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1046 PHINNEY'S LANE (2)
,t,7 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION N Ck(� Up Map pp Parcel A lication # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee s�� Date Definitive Plan Approved by Planning Board Historic - OKH N _ Preservation/ Hyannis Project Street Address 11 (o PH iAl N Ys LANE Village Owner /"! 1 CYfi&L � 11AZ�06 Z Address Telephone Jr Q9 " -771 - .5WX0KG_S Permit Request nqM11,Y -CW T r U - �Y00)6NA-tc �s 7" Z N)yhs� Z ue-Z-/\W4 t01) E Cc- , 6Y G b Is!5lba Square feet: 1st floor: existingproposed UV 2nd floor: existing proposed Total new mac: Zoning District _ Flood Plain Groundwater Overlay 00 Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highwayi_❑Y a ❑ No I Basement Type: ❑ Full ❑ Crawl ❑Walkout 00ther 11AIZ 63'`b MIL, Basement Finished Area (sq.ft.) Basement Unfinished Area (sq ft)% -n Number of Baths: Full: existing new Half: existing T_ new Number of Bedrooms: existing —new Total Room Count (not including baths): existing _�new First Floor Room Count 3 3 rn tig Heat Type and Fuel: )W Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes )&No Fireplaces: Existing I New Existing wood/coal stove: Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage:A existing ❑ new size _Shed: ;d existing ❑ new size _ Other: ' Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes 1i No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (�wUiYSt _ - - (BUILDER OR HOMEOWNER) Name L r7 Lf` �• V-Rt- Telephone Number 6O 9' 7 j/db 1 L Z5 Address ,[� ��� //'f � License# Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO e SIGNATUR DATE ` 7 t + ; FOR OFFICIAL USE ONLY 1 7 , APPLICATION # BATE ISSUED :s MAP/ PARCEL NO. x . ADDRESS VILLAGE ,t OWNER • i DATE OF INSPECTION: t FOUNDATION ti r . FRAME INSULATION FIREPLACE r. ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING j DATE CLOSED OUT 'ASSOCIATION PLAN NO. Town ofBarm L-.It 0372 P:u294 THE 0 3 —'?4_ 21 A r`' g u O Regulatory Services .� Richard V.Scali,Director • BARWSTAaLF, • M' Building Division rend• Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 AGREEMENT FOR FAMILY APARTMENT I Michael G. Vazquez, the undersigned,being the owner of property situated at 1046 Phinney's Lane, Hyannis, MA holding title under a deed recorded with the Barnstable County Registry of Deeds in Book 19294, Page 195, being shown on Assessors' Map 273 as Parcel 010, hereby agree, certify, warrant and represent to the Town of Barnstable that the accessory attached apartment, which contains living quarters, is intended for use as a family apartment,for year-round occupancy. This unit shall be used for a"Family Apartment" (as defined in Zoning Ordinances) which would require compliance with the Family Apartment Rules and Regulations. The family apartment unit must be occupied only by the property owner or a member of the property owner's family as accessory to an owner-occupied single-family residence. Occupant(s)of Main Residence: Michelle Vazquez and Ruby Vazquez-Newton r Relationship to Owner: Sister and Niece • MAR 2 4 2017 Resident of Family Apartment: Michael Vazquez ! �1 OWN O.8 ,I�ST,,�,i_ Relationship to Owner: Owner This unit shall not be rented as an apartment or as a single room,or in any fashion,which rental would be a violation of the Town of Barnstable's rules, regulations, and zoning ordinances. Prior to occupancy of this unit, affidavits reciting the names of occupants are to be recorded with the building department. This agreement shall be updated whenever a change occurs or every calendar year. This Agreement shall be duly recorded or filed at the Barnstable County Registry of Deeds/Land Court for,the purpose of alerting future owners of the property of this binding Agreement concerning the use of the property as herein stated. The consideration for this Agreement is the issuance of a building permit and/or certificate of occupancy.by the Town of Barnstable Building Department. WITNESS our hands and seals this 2 ZJ day of 20�z TOWN OF BARNSTABLE: ONYR: f By: PMic ael G.Vazquez 4Q Paul Roma, Building Commissioner THE COMMONWEALTH OF MASSACHUSETT BARNSTABLE COUNTY, SS Date Then personally appeared the above-named (owner), Q "Z and made oath as to the truth of the foregoing instrument,before me ELIZABETH A DIKTER Notary Public Notary Public My Commission Expires: qsamplc COMMONWEALTH OFMASSACHUSETTS My Commission Expires On BARNSTABLE REGISTRY OF DEEDS October 19,2023 John F. Meade. Repictar 1Tie Commaznvealdt of M as'sachasetts rA Dpp artknezrtefr4dus-frialAcciderats - =. Q�.ce oflTrtttigatioras ` 600 Was hzgtorr Street wrvwnmasmgovldia 'torIrers' Campensatian Insurance Affidavit:idavit:BO.ilersIC+antractursJEIectririans/Phnmbers . ApplicantInfarmatitzn Please Print 1`I a !]CiF1P_CC � $�Ral �� Address: Areyou an employer?Checktheappropriatebom ' Type of project(required)- L❑ I am a employer uith 4 ❑ I am a general contractor-and I 6. [-]New construction employees(fall andtor part-time)-* 'have 7ure3 the sub-contractors; _ 2.❑ I am a sole propdetor ar . rtner- listed on the attached sheet. I- ❑Remodeling P These sub-�camt #o veracrs ha ship and have as employees $_.❑Demolition w g far me in a i employees and have wodwrs' orlino any capacity. - 9. ❑Building addition. . [No wpd rs' comp.insurance comp-insuranv-4 required-] 5- ❑ We are a corporation and its UQ❑Electucal repairs or additions 3)V I am a homeoumer doing all work officers have exercised their 1 L❑Plumbing repairs or additions myself [No woddrim,camp- tight of exemption per MGL 11[_1 Roof repairs fncrtrasloe required-]i c.152,§1(4)6 and we have no employees_[No workers' 13-0 Other coal.insurance required_] *Any WHcEItffistchec1mbox �.s't 9�Sd t�0�17CY�1e SEChafl�IP1AW�1DPi7L[�iF1PFI Gta�GPIS'CDIDPPIISHtlaTt�7��3Ly IIIfaI3II9iIDd #Homeowners who sab=it Efiis fffia=maczling tbsy are3ain�alFwoaj:andtfi�hize autsjdecontnlctotsamst su mitanezvaffidavit in&zdna sash_ fc'anttncto *ztehecicibasboxmustattachesauadditionalsheetshovringthenameofthesub-comtwtirs•andstatewhetherarnotftseentitinh-le empiayees. warke&ramp.pokey number. I am ara ernpI r fJerrt is prat�fdfrtg markers'cotr>pe:isrrftrsn irtsairattce for d:}•entpT yes ,Setoiv is dig po-Zi y and tab sfic I><formretfon � Insurance CompanyName: -Policy,41-or Self-ins.Lic-,4*. 1;�pirauI7ate: Job Site Address:— City/Statl5dZip: Attach a copy of the wort-ere compensalionpolicy-declaration page(showing the policy number and respiration date). Failure to secmm coverage as required under Section 25A of MGL c 15-can lead to the imposition of crimmi al penalties of a fine up to SU.00 0U 6d/or one-yearimprisvnmeaf,as Drell as civil penalties in the form of a STOP WORK ORDEAand a fine ` of up to$250-00 a day against the i olator. Be adtdsed that a copy of this statement maybe forwarded to the Office of Ir rvesti'gations of the DIAL.for insurance coverage veriffca#ion. T do Hereby c .tdc�r tFt 'is t na] s a.feat ut]'f iatflie infot magazr prm r£ed abmv.is�bars mid carrect Sia�atnr Bate: 2 C Phone i t3,i'acial use,onT. Da not o-vrite in this area,to be corupl<eted by c-fty ortoirn official City or Town: FermitUcense;9 Issuing Authority(c rde one): L Board of$•eadth 1 Building Department 3.City/rown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phony#- - --- - - 6 laformati and lnstruc ions ' hfassachoseft s Geheral Laws chapter 152 requires all employers in Provide workers'compensation for their employees_ prrrwF-bD this sue,an.Maya,is defined as-' ..every person m tho service of another tinder any contract ofhh7D, egress or implied,oral or WHEIraf An arzplvysr is defined as"an individnal,partaez-J#P,assocfidon,cozpozafion or other legal entity,or any two or more of the foregoing engaged is a Jomf @,and.mcludicg the legal represenia{ives of a dwz3 sed employer,or the receiver or trustee of an individual.,partnm-Jaip,associafion or other legal entity,employing employees. However the owner of a dwelling house having not more than tbree apartments and who resides therein,or the occupant of the dwelling house of another who employs pawns to do maiab�nance,conshuction or repair wail-on such dwelling house or on the grounds or bmlding agpurf�thereto shall not because of Bach employment be deemed to be an employer." M- GL chapter I52,§25C(6)also States that'every sib or local licensing agency shall withhold$ie issuance or renewal of a license or permit to operate a business or to construct btuldiogs itt the commonwealth for any applic 2mtwho has not produced acceptable evidence of c6mpliance Wn the hisuxance.cbverageraquked_" Additionally,MGL chapter I52,§25C(7)sf�s"Neither the connnaawealth nor any ofits political snbdivi_sions shall enter mto any contract for the peffbr nce of_pubhG wozic umttl acceptable evidence of compliancewith the i„sarance.. re--c emeufs of this chapter have been presenfnd to the,coniiacting anmority:7 Applicants Please flI out tine wozlrers'compensation affidavit completeIy,by checkiag as boxes that apply to your situation and,if necessary,supply sol-contractor(s)name(s), addresses)and phone,numbez(s).along with their cerifficate(s) of as -a„ce. Lion dLiabulity Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not rDTi to carry workers'compensation insurance- If an LLC or UP does have employees,apolicyis required. Be advised thattbis afdida-yitmaybe submitted to the Department of Industrial Accidents for conf=ation of fi m mince coverage. Also be sure to sta and date the affidavit The affidavit should be-retnmed to the city or tnwn$iaf the application for the permit or license is being requested,not the Department of n T Accidents. ShouIdyou have any gnesfrons regaling ilia law or ifyon are requaed to obtaia.a workers' compensation policy,please call the Departmeeot at the n=bea listed below Self-indeed eon3pauies should enter their self-m�ce license number on the appropriate line. City ar Town Officials t _ Please be sore that the affidavit is complete andpr!3t dA Igplly. The Dep2a:menthas 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 Pleas e b e sure to fill in the pcnma Nicene number which will be used as a reference number. h,addition,an applicant that must submit multiple permAJHc=e,applications is any given year,need only submit one affidavit indicatmg ca re_at policy inf= ation Cif necessny)and under`Job Site Address"the Sh applicant oT, write"aII IocatiLns in or town)_"A copy of the-affidavit that has been officially stamped or maimed by the city or tovm may b(-,provided to the applicant as proofthat a valid affidavit is on file for faiae'pemits or licenses_ A new affidavit must be Bled out each year.Where a home owner or citizen is obtaining a license or pemritnotrelated Eo any business or commercial vie (ie. a dog license or permit to bum leaves etc.)said person is NOT required to complete fbis affidavit The of of Investigations would lJke to thank you in advzmce for your cooperation and should you have any gaesiions, please do not hesitafn to give us a call The Deparimenf's address,telephone and fax m=ber: TIC CanuamWealtbL of M Szaahnsftt s ' De-pa rl mant of Ira ustda1 AODUannta face of fnve tiou • ��4�ashir�gtan � Beau=MA Oi 111 ` (,-L 4 617 -4 QXt 4�6 or 1-977-MA.S � Fax 617 727 7M Revised 4-24-07 g�Wdia Town of Barnstable Regulatory Services dFT rb�._ Richard V.Scali,Director Building Division R•RNSTAHf 4 + _ Paul Roma,Building Commissioner - - � i639. m� 200 Main Street, Hyannis,MA 02601 � EpM�� www.town.barnstable.ma.us Office: 508-862-4038 Fax 508-790-6230 HOMEOWNER LICENSE EXEMPTION ^ /J(��av PleasePrint DATE: ) � �'�/ �/f/,�JOB IACATION: / Lam'" " 7/1� number street village "HOMEOWNER": V l� �DO— !! C ` v 1� name home phone# work phone If CURRENT MAMING ADDRESS: " " e city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building hermit. (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 pr dur and quireur.1119and 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- this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFU-ES\FORMS\building permit forms\EXPRESS.doc 06/20/16 Town of Barnstable Regulatory Services F .r RaTlNRF1Ri� t ARSL �, Richard V. Sca%Director i639- Nun Building Division. Paul Roma,Building Commissioner 200 Mafia Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 . Fax: 508-790-6230 _ �• 4 � C _ ."'� '•�l l�`s�.::� � ... wt`:!, �j :� 1� 4 yet, .`�� ,. \• Pro a Owner Mush Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my bebal� in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:F0RMS:0VR4EEtPER1vffSS10NP00LS � 10� T�'11111�1� S LPiIIE CQNT�RVI I1� hll�t aZ(.3Z (,VflZQV�G ) �..e e��' 01Tr pF �IO4u (MAIVI A PiA RO E .COIN SMOKE���Ec To�s��v�OEwED �VI - a coo � 3 "V 1Gp 1i1GH tlo E M iN R � I 7`f:; j aELE Ei ' dG GEPT. DATE IMPORTANT- UPGRADE REQUIRED _ STATE BUILDING CODE REQUIRES THE UPGRADING OF hil,L DI=PAHTLtCivT DATE PA dd14Ly RP 1 11nn K lETj�jT FO T ENT �? E1 ING' HEN. ;'"" TU.RE�tint HPYO.REL FG EF�WI�I�I�G ���1 I ti G�� V u'l M(1��5f Af [� D TED.> € 4�` i tJ l t—� C ��L N IF IN TA L I N 0 SMOKE DETECTORS-TOE L TRIC PERMIT DOES NOT SATISFY THIS REQUIREMENT. a ' Z 6R�zEv�?•y 2 �D 5 Fi q :35 s�� f STu5 io I}P•T DQeyt d 21 ALL s fit) F y 5 p`I. ebff TH 130 F(ZOM7-D©o2 �2 siDE parzc+� ec-EzE�y a �s'r si�n� IlAI►1[!� oL`3Z CVAzQ%*Z) BI�SEr .�t /CA*w t itflt� Sale Hf" VllirNis�1 s Ice NOr lo�lb f4blA*JS LAft ceMC ul li t rn ft az`3z CvAZQvc-cw ) wq 0SMOKE- DFITGTO; S REVIEWED(fat , 3 "V t40 011E - MAW F&OoR � 7 `.n -E .� ,i_'':'-_„�!G ",EPT. DATE IMPORTANT- UPGRADE REQUIRE® KTIIIwl�T _ DATE STATE BUILDING CODE REQUIRES THE UPGRADING OF = ,� ��L1(ATUR r` L�,yP'- P(F R PER I1 ffi4G,K DI MO�RARdfFGTED.> �,� I �J TLZ NSTACLf�rOFS'MIE OKE DETECTORSTIEL RIC C G�1,1�� PERMIT DOES NOT SATISFY THIS REQUIREMENT. a ' ��J quonn BAN KacKct,) :35 Sc 's STdIo PtP'r �y FicE Map 1�� � 2) FyIL fit) 5 `t 18E� 650 TH ao2 t�2e� siDE 1p - pot�c►-� '8��zC--hlPy �St si�n� iP�fl111[f� r0�ln_- �— �n�cys �a�e; f—E-�avr�rs a�3- 016 J�O9 rar,� Snn.okes u� or MOUSE (fAftiV AFAI ) � , , . PA- 3 MOKE DFIFECTORS REVIEWED a� - _ - 3 "V NGH f1olAeo MAW F&OOK �7 }BI L s`:'__, WG i;EPT. DATE IMPORTANT- UPGRADE REQUIRE® _— i .i. OEFAHTFVIENT _ DATE STATE BUI1L�DING CODE � REQUIRES THE UPGRADING OF .T.,�_V I�TURE"� n` �SE��"J�IPE��FC,(�f''E ! !n G N I� �G� U V`l�. M tKr�if14G Afl� II Gt ED. - e; ;rr,^ � fi 2 IN TA L I 0 SMOKE DETECTORS-T EL TRIC PERMIT DOES NOT SATISFY THIS REQUIREMENT. Iz it .r-ooM. CRC j 5 r l 2��D DQG�YI Ill s" i0 F&T 1 Bf'Fi 2) n Au AL J:Ffzom.7-Do02 Pa c� ODE a � BQc�zC--�flY r St �i�nit �llll� -�-�iWA�J a�3-�►b Arri "VA �P9 rac(� .hv�kcS TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel •�� pa)ir�tS�#> �D Health Division Date Issued !�3� 13 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address / ki✓I e S n 4_ Village Al/" 00 A I s Owner o� Ae ��Z ��? Z Address Telephone , , O / — 67719 Permit Request 50/A An e �S /0Z �O .St)& o Square feet: 1 st floor: existing proposed 2nd floor: existing propos d� Val n@ Zoning District Flood Plain Groundwater Overlay w Project Valuation 6, Construction Type era Lot Size Grandfathered: ❑Yes ❑ No If yes, attach s pportinPocaentation. r-- Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units) m Age of Existing Structure Historic House: ❑Yes ® No On Old King's Highway: ❑Yes 0 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ® Other P 2 F" i L w Basement Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing_ new Half: existing new Number of Bedrooms: -3 existing I new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ® Gas ❑Oil ® Electric ❑ Other Central Air: ❑Yes ® No Fireplaces: Existing_ZNew Existing wood/coal stove: ®Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: IS existing ❑ new size _Shed: 21 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) 2P,� � - 7�l �� 771 NameA' k - /R Q P Tele hone Number p Address /O �49� tn A A -e License # M Ck Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE q Z 5 FOR OFFICIAL USE ONLY Wr 'APPLICATION# DATE ISSUED MAP PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION;., a FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ...... - The-Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers .AIDDlicant Information Please Print Le "bI Name (Business/organization/Individual): //I/9G Address: d I A PS Q� / City/State/Zip: Phone #!��' 7121—b 7 7 F2_ re you an employer? Check the appropriate box: ❑ I am a employer with 4: ❑ I am a general contractor and IF7. of project(required):. employees (full and/or part-time).* have hired the sub-contractors New construction ❑ I am a sole proprietor or partner- listed on the attached sheet Remodeling ship and have no employees These sub-contractors have g• (� Demolition working for me in any capacity. employees and have workers' [No workers' comp• insurance comp. insurance:# 9• ❑ Building addition 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 insurance required_]t c. 152, §1(4),and we have no 12.0 Roof repairs employees. [No workers' 13.❑ Other comp, insurance required,] *Any applicant that checks box#]t H must also fill out the section below showing their workers'compensation policy information .omeowners 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 up to$1,500.00 and/or one-year impiisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t e pains and Le allies of perjury that the information provided above is true nd correct Si ature: Date: 13 Phone#: Z7 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#: .. I In- formation and Instructions a 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 Iicensing 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 numbers) along with their certificates) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation.of insurance coverage: Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,.not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-.insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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 60.0 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.goY/dia .c Town of Barnstable F THE Tp� do Regulatory Services Thomas F. Geller,Director >URNSUBLE, 1619. Building Division ATFo►+��a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www,town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: A lage numb street "HOMEOWI�'ER";//1 oP L dl� Q 1A j2 work phone# name home phone# O CURRENT MAILING ADDRESS: n S h e,� n & i/; I1 Ind- dZ63 2 city/town -state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Persons)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 ts and that he/she will comply with said procedures and minimum inspection procedures and requiremen requiremen , i 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 lo9:1.1-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 asupervisor(see Appendix ar _ 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\homeexempLDOC } �ZHE► Town of Barnstable Regulatory Services uAes. $ Thomas F.Geller,Director 1639. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 8-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner o the subject property hereby authorize to act on my behalf, in all matters relative to work authorized bythis building rmit application for. (Address.of Job) Signature of Owner Date , Print Name If Pro erty er is applying for permit please complete the Home ers .License Exemption Form on the reverse side. Q:FbP ms:OwNERPERMISSION t goof C 0 2S U tv ZOSEP I 2 0 v W DoAt I�� s Coll, cpo TOWN OF B R► STABL I/ P 23 Inn'[._: 3 t �Ut OV'S"NIIA, 0 3 r. i Michael Vazquez 8/15/2013 Created By: Jonathan P. Carroll PT DPT Don't have a computer or email address? Enter My DVD Code using your DVD remote. _ MY DVD:CODE: 270 - 434 7: 270 - Abdominal Draw In -- Bent Knee Raise 8:_434- Isometric Abdominals -- Unilateral LE Press - • Lie on back with head supported and • Lie on back with head supported and knees bent ,_ knees bent " • Draw belly button toward spine, ` • Bend one hip and knee to 90 degrees tightening stomach muscles • Resist movement-toward your chest by • Lift one foot off surface 6 inches, then placing same side hand on knee until < ' lift other leg lower first leg then lower .• • abdominals tighten second leg • Hold and repeat as instructed • Do not arch back during motion • Cross over, push into op posite pposite knee • Repeat as instructed Sets: 2 Reps:-10 Resistance: Blue Sets: 2 Reps: 10 Resistance:-Blue .......... ._.. ti 1 G 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 the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form 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 Certificate that is required by law. Fill in please: ' DATE APPLICANT'S YOUR NAME/CORPORATE NAME BUSINESS TYPE: B INESS YOUR HOME ADDRESS: O � �Nl�� S lU� C ' -�/'�-V.G .E � DZ,� t Wee TELEPHONE # Home Telephone Number -ag0- 7 r=mail Address , 0, 2,L6- , =,QP(,Q-)aM / cam NAME OF NEW BUSINESS L ' Have you been given app ADDRESS OF BUSINESS J!Z�]2 Ar1#--J0?-6 MAP/PARCEL NUMBER 7 q—66 .-66 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 obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSI NER'S O Flof This indivi ual e n Info mny e�� irements that pertain to this type of business. Au h rized Sign a re** �~ U COMMEN 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 12-15-11 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St.Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for 1046 Phinne 's Ln. H annis has been inspected by a certified Building Performance Institute(BPI)Inspector. => P a Ceiling: R-30 cellulose Floor: R-19 fiberglass All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey c)T=T777777777 77 .,7):. t °1�n m._ J. .... ........� 'r .. .. 1 ' J . I Town of Barn P. 3933-7 2 P:u 294 01 4-09 I"E' i•� Regulatory Services . �.. �-a-g __ _� Richard V.Scali,Director snuvsr LF. _ M'S Building Division 039. �Eo na'I" Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 AGREEMENT FOR FAMILY APARTMENT I Michael G. Vazquez, the undersigned, being the owner of property situated at 1046 Phinney's Lane, Hyannis, MA holding title under a deed recorded with the Barnstable County Registry of Deeds in Book 19294, Page 195, being shown on Assessors' Map 273 as Parcel 010, hereby agree, certify, warrant and represent to the Town of Barnstable that the accessory attached apartment, which contains living quarters, is intended for use as a family apartment,for year-round occupancy. This unit shall be used for a"Family Apartment" (as defined in Zoning Ordinances) which would require compliance with the Family Apartment Rules and Regulations. The family apartment unit must be occupied only by the property owner or a member of the property owner's family as accessory to an owner-occupied single-family residence. Occupant(s)of Main Residence: Michelle Vazquez and Ruby Vazquez-Newton BUILDING I)t-PT Relationship to Owner: Sister and Niece MAR 2 4 2017 Resident of Family Apartment: Michael Vazquez TOWN OF BARNST SLF Relationship to Owner: Owner This unit shall not be rented as an apartment or as a single room,or in any fashion,which rental would be a violation of the Town of Barnstable's rules, regulations, and zoning ordinances. Prior to occupancy of this unit, affidavits reciting the names of occupants are to be recorded with the building department. This agreement shall be updated whenever a change occurs or every calendar year. This Agreement shall be duly recorded or filed at the Barnstable County Registry of Deeds/Land Court for,the purpose of alerting future owners of the property of this binding Agreement concerning the use of the property as herein stated. The consideration for this Agreement is the issuance of a building permit and/or certificate of occupancy by the Town of Barnstable Building Department. �1 WITNESS our hands and seals this 2 Z day of 20ZZ TOWN OF BARNSTABLE: OR: i By: /MTicKaZel G.Vazquez . Paul Roma, Building Commissioner THE COMMONWEALTH OF MASSACHUSETT BARNSTABLE COUNTY, SS Date Then personally appeared the above-named (owner), V\a L)QZ and made oath as to the truth of the foregoing instrument,before me I ELIZABETH A DIKTER Notary Public �s Notary Public My Commission Expires: 10 qsampl COMMONWEALTH OFMASSACHUSETTS My Commission Expires on BARNSTABLE REGISTRY OF DEEDS October19,2023 John F. Meade, Register � � � / QECEIPT x �inted: March 24' 2017 1 DARNSTABLE COUNTY REGISTRY OF DEEOS JOHN F. MEAOE, REGISTER Trany#: 71721 Opor:M0NIQVE MICHAEL book: '30,/2 Page: 294 Inst#: 14094 01 7b4 Aec:3-24-2017 @ 12:18:52p BAAiN 1046 PHINNEY3 LN �. `OC "PSCQIPTI0N TRANS AMT 1 vaZuVEZ' MICHELLE ' NOTICE County Fee $ 10.00 10' 0`' 3urcharge CPA $20 UO 2u (1' State Fee $40.00 Surcharge Tech $5.00 — |o,a| fees: v�^ Total uka/gpy: � CASH PMT ANMEN' -CASH °c � Over amount: 00 � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map a '3 Parcel Q` �} Application # ( OC.O (09 Health Division Date Issued Conservation Division Application Fee 0 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board v Historic - OKH _ Preservation / Hyannis Project Street Address t 04 6 p 611)A vI 'S Loot Village_ CeAftc)(I Ile Owner Vd,Z q wez. Address j.0. Box b+4 . Cen�erV'iI1 e Telephone Permit Request ' s• - ` - r rQ, wrA��L Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 4 d%00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family )d Two Family ❑ Multi-Family (# units)_ Age of Existing Structure 1750 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.)_ _ Basement Unfinished Area (sq,ft) Number of Baths: Full: existing new _ Half: existing new` a Number of Bedrooms: existing _new w Total Room Count (not including baths): existing __new First Floor Room Count`"' Heat Type and Fuel: ❑ Gas Oil ❑ Electric ❑ Other > Central Air: ❑Yes X No Fireplaces: Existing New Existing wood/coal stover ❑Yes ❑ No rn 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) - _lI amk0o-96WI Name 'S°l'ft Telephone Number 5 09 ' 3 98" 0 3 T n Address License # 5 oA., Ya(Y1'10 LtA , m N 0 6 6 9 Home Improvement Contractor# 1 6`I q 3 d1 Worker's Compensation # `WC 3� 9 '-T 9-+�, ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO ) o Vmat&A SIGNATURE __DATE ,►� 3 1 1 FOR OFFICIAL USE ONLY APPLICATION# s ' a � I,DATE ISSUED •-<.,,,��, j--�r ,�.:���� _ ,. MAP/PARCEL NO. ` ADDRESS VILLAGE f x OWNER DATE OF INSPECTION: r ' 3AF0UNDATION,",j- , a FRAME . `INSULATION;' ,4 FIREPLACE r ELECTRICAL: ROUGH ^ FINAL PLUMBING: ROUGH FINAL *— ' :GAS: .a+ ROUGH FINAL � !FINAL BUILDING!,,' �� '�' ��►� i :DATE CLOSED OUT- ASSOCIATION PLAN NO. ' r` f ' I7te Commonwealth of Massachusetts Department of Industrial Acadents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Wor ers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ��,, /1 Please Print Legibly Name(Business/org=zatiowbc ividual): 1[' ,�. l�y��t �� 1� ` de Address: I -C, ' lA u ty m mein t3 � City/State/Zip: S • UlMogUi Ma &,(O�gone#: - 3qg- Are you an employer?Check the appropriate box: Type of project(required): 1.M I am a employer with I H 4. ❑ 1 am a general contractor and i employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' q ❑ Building addition [No workers'corhp. insurance comp.insurance.} required.] S. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 L[]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 1 4 employees. [No workers' 13.®OtherT�Q,T M camp.insurance required.] *Any applicant that checks box#1 must also fill out the section below shoving their workers'compensation policy information. t Homeowners who submit this affidavit indics.ting they axe 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 an an employer that is providing workers'compensation insurance for my employees. Below is the policy and,job site information. Insurance Company Name: _ l P_G�n e o to V ZnS Uiro n o n1 D Ol,/l Y Policy#or Self-ins.Lic.# —rW La 3, 9 4-9 4- Expiration Date:___ I 0 e�•i l a 0 01. 7 Job Site Address:_ 0 6 Q b t n n C y S lean(° City/State/zip:Ca n�'t''I e I Attseh a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certfy under the pains d shies erjary that the informadon provided above is true and correct Date: 3 �rl 1 Phone#: - 39 fS- — Official use only. Do not airbe 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.Cityffown Clerk 4.Electrical Inspector 4.Plumbing Inspector 6.Other i Contact Person: Phone#: ATE ,4co O® CERTIFICATE OF LIABILITY INSURANCE D0/20 DNYYY) l0/20/2011 TKiS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER CONTACT -NAME: Shannon Sperrazza Risk Strategies Company PHONE . (781)986-4400 FAX o.(781)963-4420 15 Patella Park Drive -ADDRESS:ssperrazza@risk-strategies.com Suite 240 INSURERS AFFORDING COVERAGE NAIC q Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURER B:Safety Insurance Company 33618 Michael McCluskey, DBA: Cape Save INSURER C.Technolocry Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 1 INSURER F: COVERAGES CERTIFICATE NUMBER-CL11102041451 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. ILTR TYPE OF INSURANCE D B POLICY NUMBER POLICY MM%DD/YYYY LIMITS GENERAL LIABILITY' EACH OCCURRENCE $ 1,000,000 TO RENTE-15' X COMMERCIAL GENERAL LIABILITY D PREMISES fEa occurrence $ 100,000 A CLAIMS-MADE Fx1 OCCUR CPPS1994480 0/16/2011 0/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL 8 ADV INJURY $ 11000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 11208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS N NON-OWNED PROPERTY DAMAGE Per accident $ AUTOS X Underinsured motorist BI split $100000 300000 X UMBRELLA LIAB X OCCUR CPPS1994480 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ 1 $ C WORKERS COMPENSATION Executive excluded X WTOCRV STATU- I 1OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE from coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y❑ N/A (Mandatory in NH) 3297972. 0/21/2011 0/21/2012 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a National Grid, d/b/a Boston Gas Company, d/b/a Essex Gas Company, Action Inc. , and Housing Assistance Corporation are listed as additional insureds as respects General Liability as required by written contract. L ATE HOLDER CANCELLATION 0-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. using Assistance Corp4 Main Street annis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/SMS5(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. 1m-ii m Tho antliD 1 name anei innn ago roniefonaii marke of Ar:npin Nlassuc-husetts- Department of Public Safeti Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted.to: IC z� WILLIAM MC CLUSkI 37 NAUSET.ROAD..' v WEST YARMOUTH,':MA 02673 ;. a Expiration: 6J28=13 ('ununis�i."ner Tr##: 102776 — = Office of Consumer Affairs and usiness Regulation _ 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164432 Type: DBA CAPE SAVE Expiration: 10i6i2013 Tr# 217656 MICHAEL McCLUSKEY 7C HUNTING AVE. _. S. YARMOUTH, MA 02664 Update Address and return card.Mark reason for change. OPS-CAI 0 sonn oaoa oyoi2�s (_� Address f"'? Renewal (" I Employment (- Lost Card . �tkt ��irrrrunti r� Otfice of Consumer Affairs&Bu'siness R add License or registration valid for individul use only � -- , HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 164432 Type: Office of Consumer Affairs and Business Regulation Expiration: 1002013 � DBA ]0 Park Plaza-Suite 5170 CliI.- " AVE Boston,MA 021.16 MICHAEL McCLUSKEY 8201 S.HOURD CT ��� sf CHAPEL HILL, NC 27516 Undersecretary - ot valid without signature CAPE SAVE Weatherikation 508-398-0398 , August 22, 2010 To Whom it May Concern: William J. McCiuskey is an employee of Cape Save. He is authorized to negotiate contracts and building permits for our company. Michael McCluskey Cape Save—Owner 919-593-5939 cell X Huntington Avenue,South Yarmouth,MA 026" ' 460 West loam Street HOUSING Hyannis, MA 02601-3698 - S ENERGY &HOME REPAIR T (505) 77I-51400 F (508)79 2� 0-�. 25 COIFPORATION T rY on A lines wunv.haconcapecod.org HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. Il� ���� hereby consent to and agree that weatherization work may be done by the Weath4rization Program of Housing Assistance Corporation( herein after referred as "Agency") on the property located at: 7 The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: Weather-stripping& caulking of windows and doors,insulation of attics, sidewalls &basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreeme t sted and eely give my consent. Home Owner: (Signature) Date: I Agent: (signature) 3 Date: HAC approved Weatherization Company :_COLK Save Caliber Building &Remodeling Cape Cod Insulation =Cape Creswell Construction Frontier Energy Solutions Lohr & Sons Peter Smith Resolution Energy Rock Solid Construction All Cape Insulation its-,`.SQ s60,rrr,7oyh v 31311.14-ork Derf ii release doc.duc 4J7 .............................. BREY77, ...........:...:.:.�.:_.............:...... ....._..... .. EDYSFRIENTURK TROP PURE PRM 0!'T59OZ9! !t1 LOL BUTTER OTRS 1 LB a t 'SB BUTTER OTRS 1 LB III ram' SB SANDWICH.BREAD 20- l I + i i r 1046 Phinney's Lane C-Tn ew e, MA 02632 Michelle, The verbiage for the Family Apt. needs to state that this is going to be Family Apartment with no Construction; Main house who is living their full names and relationship to your brother. Also Apartment your brother's name and where he will be residing. This needs to be written on the Permit Request. If you have any questions,please feel welcome to contact me at 508-862-4039. Sincerely, rn o e X-PRESS PER IT. own of Barnstable *Permit# Expires ntlrs from issue date JUL 2 2 2013 Regulatory Services Fee # ]natvsr�sr.E, MASS, g' Thomas F.Geiler,Director 161 %uilding Division Tom Perry,CBO, Building Commissioner, 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax:.508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY •���<� ` Not Valid without Red X--Press Imprint � � Map/parcel Number U i Property,Address 10144 k i/i/1 k to 6 3 ®Residential: 'Value of Work " ® Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address !G G1 Y. r. �e� �io � l� d � L' �l Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor OR I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over J—existing layers of roof) ❑. Re-side #of doors. ❑ Replacement:Windows/doors/sliders.U-Value -(maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4'floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is require SIGNATURE: ..Q\WPFILES\FORMS\building permit forms\E3(PRESS.d The Commonivealth of Massachusetts Deparhnent oflndusoial Accidents Offwe of Investigafions 600 Washington Street Boslon,.AM 92111 wmv.inas&gov1di4q Workers' CQ.mpensatian Insurance A&vit: B> iersfContractors/Elec ricians/Ph tubers Auphcant Information Please print bIv Name MusinL��H ondndiv dwl): LCity/Stat&Zip: o Z Phone# Are you an employer?Check the appropriate box: Type of project(iregaired): 1.E I am a employer with 4. ❑ I arms a general oontrac;or and 1 employees(fall and/or par�im�e). * have hied the sub-contractors6_ ❑New consErucfiar� partner- listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or ship.and bat*e no employees These sub-contractors have g_ ❑Deawlition. w forme in a employees and have wcdcers' working any capacity- 9. ❑Building addition [No workers'comp.insurance comp-msurance.1 required] 5. ❑ Vile are a corporation and its 1 G•❑Flectrical repairs or additions c 3. I am a homeowner doing all work officers have exercised their 11_❑Plumbing repairs or additions myself [No workers'camp right of exemption per HfGL 12.1 Roof repairs 3 insurance required]r c.152, $1(4),and we have no employees_[No workers' 13:❑other comp.insurance required.}. `Any apphcaau that checks box#1 mast also fill out the section below showing their waakets'compessatierapolicy infnrmatiaa 1 Homeowners who submit this affidavit i g they aaadomg all work and rhea hire outside caaEttactors mast submit a new affidavit iodicatiag sac11 FCanttacwrs that check this boar must attached an additional sheet showing the came of the sub- bons and stare.whether or not dose entities have employees. Ifthe mb-caatmams have employees,they must provide their warkme romp.pelicp numb- lain an emplo3,er that is peovidfng workers,congw radon insurance for -ewpfkywe.% Betov is the po&y an d jab srte informad'on . Insurance Company Name: Policy#or.-Se1€ins.Lic.#: Expiration Date: Jab Site Address: GityfStateZp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and date). Failure to secure coverage as required under Section.25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to$1,500._aG and/or one-year iimprisommes*as well as civil penalties in the form of a STOP WORK 1ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cov'ecage veriftation Ido hereby ce ya order the poi anrdpeina.Itiss rofpedmq that the fnformadon provided abava rs bus and correct: . 'Date: si Phone N: Official area only. Do not writs in this area,to be cr:twplsted by city or tome official City or Town: PerinififLicense# Issuing Authority(drele one): . 1.-Board-of Health 2.Building Department 3.CAyfrown Clerk &Electrical Inspector 5.P'hambbi g Inspector 6.Other. Catact Person: Phone#. pF THE Tp� r • SARNSTAE r "�:BL,� Town of Barnstable iOrEn r,�r A Regulatory Services Thomas F.Geiler,Director. r- Building Division. Thomas Perry,CBO Building Commissioner, 200 Main Street; Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) _ Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on.the reverse side. i. Q:IWPFILESTORMbuilding permit forinAEXPRESS.doc oFVME Town of Barnstable _ Regulatory Services s�uvszesze ' Thomas F.Geller,Director'. 9�AMASS. q. A�O� , rFOI�.t Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town,barnsta ble.ma.us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print f~ DATE: T D JOB LOCATION: 1 I1 feS �"��Pi P1 �A ii A I number street village village `"HOMEOWNER": I L c�e ! �//r ZVC {�I,C — e�O ~7 7J 6� name home phone# work phone# 0 e CURRENT MAILING ADDRESS: 1 A_n W d 2 city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned "homeowne,;W certifies that he/she understands the Town of Barnstable Building Department minimum inspection proc res afid..re I e n and that he/she will comply with said procedures and requirements. ignature of Homeo er• 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. 0:\WPFILES\F.ORMS\6uilding permit forms\EXPRESS.doc