ H0ME IMPROVEMENT CONTRACTOR L--------------------------- -- P.es:stration 100740 Expiration 06/23/98 Type — PRIVATE CORPORATION HOME IMPROYEMEXT CONTRACTOR F Y Rellst-,ation 100740 CAPIZZI HOME IMPROVEMENT., INC. I — j Type - PRIYATE COR?ORAT:ON Thomas Capizzi , Sr . Expiration 0b/Z3/48 1645 Newton Rd . I Cotult MA 02635 CAPIZZI HOME IMPROVEMENT, INC I� Thaws Capiz_i, Sr. Helton Rd. ACNUMs'R"i0R Cotult MA OZb3E i�'� i DEPARTMENT 4 _ ONE A314GUR DOSTUN of 'kUG_g0,N-.SUPERVISOR LICENSE 1 7 :. .:�:t= Explres: . ..._: �A 5 Xlk�i GAPIZiIf3R • ' "� •; DNS ABLE,3'' A` 02663 �' - ;• The 6ininon H-c•alth of Alassac•husetts •'-:i:, Department(!f hidustrial A ccidents . 1 Office vl/ayeslig2gans ��'-•r i K 600 N'ttshinglon Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit ,kFpl iTaWf-Fnf rm tl ri: I NTY L.i 6 - - _ame: i location! city ❑ I am a homeowner performin;all work myself. ❑ I am a sole proprietor and have no one working in any capacity r •�sr:.,c a 'Y r�*3 ." '*• �...Ro^. ^."�'.�LZ.:.�•= y..rb� - .:'E.' _' w,r•�.i .cam.-. �.L '.._._be,....rt-..!L:a.�'•'� r-=. •��*z...�..''R'ti'.�"'2`..c.L.a,,.x:w`�;:,. �.�.�,,��,. �'^mf�e`TrS:;� `*'?!y'+!.S'4j•r..�. -r ❑ I am an employer providing workers' compensation for my employees working Lin this lob comnanv natnc: address: cih.. bon #• insurance co f ,�yLli' Polio # E... ,-.-• ., . .a ❑ 1 am a sole proprietor,beneral contractor,or homeowner(circle are)and havt-h red the contractors listed below who have the following workers' compensation polices: company name: address: citz phone#• insurance co. olio,44 —__-._._,.,_._._.__:�.i.:..-... _ .J:r��,�rd:i]r �L.GL;dtsl-+L:a:M1::l..:+.id h.�_...�1sL.._'y�S'�`- ••�-\,. ..i% �;.���...uri+b7'o G:"'i`.:� 't�, company name: address: - - crtv• insurance co. olio•# 'Attac6 additional sheet if necessary_�ce"'"""o ...+ua>,rt+�.car =%• -..-.+:r:+:iLitrli- �rficSiT�''�Y:-'^•-•'�•,�y *�<�-'��,e•,.w.. .1r �.rr��. Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition c`criminal penalties of a fine up to S1 500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fire of S100.00 a day against me. I understand-(lint a cope of this statement may be forwarded to the Orricc or Investigations of the DIA for coverage vHfication. t do hereht•certify and r t airs and tallies of perjuq•that the information provided c5ove is true and correct. . Si2naturc l Date Print name —Phone2riS official use Only do not write in this area to be completed by city or town official r: ciry or town: permit/license>; P f-tt3uilding Department k' pLiccnsing Board O check if immediate response is required OSelectmen's orrice Dllealth Department contact person: phone t;; 00ther The Town of Barnstable NAM Department of Health Safety and Environmental Services Bui'iding Division : - 367 Main Stmct,KT ais MA tl260I Pilph C.ross= OfftcG SOS-79a�Z27 H�$Co�snor,� F= 308-775-3344 For office use aaly Permit no. Date AFFIDAVIT HOME Il4 ROVER ENT CONTRACTOR LAW SUPPLEMENT TO PERMIT AFPLICAIION MGL c 142A requires that the-rc= =ction,alterations,rcnovadon,hair, ol� impravement,.rcma%m, demolition, or eonsuuetioa of an addition to"any pre-existing owner ocaspted building containing at least one but not more than four dwening units or to structc rs whuh are 24aceat. to such residence or building be done by registered aratractors,with certain t coons,along with W= " Type of Wank: r Est.C,ost-�z Address of work: �.�� ��,-•„ 41r9 �� 0v6mcr.Name: /V O- / Date of Permit Application: I hercbr certify that: { i Registration is not required for the following mumn(s): Work ecduded by law cb rmel S1,000 Building not ow=-o axpied Owns gnihng owa mmit Notice is hereby gh-=that: OWNERS PULLING THEIR OWN PEANUT OR DEALING#T NUOT EMC ESS . 00 VOR APPLICABLE HOME Vv ROVE RENT WORK TMORiES ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c I42A • SIG,iED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the cmm=- RrgJmation No. Date rraraeD-�.� OR Town of Barnstable Building Department ComplainUInquiry Report Date: Rec'd by: Assessor's Complaint Naine: Location P� Address: Originator Naine: Street: State: Zip: Telephone: D/E Complaint . Description: GL� Inquiry CI Description: For 0I ce Use Only Inspector's Action/Comments Date: Inspector. Follow-up Action 7- e-W - -7 9.�5 u C/ — Additional Info. Attached (lint,I)ismbuQon. IG7rite-Depamncnt File [R325 102 . ] LOC10120 HARBOR BLUFFS ROAD CTY107 TDS] 400 HY KEY] 238941 ----MAILING ADDRESS------- PCA] 1011 PCS] 00 YR] 00 PARENT] 0 GREENE, JOAN C - MAP] AREA169AC JV1314350 MTG10000 45 KINGS RD SP1] SP21 SP31 UT11 UT21 . 20 SQ FT] 1387 CANTON MA 02021 AYB] 1951 EYB] 1975 OBS] CONST] 0000 LAND 36000 IMP 99500 OTHER 900 ----LEGAL DESCRIPTION---- TRUE MKT 136400 REA CLASSIFIED #LAND 1 36, 000 ASD LND 36000 ASD IMP 99500 ASD OTH 900 #BLDG (S) -CARD-1 1 99, 500 DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE #OTHER FEATURE 1 900 TAX EXEMPT #HN 120 RESIDENT'L 136400 136400 136400 #SN HARBOR BLUFF RD HYANNIS OPEN SPACE #DL LOT 65 COMMERCIAL * LC7615B INDUSTRIAL #RR 0659 0098 0921 0070 #SR LOOKOUT LANE EXEMPTIONS SALE] 06/83 PRICE] 107000 ORB] C92180 AFD] I LAST ACTIVITY] 03/21/86 PCR] Y I ,-i77 r ;•4 � �+` .� 7i, 1 �h`�� i ,rya RESIDENTIAL= PROPERTY t : Ira MAP NO. LOT NO. 120 'FIRE DISTRICT STREET Harbor Bluffs Rd'.. ` Hyaani8 SUMMARYp t. ,'. 3 25 ZOZ '3 LAND; 6 O<« ao ,✓ H BLocs: : 7 54!d f OWNER % � P4° d� jlr.db'td!1 TOTAL t3 Qi LAND' ' n RECORD OF TRANSFER . .DATE eK PG I.R.S. REMARKS: Lot, 65, LC 7615—B (Sht.2) w BLDGS. B TOTAL j : y sJa s ZOa LAND. Real �. _ �.: -. O1': 'BLDGS. sal' S Hood; Victor C. & Constance C 7-15-77 Ctf. 1175 ($49,8 TOTAL-. LAND ''�O1 O BLDGS: fz TOTAL,' r LAND i -3: TOTAL , -,, LAND t . . i BLDGS: s++ '—� .TOTALA o _ '^LAND y 7C k TOTAL` ?S ��cttik" 3 f LAND,: INTERIOR INSPECTED: BLDGS. DATE: / \ .-TOTAL' / / LAND e Aj t;t a ACREAGE CO PUTATIONS ;• .. BLDGS. $ •, LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE 'TOTAL , j y HOUSE LOT �/S7o oZO �c7O0 60U /�000 ,• :LAND:.. CLEARED FRONT BOGS: REAR TOTAL WOODS&SPROUT FRONT LAND s �, .REAR BLDGS.' WASTE FRONT REAR %�< BLDGS. : r`f TOTAL q .LAND: �C. BLDGS'._ °".:r• �ty�i i �-" LOT COMPUTATIONS LAND FACTORS TOTAL + FRONT DEPTH STREET PRICE DEPTH qb FRONT FT.PRICE TOTAL DEPR. COR. INF. VALUE• HILLY TOWN SEWER -LAND 3 ROUGH TOWN WATER. BLDGS: HIGH''` t 'y TOTAL' ✓!i/ GRAVEL RD. t 4 ^,LOW' DIRT RD. ND,- •,� ,: SWAMPY. �� NO RD. 1`:.: BtnBGS. '_ FOUNDATION BSMT. & ATTIC PLUMBING' a= Conc.Walls e{ Fin. Bsmt.Area Bath Room Base / BLDG COST ,##T`! f r f , s t , Cone.Bik.Walls Bsmt. Rec.Room St.Shower Bath : Bsmt ;� PURCH. r Cone. S ab..., Bsmt.Garage' St. Shower Ext., Walls P, t ? j �; t ^' + r 'DATE 4 ,. er U.RCH .PRICE r x.7a'g• "°s. < t. ' � x,u •rave44 Brick Walls. Attic f..&Stairs )'/0 Toilet Room Roof RENT + 1 f• 4x r +Stone Walls Fin.Attic Two Fixt. Bath Floors Piers INTERIOR FINISH lavatory Extra Bsmt.. F 1' 2 3 Sink s/a r 2 r Plaster Water Cie. Extra . Attic EXTERIOR WAE LS Knotty Pine Water Only t+ ti1'r Double Siding Plywood No Plumbing Bsmt Fin; a Single Siding Plasterboard LA I,it. Fin. l• 0���_ t, '/ .�3s /e2 =3t rcd, CUl9D hingles TILING }rr f$>f e Conc. Blk. G F P Bath Fi: € + „"2 Heat �j / / ( ,.'• Face Brk.On' Int.Layout Bath FI.&Wains. Auto Ht.Unit �Ss 4 Veneer Int.Cond. Bath FI.&Walls Fireplace 8S0 �/ y• 1 c, � #' Com. Brk.On HEATING Toilet Rm.Fi. j /� 7a" /g $ Plumbing c e Solid Cam. Brk. Hot Air G✓ Toilet Rm.FI.&Wains. Tiling Steam Toilet Rm.FI.&Walls Blanket Ins. Hot Water St. Shower -Roof Ins. Air Cond. Tub Area Total Floor Furn. i s. / B � #Z, ROOFING COMPUTATIONS' a+ n a 4 a elf t r • Asph Shingle Pipeless Furn. / S.F. Wood Shingle No Heat a S.F. Asbs.Shingle Oil Burner naec x' t, kR'aF� +rk " n.. , tt L Slate Coal Stoker 7a S.F. ,T 1 3 S F S / :2 e2 A10 Aa l v�•` 1%ro did Xl,,,g Tile Gas - S F OUTBUIL'`DINGS ROOF TYPE Electric , Gable Flat S.F. 1 2 3 4 5 B J 8 9 10 11 2 ;3 ,4, 5 BIT 8 9 .10 '+MEASURED; l 'Hip Mansard FIREPLACES S.F. Pier Found. Floor , /Grp " Gambrel Fireplace Stack e v Wall Foued. 0.H.Door y r S s � ! LI T It FLO IRS- Fireplacei Sgle.Sdg. Roll Roofing Conc: LIGHTING a t r t ,1:.,.. Dble.Sdg. Shingle Roof 4 ` e M 4 Earth No Elect. t 'DATE Pine s Shingle Wells Plumbing t ` 7s I Hardwood ROOMS Cement Blk. Electric /� flp.Asph.Tile Bsmt. 1st TOTAL / Brick Int,Finish 1 P ICED I 77 Single 2nd 3rd FACTOR REPLACEMENT ` OCCUPANCY CONSTRUCTIONI�y� SIZE. AREA CLASS GAGE REMOD. COND. REPL. VAL. - Phy..Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL, m, „r DWLG. 3_G I. i rt c3 . t , r.'•TOTAL , Y r