The URL can be used to link to this page

Home My WebLink About0027 KEATING ROAD a � `��.�„y ,�R _ —_ Town of Barnstable Building t,� . .� - �.. - s ` Post This Card Solthat it is Visible From the.Street-Approved Plans Must be Retained on Job and this Card Must be Kept rwxtv�tnic.�, : e asnsa Posted Until Final Inspection Has Been Made. Pey�illlt a 11 m Where;a Certificate of Occupancy is Required,such:Building shall Not be Occupied until a Final.Inspection has been made. Permit NO. B-19-4068 Applicant Name: VICTOR J. WIINIKAINEN Approvals Date Issued: 12/04/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 06/04/2020 Foundation: Location: 27 KEATING ROAD, HYANNIS Map/Lot 306-006 Zoning District: RB Sheathing: Owner on Record: ABODEELY,DAPHNE F Contractor Name:"%.VICTOR J WIINIKAINEN Framing: 1 Address: 78-2 SOUTH QUIN$IGAMOND AVENUE Contractor License: CS`000998 2 SHREWSBURY, MA 01545 i Est. Project Cost: $5,200.00 Chimney: Description: re-roof-Yarmouth ........__,..., ., ---- - -- ., _ $35 -Permit-Fee: - - _ e :00" Insulation: f Fee Paid;°t $35.00 Project Review Req: Final: ` Date: 12/4/2019 l Plumbing/Gas 49, i Rough Plumbing: - — Building Official Final Plumbing: 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 application and the approvedconstruction documents for 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. - Final Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,public inspection for the entire duration of the work until the completion of the same. �` .Electrical. The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this'permit. Service: Minimum of Five Call Inspections Required for All Construction Work } 1.Foundation or Footing k Rough: 2.Sheathing Inspection — .ri r •�.. - �- — ° 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). • Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Q Application number...P....... Q„ Fee ..................... .............................................. • D EPT• NAM - Building Inspectors Initials............. .................. NIS M� DEC Date Issued......................... ,itif�°?...................... 16WN Q EA�NSTAgLE Map/Parcel.......i 36. . TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDINGA INDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: NUMBER STREET VILLAGE Owner's NameA&(AI 1) Phone Number�� 7 9/- Email Address: Cell Phone Number i i Project cost$ Z ® O .� ; m Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize V l'4-No T r "G 1 /V�IT-A to make application r buil 'ng pe in accordance with 780 CMR Owner Signature: ' Date: _ :2-, ^4s L TYPE OF WORK ❑ Siding ❑ Windows(no'. change)# ❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review ®Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 9 AI a xe CONTRACTOR'S INFORMATION Contractor's name Y YC 7'O -1 VY t��tl i j� 1� 9!Y Home Improvement Contractors Registration(if applicable, (attach copy) Construction Supervisor's License# '000r (attach copy) Email of Contractor 0 C 3 o 9 Wi f N 60 Phone numbetJ4!6----9--?L 2 7810 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN APPLICATION NUMBER........................................................... - *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No - - (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No_____,if yes, a gas permit is required. Natural Gas Yes . No , if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CAM the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature 11615p— � —Date� All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 'Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers APPUcant Information Please Print Legibly Name (Business/Organization/Individual): ;C t! © J +� ►'1',f��/d� 21� /Y Address: �a C/4�<_ Co® City/State/ZipM&4(15 "1LZ AIX o2,k 34 Phone#: 7t?1C Are you an employer?Check the appropriate box: 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 sub-contractors 6. ❑New construction 2.UJ ram a sole proprietor or partner- listed on the attached sheet. .. 7. Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• � 9. ❑Building addition [No workers'comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ Lam a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. j right of exemption per MGL 12. repairs insurance required.]tc. 152,§1(4),and we have noemployees. [No workers' 13.roof ther 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. t 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/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: � �%° Date: 2, 4>1 JF Phone#: r/ "Y 3 Z'2 7y/Q Official use only. Do not write in this area,to be completed by city or town official j City or Town: I 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: i ' 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 defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§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-contractor(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 workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Q>llfice of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons! , Q%iikrvisor CS-000998 � � 'g� plies:09/20/2021 VICTOR J W"IKAtNEI�I1 x PO BOX 69 ' WEST BARNSABLE flAA,Q2668 Commissioners 1 tt Al OHice.?pf Consun►argffairs.&Busirtess 6i egutation k HQME IMPROVF, ENT COMTR64CTOR T1E �Rtlmdual. ' Exolrah4� . �r � f107/2020 VICTORJ.W IINfft, N` r " Kim_ 3 7f V,•ICTORJ:WIINIICI(Ni' 58;CAPE GOD LN `' �•s•}-..` k BARNSTABLE;MA 02630' Undersea t retary .n:,.. "; r 9 F� Application number... I. a",*.... 4, Date Issued. . s................................ DEC 112010 sQ, � ` Building Inspectors Initials..... ........................... ABLF yoco - sa(Map/Parcel.... .......................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 27 go, AKANW1.5 NUMBER STREET VILLAGE Owner's Name:PA c if Aso D c el-y Phone Number -re Email Address: ti tM Cell Phone Numbers ; ± U ( a Project cost $ Check one Residential Commercial OWNER'S AUTHORIZATION � f a aY As owner of the above property I hereby authorize 1! / �y� X W� f�f ACA to make application fo building petin accordance with 780 CMR Owner Signature: _ Date: 3 6 G' TYPE OF WORK ❑ Siding Windows (no!header change)# / ❑ Insulation/Weatherization ❑ Doors (no header change) # Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) / Construction Debris will be going to YAR,,''j 4 40-1 CONTRACTOR'S INFORMATION Contractor's name y c 7-0 f Home Improvement Contractors Registration(if applicable) # f CS 4D (attach copy) Construction Supervisor's License# CS 0 F (attach copy) S+( m CA "37, � ? Email of Contractor VJ C P8 t-f<f N 1 IfAllyZeV Phone number-4 o 9 3,0� 791( 0 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER................................... ......�...::.... , *For Tents Only* Date Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent- - X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I.understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature /` Gi� -�� Date f/-^- 20 All permit applications are subject to a building official's approval prior to issuance. 3 The Commonwealth of Massachusetts Department of Industrial Accidents j Office of Investigations 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): V/ G D o Address:,,> Y (;/4 PCC C op / S, City/State/Zipi3A R -57W,OR,5'/'U C 26 3-6 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I _, pployees(full and/or part-time).* - have hired the sub-contractors 6. ❑New construction 2.Imo"I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY $ 9. ❑Building addition [No workers' comp.insurance comp.insurance. re required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ q ] officers have exercised their 11. Plumbing repairs or additions I am a homeowner doing all work ❑ g P • myself. [No workers"comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no �-� A employees. [No workers' 13.[ ther GG comp.insurance required.] 0,;'Y' g S ,! 4 R0 VV *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: 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/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under the pains andpenaldes ofperjury that the information provided above is true and correct. �f. C Signafore: � Date: Phone# 0 �A 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 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." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(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 cart'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 workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that 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. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number; The Commonwealth of Massachusetts 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 . .t..r Office er of Consum Affairs&Business Regulation T OME 1MPROVEMENT CONTRACTOR Tlr`RE Individual + � s Ex Iro ation : -06/07/2020 e A..' VICTOR J WIIiKA1�N a rg �. VICTOR;J W IINIKAINEN_ ! AP G{ 58 CAPE COD LN BARNSTABLE;MA 02630 Undeasecretary i 4 Commonwealth of Massachusetts Division:of Profesmonal:Licensure �. Board ofi Builctng Regulation.s''and:Standards CQnstr ti6 r3 Sta{ !Visor CS-000998 Ex�plres 09/2912019 xi , r � VICTOR J WIINIKAINENr T PO BOX 691;49 WEST BARNSTABLE MW62668°� A"1. commissioner (, Town of Barnstable *Permit Fapires 6 months from issue date-_ Regulatory Services Fee 35 i anxtvsrasz.E, + . Richard V.Scali,Director AIMPRESS KOMI Building Division Tom Perry,CBO,Building Commissioner JUN 0 o ?D b 200 Main Street,Hyannis,MA 02601 TOWN �� p�N��-A�L� www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number , Property AddressZ ��i'Y� O esidential Value of Work$ l Go Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name G1 G 1�. '. I� </ <1 1 /j��J� Telephone Number [3g >9j2 7 f® Home Improvement Contractor License#(if applicable)Z!�z>6 15' Email:_ Construction Supervisor's License#(if applicable) ,t ! a ❑Workman's Compensation Insurance Chec one: kr 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 Reque (check'box) pdA/Vr,9 A i � E-ke-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken toY1Qt� ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. l SIGNATURE: �-'_-- Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc . Revised 040215 Tlie Comrfromwealth o,f?l ssaclrrrsetts Deparament o,f'Industrial Accidents f3} -ce of fmwi igations 600 Washington Street r_ Boston,ALA 02111 svPsnv rase govfdia Workers' CampensafiGn Insurance Affidavit: B•nildersiCantradurs/EIectricians/Plumbers Applicant Information Please Print Ledbly Name(3usinemiommizeim adividnal}_ Y,c a Address C*"g Cap 1 jy City/State17ip- RN,5ef a4 c2 3o Phone �a� 3�• �l� Are you an employer?Check the appropriate box: Type of project(required): I_❑ I am a employer with 4 ❑I am a general contractor and I 6. ❑New construction (full anNor part-timed* have hired lase sub-contractors 2.9D'fam a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees. These sob-contractors have g. ❑Demolition Wad-ing for ss:e in any capacity. employeees and have wod=s'[No workers'comp.insurance comp.insurance.i 9. ❑Building addition re mired-] 5. ❑ We.are a corporation and its 10-0 Electrical repairs or additions officers have exercised their 3.❑ I am.a homeovEmer doing all vgorlc 11.❑Plumbingrepairs or'addi#ions nsysel€[No workers'comp- Tit of exemption per MGL 12.❑Roofrgmirs insurance required-]6 c.152,§1(4),and we have no employees.[No wod=s' 13.[ ther R��f/Y�L comp_insurance required-] •Any applicant that chedu box 91 mast also fill out the section below shoving their wo&eze compensation policy informatiao_ T Homeocvuers who submit dis affida«t indicating they are doing all'wa k and then hire outside contractors amst submit a new afisdavk in&catmg suc IContracturs that check this box must attached an additional sheet showing the name of the sub-comtrw-tm and state whether or nut those entities hzve employees.Ifthesub-contr.=orshave empIoy-s,they must pm'ide their workers'comp.policy number. I am an ersplo}tirr tleatis prarzdirrg svarkers'caerperesatr rr irrszrrarrce for asr}*enrpFu}�ees. Belorp is flee policy and job site it formation Insurance Company Name: Policy 4 or Self-ins.Lic. Ekpiiation Date: Job Site Address: City/State&ip: Attach a copy of the workers'compensation policy declaration page(showing the,policy number and respiration date). Failure to secure coverage as required under Section 25A.of MGL c.1572 can lead to the imposition of criminal penalties of a fine up to$1,50D 00 andfor one-year imprisonment,as well as civil penalties.im the form of a STOP WORK ORDER and a fine of up to$250-D O a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of'the DIA for insurance coverage:vacation. I do hemby cerlsfy tinder thy pains andpenaldes cr.fpet jur},that the infor madon pr ouitfed abmw is tnw mid correct Sienatt2re:///�� Date: 01, Official use corny. Do Trot ivrite in tlr s area,to be campLieted by city artoorn official City or `own: Perwitffikense 4 Issuing Authority(tdrde one): 1.Board of Health 2.Building Department 3.Qtyffown Clerk 4.Electrical Inspector .Plumbing Inspector 6.Other Contact Person: Phone 9: f Information and Instrnctlons MasssachusetEs Geheral Laws chapter 152 r_,cp s all employers to provide workers'compensation for their empIoyees- e Pmsaantto this st8 rife,an.��3' e is defined as."_.every person in the service of another under any contract of hire, express or jplied,oral or written." An ernpinyer is defined as"aa individual,partnership,association,corporation or other legal eat t5r,or any two or more for in a joint enterprise,and including the legal representatives of a deceased employer,or the of theforegoing engaged receiver or trustee of an individual,partnership,association or other legal entity,employing employers. However the owner of a dwelling house having not more tban three apa d ments and who resides therein,or the occupant of the - dwelling house of mother who employs persons to do mafitenance,conshuction or repay work on such dwelling house or on the grounds or building appurtenantthereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also sites 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 wn the iusurance-coverage required- Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor ally of ifs political subdivisions shall enter into any contract for iheperformance ofpublic woikunttil acceptable evidence of compliance with the inerranc6._ rcqL:u=ents of this chapter have been presented to the contracting anfhouty." , Applicants Please fill out the workers'compensation affidavit completely,by checl the boxes that apply to your sitnation.and,if necessary,supply snb-Contractor(s)name(s), addres (es)and phone number(s)along with their certificate(s)of in ern ce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cauy worriers' compensation inset ance- If an LLC or LLP does have employees, a policy is required. D e advised that this affidayit may be submittbd to the Department of Industrial Accidents for confsmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retxlmed to the city or town that the application for the pem-dt or license is being requested,not the Depart acat of Industri2l A_ccidmts. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Deparment at the number listed below. Self-insured companies should enter their self-in mn-an ce license n=ber an the appropriate line. City or Town Officials t Please be srae that the affidavit is complete and prfirted.legibly. The,Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant_ Please be sure to fill in the peunitllic=e,rntnber which will be used as a reference number. In addition,an applicant that must submit multiple pemmitllicense applications in any given year,need only submit one affidavit indicating current p olicv inf6i nation Cif necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)-"A copy of the-affidavit that has been officially stamped or macked 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 ventine (Le. a dog license or permit to bum leaves do.)said person is NOT regrmed to complete this affidavit The Office of Investigations would at to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Departrnent's address,telephone and fax number- The CammantwealtbE of Massachusetts Ilegar(mmt of ludmidal Accidents (504,washivml Strut Boston,MA G211 k T(,-L:#617-727-49-00 Qx- 4-06 or 1-9 MASSAFE Fax#617-727-7M Revised 4-24-07 .mas..gQvfca I � - elm snxxsrABM * , ' ,m� Town of Barnstable prFo � Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO t Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us ' Office: 508-862-4038 } Fax: 5.08-790-6230 t Property Owner Must Complete and Sign This Section. If Using A Builder I, 0�-& , as Owner of the subject property hereby authorize// &--'71-' Lt �/11QI/(J to act on my behalf, in all matters relative to work authorized by this building permit application for: ` ' `l (Address Job) Y Signature of Owner ate f Print NanAe i If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPFILES\FORMS\building permit formsUTRESS.doc Revised 040215 Town of Barnstable 4 Regulatory Services E of °ty Richard V.Scali,Director Building Division 7 saatvsxasrs Mass Tom Perry;Building Commissioner v 1639. 200 Main Street, Hyannis,MA 02601 �ATFD www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HCMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINMON 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 10:9.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming,the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often e unlicensed persons. In this case,our Board cannot results in serious problems,particularly when the homeowner hires p e, proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is P g 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\building permit forms\EXPRESS.doc Revised 040215 License or registration valid for individul use only before the expiration date. If found return to: a Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without,signature 7 T»ims' '` :..errk '2i7 _.» �a��K ,,P. Office of Consumer Affairs&Business Regulation ' ME IMPROVEMENT CONTRACTOR Type. 4 Ugistrati0n: „1b0053 Individual ` -IiEf�6:,. iration: _.___ I VICTOR J.WIINIKA:@EWE ' I.Victor Wiinikainen `; 58 CAPE COD LN ,r_,..: r BARNSTABLE,MA 02630 Undersecretary l ) d C A M 'A N U ate-. Cn Uj a c o w Construction Supervisor Restricted to: EUnrestricted-Buildings of any use group which contain 5 N , _ -less than 35,000 cubic feet(991 cubic meters)of enclosed .o , f° a' co .� _ s - space. (U tY rn. f w 4 ' 4 �.o y U c Y �H vi 7 m p ? N U ~ y u 3�W o c --imQ E 070 0 0:Xm P o � O m N Failure to possess a current edition of the Massachusetts op o v O State Building Code is cause for revocation of this license. U _ 0. DPS Licensing information visit: WWW.MASS.GOV/DPS f ie i 3—zt—/6 pol—'7 Town of Barnstable Ap ��jjit# � r® Qlmi6 0 U'from issue date Regulatory Services �I/lV®LF eEARNSTAMA (r 7� M^ . Richard V.Scali,Director 11/VCAS 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 PEPMT APPLICATION - RESIDENTIAL ONLY _ 6 �6 b Not Valid without Red X-Press Imprint Map/parcel Number p Property Address e Residential Value of Work$ >� ,� s Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A4 e/`-f Y-E p C7f,�: Z-4 X Contractor's Nami C e rog J- 1'�''t lWL/ EQ 1� Telephone Numbei�®' 3 kz 7.910 Home Improvement Contractor License# if a licable 040 3 Email: P ( PP )� Construction Supervisor's License#(if applicable) 0 O 6 4? ❑Workman's Compensation Insurance Check one: 2'ram 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(hurricane nailed)(stripping old shingles) All construction debris will be taken to 0 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 100j'R &e 721,At G g{y� ["`Re-side.S 1`'1 A z Z. ro A 1 Glf�� :sr e,F ir,`= ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter.of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is _ required. SIGNATURE: ,�� "��—' _ Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc . Revised 040215 .� Ile Commomreaitii of—Massy djusetts Departrneait of1ndustria1Accidents - Office of1mwstigations ti00 Washillgion Streety.. Bast-on,tM4 02111 form- pass gm/dia Workers' Campensafien Insurance Affidavit BuildersiContradurslEIecfr clans/Plumbers Applicant Infarmai an Please Frinf 1e6W Name(Busffiessfl ganization(Inchvidna4}: {!6 cG(n. .1 a YY l i sit i� �lz lam" i Address:,,r,g P 4 14�v Gt3r/Statef -0h9W>Z 9,,C%A4 0 2 b:3o Phone ig: �� 7�/D Are:you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4: ❑I am a general contractor and I 6. ❑New construction employees(full and/or Part-time).* have hired the sub-contractors 2 JOT=a sole proprietor or partner- fisted on the attached sheet. 7- ❑Remodeling slip and have no employees. 'These sub-contiac#ors have 8- ❑Demolition working far tyre in any capacity- employees and have worms'[No vuorkars'camp.instance comp-%nenrancel g- ❑Building addition required] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeownerofficers have exercised their doing all work 11.❑Plumbing repairs or'additions tx 3y f- [No workers'comp- right of exemption per MGL 12.❑Roofrepa=' c.152 I and use have no inc�tance required-] t .� iit� �. �� S/��. ff LQ employees-[No workers' 13. ther camp.insurance required-] 'Any appBc that checks box 91 most also fal out the section below showing their woikere compensati nparky'intnrmatimL 1 Homeovuners who submit this dUda[rit in&catmg they are dais all Want and then}tire outside contxactars— submit a new aMdavit mdicatia;such- fCanuactors that chart this bat must attached an additianal sheet shooting the nme of the sub-contractors and state whether or not those entities have employees. Ifthesnbtantractorshave employees,theymusipmu-ide their workers'ramp.poliLy number. her. I ant are inmirauce for arty entplayees Eetory it the poicy and job sfte information Insurance Company flame: Policy-,'*L or Self-ins.Lic-4: Eipiration Date: Job Site Address: City/StateJZsp: 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 an&for one-year imprisoummtt,as well as chit peualties.in the form of a STOP WORK ORDER and a fine of up to S250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of'the DIA for insurance coverage verification. I do hereby certe;,tinder the pains owd pen alffes afperrjurp thatAe utforma#ian pm ded abm a is bw wtd correct Date- Phone 9- 1�rdy 9 7810 afficial use only. Do not ante in this.area,to be cainp&ted by city artonrn oficiat City or Tanrn: Pertgiff- cease# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Citytrown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone it: Jifarmatian and Instruefions , w efts General Laws 152 requires all employers to provide workers'compensation far their employees. M�carhus �� n P=M=ttD this stye,an.Mp&gM�is defined as-"_.every person m the service of another under aQy contract of hire, express or implied,oral or written." An e27pioy8-is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged is a Joint enterprise,and including the legal representa&es of a deceased employer,or the receiver or tmustee of as 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 maintena ce,consaurf'on or repair work on such dwelling house or on.the grounds or budding appurEenantlhamto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also sues chat"every state or 16caI 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_" AdditionaIly,MGL chapter 152, §25C(7)states`2leither the commonwealth nor airy of its political subdivisions shall enter into any contract for the perfammance ofpublic work unto aoceptab15 evidence of compliance with the insurance, r nients of this chapirr have been presented to the contracting auihozity." egmre , Appficar�ts , Please fill out the work='compensation affidavit completely,by checking the boxes that apply to your sitnation and,if necessary,supply sub-conimactor(s)name(s), address(es)and phone numbers)along with their cert facate(s) of LP with no to ees other than the - Companies or Limited Liao Partnerships(L ) emp Y ce. Limited Liab C) �Y mcr„�n .i-1T<y mp (LL members or partners,are not required to carry workers' compensation inso ce. If an LLC or LLP does have employees,a policy is rmpired. Be advised that this a$idayit may be submitted to me Department of Industrial Accidents for confirmation of ium ce coverage. Also be sure to sign and date the affidavit The affidavit should be retrmmed to the city or town that the application for the permit or license is being requested,not the Department of h1dusftlal Accidents. Should you have any questions regarding the law or if you are required to obtam a workers' compensation policy,please call the Department at the number listed below: Self-hou-ed companies should enter their self-insurance ce license mbar an the appropriate line. City or Town Officials 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 Investigations has to contact you regarding the applicant Please be sure tr)fill in the pemlitllicrose number which wM be used as a reference number. In addition,an applicant e • cease applications th any en ear,need only submit one affidavit mdicatmg current that must submit multrple p nnttlh app Y� Y - �� " " or policy ml�rnation(;if necessary)and under Job Site Address the applicant shoT?Id xrite all locations m (�Y 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 futr<re 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 venizre (Le. a dog license or permit to bum Ieaves eta.)said person is NOT regret ed to complete this affidavit The Office of Investigations would hke to thank you is advance for your cooperation and should you have any questions, please do not hesitate to give us a call.. The Dgpa enf s address,telephone and fax number. Thy f OMMOn tth of Massachu-smM . D:ega�menfi c}f lzidnsitzal Accidents . . . Office of lnivestintio= ��-l�asliingtQn Str�� Boston�MA G1 I I I Ttr1.4 617 727-49OG Qx- 4-06 or 1-9 MASSAFI� Fax 9 617-727-7749 Revised 4-24-07 as,,,�gQ-vf dia i OFF r011y � sARN6TABLE. ,.� Town of Barnstable ArEp�� Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 1�( , as Owner of the subject property hereby authorize V to act on ray beh4 in all matters relative to work authorized by this building permit application for:` rA d Vl � (Address ob) Ci Signature f Owner l5ate Print NA e s if Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the " reverse side. 4 ' QAWPFILESTORMSUilding permit forms0TRESS.doc Revised 040215 i Town of Barnstable Regulatory Services �y �oFs1WE tQ Richard V.Scali,Director Building Division `* BARMSrAISM Tom Perry,Building Commissioner MASS. vQ 1639. � 200 Main Street, Hyannis,MA 02601 �;erEn www.town.barnstable.ma.us Office: 508-862-403 8 ' Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: - city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures.'A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15),This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. . To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend.and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit formsT-3TRESS.doe Revised 040215 c7. ��/�aoaa�ivae Office of Consumer Affairs&Business Regulation_ E IMPROVEMENT CONTRACTOR Type. Uqestration: ;9�0053 ration: -f A Individual VICTOR J.WIINIKAII,�,,,` Victor Wiinikainen _ 58 CAPE COD LN t. BARNSTABLE,MA 02630 "` Undersecretary Massachusetts Department of Public Safety ' lug Board of Building Regulations and Standards License: CS-000998 ' :;rs Construction Supervisor F, VICTOR J WIINIKAINEN PO BOX 69 i WEST BARNSTABLE $ ' 'S )I'1511• Expiration: Commissioner 09/29/2017 i License or registration valid for individul use only { before the expiration date. If found return to: H Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5170 i Boston,MA 02116 Not valid without signature Construction Supervisor Restricted to: Unrestricted-Buildings of any use Group which contain -less than 35,000 cubic feet(991 cubic meters)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. a DIPS Licensing information visit:WWW.MASS.GOV/DPS f ♦l W6 53 • �� Town of Barnstable � *Permit#' :om� to s : RegulatoryS Q` /05- 11 � Services Fee KAM %63 $ Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner 200 Main Street.Hyannis,MA 02601 X-PRE1 T Office: 508-862-4038 Fax; 508-790-6230 SEP 16 •2005 V' EXPRESS PERT MUTT APPL?CATION RES�E1lTT�A�, lei OF BARNSTABLE Not Valid without Red X Press Imprint ap/parcel Number CS operty Address .47 KSW C l ,/G Opp C� ridential Value of Work ! 1� —e Minimum fee of•$25.00 for work under$6000.00 wner's Name&Address_ Pa nI R 14 co ®s :E L- ; 2- 9,3,e4—P1Z1 S'4 C7 ,s/L AV ,.9 ontractor'.s-Name .L`/ (® � �► VI G/'l�L e'er TelephoneNumbez ome Improvement Contractor License#(if applicable) .. L �.. � . onstruction.Supervisor's License#(if applicable) ]((Jorkman'.s Compensation Insurance Check one: E'1'am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance issuance Company Name Porktnaa's Comp.Policy# ;opy of Insurance Compliance Certificate must be on file. 'ermit Request(check box) 106 E' � �� ® � £�� `�Q e R�rRe-roof(stripping old shingles) All construction debris will be taken to�/?/V'70 V uC Pl S� LK ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [] Replacement Windows. U Value (maxi1mum.44)- *Where required: Issuance of this permit does not exempt compliance with other tows departtnent regulations,i.e.astoric,Conservation,ate. • ***Note: Property Owner must sip Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature Q:Forms:expmtrg. I, Etavist%3004 ira f� t oF. . Town of Barnstable Regulatory Services t.sARsisll+B Thomas F.Geiler,Director o h Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I 0 ,as Owner of the subject property hereby authorize to act on my behalf in all matters relative to work authorized by this building permit application for: I - 64� (Address ob) .�7- �ignat4e of Owner ate Print N e Q:FORMS:OWNEUERMIS SION a tipos a°. R e�u1a . ?JIG � N�R O � e_ .. 1M Op53 .. f Oo yp� t. Sk 4.4 �J\\N1t 1y r.y i.m tta r V\G�OR �Ka�ne�'ti \NX0 N V+e1O P�GOO 4 P 0�63� G P M 5$ NS,\PgvE, .� r T, - 'PRESS Town of Barnstable *Permit# ^ 0 6-7 6-7 Expires 6 months from issue date NoV 16 2007 Regulatory Services Fee ze,- TOWIV pF BARNS Thomas F.Geiler,Director TA8LE 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 Vafid without Red X-Press"Imprint Map/parcel Number s a 6 s Property Address B' 0esidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address � e_1r Z L P 1 V:� Contractor's Name V Telephone Number '7,g/es . Home Improvement Contractor License#(if applicable)- Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance C�,�h,ec one:, 0 1 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 be on file. VP Permit Request(check box) �Ze-roof(stripping old shingles) All construction debris will be taken to x"O/3res ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. C SIGNATURE: Q:Fo=:expmtrg Revise061306 I ' The Commonwealth of Massachusetts Department of Industrial accidents Office of Investigations 600 Washington Street Boston,MA 02111' www.mass.gov/dig ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information .Please Print Le0bly Name(Business/Organization/Individual): 6CSpz �� -Q a Address: City/State/Zip;��i>'C i�4-,S /Ve"94-1hone.#: 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 6. ❑New construction . employees(full and/or part-time).*• have hired the sttb-contractors listed on te-attached sheet. 7. ❑Remodeling 2.�am a'sole proprietor or partner- . These sub-contractors have . Demolition: 8. • ship and have no employees . ❑ . employees and have workers' working for me in any capacity. t. 9. ❑Building addition [No workers' comp.333S1 0e Comp.insurance. 10.❑Electrical repairs or additions required] 5. ❑ We are a corporation and its eP '3.❑ I am a homeowner doing ill-work . officers have exercised their 11.0 Plumbing repairs or additions ' myself[No workers' comp. right of exemption per MGL 12. oof insurance.required.] repairs c. 152, §1(4),and we have no . ed. t 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 HorneownenLyho submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 m 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: I 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 tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK.ORDER and a fime of up to$250.00 a day against thq violator. Be advised that a copy of this statement maybe forwarded to the-Office of Investigations of the bIA for insurance covers ga verification. I do hereby ce der the ains•ahil penalties of perjury that the information provided�abovg is true and correct Si ature: Date: i Phon p 6 — -!o - Official use only. Do not write in thin area, to be completed by city or towmoffcciai City or Town: ' permit(License# Issuing Authority(circle one): --I.Board of Health 2.Building Department 3•City/Town Clerk 4.Electrical Inspector.5.Plumbing Inspector 6. Other Contact Person: Phone#: NOV-16-2007 09:54 15087996522 15087996522 P.002 LI/13/cuur ci.00 ["%A j Town.of Barnstable Reguiatou Services I Thomas F.Geiler,Director ' . Building Division Tom Perry,lauildizag CoMInWoncr 200 Main Stmet,Hyannis,MA 07601 www.town.barnstable ma-us Office: 508-862-403$ Fax: 8-790-623;0 { Property Owner Must Complete and Sign This Section if Us' A Buil hereby authorize der v as Owner of the subject propext W to act on my6t A. in all m=ers relative to-vnoork authofind byth is building pr application for, (Address of Job) l 4i� igrla of Owner Date Opp P-m— Print Name i If Pro e isle applying for permit please complete th : Homeowners License Exemption Fora on the revere side. i - qFosuMs:oNvxeaA"zssIox i TOTAL P.002 r� Town.of Barnstable- 0-4 Expires 6 mOMU from 1=W dots O,p Regu�ato Services. • Fen. Thomas F.Geiler,Director ' Building Division Tom Perry, $uilding Commissioner 200 Main Street, Hyannis,MA 02601 Y.-PRESS . V Office: 508-862-4038 17, 200S Fax: 508-790-6230 EXPRESS PERAM APPLICATION - RESEDENTML N ONLY Not Va#d without Red X-Press Imprint T OF BARP1 Map/parcel Ntmuber 3 O (,,- O o S Property Address ? esidential Value of Work Owner's Name&Address 9 ^1 P/6'X s,��rs, .� d�.;s'��' Contractor's Namet'1140/V B .��A4 � Telephone Number��3 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) o CS d ❑Worktnan's Compensation Insurance Check am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance. Insurance Company Name Worlmian's Comp.Policy:# 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) er ®A)9l_04>A�tA-� Reside��sklz5�+ �lacement Windows. U-Value (rma •`4) 'Where requited: Issumtce of this permit does not exempt compliance with other town departttmt regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. H Improvement Contractors License is required. Signature i -i - ti Town of Barnstable Regulatory Services = BAWMAZA = KAM Thomas F.Geller,Director Building Division Tom Perry, Building Commis9ioner 200 Main Street, Hyannis,MA 02601 Office: 508-8624038 Fax: 508 790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 4/•tom —,as Owner c f the subject property e hereby authorize �� U ��` `Cal e ' to act on my behaK in all matters relative to work authorized by this building permit application for. �-7 t--4 e-� Q (Address of J ) l�vi,s" Signature of Owner V Date 1A0 w- l �� fi A Print fiame • a Boa jRof Buildin g Regulations and Standards HOME IM OVEMENT CON Rep-stratlt� TRACTOR t' 1,00053 dual 'VICT OR J. WIINf l Victor kQ1NNa .. > Wiinikainen � f ' 58 CAPE COD LN I BARNSTg6LE, "a •• MA 02630 -- - — Adml -_ nistrator - z •- r� 1 S ow e Zj • Town. of Barnstable °Pcrnait N 0 0 4 ltaq�bu,f rnonthrfJ•o►n fine dair s ,,.�„p� Regulatory Services Fc _ HA — ,esy, Thomas F.Geiler,Director ° Building Division Tom Perry, Building Commissioner 200 Main Strect, Hyannis,MA 02601. PRESS�o PERMIT Office; 508-862-4038 Fax: 508-790-6230 EXPRESS PERI✓M AFVXACA_ri0N - 'RESIDENT J-, ONLY 2 0 2003 Nol-Mid without Red X-Pru,rntprinr TOWN OF BARNSTAELE Map/parcel Number 30U, �Ofo Pzoperty Address 2-7 e l44 1 N 6- '(�t- n \�Residential A Value ofWork �N Owncr'same&Address �. - -. zo—DeE L _ Contractor's Name c,) , &-z--ao LD(-E A Tclepb,ono'lumbers`"�0�0 �-vQ " 1\ Z-7 Home Improvement Contractor License#(if applicable) Construction Supervisor's Liccnae#(if applicable)-----( S�(p VWorkman's Compensation Insurance Check one; ❑ I am a sole proprietor ❑ I am the,Homeowner I have Worker's Compensation Insurance t Iruurancc Company Name I rav e. e of s 1: workrnan's comp.Polley# -7 PJ L)1-q a a Y-� 5.3 -- (02-- Permit RequNt(chock box) Re-roof(stripping old shingles) All construction debris will be taken to__ � ❑Re-roof(not stripping. Going over cxinting layers of roof) ❑ Re-side ❑ ReplacementWiadows. U-Value (maximum,44) ❑ Other(specify) •Where required: Issuance of this pwail does not tx"t cornpliaacc vnth othcr town depart mAl regvltt one,I.e.l tswnc,conacrvttion,ctc. Signature uAllon- Q:Fomu:Mmtrg Ravi�edl21901 i y PROPERTY OWNER MUST COMPLETE AND SIGN THIS SECTION IF USING A BUILDER / ROOFER ,(Please return this form to Cazeault Roofers with your signed proposal/contract) as Owner of the subject property Hereby authorize Paul J. Cazeault & Sons Roofing_____ To act on my behalf, in all matters relative to work authorized by this building Permit application for (address of Job) ✓ V�Q Signature of Owner V Date Print Name s Cu Board of Building RCIII-1 ions and Standards One Ashburton I='lace - Room 1.301 Boston_ Massachusetts 02108 Home Inaprovemerit ,�' ontractoi- ReLostratioii Registration: 103714 Type: Private Corpnatiol Expiration: 7/9/2004 PAUL J. CAZEAULT & SONS, INC. Paul Cazeault P.O. Box 2781 Orleans, MA 02653 Update Address and return card. N1:u-tc reason for change. Address I Renewal D:nlplo)munt Lost Card I 11 3 Board of Building Regulations and Standards License or registration valid for indiyidnl use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 103714 Boa rd of Building Regulations:ind St:uula rds Expiration: 7/9/2004 One i\shburlon Mace Itm 1301 Boson, NIa.02108 Type: Private Corporation PAUL J.CAZEAULT&SONS, INC. Paul Cazeault 22 Giddiah Rd. ✓�+�: �iirmia�wiuoea o�✓fl /� � Orleans,MA 02653 Administrator I`loj 1 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 026325 t Expires: 10/20i2005 Tr,no: 8603.0 Restricted: 00 PAULJ CAZEAULT 1031 MAIN STv OSTERVILLE, MA 02655 Administrator �- Board of Buildin a ulations - One Ashburton Place, Rm 1301 e�4 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Number: CS 026325 Expires: 10/20/200.5 Restricted To: 00 PAULJ CAZEAULT 1031 MAIN ST OSTERVILLE, MA 02655 Tr.no: 8603.0 Keep top for receipt and change of address notification. �'� •.: -- T M.�M.aID—D/Y- Y) AdlTbRD- OF LIABILITY INSURANCE DATE 5/2003 PRODUCE ISSUEDTHIS as A MATTER OF INFORMATION I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I McShea Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR 749 main street, Suite#H ALTER THE COVERAGE AFFORDED BY T11E POLICIES BELOW. Osterville, Na- 02655 INSURERS AFFORDING COVERAGE 508--42L4_.90.11__ �— — — INSURED paul J Cazoault To gong Roofing Inc. 'tNI SVIIERA, W®stern H6r l�. ri�� Co. - INsuRCRB: Travalera Ind>>�Bity_ C'0_Q.f.11l 1031 Main Street INSURERc _ ooterville, ma 02655 NSURERD I IBnO—r%gn—Fir1 i4 �INSVHFRF COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL-ICY PERIOD INDICATED NO1 WITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 3E ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY T'HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND COND17IONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. "SR TYPE OF INSURANCE POLICY NUMBER PoutZ EFFECTIVE POLICY EXPIRATION LIMB 4 IE+TE IMM/pp/Y E. MMJOD/Y _ GENERAL LIABILITY - LGENEIIAL CURRENCE - U"Q Q. x COMMERCIAL UtNFRAL LIABILITY - MAGE(Any one We) I S fCLAIMS MADE I OCCUR - P(Any one yorwo )- 'S A _ SCP0467325 04/30/03 04/30/04 NAL&ADV INJURY LU"000.000 AGGRFWITE_I b 2.0 00,Q Q GEN'LAGGREOAIt LIMtTAPPLIESPEIi. PRODUCTS-COMPiOP A(.G S1�000.OOQ POLICY D PNO- lOC JECT AUTOMOBILE LIABILITY COMBINED`iINOLL LIMIT ANY AUTO (Ea ecodent) S ALL OWNF-D AUTOS BODILY INJI_IRY IPaI Don:on) SCNCOULED AUTOS HIRED AUTOS DODILY INJURY i NON-OWNED AUTOS - (Pm a::cidem). PROPERTY DAMAGE S (Per arcident) GARAOE LIABILITY AUTO ONLY EA ACCIDENT S ANY AU10 EA ACC S OTHER THAN .._. ... AUTO ONLY: AGG�— EXCESS LIABILITY LACH OCCURRENCE S OCCUR ` l CLAIMS MADE' AGGREGATE S _ S OFDIICTIDLE _ $ HtIFNTION S S I_ WORKERS COMPENSATION AND )( 1w-RYLIMITS EP EMPLOVERS'LIASILIYV 7PJUB-922X653-502 _ 08/10/03 08/10/04 ., El.EACH ACCIDENT f E;L.DISEASE-EAt:MPLOYLl E.L DISEASE•P01 ICY LIMIT S OTHER I DESCRIPTION OF OPE RAT ION9ILOCATIONSNEHICLES/EXCLUSIONS ADDED BY EN9OR6EMEn1iBPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL. �_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT=AILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIA841TY.OF ANY HIND ON THE IIISURER,ITS AGENTS OR REPRESENTA 1. 9. • AUTHORIZED R RE T / ACORD 25 S(7/97) o ACORD CORPORATION 1988 t s1. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel & Permit# #638� Health Division Date Issued o� Conservation Division Fee 0—V Tax Collector , --` /3��2 f�0 p „ Treasurer Planning Dept. , Date Definitive Plan Approved by Planning Board d Historic-OKH Preservation/Hyannis Project Street Address kd PJ-S Village Owner Address — 'VOL,V Telephone Permit Request jEY)sbyCL `t am cSkjw/as t5D amAke A)eop oSAIu61E - Square feet: 1 st floor:existing_ proposed 2nd floor:existing proposed Total new Estimated Project Cost o� Zoning District Flood Plain Groundwater Overlay 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 0 No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other ' Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size _Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name ATelephone Number a2 'Address _ 3 License# � �'�(o< < Home Improvement Contractor# Worker's Compensation# J0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR DATE } - FOR OFFICIAL USE ONLY ' ` ERAIIT NO.. DATE ISSUED _ MAP/PARCEL NO. i a r . ADDRESS VILLAGE a� OWNER ��, r - i _ • s DATE OF INSPECT"• FOUNDATION FRAME + INSULATION •x FIREPLACE r` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH' FINAL f GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT q - ASSOCIATION PLAN NO. d ' 1 The Town of 13arns' table 9 Department of Health Safety and Environmental Services P Building Division { 367 Main Street,Hyannis MA 02601 Office: 508-8624038 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 ire-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. n 1j G�U"� �1�� Type of Work: 7�1dGh s�/&&x r i�kJx/� (��`RZ:D n lh .• Estimated Cost Address of Work:�J kEJQ-- 1U Y t i O A)A)M Owner's Name: M kE 4sP)0 p EF—/ L/ — Date of Application: 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 V1 ORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I he/re y ply for a permit as the agent of the own . 6 ,--3 Date Contra r Name Registration/No. OR Date Owner's Name q:fomu:Affidav _ �""-_ L!1(. i.Uiiirr'Lvlr►'i�l:ullrt UJ i►`u:1Jci�fttlJCttJ —_ Department of Industrial Accidents Office 0118sOM911Uoas 600 Washington Street Boston,Mass. 02111 Workers' Co m ensation Insurance Affidavit name: A.,& DEFh location: / J� cityhone# /_ 7 ❑ I am a homeowner/performing all work myself. ❑ I am a sole rietor and have no one workin in any capacity ''///%%%%%///%/%%/%O% %%/%%%%%%%%%///%%%%%//%/%%/ %%%%%///%%/O/%///��%%%///%/��%%%%%%%%%%%%%%%%%%%%%%%%%/G%%%%%%//%/�%//l//%//l%%/�'�////%/j [ 'I am an employer providing workers' compensation for my employees working on this job. company name: �} address. T � �. j�1� phone#: F . f/KI r •t insurance co. I�� ohcv#> ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company>name: address. rity:;. bhone#. ':ii .: ... .:. ....... ....... ... .. ...... ................ ......... .. .:::. .. -" .. ..... ................ .... ............. .. .. .....:...... ....... .. .. �J.. ... .:v:. ::. ii:':ii:�ii ...::: ........................ .... tunrance.co... , . . . ....... ;''.: __... .. .. .,.:. " >:, company name XXX address. city . pht►ne# :.... . ntnrance co.;: olicy#.:< Failure to secure coverage as required under Section 25A of MGL 152 can had to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as dvn penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that s copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is a w.and coned Signature Date I�� 0( Print name _. F L " Phone# $ J-1 ! J official use only do not write in this area to be completed by city or town ofdal city or town: permit/license# • ❑Bufiding Department ❑check if immediate response is required ❑Licensing Board ❑S.1 Selectmen's Otbce ❑Health Depar�nrrnt contact person: phone#; ❑Other 0evned 9/95 PIA) L i s ✓/2G' CJO'!J L �� 2GG6'�6 I 5 HOME IMPROVEMENT CONTRACTORS REGISTRATION I Board Of Building Regulations and Standards One Ashburton Place - Room 1301 I a I Boston , Massachusetts 02108 --- -- ittOME IMPROVEMENT CONTRACT Expiration 07/09/00 Registration 103714 I Types — PARTNERSHIP I -- — HOME IMPROVEMENT CONTRACTOR Registration 103714 I — Type - PARTNERSHIP PAUL J . CAZEAULT & SONS ROOFING I Expiration 07/09/00 I Paul J . Cazeault I SONS ROOFI 7 8 1 AIEAULT 3 SO 2 J. C 22 Giddialt Rd . P .O,. Box I PAUL Orleans MA 026S3 I � Paul J. Cazeault ��22�>,ddialt Rd. P.O. Box 27t) I ADMINISTnATON Orleans MA 02653 Board of Build'n Regulations g One Ashburton Place, Rm 1301 Boston, Ma 02103-1616 License: CONSTRUCTION SUPERVISOR LICENSE Number: CS 026325 Expires: 10/20/2001 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 026325 PAUL J CAZEAULT Expires: 10/20/2001 Tr.no: 7665 1585 MAIN ST It Restricted To: 00 OSTERVILLE, MA 02655 PAUL J CAZEAULT 1585 MAIN ST OSTERVILLE, MA 02655 Administrator . CERTIFICATE OF LIABILITY INSURANCE 08/11/9 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Ma;tors '& Servant, Ltd. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 5700 Post Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 1158 Cant Greenwich, RI 0281E3 INSURERS AFFORDING COVERAGE INSURED INS UREHA:Transcontinental Ins. Co. (CNA) INNSUSU Paul J. Cazeault & Sons Roofing _ -RER-'..-.---R:----_...._...--_-._ ..__...-_-_-...__..-----_._....._......_..._._ __..._. . . ._ INSURER C: INSURER O: INSURER F1 COVERAGES TI(C POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY DE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSiI F'OIIfY FFFF FCTIVF PO U7;Y F..XPIf1AlIpN LI M115 _ LTA TYPE OF INSURANCE PULIICYNUMBER DATEIMMIDD p r� DAiE MM DO A GENERAL LIAUILITY C180024822 04/30/99 04/30/00 EACH OCCUHHENGt 3-1,O_00,000 X COMMEHCIAI-(;I:NEHAL LIA0I1-11Y FINE UAMA( E(Any unehre) S100, OOO _I CLAIM�ST MADEI �XI OCCUR MFD FXP(Any one person) SrJIfOOO --__ X PD Dell 1 , OOO PFASONAI AAOV INJURY 1.1,000, 000_ — �— [:ENEHALAGGHE(iAIE S2,000,.000 (iFN'1 A(i(iH FCiAIkIIMII APPI IFS PEN: PHOIIIJC IS•COMP/OP A(ifi L2,-O001..0.0.0.. ... Vol ICY X PH " LOC O 1FC1 AUTOMOBILE LIABILITY - (:OMHINFUSINU1.FI.IMII S — (E(I maidenly ANYAUTO Al 1 OWNkU A1)NOS BOUILYINJUHY S (Per person) SCHFI)lll.F1)AL7105 IIIHi-.DA1JIO3 HODIIYINJIIHY $ — (Per ecdAenq NON-OWNEDAUTOS -- PHOPFH1YDAMAGE S (Per ncudenl) GAHAG L•LIABILITY AU10ONLY FAA(;GIITENI S ANY AU 10 OTIIEH TI IAN HA AGC: $ ALIIOONLY: AGG S EXCESS LIABILITY - EACHOCCLIHHENCE I OGGUH El CLAIMS MADE AGGHFGATF $ S S DFOUCTI81F ......................_..._..__...._.._ ..........___. . ...._. . . S HFIINI[ON S p n A WOHKEH$COMPENSATION AND WC199413744 08/09/99 08/09/00 X iYpY IA 11t. IFI _ EMPLOYCAS'LIABILITY F.I..F.'ACHACCIOFNT i100. 000 - F.L.OISEASE-EAEMPLOYEE $100 000 FLDI^.EASE POLICV(IMIi 600,000 OTHLII OLSCAIPiION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER. CANCELLATION SHOULDANYOF THEABOVE DESCRI BEDPOLICIES B ECANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILLENDEAVOR 10 MAI L3jDL—DAYS WAIT]EN NOTICETOTHE CERTIFICATE HOLDERNAMEO T07HE LEFT,BUT FAILURE TO DOSOSHALL IMPOSE NO 08LIGATION OR LIABILITY OF ANY KIN 0 UPON T H E INSURER,ITS AGENTS O!1 REPRESENTATIVES. AUTHORIZED REPRESENTAjIVE Acom 25-S(7197) U S8 2 8 9 4/M8 2 8 9 3 BAM 0 ACORD CORPORATION 1908 —Engineering Dept. (3rd floor) Map 3 (` c, Parcel �o 'rr,Termit# J 7-] } House# • :F0� Date Issued 9 D Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) - Fee Conservation Office(4th floor)(8:30- 9:30/ 1:00-2:00) jefinifiv( ept.(1st floor/School Admin. Bldg.) 1NE Plan Approved by Planning Board 19BARNMBU,59.TOWN OF�BARNSTABLEBuilding Permit Applicationtreet Address Village Xt,YJ AJ JJISS Owner Address ' t� Telephone r Permit Request � d i 1j .� 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 ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New 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 Telephone Number . /(�7 Add re s License# , Home Improvement Contractor# Worker's Compensation# f'7(}&"d 6-, 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 .11 "' Pou,ADATE BUILDING PERMIT DENIED F THE FOL OWING REASONS) ' ,1` �.� FOR OFFICIAL USE ONLY A PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS i VILLAGE OWNER DATE OF INSPECTION: FOUNDATION Y FRAME INSULATION FIREPLACE E ELECTRICAL: ROUGH FINAL ` f k PLUMBING: ROUGH FINAL; -, 't GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT . ASSOCIATION PLAN NO. - ' t _ y � _ ___ The Commonwealth•of Massachusetts =`` -• Department of Industrial Accidents ::�� = � -:-1'�-� OIfiCC Of/QYeSlf�81/OOS .. •. . 600 Washington Street +i Boston,Mass. 02111 Workers' Compensation Insurance davit NNEIN name: A �E1�;`7 location• c city phone# ❑ I am a homeowner perfofming all work myself. ❑ I am a sole DrEll,netor and have no one working in any capacity ❑ I am an emplover providing workers' compensation for my employees working on this job. companvname• IpAut ui"pSeNs FBOFipi address- dtv- +M_RS'pnN phone#: 428-1177 insurance cn. olicV# ///// / // // ///%////// //// ////////i%%//////////// ////// /// // / /////%/////// / /lG//////;///,;,. ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: companv name: address: :.. city phone#^ olicv# company name: address• dtv •.... phone#: sw :::..:.. Wnrance co. :.. .;::. ollcv# Failure to secure coverage as requited under Section 25A of:11GL 152 can lead to the Imposition of criminal penalties of a One 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 line of S100.00 a day against me. I understand that s copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage veriacation. I do hereby certify under the pars and penalties of perjury than the information provided above is true and correct. , . Signature �'�, :' Date Print name PAUL CAZEA LT _Phone# a9R-1177 ofiidal use only do:vnites area to be completed by city or town o(IIdalcity or town• permifNcetue tt ❑B7uddinDel].=nnent❑L❑check if Immediate rered ❑Se❑ ntcontact person• phone t!• ❑ Qrvuea 9/95 PIA) �TME r, The Town. of Barnstable % s"atrsz�si.E. 9� � Department of Health Safety and Environmental Services '°rFo riot" Building Division 367 Main Street,.Hyapnis MA 02601 Offic,:: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commis For office use only 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 exceptionss,,along with other requirements. Type of Work: 11�.d A . \�4/oa-kk � Est.Cost��&M � Address of Work: �Y / kef37`/ C &a •• Owner's Name b W'A J)E /4 AD /U - Date of Permit Application: I hereby certify that: Registration is'not required for the following reasmn(s): Work excluded by law Job unifier S1,000. 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 th gent of the owner: /4:3? Date Contracto Name Registration No. OR Date Owner's Name 1 �~ ACORD,. CERTIFICATE OF LIABILITY INS�JRANCECSR DR 09 DATE(MM/DD/29/98/YY) PAULJ-2 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Drake,Swan & Crocker Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency, Inc. HOLDER.THIS'CERTIFICATE DOES NOT AMEND,EXTEND OR 14 Lot r s Hollow Rd. ,PO Box 429 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Orleans MA 02653-0429 COMPANIES AFFORDING COVERAGE - COMPANY David D Rust A Assurance Co. of America Phonetic). 508-255-3212 Fa.No, - - ---._- ------- III URf=D - COMPANY B Credit General Insurance Co. COMPANY Paul J. Cazeault & Sons, Inc. --C-----'---------------------------------- ----- P 0 Box 930 COMPANY Marstons Mills MA 02648 D COVERAGES 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- -----. ..._ POLICY EFFECTIVE POLICY EXPIRATION LIMITS r.'., IYPE OF INSURANCE POLICY NUMBER DATE(MM/DD/YY) DATE(MM/DDIYY) LIR I GENERAL AGGREGATE $ 1000000 GENERAL 05/01/98 05/ PRODUCTS ----------------- 01/99 PRODUCTS-COMP/OPAGG $ 1000000 _ . A }{ I COMMERCIAL GENERAL LIABILITY CFP25552812 -- --------- ! I - PERSONAL&ADV INJURY s 500000 I I CLAIMS MADE L X.I OCCUR EACH OCCURRENCE s 500000 OWNER'S&CONTRACTOR'S PROT ------ ' MED EXP(Any one person) $ 10 0 0 0 FIREDAMAGE(An one fire) s 300000 1 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ I I ANY AUTO --------- ALL OWNED AUTOS BODILY INJURY $ (Per person) ------ ___ —_-_ SCHEDULED AUTOS — — 1IIRED AUTOS BODILY INJURY $ (Per accident) 1 i NON-OWNED AUTOS ----- "--"----------- ,' i PROPERTY DAMAGE $ AUTO ONLY-EA ACCIDENT $ --GARAGE LIABILITY , ---- ------------ ----- _OTHER THAN AUTO ONLY: ANY AUTO -- -- EACH ACCIDENT $ ----- AGGREGATE s - I i EACH OCCURRENCE $ I EXCESS LIABILITY $ AGGREGATE _ } i i UMBRELLA FORM ---- ---- ------ $ I I Ol"HER THAN UMBRELLA FORM- WC STATU. OTH- tij WOIZKEkS GOMPEFdSAi iOhr nND I ' Y TORY LIMITS,_)_____ l 1 , EMPLOYERS'LIABILITY I EL EACH ACCIDENT $ 100000 B j THE PROPRIETOR/ }{ INCL SWC17005902 08/09/98 08/09/99 EL DISEASE-POLICY LIMIT $ 500000—_� PARTNERS/EXECUTIVE - EL DISEASE-EA EMPLOYEE $ lOOOOO OFFICERS ARE'. EXCL i OTHER I i DESCRIPTION OF 0PERATIONSILOCATIONSNEHICLESISPECIAL ITEMS ; Roofing. Corporation active 10/1/98. 1 } j CANCELLATION CERTIFICATE HOLDER _ 11 PEACOC 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL I l 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND ON T E COMPANY,ITS AGENTS OR R PRESENTATIVES. AUTHORIZE EP ATIVE� WJ I � � " ACORD CORPORATION 198 IACC I f , a � S `P`* �. sx,r ,�, d ,5�r� 's'"��x:s.w x l ..� #a` �" ,��t k.;,• tt„r �:.. "t ,�,;,,,. c�" „ 7G�iGG IJQ��Q�t� �,r?li��sL(.(.fK/��GLLtI�� o w y° �,� •.A �� } f Y� -T• "�"X:r �41 'Y• S T i Y� IF LiMD` e� . HOME IMPRO IEMENT A'TORS RE.( ISTRA �� -vim ti�.� One �shburt�oriP.T�ace��"'` R.aom .1•- 0>1• Bos-��ta�. MassacsMIX etts ,.='8 w '° hJQPIE I-1P OUE�1ElVT ONRAC ,QR - a xt < a Regiatratlon 0374 '" TSONSROOFING I � F11JL. J CF1Z AIJL� ,_ r TYP ARTNERSAIP k p Cazea4u�lt 3 �� I^ `. Ez� at�o 0710 /00 ��,� 5 CAZEAULT `S 5 O'OEI ;a�Tea.ns. M 02;658 � x, Q; . ON P.,A. azeaul't. "� �yx +�� `*s= Y h��y��M� •" #. �. ;��F. �ADMINISTHATOR Q �8a0 53. ..r , . [Kflt)'3TME,hdT OF PIJRLIC )AFI=TY 136726 ONE ASI•;fiURTCIN PLACE, FZM 1301 E30STO,N M,A 02108--161.8 rONSI-RUCTION SUPHZVTC 30f? L I_Cf PdSt" ' Number: Expires: € 1 Restricted To: 00. i =b �z PAUL J CAZEAUL`I' r 1585 Ma,]:t•I ST OST`E:RVILI-I= h1A 0265si •e;_ __. x r P - KQep top for receipt. and change bf address not,i.fi.cat.i.on. :,,, _ ✓fie >�ammw�uuea�:�o�✓�.Craoac/uael�a"� DEPARTMENT OF PUBLIC SAFETY CONSTRU6-4 `SUPERVISOR LICENSE F Nuetberc Expires: Rests t d7 B0 C7LtFAUIT 1585 MAIN`ST j: OSTERVILIE, NA 02655