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0045 MELBOURNE ROAD
;1✓l/1/fFsL6ouev� �- - --_ J O O ' o. ® W N 4J I � 1, i l . ° . Town of Barnstable Building y,i,n.„f � � �e ../:W � �' � �s::' s�.:�Zb� ": rL� >� � ..'� ,i., � ,.•�,,,�-s',..mz�. .:ry, � �„1't,'. ' '- � ���.�'..,, Post Th�s�Gard So That it,is Ulsible::From-,the Street A �oved�PlansfiMusL�be�Reta�ri*d-oa Job andthis Card,Nlustbe Ke 't BARNlTrA838. • �a u.,,. •� ,� c „ . �,: t,� Epp. r a � � � X �` P M"� Posted�Until�Final�lnspection Has BeenMade � �` � � � � E � w � Permit � 163p d A� l ,s "z:sy 3r�rz�' a'., x: ' ,f. � ��b , ;° Where a Cert�ficate�of Occu anc :is�Re. aired,,such Buildingshall�Notbe 0ccup�ed'untll a FInalTlnspectlonhas been made,��'� ., �,.<...�..�.�,h✓.a�.«r.. t..,.,�,.a.p �a � .'�a_.:. _u'.. «�:.,�; .._�;T-=aca. ...��..,_":;;;:k: ". °�... a �` _off=�ar. ...���;�.... Permit No. B-18-1949 Applicant Name: MDH CONSTRUCTION INC. Approvals Date Issued: 06/22/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 12/22/2018 Foundation: Location: 45 MELBOURNE ROAD, HYANNIS Map/Lot 268 246 Zoning District: KB Sheathing: Owner on Record: CONNORS,LAUREN M Contractor Name MDH CONSTRUCTION INC. Framing: 1 N Address: 45 MELBOURNE RDContractorLlcense 183807 2 z HYANNIS, MA 02601 � ro�e" Est P� ct Cost: $3,000.00 Chimney: Description: Insulation/Weatherization Permit Fee: $85.00 Insulation: Fee Paid $85.00 Project Review Req: x Final: 'A ate 6/22/2018 Plumbing/Gas Rough Plumbing: Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authoraied by this permit is commenced within six mo the afte IC ssuance. Rough Gas: c ; All work authorized by this permit shall conform to the approved application and the'approved construction documents fo6*hlch this permit has been granted. to ` Final Gas: All construction,alterations and changes of use of any building and structures shall be incompliance with the local zomng,by laws$and codes. "s . This permit shall be displayed in a location clearly visible from access stree or road and shall be maintained open for public mspectibn for the entire duration of the work until the completion of the same. - Electrical gig Service: The Certificate of Occupancy will not be issued until all applicable sign Lures by the BUllding and Flre®ffitials are,provlded onanis permit. Minimum of Five Call Inspections Required for All Construction Work n Rough: 1.Foundation or Footing �„' �W•,;,�. „ •_ „ ` 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Health 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. 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 Town of Barnstable Building �iP �.e �,,: �13��• ,,,� `;,,wzs'✓� ,.� ,� � ;., ; ��_, �� x, �i,� �'Y, , ' .;� �, a Kept �£" Posted Un„tihFinal Inspection Has�Been Made �� � � � �� � � � � Permit �Whe e a Cert�ficate,of Occupancy is Required,°sucfi Build�n shall Not be°Occu ied`unt�l a,Final Ins eetion��has` '= Permit No. B-18-1949 Applicant Name: MDH CONSTRUCTION INC. Approvals Date Issued: 06/22/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 12/22/2018 Foundation: Location: 45 MELBOURNE ROAD,HYANNIS Map/Lot 268-246 Zoning District: RB Sheathing: Owner on Record: CONNORS, LAUREN MNr ContractorName MDH CONSTRUCTION INC. Framing: 1 Address: 45 MELBOURNE RD Contractor Licemse 183807 2 x- ,5 HYANNIS, MA 02601 Est Project Cost- $3,000.00 Chimney: Description: Insulation/Weatherization PermitFee: $85.00 Insulation: Project Review Req: Fee Paid= $85.00 Date 6/22/2018 Final: Plumbing/Gas 3 � Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work a thorized bey this permit is commenced within six month, fter issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documentsl6r,which thrs permit has been granted. All construction,alterations and changes of use of any building and structures shall be incompliance with the local zomng by laws;and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or coid�and shall be maintained open for-4public nspection for the entire duration of the §" ` work until the completion of the same. Electrical KAN The Certificate of Occupancy will not be issued until all applicable signatures, the�Bu�d ng and Fire Officials are provided on"this"permit. Service: on Work: Minimum of Five Call Inspections Required for All Constructi 1.Foundation or Footing � � Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application number...... ........ ................................ ?'Z .t$........................... Date Issued................. ........ ` Z * a � , MAW ' . t Building Inspectors Initials...... ...... . :................... JUN 18 2018 Map/Parcel....' ` .............................. ...... ... ..... TOWN OF BARNSTABLE S EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: N �, ►�wvo A v Co NUMBER STREET VILLAGE Owner's Name: 3 OCL Y►h -� C4 a Phone Number Email Address: Cell Phone Number Project cost$ 73 00 t Check one Residential Commercial - I OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 5 r e 'd.�G e A-& to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK Q Siding E-1 Windows(no header change)# Insulation/Weatherization Q Doors (no header change)# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name �IJ l� �� S ✓v c�rl v L-j Home Improvement Contractors Registration(if applicable)# t 3 e o -7 (attach copy) Construction Supervisor's License# G 7 (attach copy) Email of Contractor AI ,,a4, 4� � � �,����Cd„����►'^Phone number `)7 v( -1)3 ..4616& U ALL PROPERTIES THAT HAVE STR ES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN. .1I9TA#AI .Inr-rr%01P' Aoncnve► RIPMRF d PFRM►T CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* Date Tenf(S)will be erected Removed on number of tents total Does the' tent have sides?Yes No (If yes please attach floor,plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CAM the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLI T'S SIGNATURE /V/Signature Date ell 6,11 All permit applications are subject to a building official's approval prior to issuance. r The Commonwealth of Massachusetts Department of Industrid Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit'Builders/Contractors/El pctri se Print Le bs Applicant Information M C g-4Y t o Name(Business/Organiration/Individual)' / ( n� Address: Yf City/State/Zip: (f 136(%Phone#: ro hate bog: Type of project(required): Areyoun an employer. heck aPP P 4. I am a general contractor and I 6, New construction 1,[&I am.a employer with have hired the sub-contractors employees(full and/or part-time).* listed on the attached sheet. 7. ❑Remodeling 2,❑ I am a sole proprietor or partaer- These sub-contractors have , g• �]Demolition ship and have no employees employees and have workers' 9. �]Building addition working for me in any capacity. comp.;,,ter e o workers'comp• Electrical repass or additions insurance 5. We are a corporation and its 10.❑ required.] officers have exercised their 11.❑Plumbing repairs or additions 3,❑ I am a homeowner doing all work right of exemption per MGL i�,0 goof repairs myself[No workers'comp. ` c.152,§1(4),and we have no insurance required.]t 13.0 Other employees.[No workers' comp-insurance required-] *Any applicant that checks box#1 must also fill out the section below sbowmg their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sb prshowing the name of the ovide their workers'comp policy renumber.rs and state whether or notthose entities have ompioyeeL If the sub-contractors have employees,they must p is the policy and job site I am an employer that is p roviding,workers'compensation insurance for my employees. Below information. 4� � J I v c- hsurance Company Name: l Expiration Date: Policy#or Self-ins.Lic.#: 1 W L B City/Stage/Zip: 2 6 b Job Site Address: �� �—�`���'�'�c' compensation policy declaration page(showing the policy number and expiration date). Attach a copy of the workers'comp P cy penalties of a Failure to secure coverage as required under Section 25A of MGL o. 152 can lead to the imposition of criminal to$1,SOO.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine fine up the violator. Be advised that a copy of this statement may be forwarded to the Office of of up to$250.00 a day against ce coverage verification Investigations of the DIA for insuran rtify of erjrcry that the information provided above is true and correct I do hereby ce Si e: 6 � Phone Official use only. Do not write in this area,to be completed by city or town official Permit(License# City or Town: Issuing Authority(circle one): inspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical 6.Other Phone#: Contact Person: Information an d 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 k 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 numbers)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-wed 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 permilOicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/Heense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided,to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would 111ce 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 Ilepartmmt of Inc trial Accidents ` Me of iuvestigatims 600 Washingtau Stet Bostwa,MA 02111 Tel.#617-727-4400 ext 446 or 1-877-MASSAFE . , Revised 4-24-07 Fa x#617-727-7744 wWw.mass-goV/dla t:l DocuSign Envelope ID:19B4FFF7-2AED-43E0-9AEA-05EB950A0987 Permit Authorization mass save Form Site ID: 3403704 Customer: Joanna Callahan I' Joanna Callahan , owner of the property located at: IOwner's Name,printed) 48 Fernwood Avenue Hyannis, MA 02601 (Property Street Address) (city) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. �DocuSigned by: Owner's Signature: if iE8469Bf7B74i9... Date: 4/24/2018 110:03 AM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: RISE Engineering Phone: 401-784-3700 Email: 0. Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration t N Type: Corporation MDH CONSTRUCTION INC. ,,', Registration: 183807 „ Expiration: 11/15/2019 PO BOX 6413 . PLYMOUTH,MA 023621 r Update Address and Return Card. SCA 1 ES 20M-05/17 - - Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:, ration before the expiration date. If found return to: Registrat Expiration Office of Consumer Affairs and Business Regulation 183807-= --;=1 i/15/2019 10 Park Plaza-Suite 5170 MDH CONSTRUCTION INC- Boston,MA 02116 Y I 4 IIIATTHEW,hARRIS' , } t'F`CG J98A ESTA RD PLYMOUTN MAIV360 Not valid without signature Undersecretary ,k 4s„r .c,�'r- .r,, 6 ' ,._, • ;", � #_ •v .''�'#n i a -s•�s `'ram ��'n�, X ter+,f ysu-r• •- §""t� y"'s. 4.3 , r ;. - Est 4vfi.. -x' +>`» d `i'.. ', '.kY.� ^ivrY�` -Y - �. t t E_: }-• . J %. ^c' 9(` fe A =@` gr' 'fi°e` "3. - .,yt}` '` d�.Ct s a' �', 'r e 1 K R �. a i - ..'n i ,ice ' r ur t h, . l .- •ca & ., x 7 s a �E. 41 N Goenriionwealt- of Massachusetts i� Division ofPRofessionarLicensuree Board of.BuiFding,.Regulatiory and Standards 3 Con st�uctl6rt%dpervisor is CS-1;05679 1:spires: 11/0712019 �a MATTHEW DIHARRIS 98 A ESTA ROADx� PLYMOUTH MA 02360' N, COMMissioner. t 1, �c CERTIFICATE OF LIABILITY INSURANCE pATE(MMlDD)YYYY► L... 01104/20/8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS;NO RIGHTS UPON THE CERTIFICATE.'HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE.AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BE TILE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must he endorsed. If SUBROGATION IS flEDbjeo the terms and conditions of the;policy,certain policies may require an endorsement A statement on this certificate does note certificate holder in lieu of such endorsernent(s). PRODUCER. CONTACT Christophef JOrdan __ Professional Insurance 8i Risk Brokerage,LLC ;mac° ,7$ 26-7475 w� 1 NoT31 Schoosett St.Suite 309 c ordan irbinsurance.comADDRES, _,�1 �PPembroke MA Q2354 Lvsu E al�o1Lgt!COVERAGE INSURER A: AIM MUTUAL _ INSURED rNSUR><R B The Main Street America Group 14788 MDH.Construction,Inc. INSURER 'z Penn America Insurance Co A_ (32859 PO Box 6413 INsuRER o:Scottsdale Insurance Co x 1 41297 Plymouth MA 0236Z INSURER F: M S COVERAGES CERTI:FICATE;NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR! AODL SUBR' J .POLICY EFF POLICY E%R t LIMITSLTR i _TYPE OF INSURANCE I ? '.I POLICY NUMBER. M 1 MID - - ,(.T COMMERCIAL GERERAt:LIABILITY s � ��..EACH OCCURRENCE �S 1,000;000 v'` i ) i ( VIDWAAGE rO R.EMED _1S 100000 C €_ !_yJ CLAW34AAA)f, :X oecuzi. i I ( Pt3EMlSES E:3. ccuczfrr�� f X t ISO FORM_CG0001 _ X ; X {PAC129672 05115117 05115118 ;ME9 ExP�Ana�,e 5 5 0 :�__,.�_,.,_.._.. ' X ', Contractual l..tabil ry ; wEasQNni s rev rnf turtY i 0,000 C GEEN'L AGGREGATE LIMIT AP-PLILIENS PER I ! i GCNERAL AGGREGATE' I$2,000,000 s POLICY L:.-'.-J JPEG" I lCiC ' 4 1 ;FR604.DCT$, C PIO' tGG S2y000.ON _ f ;OTHER; i II 1 COMBINED SINGLE LIMIT i g 1,000,00o AUTOMOBILE LIABILITY 4 ( l ; dartl t ;ANY AUTO t BODILY INJURY(PEr¢e*son) 1 S .. ��_Z ALI OWNED t SGHEOULED _ AUTOS AUTOS l X s.X ;M3F0206I' j 06/18/17 0611811$ BI niLY INSURy tPet aet;de sll 3 tiOaitJt NFD y 1 7 PROPERTY DAMA X i HIRED AUTOS I AUTOS ii# I tl''aeade l t X 111SOCA0001 y UMBRELLA LIAR OCCUR l t i EACH OCCURRENCE +__J 1 1000,000 D EXCESS LIAR CLgtfpSAot X X XBS0076026 05115117 105115f18 nGGREATE 1 F f',o00.00E} j DEO I X RETENTION S10,000 i i 4 :WORKERS COMPENSATIONa X PER. i 3 OTH 1 'AND EMPLOYERS'LIABILITY r S7Bf2lTE _.EB ___ r YIN N i t L. EACri ACCIDENT 9=500,000 (AIdYPROPRtETCR1PAR,NERJEkECUTtVE i 1 -. — A 'OFFICERIMEMBER EXCLUDED? ,N I A I X VWC1006019.37520ti7A 09104N7 09104t18 (Mandatory inNHl ; CIA asea�E:EnMP�OYI E s SOO,000 (If yes,descrtbo told p E I r i a' IDES RIPTIONOFOPERATiONSbelo i 1 EL DISEASE-POLICY LINT 9s500,000 Comprehensive Ded $500 B ;Auto Physical Damage. �I113F0206P 008/17 I06118118 �Collision Deductible $500 1 1 t i `DESCRIPTION of OPERATIONS I LOCAT TONS-I VEHICLES (ACORD-101,.Adti%tional Remains Schedutn,may,be ettached it-more space Is rocµitred) CERTIFICATE HOLDER,___ CANCELLATION SHOULD ANY.OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, i.NOTICE WILL BE DELIVERED IN ACCORDANCE.WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE i F - <DA> 01988.2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Town of Barnstable • g H In i • .nnrrznu�as, r �,�; � � �, � � � , a Street .Approved Plans Must be�Retamed on Job and�this,Card Must -e.Ke t RA" `-' M PostedUntil Final l �z ;: v p Permit of Occu anc �s Re uired,such�Bu�ld�n shall''Not be®ccu red unto a F,�nah Ins ectton asbeen ma P Y Permit NO. B-18-1949 Applicant Name: MDH CONSTRUCTION INC. Approvals Date Issued: 06/22/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 12/22/2018 Foundation: Location: 45 MELBOURNE ROAD, HYANNIS Map/Lot 268 246 Zoning District: RB Sheathing: Owner on Record: CONNORS,LAUREN M Contoctcrr&Name MDH CONSTRUCTION INC. Framing: 1 Address: 45 MELBOURNE RD EontrIl t ctor icen e 83807 2 HYANNIS, MA 02601 �* Est Project Cost: $3,000.00 Chimney: Description: Insulation/Weatherization F P $85.00 ermit;ree: Insulation: Project Review Req: Fee ,aid:` $85.00 N-Qat 6/22/2018 Final: 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 a'fter:issuance. Rough Gas: All work authorized by this permit shall conform to the approved appl coat nand the approved construction documents1forwhich this permit has been granted. All construction,alterations and changes of use of any building and structures shall pe incompliance with the local zoningby taws and codes. final Gas: This permit shall be displayed in a location clearly visible from access street orr ad and shall be maintained open for public�mspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by thBuildmg and Fire Officials are`provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work 1.Foundation or FootingIt z , 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 Town of Barnstable Building Post';This Card�So�That rt is°�/isible�From`the,Street ,A,, rovedPlans�Must:be Reta�ned4on Job andtthisACard,Mus�be,'Kept gg dUPermit Permit No. B-18-1949 Applicant Name: MDH CONSTRUCTION INC. Approvals Date Issued: 06/22/2018 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 12/22/2018 Foundation: Location: 45 MELBOURNE ROAD,HYANNIS Map/Lot: 268-246 Zoning District: RB Sheathing: Owner on Record: CONNORS, LAUREN M Contractor Name MDH CONSTRUCTION INC. Framing: 1 Address: 45 MELBOURNE RD F Contractor Liceri"se 183807 2 r \ ;� . HYANNIS, MA 02601 � �61 Est Project Cost: $3,000.00 Chimney: W. f Description: Insulation/Weatherization -Permit Fee: $85.00 Insulation: Fee id: $85.00 Project Review Req: t; Final: y Date 6/22/2018 R%� _ Plumbing/Gas Rough Plumbing: Building Official � •< Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorze -', by this permit is commenced within s x months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application Wakand the;approved construction documents forwhichthis permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structure-s,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 amend shall be maintained open for�pu6lic inspection for the entire duration of the work until the completion of the same. Electrical 5 The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:4a s 1.Foundation or Footing „ r . v ,• „ , , Rough: 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health _ Where applicable,separate permits arerequired for Electrical,Plumbing,and Mechanical Installations. -- - - - - 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 -' rr Application number ................:............................... BL, ® Date issued.......:......"'.I Z.........a........................... , Building Inspectors Initials.. .......... s � JUN 18 2010 L o� �9 / _ Map/Parcel....... .... ....................................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION- 'J h Y) Address of Project: "I o,,,�M e NUMBER STREET VILLAG Owner's Name: L v If�� ►`1 Phone Number Email Address: Cell Phone Number Project cost$ EGG Check one Residential ✓ Commercial OWNER'S AUTHORIZATION c z As owner of the above property I hereby authorize Se- t to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK F-1 Siding F-1 Windows (no header change)# Insulation/Weatherization © Doors (no header change)'# Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name �d�S t C. Home Improvement Contractors Registration(if applicable) # G (attach copy) Construction Supervisor's License# 0!) G 7 Cl (attach copy) �tJ er �(w+�,S ��ee �< c4 d `ePhonenumber --7 - L�3 Email of Contractor - `AU f`� .�� L -� ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OR IF T a SUBJECT R BE RT Y IS I 1 D ' e I APPLICATION NUMBER �l *For Tents On1_y* Date Tents)will,be e,rected Removed on " _ Y number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D., Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CAM the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLIC T'S SIGNATURE Signature Date G All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington-Street _ Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/El Pleascianse Print L umbers App [cant Information Name(Business/0r9anizat101&fflvidual)' / 1 H Address: C State/Zip: A4 G?3`6 Phone#: 77 Lt— 3 ity/ a�`� ' Type of project(required): Are.youan employer?Check the�pproP b I a general contractor and I l.[ -Y am.a employer with- 6. ❑New construction employees(full and/or part-time).* have hired the attached sheet 7. Remodeling listed on the attached sheet. 2.❑ I am a sole proprietor or partner- These�-oon��rs have . g. [�Demolition ship and have no employees employees and have workers' 9. Building addition working for me in any capacity. imp.;r,snse I airs or additions o workers'comp•Dance 10.❑Electrical rep [1`I 5. ❑ We are a corporation and its required.] officers have exercised their 11.[]Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 12.❑goof repairs myself.[No workers'comp. c.152,§1(4),and we have no 13.[�Other insurance reed.]t employees.[No workers' 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 tContactors that check this box must attached an additional sheet showing they he narne of the sub-contractors workers'comp. o icy number and state ether or not those entities have employees. If the sub-contractors have employees, they must plicy and job site providing workers'compensation insaranCefor my employees. Below is the po I am an employer that isP r information. A Insurance Company Name: t✓ 10® G 6 O Expiration Date: Policy#or Self-ins.Lie.#:v ` -' �P �J Gi s V1 e City/State/Zip: 4 r►'^� 0 6 � Job Site Address: licy declaration page(showing thepolicynnm er and expiration date). Attach'a copy of the workers'required derSection 25A of MGL c. 52 can lead to the imposition of criminal penalties of a Failure to secure coverage as requir 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 tine the violator. Be advised that a copy of this statement may be forwarded to the Office of, of up to$250.00 a day against a verification. Investigations of the DIA for insurance provided above is a and correct. e d pen 'es of perjury that the information P I do hereby c � I Date: Si ature: f, J d Phone#: � �^ � 1 4 official use only. Do not write in this area to be completed by city or town official PermitlLicense# City or Town: Issuing Authority(circle one): t 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 1.Board of Health 2.Budding Departmen ('Other Phone#: Contact Person: 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 iri the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate_a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage*required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority," Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability'Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 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 Commanwealth ofM ssachusetts I)Vart meat d Industrial Accidents Qfite a£Investigadow 600 Washington Street Roston,MA 02111 Tel. 617 ` 27-4900 ext 406 or 1- -MASSY Revised 4-24-07 Fax#617-727-7749 WWW-M gov/dia . DocuSign Envelope ID:8150647D-9C8F-445D-9COC-AF8A32E40D00 Permit Authorization mass Save Form Site ID: 3411832 Customer: Lauren Connors I, Lauren Connors ,owner of the property located at: (Owner's Name,printed) 45 Melbourne Road Hyannis, MA 02601 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building_permit to perform insulation and/or weatherization work on my property. DocuSigmd by: Owner's Signature:! 219FOE9D22AM2A.. Date:5/16/2018 1 8:05 PM EDT FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date i Name: RISE Engineering Phone: 401-784-3700 Email: 4J �!4� �IrVV/� /��(/}�f{�('////`�.•, U��I!AV V/jl�C�'��� . Office of Consumer Affairs and Business Regulation One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Type: Corporation Registration: 183807 MDH CONSTRUCTION INC. . Expiration: 11/15/2019 PO SOX 6413 PLYMOUTH,MA 02362 Update Address and Return Card. SCA 1 0 20K4-05/17 /ee�mrranaseii�ril//r.o�r'-l�cr:;.rar�r�:r�l/�. Office of Consumer Affairs&Business Regulation TOME IMPROVEMENT CONTRACTOR Registration varid for individual use only TYPE;,Corporation before the expiration date. If found return to: Repistraf ft Wiz: Expiration Office of Consumer Affairs and Business Regulation _-=11/15/2019 10 Park Plaza-Suite 5176 MDH CONSTRUCTION INC= Boston,MA 02116 y s— � .. t MATTHEJ�J HARRIS N PLYMOUTH MA 02360 •- Not valid without signature .� S§= �* st�;g; 3 {Underseretarys YS s -M pi { 4 9 '�,t�m ` " -s, s '�y`°� r aT arse �xt �e ax � �x ga Abe �3 Y £ U 4''$� M4 -� `h�"� i. a"y ,w` z ''- § GomcnonwJR, of Massachusetts Division of Professiomaf Licensure Hoard of.Buil.drng:Regv{ation.s and Standards Con strr4_i tt6r5%bpqrvisor CS-105679 .E L 1'c ;� z y; , pies: 11l07/2019 MATTHEW D 11ARRIS f 98 A ESTA ROAD 1 PLYMOUTH MA 02360 Commissioner.. , ,nco (JaM1DD1YYYY> CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUER AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLIC4ES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the Policy,certain policies may►equire.an endorsement. A statement on this certificate does not confer rights to the certificate'holdeT in lieu of such endorsement(s). PRODUCER CONTACTNAME Christopher Jordan_ _ AX Professional Insurance&Risk Brokerage,LLC PAHc°Nt� Ex►I 1 825 7475 _ _ i� j(781)826-7484 31 Schoosett St:Suite 309 E-MAJLAQDRESS;_cjordart@pirbinsurance corn Pembroke MA 02359 —. INSURERL4)AFFORDING COVERAGE N_AJC# iNsuRER A: AIM MUTUAL_. 133758 INSURED INSURER B; The Main Street America Group_ � 14788 MOH Construction,Inc. MSURFRC: Penn America:fnsurance Co . 32859 PO Box 6413 INSURER D: Scottsdale Insurance Co 141297 'Plymouth MA 02362 Y INSURER F z. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR-i'HE POLICYPERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS, INSR: � ADD[5UBR. 1 POLICY EFF POLICY E LT i TYPE OF INSURANCE ; XP POLICY NUMBER ! M IDDIYYYY I MMI ! LIMITS I X 1 COMMERCIAL GENERAL LIABILITY `- ? $1 000,000 { � "EA) CIA OCCURRENCE � _ t } {DAMAGE TO RE _NTED C Ct.AJatiS•IvtADE °X i OCCUR t { ES!Pt9tSES CE�x"=.csuup ' s 10D;000 { X ! ISO FORM CG0001 X 1 X i PAV0168133 i 05/15/18 05115119 1 tgEu EXP IAn.j;3�erson� S 5,000 X Contractual Liat)ili ( ( PE_{SONAL s ACv IWILPYw s :II¢0,000 . ��. _ GEN'L AGGREGATE LIMIT APPLIESPOP, 3 �GENERAL ACGREGKrE �52,000;000 j I } * -- ! POLICY[FX_'" j �y LOG 1 j i { i PRO�UCTS FC?MP�OPAGG'4 S2rQ00,000" _ - � tS 44 i I f J flTNER' COMBINED SINGLE LIMIT S 1;000,000 AUTOMOBILE LIABILITYI. t t , f t _ 1 tt a t.!F-a r$rseenta I� BSI ANY AUT{) ; $. I t?CaOtLY(NtURY{Per patsanJ F s �� > niros N�=a 1 X 'SCHEOU'"UTOS X X }M3F0206P i06/18118 i0018119 8fl0ILYINJIJRYtpereczd�Jill b NON-OVIINEO ! # I i i..PROPERTY S i X ;HIRED AUTOS ?^ `AUTOS I t X rtSOCA0001 X l UMBRELLA LEAS 1 X i occu+7 #€' ; I EACH OCCURRENGE� S 1,000,000 'EXcssLlAe . t00D a -nep� 1 1 ; i DED i X RETENTI NY510,000. 1 3 a S `WORKERS COMPENSATION ? - X- J OTH- i PER AND EMPLOYERS'LIABILITY YIN; I I =sxfilll2l=r:�..._.S.E�.Y-�. '— ANY PROPRIETORIPARTNERFEXECUTJVE: I i I E.4 CACH ACCIDENT J S 500,000 A OFFICERIMEMBER EXCLUeEDz [N ,NIA X 1 VWC10060193T52017A `09/04117 09104/18 z (Mandatory in NH) ? ( { I I E L.DISEASE=EA EMPLOYEE 5 500,000_ If es.OesGnbC d ades I f v O SCRIPTION OF OPEP.ATIONS befow ' ' I. I E I..DISEASE<POLICY LIMild$500,000 I # + 1 Comprehensive Ded $500 B Auto Physicat Damage, 4 M3F0206P t 06I18118 )06/1811.9 Collision Deductible $500 DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may oe attached it more space is required) CERTIFICATE HOLDER:, CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES-BE CANCELLED BEFORE_ THE EXPIRATION DATE THEREOF, NOTICE WILL BE .DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVEi� ` r^.�,= 4DA> A t 6XI-1 7"1988-2014.ACORD.CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD d fie Town of Barnstable..Tj� � � . •" 200 Main Street, Hyannis MA 02601 508-862-4038 Application for ]Building Permit Application No: B-17-1960 Date Recieved: 6/21/2017 Job Location: 45 MELBOURNE ROAD,HYANNIS Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: NICHOLAS A LAGADINOS State Lic. No: CS-012653 Address: Cotuit, MA 02635 Applicant Phone: (508)428-4097 (Home)Owner's Name: CONNORS,LAUREN M Phone: (508)862-2774 (Home)Owner's Address: 45 MELBOURNE RD, HYANNIS,MA 02601 Work Description: rip and re-roof 20 sq. Total Value Of Work To Be Performed: $8,500.00 . 1".. 3 �v -71 `Zo Structure Size: 0.00 0.00 0.00-1 Width Depth Total1,Axea Co e4� D I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other wdrrUr 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: Nick Lagadinos 6/21/2017 (508)428-4097 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost: $8,500.00 Date Paid Amount Paid Check#or CC# Pay type Total Permit Fee: $43.35 6/21l2017 $43.35 XXXX-XXXX Credit Card 7800........... Total Permit Fee Paid: $43.35 2k TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel v Application # U Health Division Date Issued �3 Conservation Division Application F(16 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Addresss Village 'S' Owner Address Telephone 2-774/ Permit Request X Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ��• �� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 9 Two Family ❑ Multi-Family (# units) �? (3. Age of Existing Structure `�®� Historic House: ❑Yes ❑ No On Old KiAg'� Highwa ❑ s ❑No Basement Type: Jd Full ❑Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) — Basement Unfinished Area (sq. ) : Number of Baths: Full: existing new � Half: existing nee�w—� Number of Bedrooms: 3 existing v new o r Total Room Count (not including baths): existing new Q — First Floor Room Count Heat Type and Fuel: MGas ❑ Oil ❑ Electric ❑ Other Central Air: aYes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name o!rl'd Telephone Number Address / 1")4 License # � r �/�- r/f'y ��_ ii� ©1�6•� Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RE t LTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE FOR OFFICIAL USE ONLY APPLICATION# r ' t DATE ISSUED MAP'/PARCEL NO. ADDRESS VILLAGE t; OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t` FINAL BUILDING y C DATE CLOSED OUT ASSOCIATION PLAN NO. _ r i r i. = The Commonwealth of Massachuseft Deparhnent of Industrial Accidents Office of Investigations i 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A" licant Information Please Print Legibly Name (Businessiorgaai�zfionandividuo): Address: /6 / (nJ City/State/Zip:- ��'i!` � � Phone#: Are you an employer? Check the appropriate box: 'hype of project(required): 1.0 I am a employer with 4. I am a general contractor and I employees (full with part-time).* have hired the sub-contractors 6. ❑New construction2.�2D am a sole proprietor or partner listed an the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition. workmg for me ' any capacity. employees and have workers' 9.. 0 Building addition [No workers'comp, insurance comp.Msur nce.t 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 I I.❑Plumbing repairs or additions myself [No workers' 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 . comp.insurance required.] *Any applicant that checks box P-anust also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: .policy#or Self ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year' risonment,-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 vi atof. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for' e coverage.verification. I do hereby.certify u e- d penalties of perjury that the information provided above is true and correct Sip-nature: Date: Phone#: Of)7dal 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 $.-Plumbing Inspector 6..Other Contact Person: w. 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 ofhire, 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,ass6ciation or other legal entity,employing'employees. However the' . owner of a dwelling house having not more than nthree aparti end and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,;construcdon or repair`work ou such dwelling house' or on the grounds or building appurtenant thereto shall not becau e of such employment be deemed to be'an employer." MGL chapter.152, §25C(6)also states that"every state or local licensing agency shaII withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter-have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking-the boxes that apply to your,situation and, if. necessary,supply sub-contractor(s)name(s),address(es)and phone nuinber(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 mrmber listed below. Self-insured companies should enterthair 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 6f Investigations has to contact you regarding the applicant Please be sure to fill in the permit/Iicense number which will be used as a reference number. In addition,an applicant that must submit multiple peimit/licease 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"ah locations in (city.or ' towti)."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 bus mess 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 hlce to thank you in advance for your cooperation and s iould you have any questions;' please do not hesitate to give us a call, The Department's address,telephone and fkx 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-MA.SSAFE Fax# 617-727-7749 evised 4-24-07 www.mass.gov/dia r °FWE - Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bar'nstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder Ulz�e�/ ��'sl/dtJclz� as Owner of the subject property hereby authorize s-� ! /ca to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner ignz tote o Applicant v Print Name Print Name Date Q:FORMS:0WNERPERMISSIONPOOLS 612012 Town of Barnstable Regulatory Services t ReRNPIARr_R « Thomas F. Geiler,Director 16g9- Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:•508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print. DATE: JOB LOCATION: number street village "HOMEO` VIER": name home phone# work phone# CURRENT MAIL]NG ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner occupied dwellims 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 HOMEOW-MR 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 strictures. 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 responsiole 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 Deparhnent minimun inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: T tree-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Constriction 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 conatruuction Supervisors);provided that if the homeowner engages a persons)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&Rsgulations 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/herrespansrbifities,many communities esquire as part of the permit application, j 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 j several towns. You may care t.amend and adopt such a form/certification.for use in your community. Q:forms:homeezenrpt r - LOT 47 N8975'34"W 143.51' — iv jif o , Q) LOT 48 Nc. plo 1 •,�S O nO; PLAN: S85 7536 T — CALL.• S897533"E 119. 41 LOT 49 Plan RES.. ZONE.- 'RB'° This MORTGAGE INSPECTION Bank IUseoOnly FLOOD ZONE.- "C" THE DISTANCES AND MEASUREMENTS'ON THIS PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY. TOWN: _ T � _O _ REGISTRY OWNER: JUDITH T {YINSTDN k PATRICIA T SULLIVAN DEED REF: _L82V-84--__ ---- BUYER: -L-4-UEFN_M C01VLVQ8S-------------------- DATE: 06A8�2000--------- PLAN REF: z5O/143---------SCALE:l"= 3d---FT. I HEREBY CERTIFY TO TODAY MORTGAGE SERVICE'S ___ YANKEE SURVEY ___ _ _____ ____ ________THAT THE BUILDING SHO CONSULTANTS WN_ON_ THIS PLAN IS LOCATED ON THE GROUND AS SHOWN AND THAT ITS POSITION DOES ---- CONFORM MAL 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE & INDUSTRY ROAD TOWN OF ___BARNSTABLE_____________AND THAT IT DOES_ NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD 3m ARSTONS MILLS, NIA_ 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED 08,-_19:B5_ TEL 128-0055 C nity-_Panel 250001 0008 C FAK: 420-5553 THIS PLAN NOT MADE FROM AN IN SURVEY 28970 JF P A. dERITHE��. PIS NOT TO BE USED FOR FENCES. BL11LD[NG PERMITS. ETC. " M i I r r- - ,:�T ILL LJ I , t -+- -1- - -- I - -- ---- — � ....................: ex, `porzzrzaoaar,�ea�Office of of Consumer Affairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: 11,8952 Office of Consumer Affairs and Business Regulation OME IMPROVEMENT CONTRACTOR egistration: Type: Expiration &10 15 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 THOMAS P DAMELIO BLDG&REMODELING THOMAS DAMELIOI 16 WHITE BIRCH W. BARNSTABLE,MA 02668 Undersecretary ''Not valid without signature Massachusetts - Department of Public Safety Board of Building Regulations and Standards Construc6iin Supervisor I & 2 Family License: CSFA-047420 THOMAS P DAMI;Y.IO 16 WHITE BIRCH W BARNSTABLE MAO GS ��A Expiration 04/07/2015 Commissioner 9 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel ?04 p Permit# 013 Health Division /1r© C° !F!�'�/ 7 ate Issued 6h d a, Conservation Division E r. Application Fee Tax Collector Permit Fee / Treasurer 4s r°4'i S;L -----..SEPTIC SYST0 d9 MUST BE I^;STALLED IN COrMPLIAhrcE Planning Dept. WITH TITLE S Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE ANE TO MI REGIILA,-.IONS Historic-OKH Preservation/Hyannis Project Street Address '� /�i�'� Jr/.e de- 0 Village /0 e AILIO-AlAkj 'Pe)/LII Owner Z��/�/i1 (,dNIti'mS Address go cQrwJ ��. &0/,keoi A4 Telephone ��/'— :5,2/ —14 3 A 4 Permit Request_1� ' �i�.� d 1�� �— �'l� �ll�r�4"� ;; �A Square feet: 1 st floor: existing/13010-lm proposed 2nd floor: existing 1#14 proposed — Total new Zoning District Flood Plain Groundwater Overlay Project V'aluation'��,5y©• Construction Type "dO ?-IZOip 9� . Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family (tY wo Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) —D Basement Unfinished Area(sq.ft) 10-50 S'eC Number of Baths: Full: existing new Half:existing / new Number of Bedrooms: existing new —®— Total Room Count(not including baths):existing new —o — First Floor Room Count �v Heat Type and Fuel: ®'Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing / New 0 Existing wood/coal stove: ❑Yes t"o Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use _ Proposed Use BUILDER INFORMATION Name tv�3 /!`v Telephone Number'" Address 1Ae 4 License# V 12 D e 2 Home Improvement Contractor# Worker's Compensation# ///� 10, ALL CONSTRUCTION DEBRIS ULTING FROM THIS PROJECT WILL BE TAKEN TO _ _6&2& SIGNATURE DATE ��� O FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED ' MAP/PARCEL NO. ADDRESS VILLAGE , OWNER ` DATE OF INSPECTION: FOUNDATION jS p ,C r FRAMEt INSULATION 6/,VS 0 d A 9"/2 Z 3 " • " FIREPLACE rl ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGHS {:g kri FINAL' t . . FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. dV(HE l° Town of Barnstable Regulatory Services WNsT"LA Thomas F.Geiler,Director HAM E 6 p.�a` Budding Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 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. a'4e� Estimated Cost ,d �' Type.of Woxk: G �yy��,,�/ Address of Work: ol 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 ElBuilding not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent o e owner: D to Contractor Name Registration No. OR Date Owner's Name RESIDENTIAL BUILDING PERMIT FEES ' APPLICATION FEE New Buildings,Additions $50.00 CIO Alterations(Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE _ ®O square feet x$96/sq.foot= l� x.0031= plus from below(if applicable) ALTERATIONSIRENOVATIONS OF EXISTING SPACE _J —square feet x W/sq.foot= A& x.0031= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq.ft, , >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: x.0031= square feet x$96/sq.foot= STAND ALONE PERMITS , Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fe projcost M CMR Appendix 1 Table d31.1b(continued) Prescriptive packages for One and Two-Famity Residential Buildings Heated with Fossil Fuels MAX MUM MINIMUM s� �Heating/Cooling Glazing Glazing Ceiling Will Floor Baesa seat eiet FApuiproent Efficiency' Area'(Yo) U.value= R-value' R-value' R-valULJ R-wall R� T re 3701 to 6500 Hesting Degree Days° Normal 12'/5 0.40 38 13 19 10 6 19 19 10 6 Normal 1. 0S2 30 6 ES AFUE s 12•/. U0 38 13 19 10 N/A No=al T 15% 0.36 38 13 ZS N/A 6 Normal U 15% 0.46 38 19 19 10 N/A E5 AFUE `7 15% 0.44 38 13 25 N/A I ES AFUE Rr 15% 0.52 30 19 19 10 N/A Normal X 19% 0.32 38 13 25 N/A ld/A Normal y I S'/a 0.42 38 19 25 A 90 AFUE 6 Z 19% 0.42Ho 8 13 19 10 6 90 AFUE AA 18% 0.50 19 19 10 1. ADDRESS OF PROPERTY: ? 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 353 S� 3. SQUARE FOOTAGE OF ALL GLAZING: Sr 4. %GLAZING AREA(#3 DIVIDED BY#2): �� a 5. SELECT PACKAGE(Q--AA-see chart above): -� NOTE: OTHER MORE INVOLVED METHODS OF DETE NU ING ORGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-580303 a 780 CMR Appendix J Footnotes to Table A2.1b: '' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space, but excluding opaque doors)to the gross wall area, expressed as a percentage. Up to 1%.of the total glazing area may be excluded from the U-value requirement. For example, 3 ft of decorative glass may be excluded from a building design with 300 it'of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units: center-of-glass U-values cannot be used. The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation.thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 4 Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing, and interior drywall. For example, an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces (such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement d::scribed in Note b. The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3;4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. . 'For Heating Degree Day requirements of the closest city or town see.Table J5.2.1a NOTES: a) Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b) Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door,is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). , c)If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). r ��pTHETph, Town of Barnstable y "s Regulatory Services ' BAMSrABLE, ' Thomas F.Geller,Director 9 Mass. 163 p.�p`0 Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 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 r/d to act on my behalf, in all matters relative to work authorized by this building permit application for (address of job) 111103 Signature of Owner Date LGU�(�► NVL V1��S Print Name f M Q:FORM&O WNERPERMISS ION (` __=- . The Commonwealth of Massachusetts tn. - .. - =- I Department of Industrial Accidents = office o//nsestigatiefts . .. 600 Washington Street -=- . Boston,Mass. 02111 . Workers' Com ensation Insurance Affidavit name: a,&e--r ,-e-,/.-d location: �e,4 fig�,z.le— ,A city A,ow,p,�,J `, J// e 7,1 a/ phone# -42,P-542-l" —d*P d-7 ❑ I am homeowner performing all work myself. . ❑ I am a sole r rietor and have no one w ildmn in an ca acrty I I'll, %% % /%%%%%%%%/%%%%%/��/%%/%%% %%�� %%%//////��%//%%//%/���%%%%%/%%%%%/%%��/�%%%%�%/%�%%�%%�%%//G%%/ ❑ I am an employer providing workers'compensation for my employees working.on this.job. ..... ......... ......... ......... ............:::................. :.:.. :;:::.N.,;:: :.:.>:.::;:.;::.;::.;::.:.: .::.:.:.:::.::: to an,:name::;;;:...:.:;:;;«::::: ?<>::>>.::>::>:::::::.':':';•:; 1. >:<:::>::;::»:::::>:<:::»>::>:: ... .. .:: . :'. hone city .. p #. . ... :.. ..... .insurances ali # :' %/ am a sole proprietor,general contracto ,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation I.polices: "'amc ' : ."" A '"an n chin v I� p ::.....::: .:...... •........:..:..... ..... ....................... ' . :: :......."-i.....::::::::::::.:::::.:::...::: ....:..:::::::::.:;<.:.::.;;......:::..:.: ::::::::..:::::::;;;.:::::: :::::.:..:. :::::t >::: .. .............. ............:..... .........................................::.. ............ .....vd... n.::::nw:::.:...: , .:'..: ii.-.%— v::::::iiiiiii::i::::_::._:::i=::i::.....!:ii......iii.....`+::;i:.:i:'::_:<:j^:: .:::ist:i::::!:i::i j'::::':":::?":j::::::;::i?:::::i::::::: :!:i::i::ii.':isiii}iiiiii}i::?i:i::<:j:::::i::Ci::j:vL:::::i: ::•::i:::,:::,':::i•i::ii:i' i :: :..'.:'::•:i•i:•:i: iffy}":is>::>:. ,/'" ;i ..s....,..',..::-........:--..:.:...:.:.:.:.:::...:,::..:.:.._...:.:::::::,. ..:.....::.:....::.:.�::;,.::.;::>o->::d<.>;::;>;::.:> >:<`: :<::;';:.;;:< .: :::.::.:.:::.;:.:...:.::'.;:.:.:.:. `< ' ln�itrance:ta:::.:::::.....,......:.::+,�:,..i ................................................................... oli #. .:. .::.:::.::;.;:.:;.;:.;;:.;:;.:.;:.;:.. ::.:::::.:./''///9J//////ji:. ai v i ti <`:::'S>`;::z > ?::::z: ': :; z:: ?:..—'.:::::::;:> ::?::: .I... :%:::: ......`:`::'£ :z:::::::::::::a::i: ?:::i :i ::...... >:'::::i:: ::; : .................. :. ..,. .... c an:.name:::::::.:: :.:.: :: ::::::::::::::.::::: ° . .:.::::...:....................................................................................................................................................................: :. >< +�- ... . .. . 1. ..... .. . ..........: . . .. adclrEss hn # . «::<::.: :::::: :.;' ... ;;;..;.:::,.:::;:...:;.....:.:::::........:........::.::::..:::: :ii::J:i24$:iiii::i: :::j'::i'n::i:::i:>;:y'`:'::.::f' ::' '•.":.` : I. :iii}:%: :i'I.':'<:::::i?::i:i::i': ::.:.::i::}i::::::ii::::i:j:v<5:::::i`: i::iii::ii'' :i::':isfi::ii: :..... .':>':'_.}.. ?i'>:: -:::: :y': ::i:::!•::•.:::::•::•::::::. lnsnracnteso.:::::::: 4`w</.,.•?# .::::: .:::.:....................._................................ oli #.......... ..............__.. ... ... .. ........., . ._................._..:: VA rAl // Faflure 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 f d to the Oice of Investigations of the DIA for coverage verification I do hereby certify th ains pen es of=* thatnformation provided above is true a/nd totted Signatur Date Sra . - Print name Wr / X Phone# �� �� age/ official use only do not write in this area to be completed by city or town official . city or town: permit/license# CIBuilding Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department . contact person: phone#; ❑Other (mvised 9195 PJA) Information and Instructions T 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 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 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 applicant. Please be sure to fill in the permitJlicense number which will be used as a reference number. The affidavits may be returned in+ 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 Me of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 LOT 47 - N897534"W 143. 51 � Cjl J 4L; �I , LOT 48 CpuC �I ti #45 �. ti PLAN.' S85 7536"E 119. 41 ' - CALC.' S897533"E LOT 49 Plan RES. ZONE.- 'RB" This MORTGAGE INSPECTION Bank �UseoOnly FLOOD ZONE.- "C" THE DISTANCES AND MEASUREMENTS ON THIS PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY. TOWN: _WF,ST H� iVN��PON _____ REGISTRY OWNER JUDITH TWINSTON & PATRICIA T SULLIVAN DEED REF: _1829/B4 _ BUYER: _LA-IRFN_ff C01VNQRS_-__-_-_ ____ DATE: _06�'OB,/?000_____-___ PLAN REF: _250/13_________SCALE:1"= 30 FT. [ HEREBY CERTIFY TO TOLL MORTG��iGE SERVICES YANKEE SURVEY _ _-_THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS CONSULTANTS SHOWN AND THAT ITS POSITION DOES ____ CONFORM P" 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE INDUSTRY ROAD TOWN OF B.1RNS_T.4BLE_____________AND THAT 11 IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD ARSTONS MILLS, NfA. 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_0_B_19/'85- TEL: 428-0055 C inity-Panel 250001 0008 C FAX: 420-5553 e _ THIS PLAN NOT MADE FROM AN IN SURVEY 2(q IF P: \. :tERI'1'[IE1�'. PLS NOT TO BE USED FOR FENCES. BUILDING PERMITS, ETC I ✓ACC L/.O.'h7/I)7.O9ZlI�CQG�l � �,a� •' BOARD OF BUILDIN:, RE--'G, TIpNS License: CONSTRUCTION SUPERVISOR a Num ber.ct047420 • � � Birthdate-=-0�}/07�1946 E7cQtre / �00 Tr.no: . 10673 I:E Res�rr�fe���10--� THOMAS P D4lVIEGI ? =�� .. / I 16 WHITE BIRCHAY ti` W BARNSTABLE ' 711 Administrator` Ie r»omvn�oouuea�l/ �D i Board of Building Regulations and Stand' ards HOME IMPROVEMENTCONTRACTOR Registra'6w,118952 lug Exprcati-0 0/2005 :!t • THOMAS P DAMELIO toDG&p!i. D LING THOMAS DAMELIO 16 WHITE BIRCH W"' _ W.BARNSTABLE,MA 02668 Administrator . I . f l j I i v` ' ---------- t T .......... ---------- 24, .......... - -t -- _..._- :__ �_i_._ -4- t ...............- ----------- 19 4-1 F --------------IP .............. I � � A � ' t i I - ' f f I 44- i 1 1 , r I I i F , t t ! I 1 71 Assessor's map and lot number ' Sewage Permit number ............... ............... .......... ,./c0�'1 s� ,w r ANCT F B ALE y�i TH E T® ♦1 � R 1 \ S 1� Z E9SB9TOELE, i 16 BUILDING INSPECTOR .. APPLICATION FOR PERMIT TO ..lf��?:��••�:�••�:..�.............!t................. .... TYPEOF CONSTRUCTION ...,........ ..................................................................................................... .......19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: -Location ���. . ......... . .. ... .... L..f.. �.. . ... .�'! �.h.. ............. a ProposedUse .. ................................................................................................................................ Zoning District e Fire District .....: .. .d f r7.......................................... r� --&� �a�. �'�.. .... ... Name of Owner �tR�.�!:�4: ,.�..s�'1F:4:� �:....Address ... .. ...:.. ... Name of Builder ...... 5 .............Address !6/..s?., . . , .... Nameof Architect . ........ ........................................:..Address .................................................................................... Number of Rooms ....../il .� Foundation �. . A........................... �• .......... . ....... -'..................... Exterior : �....................... .. .......:............................Roofing .... ...... :....... �......................... ...................... Floors ...��. ................ .......................................................... Interior .......................................... Heating .........................................................Plumbing .....:..............: ............................................. 6—40 Fireplace ......... L........................................................Approximate Cost ....... .y...... .`..................... ............. . Definitive Plan Approved by Planning Board ________________________________19________ . Area .....o........ .........s� ......... © 0 Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEATH 1 © ----- lel o I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name4 ............. .... ........................................... Sullivan, Patricia T. ' . l778� a�d — � No -----.. Permit for -----bm--����^ le-- ` ! family dwelling ` -----.----.� —_____________. \ � . —4 Location - 5..Melboor1ue.�Road ______. .................... .......................... � ^ ~ Owner --...Pat ricla'T..—Sol.livao____ �ra�e Type of Construction _--- ---------- - ' ............................................ —_----.----..` Plot Lot ---------. ----------' Jn�a 3O 7� Permit Granted -------------]g ' Date of Inspection --------...---l9 � Date Completed ........�����-----.]q ~ . � � . � PERMIT REFUSED -----_--------------- lA .---------`---------------.— � ^-----..—.----~.--.-----------. .—.—'.-------..----..---------., ! ._.____._______________,___._ | ' Approved ................................................. 19 -----.—.--------.—.--------.,. � -----------.------------.—,.. ~ ' Assessor's map and lot number .....! .t . .'.. .. / �u. � � ��-,e, --� Sewage Permit number ....................................................... I' A16 !" TOW OF BARNSTABLE THE N 1 Z BAHHSTSDLE, i "6 q 0 M , BUILDING INSPECTOR � PY M1• 1 (5 i APPLICATIONFOR PERMIT TO ..............f.............................................................................................................. TYPEOF CONSTRUCTION ..................................................................................................................................... ..... ......19... }( J/r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: r_°.4�I�rr�-c tom,-�-r .....:�,r�..cs/. ✓; �KcY� i�r --/ n-?�.9 R ;� � Location ................................................. +...r......... I /1�t�'�( lYtr'B'�f-t Proposed Use ..................................................................................:. ..............................................................,......................... Zoning District ..... ......:. f .Fire District ............................. Name of Owner R ....Address... . . . .......................... Name of Builder 'yt pJ/l-G' �'c:?'. !f>q �L `*-t�trn J1^d ' wf � .............. ........ ................Address .�....:.....;...........................�.........................::...,..........:��.�'`,> Nameof Architect ... 1- .........................................Address .................................................................................... Number of Rooms /' X ���"c—...................................................................Foundation .!�'..!... ' ... ............................ Exlerior /�'rrrrn�+ '! ?r �1 ' Roofing o�1�/ ...... ........................................... ...............�.......:.......� ....... ............................ _z___ Floors / ? ciz- ..........................................................Interior �... Heating ........... ........................................................Plumbing ......................yu �...................................... ............. Fireplace pp ` ,o '6 p` ........................................................Approximate Cost ......... !. ...................................................^... Definitive Plan Approved by Planning Board ________________________________19________. Areac C, .......................................... Diagram of Lot and Building with Dimensions Fee ...........::...>...r......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH f• 1 :r _a 14/ . p 3 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...................... Sullivan, Patricia T. A=268-246 17784 r_g No ................. Permit for ........add......to.......si.........le...... family dwelling ............................................................................... 45 Melbourne Road Location ................................................................ West Hyannisport ................................................ ........ Owner Patricia T. Sullivan ................. ................................ Type of Construction __...frame ......... Plot ....................... Lrt ................................ p June\30 75 Permit Granted .........................................19 Date of Inspection .................. ................19 Date Completed .................. .:.................. 19 PERMIT REFUSED ..................................../........................ 19 .... .... .................................. ................. ................. Approved ..................................... ......... 19 ............................................................................... ...............................................................................