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0309 LINCOLN ROAD
lee Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division `* BMWSUBLE. v� 1M S J% Tom Perry,Building Commissioner Arm Mpc 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: --D Permit#: 1 -5 q `y d HOME OCCUPATION REGISTRATION Date: 9 U 3 ` 1 d ) l Name: .S M h o ke 1(y/ Phone#: S 8 d gd a o l Address: 302 L;hC a 11, _ 1/ Village: CI{iI ci N KJ Name of Business: Kd 1 u e l e C tr O h i r J Type of Business: ( Pr-f r d 1; t JP' q"� Map/Lot: 7 C INTENT: It is the intent of this section to allow the residents of the Tonim of Barnstable to operate a home occupation ,�vztlnui single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the d`vellinng: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • Tlne actnity is carried on by die permanent resident of a single family residential dwelling unit,located«ztliui that dwellinng unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to dne dwellinng which are not customary ui residential buildings,and there is no outside evidence of such use. • No traffic will be generated un excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or Hazardous materials,or flammable or explosive materials,ui excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not iiadnin the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 dres,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is fisted or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation cvino is not a permanent resident of the dwelling unit. 1, the undersigned,have read and agree with die above restrictions for my home occupation I am registe Applicant; Date: a Honneoc.doc Rev.01/3/08 F YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the ne;.cessary signdtLffes, on this farm at 200 Main St:,, Hyannis. Take. the completed form to the Town Clerk's Office, 1st FI., 367,Main St., Hyannis, MA 02601 (Town Hall.) and get the Business Certifir..at.e that is required by law. DATE: Z3 (G Fill in please: APPLICANT'S YOUR NAME/S: q Ile BUSINESS YOUR HOME ADDRESS: 3 0 nc,t h Y a N c g w„ n TELEPHONE # Home Telephone Number S o% NAME OF CORPORATION:_ NAME OF NEW BUSINESS Jtrl I H C I e C,i TYPE OF BUSINESSre 10 a I U t IS THIS A HOME OCCUPATION? k YES NO (� ADDRESS OF BUSINESS 3 0 `1 U ll ► h MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtainingthe information you may need. You MUST Gd TO 200 Main St. - corner of Yarmouth Y Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMM SSaeirrforte R'S OFF CE This individrla f a p rmit c uir ents that pertain to this type of busineUST COMPLY WITH HOME OCCUPATION Avth d gna ** RULES AND REGULATIONS. FAILURE TO ,�C?OMMENT COMPLY MAY RESULT IN FINES. J` 2. BOARD OF HEALTH This individual has1been�rme I of the permit requirements that pertain to this type of business. Authoriz[[e�-d Signature** COMMENTS: 3. CONSUMER AFFAIRS (LI SING AUTHORITY) This individual as ee inf ed of t e 1' en requrr nts that pertain to this type of business. Author' ed i atur COMMENTS: �oFr�rr Town of Barnstable *Permit# Regulatory Services E.rpires 6 moral rs j r is' r me Fee Thomas F. Geiler, Director Building Division Tom Perry, CBO, BuildingCommissioner stoner 200 Main Street, Hyannis, NIA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: 508-790-6230 Not Valid without Red X-Press Imprint Map/parcel Number. Property Address_,l09 residential Value of Work 5-1-00.0 Ci Minimum fee of$35.00 for work under$6000.00 Owner's Name & Address Sb% �e� l�crI Z_ C/ 4�ti Contractor's Narne 4 04U IV&-,/ Telephone N 6 m b e r SG,F a2�G- C Home Improvement Contractor License#(if applicable) `1/ao y Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance ',-PRESS PERMIT . Ch k one: I am a sole proprietor AUG 2 5 2010 ❑ I am the Homeowner ❑ I have'.Worker's Compensation Insurance TOWN OF BARNSTABLE 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 -4,6,5les-9 ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)# of windows *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. �J GNATURE: .�� 2 ��v WPFILESIFORMS\building permit forms\EX PRESS.doc vised 0721 10 The Corr mortwealthr o,f•Massachusetts --- Departrnerit ofludustrial Accidents �a dice of bivestigafions 600 Washington Street Boston, ALL 02111 Yb 1011.Mass.govIdra Ilforkers' Compensation Insurance Affid-xvit: Builders/C'ontr.-ictoi-s/Electricians/Plumbe.rs Applicant Information Please Print Legibly Name (Btisiness�Orgam-,ation,'Individz al): Address: 6cfe� Citytstate/Zip: l S OU G a Cc Phone#: rC tf-, �o2=— Are you an employer?Check the appropriate.box: T ype of project(required): 1..❑ I am a employer ti�i.th ❑ I am a general contractor and I �naployees(full and/or part-time). * Have hired the sub-contractors I Tew canstnrction 2..U I am a sole proprieAor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors have 8. ❑.Demwlition ivorl-ing :for me in any capacity, employees and have workers' [No workers' cone.insurance comp.tnsuramce.. I 9. .Building addition �. ?r 'e are.a corporation.. .and its 10.❑Electrical repairs or additions regt red. ❑ 3.❑ .1 am a homeo-'nex doing all world affi.cers have exercised their 1 L.❑Plumbing repairs or additions myself. [No tworlmrs'comp, right of exemption per MGL 12.❑Roof repairs insurance:required.]T c- 152, §1(4),and.we have no employees. [No workers' 13.❑Other coutpAnsurance:required.] 'Any applicant thst checks box#].mast also fill out the section below showing their workers'compevsati.policy infornxatian- f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new.affidavit indicating such- 2C'ontractors that cheese this box must attacbed an sdditioml sheet shorving the name of the sub-contractors so.d state wbether or not those entities have employees. Ifthe sub-c.ontcactors:have employees,they.must provide their workers'comp.policy number. T arrt mr errrploy er that is prar�idirig nrorkers'cor9rptrrrsat on irrsatrartce for rely'e99rplr�y=ens. Below is thepolicy and job site infor triad-VIL Insurance Company Name: Policy 4 or Self-ills.Lic_ Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers'compensa lion policy declaration page(sho►sing the policy number and expo-ation date). Failure to secure coverage as required under Section 2.5A of MGL c.. 152 can lead to the imposition of criminal penalties of a fine up to$1.,500.00 and/or one-year imprisotiment,as well as civil penalties in the form of a STOP IEtORK ORDER and a fine of up to$250.0,0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D.IA for insurance coverage verification. I do hemby certify u. der-the iris ar d penaltigs nfpmr,jury that the inforinaftan provided i bovv is true and correct. Zr Date: Phone#: Official use only. Do not write in this area,to be completed by'cite or town o e al City-or To-wn: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/To-wrr Clerk 4,Electrical Inspector 5,Plumbing Inspector 6. Other Contact Person: Phone#: 6 �p THE)1, s • HARNSTABLE, * - 39. i6J9• Town of Barnstable prFD MAV A Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.ba rns to bl e.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using .A. Builder ` as Owner of the subject property" hereby authorize 01 to act on my behalf, in all matters relative to work authorized by this building permit application for: 3 Li� cv(� (Address of Job) Signature of Ow r Date Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Forma on the reverse side. I c QAWPFILMFORMS\building permit forms EXPRESS.doc _ .Revised 072110 i ' a Q�.0fHE 'L Town of Barnstable Regulatory Services 9 13�^ I'A BLE, Thomas F. Geiler, Director ,679. Aim' ra,19 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 518-862-4038 Fax: 508-790-6230 -------------------_______ HOMEOWNER LICENSE EXEMPTION Please Print DATE: C7$ I a 1119 JOB LOCATION: Oq Lt Rd- number street i lage "HOMEOWNER" 6 (A) - V X ,6�og 1$— 97 35 50:6,-�) b7 '-5"?3� name q home phone M work phone# CURRENT MAILNG ADDRESS: 09 L t_co[v, Q2d /IltLL Co O city/talon 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 F ' 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 forms\EXPRESS.doc Revised 072110 U' Office of"'Co sumera�s��°"ness egu�o� HOME IMPROVEMENT CONTRACTOR Type. Registration: 5116609 Expiration: 6129/2012 Individual B E CAUTHEN,a BILLY CAUTHEN h 86 BETH LANE y f HYANNIS, MA 0260V--, _. Undersecretary _•� Massachusetts- Department of Public Safet) p Board of Building Regulations and Standard> Construction Supervisor License License: CS 9975 Restricted to: 00 BILLY E CAUTHEN 86 BETH LN HYANNIS, MA 02601 Yw Expiration: 8/13/20Y1. ('ommissiuner Tr#: 2150 t f 1 License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 f'talid without signature I i i �THME 'Town of Barnstable *Perm►t# �71 g� E-rpires 6 months from issue date SAttNSTABLE, Regulatory Services Fee C� °1A&Q_� Thomas F. Geiler, Director p i63Q. ti3O� 'FD 9. Building Division Tom Perry, CBO, Building Commissioner Main Street, Hyannis, MA 02601 X-PRESS RE ` i°�"200 www.town.barnstable.ma.us Office: 508-862J40382 6 2009 Fax: 508-790-6230 TOWN )OXMIM MIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 7/G tfi'LJ Property Address 3 09 1,/",/C•o&,� � r, 4�11, 0 Residential Value of Work 9d_1 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address tfX,/ (fit:L-L 1 Contractor's Name l(t, JC, Telephone Number JAG�� �lJ- 3 � Home Improvement Contractor License#(if applicable) 'N Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Chec one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of rood ❑ Re-side ❑ Replacement Windows. U-Value (/- j (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. 'Note: Property Owner must sign Property Owner Letter of Permission. j ome Lmprov nt Count a ors License& Construct Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\Express\EXPRESS PERMIT.DOC Revise06O4O9 . - �ze "Laar�z�itanu�eatt� a��l�J:tucttude� . *' Board of Building Regulations and Standards ` Construction Supervisor License License: CS 9975 Expiration: `8/13/2009 Tr# 2096 Restriction:,00 BILL1 E CAUTHEN 86 BETH LN HYANNIS, MA 02601 Commissioner ; � Board of Building Regulations and Standard = HOME IMPROVEMENT CONTRACTORc „ Registration 116609 Expiration 6/29/2010 Tr# 268043 7Ype Individuals i BILLY E CAUTHEN'` j by BILLY CAUTHEN 86 BETH LANEi HYANNIS, MA 02601 -� Administrators .. License. before the or x gtstration vaiid for Plratio Indiv ,. Board of Build' n date. rffou tdul use on1 Bost Ashburton.piaRce,, on s and Sta turn to: Y °n, R,n 1301 ndards 2to$ of valiWith ,t _ hout d w' gnatsi ure r I ` The Commonwealth of Massachusetts Department of Industrial Accidents 93 Office of Investigations" ' 600 Washington Street Boston,MA 02111 5• �`�� www.mass.gov%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information // Please Print Legibly Name(Business/Organization/Individual): 009 Address: City/State/Zip: Phone.#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a y emp to er with 4. 0 I am a general contractor and I 6. ❑New construction mployees(full and/or part-titn.e).* have hired the sub-contractors2. I am a sole proprietoror"partner-- listed on the attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 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: 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 tip to$1,S00.00 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 MA for insurance coverage verification. I do hereby certify under the pains and penalties o perjury that the information provided above is true and correct Si afore: Date: Phone#: re-cp— Q PG- 3 S-6 Offuial use only. Do not write in this area,to be completed by city or town offtciaL 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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a 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 completeand 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 maybe 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 Office of Investigations, 600 Washington Street Boston, MA 02111 Tel. #617--727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia e �THE ro Town of Barnstable Regulatory Services Thomas F.Geiler,Director 16 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town_barnstable.ma.us y Office: 508-862=4038 Fax: 508-790-623 Property Owner Must Complete and Sign This Section If Using ABuilder I, IN , as Owner of the subject property hereby authorize `/�C (411:2 /e to act on my behalf, in all matters relative to work authorized by this binding permit application for. .(Address of Job) A J P///,/ � g igna.ture o ate Print Name If Property Owner is applying for permit please complete the Homeo"ers License Exemption Form on the reverse side. 'Y �►,E Town of Barnstable *Permit ���� yoF Teti Expires 6 months from issue date Regulatory Services Fee �-- saxtvsTAst E, = Thomas.F.Geiler,Director 9 MASS �b i639• a Building Division AtFD MA't 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 PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ` " Property Address /o G" ��S Residential Value of Work c Minimum fee of$25.00 for work under$ "000.00 Owner's Name&Address `��exw ' t• Contractor's Name cre., LE ���rw� �` Telephone Number Home Improvement Contractor License#(if applicable) 1 v 1 3 ❑Workman's Compensation Insurance Check one: �'� ❑ ®���I am a sole proprietor g PERMIT ❑ Lam the Homeowner [ /1 have Worker's Coi1plen Insurance JUN 2 4 2008 ;) JrInsurance Company Name , TQ(ZOR �,�pp c r b7 Workman's Comp, Policy � � � � S `-- Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side -7 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. `t SIGNATURE: t QQ Q:\VvTFILES\FORMS\building permit forms\EXPR.ESS.doc Revise020108 I 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 Applicant Information Please Print Le ibl IV Name(Business/Organizaiion/Individual): S Address: City/State/Zip: 1" Gvt1l � b33 Phone.#: � ` � ' y. t 0�- Are you an;employer?Check the appropriate bog: Type of project(required): " 1.[ h am a employer with .4. 0 I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6..❑New construction 2.❑ I am a sole proprietor or partner- listed on.the attached sheet. 7. " Remodeling ' These sub-contractors have ship:and have no employees 8.. O Demolition _ r working for me in any capacity. employees and have workers' [No workers'comp.insurance comp. insurance. t 9. []Building addition required.] 5. We are a corporation and its _ 10. Electrical"re aims or additions q ] P , 3.❑ I am a homeowner doing all work officers have exercised their , . 11.0 Plumbing repairs or additions r. . myself [No workers'comp: right of exemption per MGL 12.0 Roof r, air insurance required,]t c:-152,§1(4),and we:have.no" L employees [No'.workers'. 13.�jOther comp.insurance required.] • y`pp that checks box#1'must also fill out the section below showing their workers'compensation policyinformation. $ An" a licant t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box.must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have•.. employees. If the subcontractors have employees,they must provide their workers'comp.policy number. I am an reformat oloyer that it providing workers'compensation insurance for my employees.'Below is thepolicy and job site Insurance any Name: Uhl l. !P'1✓ S Policy#or Self ins.Ltc # _ st ., Expiration Date:.., Job Site-Address. 1 L ye_y. /l/ 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`imposihon of criminal penaltie§`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 DJA for insurance coverage verification. I do hereby ce er ' psi a en ies perjury that the information provided above is true and correct >< Si ature• Date: A9 Phone#: l 6 7. 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, §25.C(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 thatapply to your situation and,if necessary;supply sub-contiactor(s)name(s);addresses)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 maybe 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, 1.1.1 'ca11 the Department at the number listed below. Self-insured companies should enter their ,self-insurance,license number on the appropriate line. City or Towri 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 toy licantasor roof that a valid d affidavit Sis on file forFuture peernvts or licenses�A new affidavi�y be provided to the y applicant p. 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 office of Investigations 600 Washington Street Boston, MA 02111 . Tel. #617-727-4900 ext 406.or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.govtdia A-CORDrM CERTIFICATE ®F LIABILITY INSURANCE DATE(MM/DD/08YYYY) 02/2 PRODUCER 1-404-995-3000 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta, GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE INAIC# _ INSURED Home Depot U.S.A., Inc. INSURER A:Steadfast Ins Cc 26387 The Home Depot, Inc. INSURERB:Zurich American Ins Cc 16535 2455 Paces Ferry .Road Building C-8 INSURER C:Illinois Natl Ins Co 23817 Atlanta, GA 30339 INSURER D:American Home Assur Co 13380 INSURERE:New Hampshire Ins Co 23841 COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDIPOLICYEFFECTIVE POLICY EXPIRATION LTR NSRD PE FINSURANCE POLICY NUMBER DATE MMDD DATE(MM/DDIYYI LIMITS A GENERAL LIABILITY IPR 3757 608-02 03/01/08 63/01/09 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS DAMAGETORENTED 1,000,000 PREMISES Eaoccurence $ CLAIMS MADE 7XOCCUR "OF SIR: $1,000,000 PER CC" MED EXP(Any one person) $EXCLUDED PERSONAL BADVINJURY $4,000,000 GENERALAGGREGATE -$4-,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $4;000,000 - X POLICY PRO- JECT LOC B AUTOMOBILE LIABILITY BAP 2938863-05 03/01/08 03/01/09 X COMBINED SINGLE LIMIT $1,000,000, ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY. $ SCHEDULED AUTOS - (Per person) HIREDAUTOS BODILYINJURY ,. $- NON-OWNEDAUTOS - (Per accident) - -- X SELF INSURED AUTO PROPERTYDAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIDENT $ ANY AUTO . .. OTHER THAN EA ACC $ AUTO ONLY: - ._AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X �CYTAITS TERH. .D EMPLOYERS'LIABILITY 1928756 (CA) ANY PROPRIETOR/PARTNERIEXECUTIVE 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 E OFFICER/MEMBEREXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 Occurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 11928758 (KY, MO, NY, WI) 03/01/08 1 03/01/09 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR - REPRESENTATIVES. ATLANTA, GA 30339 AUTHORIZED REPRESENTATIVE USA ACORD 25(2001/08)datkinson 8213215 ©ACORD CORPORATION 1988 S 1 f." Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration 126893 One Ashburton Place Rm 1301 Ezpirat�on g%3/,2008 Boston Ma. 02108 Supplement Card �t s THE Home Depot�.At Home Senile WCHAEL BEDARD� `jam 3200 COBB GALLERIA OK_ `dtIANTA, GA 30339 Administrator Not valid ithout signature n • . V — - JUN-14-2008 18:28 HOME DEPOT HYANNIS P.005 0705•e7e•a07 HOME IMPROV•EMENT;CONTIZ�IC1' Sold,Furnished-and Installed by: Branch Name "C�c�-s15 .Da'te TIID At-Flornc Servtccs,Inc.. - d/b/a TheHome. t At Iltime Services OOd,Sire OTCeSter,MA 0I•607 Brdnch,Nnmber:.�'i 1-�A'3�:. Toll -51.82;.Fax:508 75Cr2859 . -Federal IA#.7$-2698460 ME Lie A C 02439 III ConL L•ie#16427 ,i4 J1:565522; MA Homo Improvcmcni contracmr Peg.812ti893 . dnstalbttionAiidress: �J •.. . ..1', �taCm%\��et ... aYLA. Q2fcA City.. State :: zip. -r;as td-Dtglts of Arlver s.. ; Pdi•eliascr{s):... .. .: .Lla#.&JG Mo/Yr.... .WoTkPhone: game hone: _t o' Home'Address: �SLIe (If tiitlexert:.from Installation Address):. p City . State Zip E-Jowl'Address-(to:receivcvpdates;and:piolnotionsfrotri.Thel{omCDcpot)i: = Project infur•ntation: I/We/You.(Purchaser''%the owners of thc'property located at the'above installation address,offer to contract with THD At-Home Services',Inc'..("Home Depot' to Titmisb,'.deliver and arrange for the installation of all matcriaLs as do;ciibed on.the adaehed Spa'Sheet•#�.Qc� 4 - incorporated bexeia'byrefcrcncc.andmade apart hereof. Home Depot reserves the Tlght.to.cancelthis contract'if4.upomre-inspection,of.tlic.job;Home Depot determines-that it cannot-perform its obligations due:to-a structural-problem.with the home,pricing-errors-or'because work required to complete the job*w ,not ncludedln.theSpecSheder-Contract,,: YMEN OPTIONS . -. ..... .. . ..i > (SubDJ totundvCn'ficationon�rCrcditapproval.). . CONTRACT AMOTINT"': $' �:t0 ` 1. Chef Ore Check or US Poxhd Service.Money,Ordor, . 3�.. do payable to The kTonie Ocpot). j•I.EssDxrostT $ Z. Card" In& otherpuymcot op6oa+-' c One Below eaa Express BALANCEAUE +' ll.y ,'•vl$a••• astcTCBTd ..DiNcoycf ONCOXTLE'I'ION: $ "t.1'. . The•NameDepotHod n rov .tLoun:, The He=Depot.Crod;.tCard -. .S•.. . t>finimum 25%of Contract-Amount'Aue upon". Account': ©Exl. g unt' (HII.8c 1�CC ONLY) • . execution Of this COntraCt�• .:n.yilanie Cr'.. .S. .- tL&�CC ONLY). .. Indicate PaymcntTActhod For. Acedt:_____ • BALANCEDDUE'bN-CO1�Il'LET10Nt' Name ffiBp,., ••By /oursignaturc below,I/We,agreeto allow Home Depot to charge the above referenced credit card for the deposit.indicated. 'w.ben:yoaprmide a check as paymomt you aAh'oriic wc:citha. Dote to,yemtoatinfion.fromyourchocktorielce'noacrti 'eleclronie CaMltoldc�'sSip t rc fetnd tinnsfoi.from.yow a000um of to process the payment`ati a. cjmk-tmnsactlon.When we-use informatior-Srom-yo-check to': ' HII:or.HDCC Authorization Codes uvdcc;aaelectmnicfandtranatcr..'f6d%.meybc'withdtawn.fmm, :.... yoot accocnt as-soon.ua the payment is,reecived,and you will not . De osit Final Pa ent r000ivo-yotir'chcck back.,. # Purchaser#mcs.ti>at,:immediately up on•compicti'oriof.:the.work;Purchaset will'ex ecnte a<Completioa Certificate and pay any balsnoe`due:Pitichaser lso.agm6�x btiointly.and s6emily.obligated-,and•liablaher=dcr; F.ritice A�reement;,:.This agreement and it+attachments,mcluding.any:fwarteiug agreement'contain the compleGe.agrcement bettvtxn.thc psities and can not be aznendcd ormodified tmless:itl writing in a sepa=.SgreeTept ti�gned by both patties. NOTICE,TO PURCHASER Do.notsign-this contractbefore_you read•it:,.You are.entitled-to.a.completely filled-in�copy-of the:contrxct':at,the time -YOU-sign Keep it to protect your rights. Do.not sign.a Completion Certificate before.this project.is complete. Law prohibits Keel?i pair cootraetor3 ftom requesting or-accenting a.Codtpletion-Certificate:signed by the owner prior to the actualcoutpletion of-the work to be performed a 416t-. a 46ntraCL you may cancel this:transaction any-time prior,to midnight of the.third business day after,the,date of this contract. See Notlec:of Cancenation.for an..explanadoo of this right.There will be a service charge equal'to 10%of the contract amountif job.is cancelled by.:PurchaserAFTERthe-third-business.day,but BEFORE materials arc ordered-There will be a•service.charge equalto 25a/a of the contractamountif job:is cancelled by Parchascr,AFTER materials are ordered. BY MY/OUR SIGNATURE:BELOW,1/WE:UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW OF MY/OUR.CREDIT'.HISTORY AND VWE P.UTH0kIZE HOME DEPOT TO,VERIFY AND'REVIEW MY/OUR -CREDIT RECORD WTTH"A•N INDEPENDENT CREDIT'REPORTING AGENCY AND.RELEASE!'.TBEM FROM ALL LIABILITY TNCURRED FROM INADVERTENT'OMISSIONS OR ERRORS. . BY MY/OU. SIGNATM. -BELOW;T WE AGREE'TO BE BOUND.BY TyE TERMS OF'TiIIS'.CONTRACT."1lVJE . ACKNOWLEDGE RECEIPT OF A COPY OF TM-S CONTRACT AND TWO COMPLETED:COPIES OF THE NOTICE OF CANCELLATION. SUBMITTED BY: Date:�-I y � ACCEPTED BY: Date:. Pmcb aAc Date: Purchaser NOTICE:AADMONAY:TERMS AND CONDITIONS ARF•STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT 921-07 rev42=07 C-SC ytmte 13rakhFile--:Yelloty-Customer.•Pink-:Sales:Consukant PERMIT PAYMENT RECEIPT TOWN OF B A R N S T A B L E BUILDING DEPARTMENT 200 MAIN STREET HYANNIS , MA 02601 DATE,: y01 / 11 / 0 7 T_IME': 14 `. 59 - - - - - - - - - - - - - - - - - TOTALS - - - - - - PERMIT $ PAID 25 . 00 A M T TENDERED : 25 . 00 A M T APPLIED : 25 . 00 CHANGE : 00 APPLICATION NUMBER : 200700181 ;PAYMENT METH : CASH PAiYMENT REF : r� 6091 1 Town of Barnstable ermit:a0 0 0/9' oFT EP Regulatory Services ate: P�• Thomas F.Geiler,Director _ 1* BARNSTABLE Building Division Fee 5,60 \y MASS. 1639• Tom Perry, Building Commissioner Foy 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE /1,/6,0 —14,,,e-- 6 W/7C.s SOLID FUEL STOVE PERMIT Owner: w Phone: Sl9-53'1 `07 q Install at: 3 ` O9 L;,c�lin (%� Village: l y��5 Map/Parcel: a171 0 X 0 Date: to o Y l p Stove A. New/ se B. Type: Radiant/ Circulating ? C. Manufacturer: Lab.No. ur1 °w''7 D. Model No.: Chimney A. New/Existin (If existing,please note date of last cleaning) o�h B. Flue Size C. Are other appliances attached to Flue? u�Know� D. Pre-fab Type and Manufacturer Masonry: Lined/Unlined N CZ Hearth ") o A. Materials: 'j C-) B. Sub Floor Construction: r. Installer Name: . (d 170L��/t� Address: Phone: Location of Installation: APPROVED BY: Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev i22801 TOWN OF BARNSTABLE BUILDING.PERMIT APPLICATION' Ma`p lParcel -FJS° Permit# 36 7 Health Division I? z °"w Date Issued Conservation Division -,.,Fee B-� Tax Collector J '��'� :.r � t - --�>Treasurer Planning Dept.-Na 19C6 .s Date Definitive Plan Approved by Planning Board GVb P(4ys o>.� �7w S &b V Historic-OKH Preservation/Hyannis 7 Project Street Addr ��;/JC-O Village' r Owner, d Address !g 'Telephone 2 l _29 ® .1"Ar Permit Request Square feet: 1st floor: existing proposed 2nd floor:existing proposed' Total new Estimated Project Cost C O Zoning District Flood Plain Groundwater Overlay Construction Type rx-e!Eqd Lot Size . 3 S Grandfathered: ❑Yes #No If yes, attach supporting documentation. j Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes k No On Old King's Highway: ❑Yes A(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 5(No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 011�No Detached garage:Wexisting ❑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 kNo if yes,site plan review# Current Use Proposed Use BUILDER INFORMATION ' - Name i _I Telephone Number 3(a-g— r v`rfS Address /`.4,1C_ " License# Z=-f 5—,f' J7crr �- o Home Improvement Contractor# �� d o`Z Cr Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 144S, _ SIGNATURE `� _. DATE FOR OFFICIAL USE ONLY `- PERMIT�rNO. G r Le ; DATE ISSUED MAP/PARCEL NO - � '�r * - rah' " Y` ♦ « F ADDRESSF ati VILLAGE ' - OWNER' d { c , �j yx - � } r 't� .. +S4 `•f r,t .A - ^ - � � •-_ � Y -r x. _ ,•f.,,� ' - 7 _ c .. r b- a s,•.r — DATE OF INSPECTION i FOUNDATION FRAME INSULATION / �s �/✓��� �� _' "- _ w , 'r FIREPLACE a ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH' 'FINAL GAS: ROUGH FINALS • FINAL BUILDING _ � � t s�^, � - r •- - �- � � Y ',. ' . !`' ,'` r _ f •L - ♦ y r DATE CLOSED OUT r ASSOCIATION PLAN NO. �` } The Town of Barnstable �0�' Department of Health Safety and Environmental Services Ec ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 i Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c.'142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements.Type of Work: a k2r &e-1- I Estimated Cost Address of Work: Q Y Li ve©/ice► /7y,4..�r Owner's Name: . 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 i CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENAL - S OF PERJURY I hereby pply fo a permit as the agent of the o a Contracto Nam Registration No. Date O er's Name q:forms:Affidav - --- -- The Commonwealth of Massachusetts + - Department of Industrial Accidents L _ � . Office ofinsestigations 600 Washington Street � s+ Boston Mass. 02111 Workers' Com,pensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in any ca acity I am an employer providing workers' compensation for my employees working on this job. company name: :19/A,, address city: V A-/-P-L.e v2LDn,e 'e �Yd.4 phone#: — (A0 vZS insurance ca. P01icV# % o O e- SSv ❑ I am a sole proprietor general contracto , or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: - address: _ . city: phone#: insurance ca. company name: address: - city: phone#: insurance co. .... olii:v# ; . % /%/%///%%%% Failure to secure coverage as required under Section 15A of MGL 152 can lead to the imposition of criminal penalties of a Me up to S1,500.00 and/or one vears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of S 100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage veriticationt. 1 do hereby certify under the and penalties of per'try that the information provided above is truo and correct Signature �' �'4- Date G _ Print name /�4 s 7�4-v Phone otllciai use only do not write in this area to be completed by city or town oMcial city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's OMce ❑Health Department contact person: phone#; ❑Other (tenses 9i95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contr--= 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 receive:c: 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 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. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, 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 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. 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 applican L Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Imlestigatlons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 eea. xe:.A e�p �.x; x.x.>:.>:�x;;: s:q:p�. ,�1'�••,n• .'4:: x•. 4. e. .Q is A�� ° ° .>:4$ rm DATE(ELe<•Darn k. w x; ,w,,,1),,x«e•q•:�Lx;xM4'46•a.eiq> k CORD k. ' .o•. 'x' :* R R 4 w4n•4'fi:»fn:oxa.a llxe: a. :R e x 6. $e. » Sa rt.A'teA. <t oaxrc-:r>.�r:•xx.,:..:ax':a:.N:wu���k;D1.e.'+� A.fixe.�"eucee"`.ae.. 3wwC•�e;e�x.44.a<ese:.�2`.:�:':k•!•.`%A,.�2•C•:%�a:.�"k:r2:e PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTEFI OF INFORMATION Cape Wide Insurance Agency, Inc. ONLY THIS OC�PICATE S NO DOES NOT AME UPON NDCERTIFICATE MEND OR 6A Baxter Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE Dennisport MA 02639- COMPANY (508) 760-4755 ( ) - A XF Brokers INSURED COMPANY Michael Shastany B Legion Insurance Company 7 Frances Helen Road COMPANY C Yarmouth MA 0 2 6 7 5- COMPANY 508) 362-6258 .kp:Q;::::p:>ia'i;�:"x•>:e:F>.:..,:R:q., ;o:�P4.4ao:%iQ A;•u:C.�'�°.kXQ nx:eA4:k•:kL. .�4.Ax:x 96b.oSt•ka:x9'e 4;x.'::e;; ..,x,xo.0 :4:Ae:fe �..R.:i.y.<;,i:>.:i•Je..:ti,:4:k,t:b!l.R: �kZ:4.A�,:>.;'e�4.A.Feb:L:ekr.•f.4.>::..k eenM� ,Lae;xp.p.R.:4,¢XfeR.R :oH.k4:x¢ >:OY R .x Q '' ?�R:glt 2.h.so�e:4•�x.A.>:GP R.xn.n<:.s.4.>o LXs'. ;k w:...,,..4,�.. 36111•w i'J,:..: ..:.kA a:al h a .w9 R�W.qx:�t;f.SR6.L.!•:��x.f:e.eY..aln�:��.�.nQ Z,3:�h•, 9.• k ,:,X.ka.-....ww....,n:e: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DE$CRl$ED HEREIN 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO 7YPEOFINBURANCE POLIGYNUYBER POUCTEFPECTIVE POLICYEXPIRATION LIMITS Lin DATE(MWODnM DATE(MMIDD1YY) A OENERAL uABILITr oENERAL AooRET3ATE 000000 Y COMMERCIAL GENERAL ummuTY T O B E ISSUED 0 2/0 9/9 9 0 2/0 9/0 0 PRODUCTS-OOMP)OP A(a0 Js 10 0 0 0 0 CLAIMS MADE H1 OCCU L t ( to PERSONAL&ADV INJURY 8 OWNER'S&CONTRACTORS PROT EACH OCCURRENCE $10 0 0 0 0 FIRE DAMAGE(Any one fits) S MED E)G (Any one person) 8 AUTOMOBILE LIABILITY COMBINED SINGLE OMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY S SCFIEDULED AUTOS (Pet person) HIRED AUTOS BODILY INJURY acciderm 8 NONj7WNED AUTOS PROPERTY DAMAGE S GARAGE LIABILITY AUTO ONLY-FA ACGYDENT 8 ANY AUTO / / / OTHER THAN AUTO ONLY: EACH ACCIDENT 8- AGGREGATE S EXCESS LIABILITY EACH OCCURRENCE 8 UMBRELLA FORM / / / / AGGREGATE S OTHER THAN UMBRELLA FORM 8 B WORKERS COMPENSATION AND I Twocompk I EAR EMPLOYERS,L["ILnY TO BE ISSUED 0 2/0 9/9 9 0 2/0 9/0 0 EL EACH ACCIDENT $10 0 0 0 0 THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT 85 0 0 0 0 0 PARTNERS/S(ECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $1 0 0 0 0 0 OTHER DESCRIPTION OF OPERATIONSAX)CATIONSIMICLMSPECIAL ITEMS ,k w........ xey°la:e>:aex:ek:xe:uA:e�A.a�ri$'�: �8M'1�ef3.'y,°sc�':Rr e'4.kd xae:«:.k.:ke»::xyg:e<exu.f aRtxp.e;..:4.,;.:qL,,4ht..x.A..:.i>:.:�ae:.:l<::•ia:elA:.<a:taat:;.<}::.>:.i!.!..iSw::J•,��e.:w%o•.:.!<:•iw:xwx/:i k.:>.!.G:,<.<q...k.:Aa K•4k:, ..IR. ' >, t4::.: xe xo:a:Gaf:xk .. l 4,s G R :-:ll ? AG :•R.xR.;x0 l.Z4 eA4^F.k..«:<.o».exxy.a%.xRe;.ek.eR,.:.SStw,.x<u4x'•;fw�':X9°b kt4.f�•p 9n[��':nex;.ka'�XeR.:Nt.'fX�"a R">wAae:o<i e4x:Xae P.k:eyf.',4tti.iAw :. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 4 EXPIRATION DATE THEREOF, THE L"UIN(II COMPANY WILL ENDEAVOR TO MAIL HouS ing Corporation l�L DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAM®TO THE LEFT, Larry Dineen BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY West Main Street OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. Hyannis MA AUTOO EPREgENTATIVE �ram-y..acsrzrsx�as�:;r:•.a:::x:sz<�::u:rrxxe:ox-:n:�a.::at.:sue:e:n:.�+:a:<:e:<e:nw.k:N:a:,,:a:<::a:..:.!•:..:e:.,,..,:e:..r...:e:,w:•.e::. •..>..:�: .:.... ,..._. ... ... . .... .................... �:::�::•.;•:.�.:�.�.: GTE -Caw��� ol`111 a�� oar1d of PBuOl ing Regulations andlStandarOds j ' One Ashburton Place - Room 1301 Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 128029 Expiration 02/15/01 Type - DBA Hai$dFRR0 &W Registration 128029 CAPE & ISLANDS HOME IMPROVEMENT Type - OBA MICHAEL E . SHASTANY Expiration 02/15/01 7 FRANCES HELEN RD YARMOUTHPORT MA 0267S CAPE & ISLANDS HOME IMPROVEME MICHAEL E. SHASTANY 7 FRANCES HELEN RD &- P10UTHPORT MA 02675 ADMINISTRATOR I ff� fji'py�r,�yp /y a�, ,u Safety Tel:(508)362-6258 OEPARTNENT OF PU LIC SAFETY Service Toll Free:1-800-658-3708 Satisfaction FAX:(508)398-3579 CONSTRUCTION SUPERVISOR LICENSE t CAPE &ISLANDS Number: Expires: "For Commercial&Residential Properties" Restricted To: 9e I •Vinyl Siding •Additions •Aluminum Trim "Roofing •Kitchens&Baths "Sunrooms _ NICHgEI.E SHASTANY "Windows&Doors •Decks �►W �%1 FRANCES HELEN RD 7 Frances Helen Road Mike Shastany YARNOU T HPORT, NA 02648 iYarmouth Port,MA 02675 Principal Washingt3n, George f 3 No ...1603$ Permit for ......garage ...................... ............................................................................... 1&nooln Road .... Location ....... .. ...9.. .........................AY.a??nis...................................... Owner ..............Georges..Washington.............. +l Type of Construction .tr',Ae................ ................................................................................ Plot ............................ Lot ................................ 4 a March 27 73 c Permit Granted ........... ..........................19 --------- Date of Inspection !� Date Completed ....................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... Approved ................................................ 19