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HomeMy WebLinkAbout0022 LIGHTHOUSE LANE o7a C.�G�i�ays� ��t/ i �9�liri�llib•��. / C��t �'�' � _ i lors��fe ', 3�Zollo I L� �,►,� of Barnstable *Permit#J`I V 40 4 'hg Department ree 6 nthsfrom issue date Brian B, ,� AUG 0 9 201� na Florence,C O ` i .19, �MAE& ' Building Commissioner O W N (A H A H i,�0,' " � eel,Hyannis,MA 02601 U 4� wn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY 30 f„ - j f Not Valid without Red X-Press Imprint Map/parcel Number �J(fJ 1 Property Address 22 Lighthouse Ln Hyannis, MA 02601 N Residential Value of work$ 27,000 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address HENKE, RANDY H & KRIS A 82 PURITAN LANE SWAMPSCOTT, MA. 01907 Contractor's Name Anatoli Sivitski Telephone Number 617-710-1001 Home Improvement Contractor License#(if applicable) 168043 Email: capecodinc@gmail.com Construction Supervisor's License#(if applicable) 106040 ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name AmGuard Workman's Comp.Policy# R2WC918542 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) 54 Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Yarmouth dump ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: •N �L�4 C:\Users\decollik\AppData\L.ocal\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXYWIRESIDENTILONLYEXPRESS.doc 09/26/17 e ' j {r f • BAPNSUBM NAM �, Town of Barnstable Building Department Brian Florence,CBO Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I,� Randy Henke ,as Owner of the subject property hereby authorize Anatoli Sivitski to act on my behalf, in all matters relative to work authorized by this building permit application for: 22 Lighthouse Ln Hyannis, MA 02601 (Address of Job) 8/9/2018 SignatuW of Owner Date Randy Henke Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\ 4icrosoft\Windows\lNetCache\Content.Outlook\9NNOKXYW\RESIDENTILONLYEXPRESS.doc 09/26/17 4 The Con moniveadth of Massachuseft 1 gwhnmt of Ind istriad Accidmb Office of Lwestigafions 600 Washington Shwt Boston,MA 02111 mvw• nays govldia Workers'Compensation Insurance Affidavit Baders/Contractors/Electricians/Ph tubers Applicant Information Please Print Lezbly Name(Bush>es$/Olganizatiwjhwividmty Anatoli Sivitski At &,= 27 Mill Pond rd City/State/Zip: West Yarmouth, MA 02673 Phone#: 617-710-1001 Are you an employer?Check the appropriate boa: Type of project(required): l_❑ I am a employer with 4• ®1 am a general contractor and 1 6. ❑New construction- employees{full and/or par"=).* have:hired the sub-coaftwtors, 2..❑ I am a sole proprietor orpartner lamed an the attached sheet 7. ❑Big and have no 1 These sub-oontrac1ws have ship employees T S. ❑Demolition and havewodws working for we in any,capacity. employees I 9. ❑Budding addition [No workers-comp.instrance: comp.insurance. required-) 5. ❑ We are s corporation and its 14.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all wodc officers have exercised their 11.❑Plumbing repairs or additions oworlrers' _ sight of.exemption per MGL� j i c. 152,§1(4X and we have no 12_ Roof employees [No 13120dter Siding comp.incumanrn requited); •Any apptitaat that cheers boa#1— also smut the,section below showing &vc&es''coaWsadim policy infumutiaa 1€bnaeon rs wbo submit dusaffulaitmilicatmrfty.netaing at1 w al and then hue outsi&counutors.must sub=anew affidavit indicating sudL ZCesmuctm ffm cbect.this bop rat stiaehed i additional sheet dwwimg&e name of the s;ub<amrKm and star wbeiher or not those enfi ies herbs ewplayees-Ifthe svb,counwarsbsae em phryees,they must provide Oak workers'ctmip.policy number - I am an employer that is prov&ffig tt vyke s'compensation insumnee for my employee& Below is the paq and job site information. Imumce Company Name- AmGuard Policy*or Self-ins.tic.#: R2WC918542 E p ration Data: 02/06/2019 Job Site Address. 22 Lighthouse lane City/5tatdzip. Hyannis, MA 02601 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$1,50G 00 and/or one-year' as well as civil penalties in the form of a.STOP WORK ORDER and.a.fine of up to$250.00 a day against the violator. Be advised that a copy of this:stittement may be forwarded to the Office of bavestigations of the DIA for it m mince coverage v ficat on. Ida hereby mWfy imnA r tihe pains and penaifin of perjnry that the information provided above is hate and correct Signature: ieQ�C S� Date_ 8/9/2018 p10#: 617-710-1001 Official arse only. Do not write in this area,to be completed by city ortaim o fficiat City or Town: Permit/License# laming Authority(drdle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector g.Plumbing motor 6.Other Contact:Person• Phone#: 0/. Q� h y 5 � � 5 ' r Office ofrConsumer Affairs and=Business Regulation Boston, Mas �h�usetts 02108 ;� f ` � Home Improvementractor Registration .'. , K" = r TYPe Corporation :,.: .,. Registration 168043 CAPE COD HOME.,IMPROVEMENT,INC.:, Expiration: :;12/Oe/2018 27MILL POND;RD WE 'YARIVIOWTH,MA 02673 Update Address.and Return Card. :sCn 1 4 204-W17. j e [Ggnamrmrc�ur�ea�l� avaac/ivaeli'_ Otfice of Consumer Affairs&Business Regulation .HOME IMPAOVEMENTCONTRACTOR= E Registration valid for individual use only TYPE: orooration before the expiration date. If found return to: e' istr"i Expiration Office of Consumer Affairs and Business Regulation 168C 3 ' 12/06/2018 10 Park Plaza-Suit CAPE COD HOME F3 DM - INC. ' Boston,MA ANATOU SMTSKI 27 MILLPOND WESTYARMOUTH,MA 2 , . Not°valid wit out:signature Undersecretary I JOU0.1ai ttk,It,UO .. fsttn jt t ttt L t � �9Z0 � 1hH ' O�Ml1A!A:1S�11ft 3 , Q f�:Od; tll�l! LZ . f are ,:tf p3 ' `a , `I�Siii.SilO'lNt�d } tti # r F'h.lFi. .y.}� 5 (SIk • � .� �, r� z s rzn�-. � � � t '�'"x}fir ' A7' IA— � g! at 3 ,�tfw�>] xs P3b. i7 x y ll w74s� � +r M4 ' 3ue 1ale rrc � ia �i� Itrc� pea .� 3 • p � `a�nsa�t � ar$sa © p tAt'G v` sasna: ssev r �l�anntourt © � �5 �-�4!� sASRFL4l21�R�5eln1 ACORO® DATE(MMIDDIYYM �. CERTIFICATE OF LIABILITY INSURANCE F03/16/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorseme s). PRODUCER MWAUT Victoria Sharapova ALD Insurance Agency Inc. PHONE 617-787-7877 FAX 617-787-7876 60A Brighton Avenue A/C No Allston,MA 02134 ADDRESS, comm@aldinsurance.com INSURER(S)AFFORDING COVERAGE NAIC d INSURERA: ATLANTIC CHARTER INSURANCE COMPANY 44326 INSURED Belcape Construction LLC INSURERS: AMGUARD INSURANCE COMPANY 42390 42 WOODBURY AVE Hyannis,MA 02601 INSURERC: INSURER D: 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 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. INS TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMID MWD LIMITS A COMMERCIAL GENERAL LIABILITY L270000577 01/14/2018 01/14/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR DAPREMISES Ea occurrence)T RENTED 100,000 MED EXP(Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑ PRO ❑LOC PRODUCTS-COMP/OP AGG $ 1,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ B WORKERS COMPENSATION R2WC91$542 02/06/2018 02/06/2019 STATUTE ERH AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN --- ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD +, TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Z— m Ai 1'mil ApplicationMap Parcel U1LD1�G06� Health Division SAY Date Issued Conservation Division 2 3 2017 Application Fee Planning Dept. OWN©r 8f1F?NS?-A8LE Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address e Village &eIVIA /S 17 Owner ,i l kiw Len e Address 0 ��c�i�l�®fie lase - a, iL) /W Telephone Permit Request -7'-` ' Chem f i3o f h ire yh e Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new. Zoning District Flood Plain Groundwater Overlay Project Valuation 20 Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. Dwelling Type: Single Family Z Two Family ❑ Multi-Family # units) Age of Existing Structure Historic House: ❑Yes No On Old Kin Highway:g g g s g ay. ❑Yes Q No Basement Type: lrf cull lB"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 FFuu I: d as ❑ Oil ❑ Electric ❑ Other Central Air: Q YesZexisting No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No p 9� g Detached garage: ❑ new size Pool: ❑ existin ❑ new size B rn: ❑ xi g g _ g _ a e sting ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION - --- �-' (BUILDER OR HOMEOWNER) Name`�� / �c� Telephone Number ��` �I '72 Ade License #dr ss Home Improvement Contractor# Email�oo°�J � 1s � / Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOE,'� SIGNATUkE DATE,�� l' Y FOR OFFICIAL USE ONLY t .` APPLICATION# DATE ISSUED MAP/PARCEL NO. a' ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME yC Id lZ FFJMA INSULATION jbig, Sh011 PFAA FIREPLACE r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING L DATECL•,OSED OUT ASS,OC.IATION PLAN NO. r, T'fie C'omnionivealds of Massachusetts Departrnewt ofIndustrial Accddents u Office ce of Invest gations 606 Was ington kr.eet Bp�o�sytm,,/,,9CA/0}2�11�/1� 4 , Iat t�t'u nimm,,gov/daa Workers' Compensafion Insurance Affidavit:B,udderslContrattorsfEIectr cians/Plumbers Applicant.-Information Please Print I.e�ibly Name usine snizationllndividnai" �p / ` (B ssfOrgs cicia�T ileJ / ,�;Jo✓t Address: �j� City/Stat&Zair—C jfdkLv1&eZa0� �2 Phone n � Are you an employer?Check the appropriate box: Type of project(required): 1_❑ lam employer with. 4. I am a general contractor and I 6. 0 New construction employees(full andlor.part--timed* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner.- listed on the attached sheet. 7.XR,emodeling ship'and have no employees. These sub-contractors have g_ 0 Demolition w g for me in an capacity. employees and have workers, or�inD Y9. ❑Building additarx [No workers'comp.insurance comp.imuranc>r f required.] 5.�We area corporation sand its 10_�Electrical repairs'or additions equrr 3. 1 am a homeoKmer doing all work officers have exercised their 11.0 Plumbingrepairs or additions myself[No workers'camp. right of exemption per MGL 12.0 Roofrepairs, ins Lance required.]s c:152,§I(4�and we:have no employees.[No workers' 13:0 Other comp_insurance required_] '*Any applic=4bat checks box#1 n=also fill out the section below shouting their watere compensation policy information. Homeovuaers who submit this affixhMI imc5.ratiag they are doing all wad and dm hire outside couuactors trmst submit anew affidavit iadicatierg such.: =Coutractors t wrllecY this bwc must attached au gdditional sheet showing the numeof the sub-contractors,sad state whether,at not those'eutitiies have employees.Ifthesub-contactorshaveemployee%theymatstpiavide,their warkers'tomp.policy number- Iam Matt etleploJ�er flrrrt isprouiding ttrorkers'coat errsa(fort itrsrirarrce for xr}*enrploS�ees Below is the pohcy arrrI1ab site nfarRrrrtian. Insurance:Company Name: Policy orSelf-ins.-..Lic. 1i Expiration Date: Job Site Address: %r1 -latle City/State/Vw: a.41,/1 0 � Attach a copy of the Ica -ers'compensation policy declaration page"(shoving the policy tuber 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 S 1,500:00 and/or one-year imprisonment,as well as civil penalties ja the farm of a STOP WOAY.ORDER and4 fine of up to$250.00 a day against the violator. Be advised thata copy of this statement may,be forwarded to the Office of Investigations of the DIA far insurance coverage verification- 1,do her cc�rtifj?ender the d rabies ofgerjury.t)rat tit 0 info rmatian provided above fs true arrd carrect Sim,ature. Date: Phone (racial rrse only. Do root write i,n tins.area,to be cainpleded by eiiy or toorit official City or Tam: PermitUcense## Issuing Authority:.(cu-cle one): 1.Board of Health 2.Building Department 3.( /Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Town of Barnstable Regulatory Services .r�.MAIM . Richard V.Scali,Director NAM *63 Building Division Torn Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable-ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder r+'s ein e ,as owner of the subject property I hereby authorize • .5•+.�o n e s 4ri mig e. to act on sxty behalf, in all matters relative to work authorized by this building permit application for. a..�. 4.P h+ prase l^nC Arms M (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. Sigriatvre of C Signature of`Applicant v +' VK 5. �4,. d `,s 4 .c. £" ��rduaa bi s �r�S i r" J4� "`' 4, t' Ai p -a I� ,gig..• .� � ., 9 a .� '�. " y "ra. ♦� #f 9' w�•+.�••;vr-,•v„2e S*" g ,�/ +T�.r y^'f� N �+41 "+ °k Y f V ' 'j�.'�/j��y :�'i{/�(}��p/9" Ykt' ,y ��,.'�( �T��`y"�:p� �.. 7 ^ t b - 5 ti: 'i Ai.l it 1`.ame ��°F �. �t ,u'�"'i `+,'a�"y �' � v �J,r�wd � �` �` `� + �•c� '� �i � .� ^tom i e �� x �„ s,a �°� ,� �'"� `Fae ' a s ; Al - _,. s,.; az�- � ^3�„' '-�*J '.a'�� t�`a � � K ,�' b W-, * a'`�" .�� �' �`�'ne �` � ' � � 's�, �� 5- Act, `,� N4 yg ., _ 7 s y k* -,gip zap" -; y �— �. -. � ,� Asa � �'" t 'fix �,� a. � _ N �e �panvnaaiuuea�c a�C%UGaaeacfucaeLta � - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: tration Expiration Office of Consumer Affairs and Business Regulation ais 10 Park Plaza-Suite 5170 a • ' 2r—� 03/21/2019 Boston,MA 02116 ROBERT SCO f�4- 'E-- % ROBEFIT JONES,110-4- j 01 206 Cedric Rd Centerville,MA 02632 Undersecretary Not v without signature u t; Massachusetts Department of Public Safety lugBoard of Building Regulations and Standards Lice9se: CS-103622 ?i� Construction Supervisor ri ROBERT S JONES 206 CEDRIC RD CENTERVILLE MA 02632{ y¢: Expiration: Comm�ssio er 03/1912019 Construction Supervisor Restricted to: Unrestricted- ich c less than 35,0001culbc feet(9 S 91 cubic meters) et rs)ofontain enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:1Nww•MASS.GOV/DPS / r i , 2128'w' 1a2"";i 1r 8r 50'a"I ^iI �7I1 '1 44a1 4 i I II i I I p I I I _ N- _ CA) O A N 146" e 12 _ � - - I a rr d- � rat mi I rvn I c) I ^tea — b 15-8 22,8" 36" ° ' - ------..-..._. I� O I I _ rrt N i O^ �0' 1 W1836 Lj� W4236 !'E mcn nA mco cVo ii � �- N O N tit B24-L BSF36 DW B3D24 VAL3 ------------------------------------------- --------------------- �p .. i v N „coco N N ,S I A -4 CD ml: N p cl Cl) i i ar. v ��•--------- - I I I co I ! 39 s — K 38" �-3J,8 w r� r ! I � I 8 N I a --- -- € I I - ih 63424)L BFH2O-L BOVIDT30 61824 cr) 3 ------ - 148 I 1516 SLSNFJ13C - I'll30 UUba88 4 L r - �192"i 162 20" 35" Grabill Cabinets �192rr1�162"�• � � - 6" Olde Towne door I I , ----38t6' M E12 edge/ P4 panel � Y-15" , h Beaded inset i 19 2� j ge 24 'I i 81. r o rlt� ,"4 tl 81-6`4 Kitchen and bath in x oO �.- - --- --------- ------- Bar bases to be Greyhound I °o I 36"-- - - - z VT3D338421 Clie pproval � Date: 318ViSN8V8:J®NMOJ -,AaC 33-" 90grr ZdOZ U 9 AVW 14 15,8" y 448rr IdK 42" _ 377rr _ 123 a" All dimensions _size designations 2020This is an original design and must given are subject to verification on TECHNOLOGIES not be released or copied unless - - i ICI 10 Cm E �18�/ISN�i�S 30 NM®1 8oz �Z Xdw t '.Ld3CJ ONIG-li s ,HE Town of Barnstable *Permit# I Regulatory Services li ee 6mohsfromissuedate s RARNSUBLE, s v m s,a $ Richard V..Scali,Director P5. O �p sbsg. ��m o YJ Jq �►�� Building Division m . Paul Roma,Building Commissioner �"" �. 200 Main Street,Hyannis,MA 02601 www.town bamstable ma �',9�' Office: 508-862-4038 14jf,, ,Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDE NWftONLY f —f Not Valid without Red X-Press Inz rirbd C r Map/parcel Number l t c ` tj p Address ❑Residential Val`ue of Work-$ Minimum fee of$35.00 for work under$6000.00 Owner's_Name-&-Address 1Cr�.v Ph r, 5We"w� See , /y1a 0, q 0 7 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑-I am a sole proprietor m the Homeowner have Worker's Compensation Insurance- Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(checkbox)? Re-roof humcane 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 {maaiiium.32)#of windows #of doors: *where required: Issuance Uthis 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 re ed. SIGNATl7RE�-> Q:\WMESTORMSUildmg permit formslMRESS.doc 0125/17 `d ie CFJ A.M. ►e6ut 4mffC�l3YSe� S �` iciest o,�F'a��Aceide�t�. Of LTwft 600 Wasbbgtart&reef i3baoz4 MA 021LI 'kPFV1�F17EF3��fiP�(�IR ; Workers' CumpteII8aG1rm Immarmce Affrrlavit B.uHd2r-doantractursinechmmmm&TlumLbers AmUcaut?uformatan PleaseFrin y eifjffsfg�-i-, !!" QO P.h o-tu 3>z - Lf�?`l -I 30 3 rice you an employer?£herkthe rapriate b� Type of project(required}= L ElI mn a employer� 4 ❑I am a gez erd confractor amd I 6. ❑New oomsfiucui n employees(full andkrparWime).* 1=eNredffte sub canhnctors 2.❑ I am a sale psopzietar arpartaer- listed Opine attached fit 7. ❑Rern deligg ship and have no emp)cgees • These mb-cmat<actars have $. ❑Demolition w a forme in employees Md.have wagwre oddab 9..❑Building additiaa jhTo warms'comp_insmaace G°mP- 1 affrcers have emcised - 5.❑ We are a carparatim and ifs ld❑IIr.Et�icai repairs or ad&&= 3_ homwzmw 1L❑Plumbsmgrepairs arsddiiiofls. [No wCX1MM•gip- of em=42fica per M-GL L❑Roafrepais �r� rye rec}mi=edj Y c M§I{4h aadwe have no e=F109em[soWDA=e uEl fltber cones imsmzce required-] •$.ap xpg€®t$�stcber�sbas F<1 mast also SIla�tht sec�cabeT.owst iheawodceis"�pe�atiaapeTsyi�aamffiea tidm saw�s afF Y amd®�e1F�so3r aad�eea}�aatside c ct�snQct svkmit zuw afr t-md3aogy W rT, iCasa�csSasi cher3ci�is bna i z a mad�.ad�tiffisl shed dSax�g t�taame of the s�c�cEc��d st�etrls�h�araattbnse eati�es emnbyus .Tfthesvb ram*ar+�+Fbare emgTo c5eym¢sspmtiia�rhea Rom'tamp.gafi�manbet lam arc eaiper flirrt is prQuirlirrg�vorlcers'comrtsaticrt irtsrirancgnr m�r_mtpl �ees BeIoFv is Elie prrlicy rind job sus �-formafcaa. _ _ Iasmraace CmmipanyiXi me: •Paficg�or Self-ius.Iio_•� aaD� Job Sit�Addaess_ C¢gl5tafefp: Attach a.—campy offhe warders'compensationpolicp decEwation page(shawing the policy rsm^caber and espsation date). Fannie to seance cmvmwffl as rejuimdunder SezfirF 25A of MIM m 157 cam lead tin the imposition of criminal penalf m of a fine ap to$L 50D 0G andtor a6i�yearimpdsm as wen as rim peMMI&S.sa the form o£a STOP WORK ORDERand a fme of up'.to. a dap a6 t&d violator. Be advised'gat a iuW of els.sfatement=ybe forwarded to the DEf a of Imtestcgaf ns ofthe DIA for izlsmmc-covemga verifitafiom_ Ida herej?Y Gff*fF ru t1m D " s andP9,uakj4qfpzdW7 thntthe ire,f bnrsatimrprm••rcdabm a is bus and cw=L CPhaae s �, 3n!- -/t" Orwiid use rudf Da not write in ffia area,fit be crru4A!&d by cYy artown anal 01porTasrm: I'e itfLicease; LssuimgAuffiority(carle one): I.Bow d of mg Degarftnmt 3. row e 4AIecfticalrkspector 5.>1hmhiif r Com#art Person: Phone 9: ! i �� ri � � i � I u_ ru■ .a. i v ter- •:..w .•w 1 gnu . :■ .. •I ■ /" - •n ter■ r•n■u:■ .0 u■ of i■ 1 nuu • u •Ju n i■ L rnul- .n �•u I - • u■�• - �ftlri R ■ n•t• �• ■f: •I •'■1■twt ■ Ji 1I I • t. ■�In■�■ : so Is n/t' •11 •.• •■�■.•..• R.rlt:1■•.i r•l is■f=l••I■ •/ ■■t -'J: �+/ni• •i _■■' ••. •1 ■■/I • ■l- [■ •t■• �■J';r/ .. 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I ■■■ •I I• ■■ 1.1 1■t[■G - •.1■n l • r�1 •� ■ • U..• 1 ■•. • ill�t •■I - J 1 ��■i1 ■•1■ - ••'1•i • MI■ /iI■ ••Y.•t■ t1_ wn■� • ■�■t.1 ■• ■�/ l• .■t• ■•Y11 w. • r•1I■■•! wr •i!■n11 �■ 1 •�f.•it � �■rat w■ [. .•11■[r w1' n ■■•: I •- . ■■ - • ■ •..�1•'.l1■li ••■• / ... n n..■ •.1 n I .ti w In ••i r••■i!■:1■/It _.■■ ■•• ■ •1 ■ .t. ••:•.•■1■ �■ �'•'t ■■■iit :■n w.R 1 iN•a•11 .16/ Y.. ■iL■1 I r �•ptrt ttt:;t i u1137.Vt• ■ti■ t. ��p �- i ■ rvU= ■ / i i�� �.�.wltllt• t■±t t ii in ■ a-t \ • �1 ToWn of Barnstable Regulatory Services Richard V.Scan,Director - s ►� Building Division. Paul Roma,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 as Owner of the subject property hereby authorize to act on my beb4 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 Signature of Applicant Print Name Print Name Date Q:FORMS:OWNERPER&SSIONP00LS Town of Barnstable '. Regulatory Services j. Richard V.Scab,Director Building Division BAMMMABM = Paul Roma,Building Commissioner ��ig 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print number 7street village �xoMEowxER^: -° L--'�--y---� name home phone# work phone# CURRENTMAII:1NGfADDRESS: _._ �u/a�w5o Sct9 17,0` 0 J90 7 city/ wn state zip code The current exemption for"homeowners"was extended to include owner-ocMied 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 OFHOMEOWNER 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- f unily 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 proced and rcn ments and that he/she will comply with said procedures and requirements. P $Ign �0 meowner . 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 helshe 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. QWPFII.ESTORM.S\building permit formslEXPRESS.doc 0620/16 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �tt �� W Parcel Application # CD Health Division i Date Issued 3 ' Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic.- OKH _ Preservation/ Hyannis r rd Project Street Address LAO Village V\ ,S Owner ea .�- 4 QA Address 92- JR t- ,54 Telephone Permit Request) o Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project-Valuatio , Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name' SA 11 49 Telephone Number t 79 9 —� 3, 9 Address v`. License # Home Improvement Contractor# Email r � � ( : �`��� c CO M Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO )14 SIGNATURE r DATE 3 /D / & FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL T PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING '1• /A,O 1pc�/.- ��6JI7 RXL4, . �i v �oti�P CtcPe- DATE CLOSED OUT ASSOCIATION PLAN NO. i . 27m Corrtrtrarrrveafrft of-Massachusetfs Deparhaam afrndustrid Act de7z& Office afLnw�dgafirrxts 600 WashhWon Street - Boston,MA 02111 ' kc�vts..ma��ov�diri Workers' Campensafion Insm-ance Affidavit:BBnsldersICantractGrslEIectriciansiThmibers Applicant Iufarmai GU Please hint Le��I'y yNa= . Address Are you an employer?Check the a propriate bom T of project r 4. I am a general coatractcx�artd I Fly FT°l � ���= I.❑ I am a employer with . ❑6 New eonstrauction employees(fall an&or partrime,* bave hued the sub-coatractos 2.❑ I am a sole proprietor or partner- listed as the attached sheet. 7. El RemodeHng ship and have no employees. These sub-confractors.have g_ ❑Demolition wow for Sae in any capacity. employees and ha,,a wadi n' 9. ❑Suitdmg addition O W06M S' Camp.iMSMIE M COMP-msuranC10 5. ❑ We are a corporation and its M❑Electrical repairs or arldiTtions d 1 officers have exercised ter 1L Plumbin r arks or adclitions 3_ I am a homeoR�er doing all w� ❑ 1} eP myself[No workers'gip- right of exemption per MGL 12 0 Roof repairs. i„n=ce required-]1 C.I52:,§I{4�and we have no employam[No worlMs' 13-0 Other comp.it=ancn require&I ;Any app5czatfst checlsbos K mast also M o=the sechianbmT s3tcrtsiag dmirvm&Ers'compeam nparicy ixd=zuan.. Hameownas ¢ho subs dds Ada«i-K-Hpg 8tey axe+k<zU vrc&sad 8ma hire amide contmi+samst submit anew affida&mdirsaia sm-li fCoatzactm tbsr chwk this ban mast attached as addidanst street showing the name of the sob-eombsdo-s cad state whMher ornotthose amities ha— omplayees.I€the ff-cnn�bwa employees,t6eymustpmxidelhek workea'comp.parity numbm -Tam an elrtplayer tliatis prauidircg worker$'comperesrdzart uzmzrauce for nzy errrpla}wes $eloev is fltepv&7 and job site inforazadviL Itnsumce ampanyName: 'Policy-4 or Self-ins.Lic-4: Expiration Date: Job Site Address: citylstateMw: AE#ach a copy of the workers'compensationpolicy declaration page(showing the policy number and expiration date). Faf1ure to secure coverage as required under Section 25A of MGL m 152 can lead to the imposition.of criminal penalties of a fine up to$L 50DOD and for one-year imprisosrnenf,as well as civil penalties is the farm of a STOP WORK ORDER and a fine of up to$250-00 a dap against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Irrves(dgations of the DIAL four insurance coverage verificatim .I da hereby cai fl,wr&--r a andpenaMes o,fpej�zzrg that the in,formadva prinuW abate i;tarn and correct Si�afure: Date- 3 Z2 Ah Phone A- '7�� {'Dial uw only: Da zint wrrte in the area,trr be catnpl'eted by city artann o,of at City or Town: PennitUcense it Issuing-Authority(trcle one): L Board of Health 2.Building Department 3.CftylTown.Llerk d:Electrical Inspector 5.Plum-bing Inspector 6.Other Contact Person: Phone#: -- -- 6 ormation and lascons Massaalr=etfs Gebczal Laws chapter 152 requires all emgloyeas to provides woEkeas'compensation for their emplayees- g this ,an�Iay�e is detm ed as¢_.every person in tie seaYice of another under nay canract ofhire, eXpress ar i=plied,oral or wZh=." An ezrzployer is defined as an indreidoaI,partnership,assoaaiia 3,cozporadion or other IegaI er�ty,or any two or more of the fof eg-oing engaged in a Joint=bzpdse,and includnig the legal repmsent6ves of a.deceased employes,or the receiver or trustee of an individual,per,association or other Iegal entity,employing emPloyees. However the owner of a.dwelling house having more than trree apartments and who resides therein,or the occupant of the- dwelling house of a mfher who employs persons to do maihteaaace,constaction or repay wok on such dwelling house or on the grounds or building appmtmant tiiereto shaIl not bmanse of soda employment be deemed to be an employees." MOL chapter 152,§25C(6)also sues that"every sty or local Hcewdng agency shall withhold$ie issu_n ce 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 ofcdmpuan.c e with the incnrance.cove;ragerequired" Additionally,MGL chapter 152, §25C(7)stafiz!s'Neither the caannamwcaltb.nor ally ofits political subdivisions shall ester into any contract for the performance ofpublic wad mmI acceptable evidence of compliance with the immnmioe._ mjo ir=erts of tuts chaptE'have been.presented to the coon ft g aofhozity:" = AppIic�ats Please fill out the workers'compensation affidavit completely,by checlang e,boxes ffiat apply to your situation and,if necessary,supply sob-contactor(s)nail;e(s). (m)and phone mmober(s) along with their cm ifrcate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Parine=hips(LI P)withno =aployees other tm the members or pmineas,are not reqafi-ed to cant'workers'compensation i so:a m If an LLC or LLP does have employees, a policy isrequired. D c advised fast this affida-yh may be submitted to the Depaftment of Iudasfiial Accidents for contmmafim of m- sm-ance coverage. Also Be sure to sign and date the affidavit The affidavit should be retnmed to-.e city or town that the application fur the permit or license is being regnesied,not the Department of Iudast A=dmtz Should you.have aay questions regarding the law or ifyou are rcgan ed to obtam a workers' compensation policy,please call the Departmerh at the n=ber listd below. Self-iustaed companies should entry their self-insarance,license amber on the appropriate line. City or Town OfFi als f. Please be sore that the affidavit is complete and printedlegEb y_ The Depa hnCUthas provided a.space at the bottom of the of Lda-vh for you ti)fill out in fhe event the Office ofInvestigaiious has to contact you regarding the applicant Pleas a be sure to flI in the pent cent number which will be used as a reference number. In addition,an applicant that must submit multiple pemtllicense,applications in any given year,need only submit one affidavit indicating coareot policy ini :omation.(if necessary)and under"Tub Site A s"the applicant situ*old write"all locations in (city or town):"A copy of the-affidavit that has been officially stamped or ma imd by the city or tows may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses Anew affidavitmust be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercialventaro (ie.a dog license orpennit to bmn Ieaves et--.)said person.is NOT regnaedto comple#e this affidavit The Office of Investigations would litre to thank you is adymce for your cooperation and should you have:any questions, please do not hesitate to give us a call The Department's AE S1c telephone and f number. Canmjm t*of Massachusttts- Departnmt of Ii dial Accidents Bastou.,MA Q111 Fax#617-727 7M Revised 4-24-0 7 g� Town of Barnstable Regulatory Services ��aF raiy� Richard V.ScaIi,Director Building Division r RiRNAS& « Tom Perry,Building Commissioner p$ � 200 Main Street, Hyannis,MA 02601 qED � www.town.barnstable.ma.us Office: 50 8-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION DATE: Jos r ocAnow) Z a, Ll number viaagc -xol,Moana - V40-%krV—, ,c � 7b'1-Sq-R -y S57 312 -*R7-l-3o3 • name I p home phone# work phone)# CURRENT MAILING ADDRES S:' 02. ! 1 �w_� E�� 6i,Cb owSClJT7' O A0 7 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 OR 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 buildingRermit (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 pro cedur and r creme is and that:he/she will comply with said procedures and requirements. 'S,i,gnatLA of Hom" caner x Approval of Bnilding Official •.Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Budding 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 109JA-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 helshe understands the responsibilities of a Supervisor. On the Iast page of this issue is a form currently used by several towns. You may care t amend and adopt such a formlcertification for use in your community. Q:1wPFIL ESIFORMSIbmlding permit foffis1EYPRESS.doc Revised 061313 � ,ET y Town of Barnstable Regulatory Services g` Richard V.Scan,Director TEo,,u,c Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, ,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. (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. 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