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0301 LINCOLN ROAD
- __�------- I - - -_-- _ i I� i ti ' r Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 3/18/20 Brian Florence CBO Town of Barnstable ION Building Division o 200 Main St. TO%, 9y-p �A�' Hyannis, MA 02601 OP OaQo %4 _ RE: Insulation Pew rmt 20=276 ��F Dear Mr. Florence: This affidavit is to certify that all work completed for 301 Lincoln Road,Hyan_ nis has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey Town of BarnstableBuilding PostThis Card So That�t,is Uis�ble From the Street Approved Plans Must be Retained on Jo;b and„th�ssCard Must be Kept n wasp P.osfecl,Until Final�lns ection lias Been Made" � `�� ;` g;' �y . • i639� &, ..a ., , ., ;n- Tv, . <.,:.s r�y� ° Wshere aCertc to of Occupay is Reqred such Build g shall Not be Occupied until a�Final Inspect�onhas been made Permit Permit No. B-20-321 Applicant Name: BARRETT,CARLOS A&OUTAR,TAMEIKA Approvals Date Issued: 02/20/2020 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 08/20/2020 Foundation: Residential Map/Lot: 271-131 Zoning District: RB Sheathing: Location: 301 LINCOLN ROAD, HYANNIS Contractor Name Framing: 1 AL Owner on Record: BARRETT,CARLOS A&DUTAR,TAMEIKA? Contractor License: 2 Address: 301 LINCOLN ROAD - tk,Project Cost: $35,000.00 Chimney: HYANNIS,MA 02601 V, P"ermit Fee: $228.50 { � Insulation: Description: finish basement with 1 bedroom, bathroom,storage area 9small Fee Paid J S 228.50 kitchennette no stove, upgrade smoke detectors Date 2/20/2020 Final: Project Review Req: Not to be used as seperate dwelling intenor egress�to be G mantained Plumbing/Gas Rough Plumbing: Building Official , .. v This permit shall be deemed abandoned and invalid unless the work authonzetl byifhis permit is commenced within six m6nthsg6fter issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents,,&&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 ng by laws,and codes. This permit shall be displayed in a location clear) visible from access street orr'oad and shall be maintained open for ublc ins ection for the entire duration of the PY P P P Final Gas: work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable signatures by the'Bwlding and Fire,Officials are provided don this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work: kmy f, Service: 1.Foundation or Footing a � y 2.Sheathing Inspection y r Rough: 3.All Fireplaces must be inspected at the throat level before firest flue llinn ng is 4.Wiring&Plumbing Inspectionsto be completed priorto Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: f ~ Application Number........ .. o .... 1......... * MA S. * Permit Fee........ .. 41.....Other Fee:....................... 039. TotalFee Paid............................................................... ...... TOWN OF BARNSTABLE Permit Approval by. k.................On... .s �-�O w� BUILDING PERMIT `` Map....... ...? //.`...................Parcel............1..�,7v.................. APPLICATION Section 1 — Owner's Information and Project Location Yroiect Adddress O� �,.;p,�0\,•� �C 60twh;S ^%A czL" VillageSCAM 1''�� � r x . FEB 2 f .+F-' �...—w'-may";„y. Owner Legal Address `2z, t� vx co�V% '""�""� i' x C City vt®t v` S. State . ,E Z p i fl Owners Cell# n 10 Section 2 —Use of Structure — � cn Use Group ❑ Commercial Structure over 35; 00 cubio feet 0 ❑ Commercial Structure under 35,000 cubQ feed' ❑ Single/Two Family Dwelling Seq on,3, Type'of Perini�t ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) R Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment © Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Pool ❑ Insulation Other—Specify ��=`?Section 4 r'Work Descriptions,••. . �.: <-00VVN Last undated: 1 l/15/201 R i Application Number................................................:... T� Section 5—Detail r Cost of Proposed.Construction coo_/ Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring,Aar ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing; ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ municipal, El on Site g P P , Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed E Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No .il Last updated: 11/15/2018 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ww>N.mass gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers . Applicant Information Please Print Leeibly !CNaIIle(Business/Organization/Individual): i�VIZ—��KID 1 (E'`1\ Civvstate/Zip` tw�,S V%111 OZ 6(0 Phone#: Are you an employer?Check the appropriate boa: 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.❑ 1 am a sole proprietor or partner- wed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: 5. We are a corporation and its 10.❑Electrical repairs or additions 3..> I-am`n'.homeowner doing all work officers have exercised their I L EI Plumbing repairs or additions myself[No workers right of exemption per MGL comp. 12.❑Roof repairs insurance recp*ed.]t d c. 152,§1(4),and we have no -employees.[No workers' 13.[1 Other' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. , I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-.ins.Lic.#: Expiration Date: Job Site Address: F 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 re4uired 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 p nalties of perjury that the information provided above is true and correct. _ � . 2 Z-- ` 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers toeprovide 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-contractors)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 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 burnleaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would bike 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 r face of bVestdgations 600 Washington Street Bost M MA 02111 - Tel.#6.17-727-4900 eut 406 or 1-877 MASSAFE F49 Revised 4-2407 ax#617-727-77 � ' wwwt mass.gov/di& TOWN OF BARNSTABLE PERMIT CHECKLIST r Ml if9Sf"":'iLt•.,.r'�t!'.�s.^.i+u +' '�.°C.L.YA�,XC'"SW IG' tt. Sign Off hours forn � Health A co We pit Wtkadon Includes Ping 411 moans 1-13 ' -I.,NEW,STRUCTURES/.R,EMODELING/RENOVATION%ADDITIONS a. .Site Plan showing setbacks of proposed and existing structures commercial-One complete set of fall sized plans one reduced 11"xl7" (plans may require a stamp by an architect or engineer). X ❑ Residential -5 Sets of floor plans no larger than 11"x 17"smoke/co detectors marked ❑ Worker's Comp.Affidavit and policy(if required) ,,❑Res Check or COM check from the 2015 International Energy Cod Council(IECC) �tter of financial Interest for new houses only(not required for rebuild after teardown) �rformance bond made out for$4.00/foot of road frontage(new construction only) 2. DEMOLTION OF A BUILDING (NOT PARITIAL) ❑ Everything above plus shut off letters from following utility companies: Gas ❑ Electrical ❑ Water ❑ Sewer(if required) 3.-DECKS/PORCHES/GAZEEBOS/INSULATION/SOLAR/POOLS/SHEDS ❑ Site Plan showing proposed location ❑ Construction plans-showing framing detail(if new , ❑ Pools—Barrier details, pool specs(en ' rs design) ❑ Workman's Comp Affidavit and cy(if required) FAMILY APARTME ❑ Section 1 Plus: ❑ Family Apartments are subject to approval from the Building Commissioner. Agreement must be signed, notarized and recorded at the Registry of Deeds and returned to the Building Department. .90A LWCDLkl r0i 44AMIGS MA . I 54�5E Mt/vr' 04(5/66 WALLS W ►�S WIT14- �X-4 WALL, 6 12A� Fa.4XI 1A1614LA-1IOA,1 51j�ef o t- 51b FI AE (DbF, qO 1'411I5 9-,gILIA)6 /h/s OLATa-b Wt-rl r1 8E�a- QASS ? N9'DLA-TI-O/ gA �34fE�Tgoc�lt-, Ftv-f 0-0,bS90 1.14Y AJ-S Ln NM 1,0,-A -�o CD - a � z ® rr Town of Barnstable REc�EiPT WASS 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-20-321 Date Recieved: 1/31/2020 Job Location: 301 LINCOLN ROAD,HYANNIS Permit For: Building-Alteration INTERIOR Work Only-Residential Contractor's Name: State Lic. No: Address: Applicant Phone: (Home)Owner's Name: BARRETT,CARLOS A& OUTAR, Phone: TAMEIKA (Home)Owner's Address: 301 LINCOLN ROAD, HYANNIS,MA 02601 Work Description: finish basement with 1 bedroom, bathroom,storage area,small kitchennette no stove, upgrade smoke detectors Total Value Of Work To Be Performed: $35,000.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area 1 hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: BARRETT,CARLOS A& OUTAR, 1/31/2020 TAMEIKA Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $35,000.00 Date Paid a Amount Paid Check#or CC# Pay Type $228.50 __.— Total Permit Fee: $228.50 1/31/202022s so cash ..... .. ..... k ........ ......... .# .......... ........ ..............F..................... ............. Total Permit Fee Paid: $228.50 AM TT ISINQTA PERM71 IT Z A 'S c 30A L lNCOLIV 6zD HYANMIS, NA �► YKE DETECTORS REVIEWED; FRQWT BARNSTABLE BUI DING DEPT. DATE FIRE DEP ROTH SMAT S k-Y:RfQ _�. (fIRF!�FOR PERti+IITTING Llv►t46 kcbm 'o I C ( � A ' ff SCANNED E FEB 2 12020 ,rL,81' � �Qb®nn r s�1I m _ t ZL t 1 1'�C �N Z a C � $ 3o f MUDROOhA O 4.4 _ r 0 � i � 13�D ROOAn _ � � tea, �F r Li t �1 Z -7p 1r B b ' 9® w 1d ®��d a �'1 f 22 .,Q In A/ CA 1 Q t I � 3,4 CID Lb 17 L � n' -e � LiviN RDDM r 9 � t . �9 RV I c NVI l z � a1 SN NA1,011. o TO 1 0 BARNSTA8�E �A ilk 020 4 N3 ! AM 6: 40 � BSI �N c Lj 10 i , ; � _ - � � r � � - r Application Number............................................. Section 9- Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # 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.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors 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.Attach a copy of your H.I.C... Signature Date �:� . "/Section 11 ..:`Homeowner'"sLicense�Ezemption:�n.►. r.�.STnee•.4ro•v, w w.. s ..t �" a'T•7sTi.. .�..xy.L. o'ik.5�r°'4 Home Owners Name:, �� T �- Telephone.Number jXi, 104 Z Z3 Cell.,or'WorkNumber y: Z`tZ,' 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 V' fDatep�' ..- 2 APPLICANT"SIGNET ° ¢ 4 Sipatuke -. /Date 3, -2o Print Name ;� yy1;GKr4- Telephone Number /> . .. E=mail permit to: /A c�U-6� d-Hoc) G�w� Last undated. 11/15/201 R Section 12 —Department Sign-Offs f� Health Department ❑ Zoning Board(if required) Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13 — Owner's Authorization 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 j ob) Signature of Owner date Print Name i Last updated: 11/15/2018 Town of Barnstable Building s 9AMSTABiL* Post This Card So That it is Visible From the Street-Approved Plans Must.be.Retainedon Job and th-is'Car>d Must Kept ' Posted Until Final Inspection Has Been Made.— 'Posted , p Y 4 _ i s Where a Certificate of Occu anc is Re ulred,.such Building-shall Not be Occupied until a Final Inspection'has been made Permit No. B-20-276 Applicant Name: William McCluskey Approvals Date Issued: 01/30/2020 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 07/30/2020 Foundation: Location: 301 LINCOLN ROAD, HYANNIS Map/Lot: 271-131 Zoning District: RB Sheathing: Owner on Record: BARRETT,CARLOS A&OUTAR,TAMEIKA - Contractor Naive:,William J McCluskley Framing: 1 ` Address: 301 LINCOLN ROAD Contra 102.776 ' 4 2 H € � F9 Est Project Cost: YANNIS, MA 02601 $5,000.00 Chimney: Description: Add R-38 fiberglass, R-49 cellulose,and R-13 fiberglass to,-the attic. ; .= Permit Fee: $85.00 Dense pack the walls with R-13 cellulose.Add'R 19 fiber lass to the ? Insulation. g Fee Paid: $85.00 basement. Air seal the attic plane and basement with expanding ' Final: foam. General weatherization. ��' 4 Date:' 1/30/2020 Project Review Req: Plumbing/Gas �( 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 b this permit shall conform to the approved a l catiori and the a roved construction documents for'iiwhicK-tfiis permit has been ranted. Rough Gas: Y p pP PP � PP � � P g All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by,-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public-inspectio,.n for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures liy'the,Bulding and'Fire Officialsa�r'�eprovided on this,permit. Service: Minimum of Five Call Inspections Required for All Construction Work:) 1.Foundation or Footing =. - Rough: 2.Sheathing Inspection � .� .�• _. . 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 *Permit �EtFiE TQ�,._ �OW� O�Barnstable Upires$months from a date . ..._. :Regulatory_ Services.... Fee.. - v $ - _ Thomas F.Geiler,Director �'OrfDMP'tp,�---• _._ �. :...._..$wilding DiYiSion ® - �. _. ._ '--Tom Perry, Building Commissioner MAY 7 2005 200 Main-Street, Hyannis,MA 02601 Office: 508-862-4038 A Fax:•508-790-6230 -''- XPS : RIGITTpYOA'�'TON - 1tESID�NTIAL ONLY. Not Vaud without RedX--Press Imprint Map/parcel Number Property Address so 64011 esidential Value of Work > C� G�Minim fee of$25.00 for work under$6000.00 Owner's Name&Address ? Telephone Number�S�Dl�� Contractor s Name ����%� `� Home Improvement Contractor License#(if applicable) /fl?� 09 Construction Supervisor's License#(if applicable) []Workman,8 Compensation Insurance Check one: ❑ I am a sole proprietor C1I omeowner ve Worker's Compensation'Insurance Insurance Company Name Worloman's Comp.Policy# /C Copy of insurance Compliance Ce cate must be on file. permit Request(check ) e-roof(stripping old shingles) All construction debris will be taken to_ � � ❑Re-roof(not stripping. Going over existing layers of roof) D Re-side Replacement Windows. U-Value (maximum.44) *Where required: Tssuaace of this permit does not exempt compliance with other town depmtnent regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Co ctors License is required. Signature Q:Forms:expmtrg Rzvise063004 • • 'R v hqG � . QO 1wr� IiA �c Go c� o K M o Ua �. . . ' cm �CFq h CD • U9 Cif m rn p Vl Fj td t't ' K ram+•, � _ 4 Oot- tj nt cn r�. rt O I'd . ``� U o rn oa �o o w i The Commonwealth of Massachusetts Department of Industrial Accidents office oflnuestioatfens _ 600 Washington Street, 7`h Floor '� ---- Boston;Mass. 02111 - Workers' Compensation Insurance Affidavit: Buildin /Plumbin /Electrical Contractors ame: address: city state: zip• R.hone# work site location(full address): ❑ I am a homeowner performing all work myself. Project Type: ❑New Construction❑Remodel ❑ I'am a sole pro rietor and have no one working in any capacity. Building Addition_ [fin an employer providin workers'compensation for my employees working on this job. • }:. ,y,e .a t _rka. -t ?f•Ja �£fr: _."'Iil i ,t" r S. ` t,e»n ` ^'�1 t - :,3.., �!;r ;�`^a i'"'•yr�' � r.'++y{.' h�rdz'$q ,/+'� "iY ,' * ,fir'3''- �' iy'r t i f u ' .'�:. .J' -tit . � ?y''P t -4,...d .r, r^:�cu :1.4a,�.1�.. s5y Fr4•a�,.i�1:5c4 f �yr r. '+': } j�-':,;�r,,,,.{�:• r✓, ' ;b f. ,`.'f:,F �v',*:. 'd � T.: #�F.::t •M.�-.^+'x�:�.vrY'.'�t�..:�.r.,y�e.-a.:%%:4�-{ t _y i:::�.:':"+'� .—. .r� - ",."1`hi. �'' .e-rF, 'S'�'e. .°, >J � ..� 5 c s'rN C••.:. - 'r ' {r:: G. e•.'y ,} >.ri„ . ! e �,' 'F�'�1'+'��xm�- ° ? �'' '€'n rt +r#. � s<n f♦ + `ki r � ,'S: Kr; � ' t'' Y• h"'�,{� , '',t11}<.,�,�� 'WZ w� 'kY�y,,,,x $" r t ''Cl 'r _ .xr u� c 'R'•'Ta,+•�•t3..�G>a"4...� :Rerr `L :a,c M. {'..y , a ;`� t''"r ,.i-.:g<k �.*i4'a.'r y}rr 'SA r i•..�� t� r� z�, a�' c F �,'r"FyY♦ ti •i 3 � [„S �M1 ; ,�, '•. 'ry v:� "Z S r ✓ '�v n:' �` k< c$* !''4 �. ,C�'t':r S'�,:t .+r. :k a X-^a�.�ti,;a'4� ,.r�e �, � r � ,s '� r ka�;�- si � L� ut JK• •1 J tiY_ •+• ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the followinFgr�workers' compensation polices: _ _ _ _ ,T - .1..:. Mi'AJI.Vc, ':tT.+:v - ::!YX•:4,:i %K.:.:eS_;%',.y.,: r<rn,:. -;:A•�<s35::•,�' L.�.fa� �": Ma>.': .>_,i�::3': w, ...�n. _...1_....a .,r ..:rt r..r�„ � .,. .... •r. . .. . :rt.r ..a,ir:..,• b. > e• is +r„'i..: ..t.r ,• .>#,r .'.i�:Y+ ,,- ^, :-:£+�'.:.' •.°.!t:'; ur^z t;�i r.. _ i J•rY: a. +y 5 :r `.ry•7 5.< .V. .fit r.: ti` r �Jt a r.. - a"d��e�sw•::�r-,:❑.t�:d,,g, q ;•`.' . � ��r ,h r a,K •t 5. s r # .. .. • S ( .,51 � 'rtL-.[� � Y +`\ a' YZ ji ,,k dft,91 1 � .J �atv phone# : n,.^.FA [C 4.Ecr J ✓�.,'J LpF ,r ° ! J _�, 1 G+. SF ..' rt l t : ,.v+,.�.< r... ..-?•. _:-x.. ..< ._.,:._....,, _ �liC..:' .. _ e Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a 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 ofp7ury that the information provided above is true anddcorrect Signature Datef Print n A�L ine a z� �//�Q d F0,b'eck e only do not write in this area to be completed by city or town official n: permit/license# ElBuilding Department' ❑Licensing Board if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone N; ❑Other (revised SepL 2003) r l M Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their emees quoted from the"law" employee is defined as every person in the service of another under any employees. As quo an em p y P Y contractexpress or of hire implied,oral or written. P 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 anotaer 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 section 25 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,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. IN E Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name,address and phone numbers along with a certificate of insurance as all affidavits 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 retumed 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. City or Towns . 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. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. 1111, ow The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406 Board otBullding Re ► gulations l HOME Im and Standards Re istr-a�t'►vA, VEMENTCONTRACTOR 28560 2007 RICHARD VIL ►'dual RIC h HARD VILLA 109 WAGON :_::- / HYANNIs, LANE', 'J/ z.m MA 02601 � Administrator j f Town of Barnstable. *Permit; Expires 6 months fr i�i issue dat Regulatory Services Fee w 1ARNSTABLE, 9 Mom' Richard V.Scali,Director ArEO M(+t A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS P RMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ' A Property Address+ ❑Residential Value of Work$ hQo® �� Minimum fee of$35.00 for work under$6000.00 i Owner's Name&Address Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑- am a sole proprietor 16, j_am the Homeowner ❑ I have Worker's Compensation Insurance JUN 19 2015 Insurance Company Name TOWN OF BA.RNSTABLE 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) e-side Replacement Windows/doors/sliders..`�Value%!} (maximum.32i)#of windows #odors: ❑ 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\E)PRESS.doc Revised 040215 " ' F�n�t1..#�r�a�f-T�rF•r�r�a�(�`�/Ft��-Eririxrta�g��svrg Am ym an mx4daywF fzah+ba Type ofpz-Giect�- ❑ Ia�aemplaycrw 4-'❑I J comfm:torzndl: ❑IEFes� e�aplcsyees{€uIL e�* ��6e El a=a sole propaefar arp mh., Ii au wed s1� �- Elsbig mEi have no employees Zhe= have $- ❑DemoRbm vmrung hrme i a.any c2vaa�r an3hav�Worms' adaiiion _ - I 5- ❑ We are a am=5 hs 1�-❑ I sepses oat additions r 2 am a h dainb all wars: moose have rxfirrT cea flm 11[]Pffmmbmg nrF�or muii= =Y-,21f LNo '=np- zigIA of=vEenperhim 12-0 Raofmgaim � I€ c-15Z§1(4k mdvi,5 aD •ems ��y�t�'����..}�1� i_T - ��� _� AIC '"�'.Qf�7ata.a�a �[1CLij wlTl tiauat yl)tl���+�+K ��i11G1 lYm3L.11T # n3ai�•,,,r�-t„c�'-�a++i �T:�7L'�g:�t^^.�F�°f�M*Y G�CD�7lCIDL6?�SD�f.18C8ie�FR��m�� t Est 1 bas mzrt w kErbCani _Ift�s�r<m�sh.•-v�esm�s,8ieg��nui3e 8�- '�umg_pa�cg m�ec ag',sng*7vyet fh�isg -norkem co z%na j'�fg{ms eatgr Ym,. Heivtr it 8iep� m�rZ}vh ' warn .. A � - '•,,' - - - ' Tacnrirrirn`�""�f`� ATTIP- •:x - . F1RLT:9 Cr Self-im l ic-f- nn T bri fi- Ir3h�.tltiaif� Ciiy�Sfate�Tap: - AMLaa3a 2E COPY after ems'Maupensafinn PCELT, deClZ ati=pZgE'(ShOUiDg ffi.,PoH Y n�her mma D.n ): Fame to su=xt,gage as repimdum kx Sectm25A of MGM c.152 rmn Ica fa the inUposai=at-aimiml pmgf�es of a file up to SI 5Da GD andfor�.y--— ax rued as c iva p—Tf; in-$e fon of a SAP WDR'K ORDER-and$fi,, caf up.to.S 250-00 a day again ffie viol doL l;e advised tzf a ropy-of flus sat ed maybe fDrVraZd5d to fbn-{1ffice of offmDIA far TM,smm=coverage tfa 1 cerqg und-r f'RcFZas atli p afpadiuy ff m the i*r=a ua praui&ff ahm L-zs b-99 rfnd carmt - : • C�; -_ _ r-- •-=- -mil . . Phase� ��� � � �-- - • a mss affb� Do-zw rzita-ia fiur=ea,AT ha cad by dty aw tam of ciff£ CRY arT ow= ig LSaarcicrf'g—TfiL . I at-PT£awi 4-ElecbscalaTec# r S_P gFasp c€or fir Gorel L.-ws chaptx 152 regm=all emplq=to prcM&wcd='a omp--fion fm-ih==0PIoyees, pmmm:ftD fhis an mzpFnper is deemed as a--VVmT Poison ae fe=Vice of=nfb=mnder any eoyxac�lofbize, eXPmtw crrfimplied,oral orwriff M _" An m pkg -is dedmed as"m pata=mbm-,assmcbfir corpoisl=or off legal=617,or any,two or=it - Qf f=kregDing=gaged m a3oid Md=�ME - l lr_gA- =of a dead employq-Cr the receives r-r it e of an ,patterhip,s-mcia ion or ofber legal mt4Y,employmg emplDye� HDwever the o wnar of a dweffmgbnmsehavmgnotmom$an f n-m apattrnenfs and who residrs ffi=m,or fie oceapant of tha awtRing hausa of anger who Toys pmsons to do construction or repair work on sorh dweHing house " or on fie gro=Lds or budding 3PPmtMnmt fierefz sh LU not bmz=of smrh employment be deemed to be-an mrLploy er." ISM chapter L52, §25C(17 Elsa stains f tt¢every staff or lrx�1 tiams ng agency shall withhold ffie issuance or reaewsl Ufa f>=13L�e or petmfttn operate a bnsnxess or to rnasLI d bUadkg in the commoxtwealth far arig applicant wFzo has not prndgced acceptable evidence of cozapffance wifh. e in�rance coverage regim ed' . A drF#ona.Tiy,MGL chapter L52,§25.C(7)states-Ted the commoa ealthnor aay of itspolit►c'al subdrviszops shall enter into any for fhe pounce of pmbTm wow mitil acceptable evidence of=uphm=with the in s=n m reLeme?ts of f$is chapter haye been prEseot3-,a to fhe cog aafha aiy.' A-Pphcants Please:EH or± the wa±ers'cmmpmsaiion affidavit completely,by chj—r> dm boxes ibat apply to your sitnadon and,if necessary, supply sL±-cont RctDr(s)namt- add��s(es)and phi numbers)along w>fh thch cPaLTnc s) of Tr,�nce_ LimitEd Liabzl>iy Companies(LLC)or Lim.>fedLiability Parinersbzps(I I.P)ono employees otlLer fban the member or parb=s,are c mtregahrd to any workers'comp=sEti e;on immzan If an LLC or L.LP does have cmployms;a policy is mqufi-c�L Bc advised fhat Phis affidavitmay be submitted to the Depadmeut of Indurtiial Accidents for conf=m J:ion ofi3=ance tvv=age_ Also be sm--to sign and date the affidavit: The affidavit should be ictnmed to the city or town brat the application for the permit orlicrmse is being regae• h1 ;d,not the Depadm ent of Iudvstrial'Accidents. Should you.have any questions regarding th e 1aw or you me*egnired TD ob ;n a y*orlers, comp=SRtioa policy,please call the Departmcat at the nm abcr lisp below. Self iu ed companies should e.ate.r their self-insance license:number on the appropriate line_ - City or Town Officials :• _ Picric be e sm- tb.e affida�,rt.is complete andptiatmd legibly- The Deparhnemt has provided a spare atffie hotm. of the affidavit , you.to fill out is tiro eveat fhe Office ofjnVm6gafinns has in contaLt.you regm-ding the applicAh ' Please be sere to fill in the permit E==number which w�be used as amferrmce n=bea_ In addation,an applicant that must submit mojtipIt penn>�ermse application in any given year,need only submit one affidavit moacating cummut = policy informatia a(ifnecsssary)and under'Job Site A L'h="the applicant should quite'all locations in (city or to•4twn).-A copy of the affidavit that has been officially stamped or marked by me city or town may be.provided to the applicant as proof that a valid affidavit is on file for future permits or licersll-& Anew affidavit must be El.ed out each. year_Where a home owner or eftizeu is obtaining a license or pemit notredated tn•any business or commm-cial Venture (ie,a dog license orpeonitto b=leaves etc.)said pezma is NOTrecp to complete this affidaYit The,Office of.�gestigxtions would h1m to ffimkyon in advance faryomr eoopmatim and shouldyau.have any.questions, please dD not hesiiei:e to give tis a call_ The Depattrn ezf s ad dress,telephone and f m number: as C0=M)Da 1i of Ima ss�U • - ��� Sim 4--24-G7 . Town of Barnstable Regulatory Services oFTt+e rgryr Richard V.Scali,Director Building Division 11MMSI'ARLY, ` Tom Perry,Building Commissioner 1639. ,�� 200 Main Street, Hyannis,MA 02601 �Ec s www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: r �, JOB LOCATION: ��`-- I.LY�co(,f` wo number, street vill a "HOMEOWNER": &iW-�- �fN J �I ��— D 1+,/ name home phone# iwork phone`#�` CURRENT MAILING ADDRESS: SCE city/town state The current exemption for"homeowners"was extended to include owner-p d 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 �o�ceduresequire ;uts �that e/she will comply with said procedures and requirements. Signature of Homeowner _r. 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 forms\EXPRESS.doc Revised 040215 4` y. V r t t BARNSfABLE. MAM Town of Barnstable .erEp�y 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 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) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:VWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 « Assessor's map and lot 'number ......... ......_......../................ 'iC:SYSTEM MUST BE INSTALLED IN COMPLIANCE . Sewage Permit.number .. .� �....: e.. .:. 1. .P ... . ti WITH ARTICLE II STATE SANITARY CODE. AND TOWN yo*tHEro TOWN OF BARNS' BAWSTABLE. Q Y. DUILDI.NG INSPECTOR- APPLICATION FOR' PERMIT LJ�......c.&.4.X ........ ..................... :.......: TYPE OF CONSTRUCTION .. 1'A 7 )CIAA-!? .............. .... .�....?.......19.ZY TO THE INSPECTOR OF BUILDINGS—--- The undersigned hereby fa�pplies for a permit according to the following information: i ft i �-G<� = fz°� Location ...4��J.`...�............................�..............�:.........��1�.........�.............................................................................. Proposed Use ......�_l4il.A lf- .....................................................................................................................:................................................ Zoning District .....................Fire District /�y. ........® .......... Name of Owner ...... � '.-). eg...................Address �9��ii /i o/ ....... . '•••...... ..................................................... Name of Builder¢ ,. d P/.............................Address 5%WA�.r�'...................1A �L'`..... ....... Nameof Architect f...............:..................................................Address ..........................................................................:......... Number of Rooms .............. ..................................................Foundation ..0.0ot?/e45-- � g� ........................................................ Exlerior ........T 11/ ....Roofing ....lT.. T Floors � ,°° ! .................................................Interior `= Heating ....... ............................................................. ....... ... . .................. .... ..... . ...... Fireplace ..................................................................................Approximate Cost .... ........................................................... Definitive Plan Approved by Planning Board -----------_------_-----------19-------- . Area © ! ? .!.......... if ou, Diagram of Lot and Building with Dimensions Fee . � SUBJECT TO APPROVAL OF BOARD OF HEALTH ,�l�D r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. "! Name .. ..... � � �. ,�i a ..... Assessor's map and lot number ......................... ................. .. ....U.l.Y -.... Sewage Permit number .t. .(1.�.zt_.�.....,Y P� .. .... .... I"E.T°�� TOWN OF BARNSTABLE i . i BARNSTABLE, i a aYae BUILDING INSPECTOR APPLICATION FOR PERMIT TO .... .......f.t:.!. .....:j....fi�!Qr} ........................................................................ ............. TYPE OF CONSTRUCTION ..� or!.!P.. "..!: 1 . ............................................................................................ 1, ....... ..... t7 � ..................... ........19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a 'permit according to the following information: Location an r ! t n G c+G 4 ? .......�}X�/:�.............................................................................. ................................ ............ ............... Proposed Use .s Zoning District .......... 4.......................................................Fire District . �0.,4//!/�.................................................... Name of Owner r=t f tMko �p C ....................Address �. � ..,.............................. ....... .+..........t ...................................................... Name of Builder 4..f?. .... ............................Address / f� j� ... .. !.... !.. -( ............... ri Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..................................................................Foundation .....�.. ... ................................................................. Exterior ....... .:.. .../.............................................................Roofing .../' 41'f I L........................................................ Floors �` Airt'v� �.......................... .......................................................Interior .................................................................................... Heating ............................................................Plumbing ..................,........................................................... .... jj Qa Fireplace ..................................................................................Approximate Cost ....A.............................................................. Definitive Plan Approved by Planning Board ________________________________19________. Area . .!........... Diagram of Lot and Building with Dimensions Fee..115 " ...................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ej I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Namev.............................e.. .... , ..,.......... /Grace, #ichmzz1 . . ,—°. ~~. .yl add garage to No ................. Permit for .................................... single family dwelling � --------------------------' \ Road ' Location ���.!--������-----------. ' Hyannis --------------------------' Richard Grace � C�vne, ------.............___________.. frame Typo of Construction -------------- -----^--------------------'' "A", Plot ............................ Lot ................................ �� �g Permit Granted --.��x�...,`------lP 74 Date of Inspection ....................................lg Dote Completed ...................................... � PERMIT REFUSED ' -------.------------- lg --------^-----------------'' ------'----------------~--' --------'----------`—'-----^' � � ----.---------~—.—~.---.—.—.— App,oved ................................................ lQ ^ -----------------'-----^---' � -----------'----------~---'-