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HomeMy WebLinkAbout1118 PHINNEY'S LANE ���� ��%7� s ���� i iL oK 6�iS�IZ Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 6/12/12 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 1118 Phinney's Lane, Eenftmille has been inspected by a certified Building Performance Institute(BPI) Inspector. Ceiling: R-19 cellulose Ventilation: 9,4x16 soffit vents with air chutes All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey ZZ JYCD •� L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 Parcel O 13 Application # a 6�� Health Division Date Issued _ Conservation Division Application Fee 5 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board/ Historic - OKH _ Preservation / Hyannis Project Street Address `�i n(1 E V E S L oo t Village -q cknn Owner Li AIw Wo,(,J in q Address �+4 4oa*r_S Y&t ekpll Pra'� Telephone 5 6 8 - 3 4-5 55 Permit Request -+p At aCkc. :LACCE se a+I'C- VCA�30A fift t0 r_oag W,�^ �mhi 4 Gna r0 11e.64)- A.il_r SeAO *t t 0A4, kkdfa #.A 100,.SetA wt'+� �xPtnc�in� `k"Ow11M Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 11900 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —.new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: XGas ❑ Oil ❑ Electric ❑Other : -7 � o Central Air: ❑Yes Fireplaces: Existing New Existing wood/coal stove:Q Yet❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ew *s e_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: ) _ L -51 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes J No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name '1'apN c e. , Telephone Number _3 _ 5 9 98 Address 4- D 4n+'n S 4dn Pve� License # C `a��� �. tMOIJA h n �� e� Home Improvement Contractor# 1 69 4 3 0� Worker's Compensation# —T-WC 3d��� 9 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 5' d` r t FOR OFFICIAL USE ONLY r ' APPLICATION# DATE ISSUED MAP/PARCEL NO. ' ADDRESS _ — VILLAGE OWNER DATE OF INSPECTION: FOUNDATION Y FRAME _ INSULATION FIREPLACE s ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL '[ GAS: ROUGH FINAL FINAL BUILDING C DATE CLOSED OUT r. 5 ASSOCIATION PLAN NO. ip A 1 , s , , 4.00 West Main Street z Hyannis,MA 02601-3698 T (508) 771-5400 F (508)775-7434) H ous i nKIM TTY on all lines �S��StaliCe nn.hawncapewdmg Corporation Cape Cod Free Weathurization ! . Your tenant has requested and is eligible for weatherization of your rental home through government funding. This will be provided at no cost to you. Program regulations permit us to spend around $4,000- $10,000 in materials and labor per dwelling unit. Program regulations require us to weather-strip and caulk doors and windows; insulate attics, sidewalls and floors. All work is professionally done by established private contractors. We will conduct a final inspection to make sure that all work is completed to specifications. If you request, you will be informed of the estimated measures before they are done and provided with a list of the actual measures and costs following the completion of the work. We also need proof that you own the property. A copy of a CURRENT TAX BILL OR DEED listing you as the owner will satisfy this requirement. Please fill in all blank areas of the enclosed agreement and return with the proof of ownership as soon as possible. If we do not receive the enclosed form within two weeks, we will do a basic energy audit of the home, but no weatherization work can be recommended or done. If you have any questions please call Cathy Finn at 508-771-5400, ext. 105. LANDLO D TENANT PHONE PHONE r TENANT/PROPERTY OWNER/AGENCY WEATHERIZATION AGREEMENT 1. The Parties to this Agreement are the followirLg a t{�, (hereafter known as Tenant), (print your tenant's name) Lo—rLnn. (hereafter known as Property Owner) (print your name) and Housing Assistance Corporation (hereafter known as Agency). In consideration of the mutual promises hereafter stated, the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement 3. Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street, town) unit# , and currently leased or rented to the Tenant: a) Enter the premises for the purpose of performing a Weatherization inspection. b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the Weatherization work The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing&Community Development(DHCD) may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization work will be perfomred in accordance with the Property Owner's consent as further specified below: 1�lAL°�OIc-*owe_�.F�TNE I consent to performance by the Agency and its contractors of any t Weatherization work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work perforated and the associated value at the completion of work. I will provide a separate consent to performance by the Agency and its contractors of Weatherization work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work, including related repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherization work by the end of 2b12_ 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization work by the Agency, the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where the Property Owner receives a written extension from the Agency, time is of the essence in the performance of repairs by the Property Owner. 6. The Property Owner and Tenant authorize the Agency to receive a statement from the fuel supplierlutility supplier as to the quantity of fuel/utilities used at the above address in each of the past three years and the future three years. The information is to be used only to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling unit will not be raised because of any increase in the value thereof due solely to the Weatherization work performed. 8. In consideration of the Weatherization work hereunder,the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through 201212013,approximately one year from the time the work is completed, a) The preWi. t�' A r month will not be raised for any reason. (The rent amount must I`iii'Y 1.,' eat included in rent?Yes` No However,this Paragraph(8a)will be waived by the Agency in writing if,and only 0,the premises are teased under a state or federal rent subsidy program,in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program Please state which Housing Subsidy program your tenant is on and through which Agency: b) The Property Owner will not institute any summary process action for possession except in the case of non-payment of rent or other good cause related to the Tenant(or any successor Tenant). c) In the event the Property Owner decides to sell the premises, Property Owner shall comply with one of the two requirements below: The Property Owner shall not sell the premises unless the buyer agrees(with a copy forwarded to the Agency) in writing prior to sale to assume all obligations of the Property Owner set out in this Agreement;or --The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency,of the Weatherization materials installed and labor performed in the premises as of the date of sale. Said amount shall be paid to . the Agency immediately upon sale. 9. (Applicable only N Tenants heat is included In rental payment and blanks are filled in) At the end of the period set forth in Paragraph 8 above,the rent shall not be raised more than %per for an additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period. However, the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the Owner shall conform to the standards of the rent subsidy program. 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant,and between the Property Owner and any successor Tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger protections shall apply. I 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to the cost, as certified by the Agency, of the Weatherization materials installed and labor performed on the premises,as well as attorneys fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law; in such instance,the Property Owner shall reimburse the Tenant for attorneys fees and court costs. Without limiting the foregoing, the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant. 12. Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federal government, as well as the eligibility of the Tenant under WAP program requirements. The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement P;perms:(Jwr3�r' ' gnaturei CY1 ate: Address: �- n C- �- 7 Tenant Signature,_,-� Date 41 /Z Agency Approved Weatherization Company �� e. J G��f Q All Cape Energy Caliber Building & Remodeling Cape Cod Insulation ape Save Frontier Energy Solutions Lohr&Sons Resolution Energy Agency Signature Date CAPEOSAVE 1 Weatherization 5 8-398-0398 August 22, 2010 To Whom It May Concern: William J. McCluskey 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,Sow Yarmouth,MA 026" I The Commonwealth of Massachusetts eP f Accidents.) Department o Industrial Office of Invesdgations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aut licant Information Please Print Lettibly Name(Businessiorganizatiom!Individual): M 1�!C O Eri�T`V_\ c i 11811A- Ch 6� �lA,�,U Address: ty a ni coin tJ 11= City/State/Zip: s —Ya2-mmx- Ma 67-U gone M 3 �� 3 cm Are you an employer?Check theappropriate box: Type of project(required): 1.[K I am a employer with �Ok 4. 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 ant a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have'no employees These-sub-contractors have $. D Demolition have workers'h employees ana working for me in any capacity. 9. (] Building addition [No workers'conip. insurance comp.insurance.* required.] 5. We are a corporation and its 10.0 Electrical,repairs or additions .3.❑ 1 ant a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs �. insurance required.]} c. 152,j 1(4),and we have no employees.(No workers' 13.®OtherTft�Sl �Z)Ofl comp. insurance required.]. *Any applicant that checks box#!.must also fill out tie section below showing their workers'compensation policy information. t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or net those entities have employees. If the sub-contractors.have employees,they must provide their workers'comp.policy number. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Narne: I to, Ins LkrLkn Ce Corn POLO Policy#or Self-ins.Lic.:#: T W(' Expiration Date: 1 0 /a 1 a 0 a, Job Site Address: C pp �tth 13 Lot City/State/Zip: VLotLa(�fR.� 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 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 0B'Ice of _ Investigations of the DIA for insurance coverage verification. I do hereby certify under the painsapdRenahies erjury that the information provided above is true and correct. Signature: f Date: Ph e#: Offrciahuse only. Do not trrite in this area,to be completed by city or town official City or Town: Permit/License# _ Issuing Authority(circle one): 11 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: AC ?'1® DATE(MMIDD/YYW) l6_k CERTIFICATE OF LIABILITY INSURANCE 10/20/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must 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 endorsement(s). PRODUCER CONTACT Shannon S errazza N AM E: Risk Strategies Company PHONE (781)986-4400 (FAX. c:(781)963-4420 15 Patella Park Drive ADDILS :ssperrazza@risk-strategies.com Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:SeleCtiVG Insurance INSURED INSURERB:Safety Insurance Company 3618 Michael McCluskey, DBA: Cape Save INSURER C:Technology Insurance Company 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERf: 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 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 ADDLSTYPE OF INSURANCE U R POLICY NUMBER MMIDDIYEYYY MN DDY� LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE T RENTED 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES a occurrence $ A CLAIMS-MADE a OCCUR CPPS1994480 0/16/2011 10/16/2012 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,0001 X POLICY PROJFCj LOC $ AUTOMOBILE LIABILITY CUM-BINEEa accidentSINGLE LIMIT $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED 6208200 1/6/2011 1/6/2012 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ X HIRED AUTOS X NON-OWNED (Per accident) X Underinsured motorist el s lit $100000 300000 X UMBRELLA LIAB X OCCUR [PPS1994480 0/16/2011 0/16/2012 EACH OCCURRENCE $ 1,000,000 EXCESS LIAS CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ $ C WORKERS COMPENSATION Executive excluded X WC STATU-sT OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YINfrom coverage E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? NIA 0/21/2011 0/21/2012 (Mandatory in NH) C3297972. E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I 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. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Housing Assistance Corp 484 Main Street Hyannis, MA 02601-3698 AUTHORIZED REPRESENTATIVE Michael Christian/SMS �� - ACORD 25(2010106) C 1988-2010 ACORD CORPORATION. All rights reserved. INSn25on1nnst ni Tho arnpn n2ma and innn nru ronictcrcrl marlrc of Annan Oce o 4Aak and Business Regulation _ 10 Park-Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement,Contractor Registration Registration: 16"32 . Type: Supplement Card CAPE SAVE _ Expiration: 10/6/2013 WILLIAM McCLUSKEY = 8201 S. HOURD CT CHAPEL HILL, NC 27516 - Update Address and return card.Mark reason for change. )PS-CAI Cr SOAh-04/044101216 Address Renewal J Employment Q Last Card ✓/,TJ09)Ll7LOlZlIle�UL O�✓� GGE d - -- .-_ ., Office of Consumer Affairs&Business Regulation License or registration valid for individul use only kl _ ('HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation F. Registration::-,164432 Type: ; 10 Park Plaza-Suite 5170 Expi __=10/6/2013 Supplement Card :-- pp Boston,MA 02116 CAPE SAVE WILLIAM McCCUSKEY:- 7C HUNTING AVE S.YARMOUTH,MA 02654, Undersecretary Not valid without ' nature '= d assuchusetts- Dep:ertment of Public Safevv Board of Building► Re_►utationx and Standards Construction Supervisor Specialty License License: CS SL 102776 a: Restricted to.. IC x � WILLIAM MC CLUSKY � 37 NAUSET ROAD; WEST YARMOUTH,.MA 02673 y" Expiration: 6/28/2013 _" (ununiwiuncr Tr#: 102776 s, A l Town of Barnstable y��F�He'O�tio� Regulatory Services Thomas F.Geiler,Director ' "ARNSTABM MALSS. . Building Division - 9 9,659• �jOTfa�,��°i Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 y Office: 508-862-4038 Fax: 508-790-6230 PERMIT#/9 FEE: $ d� SHED REGISTRATION 120 square feet or less 1112TIle Location of shed(address) Village. /l dam. 9L3 75-- -�T Property owner's name Telephone number / O Y^ ��� 0 Size of Shed Map/Parcel# Sign a a Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? si I Conservation Commission(signature required) � ired) PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 IZ nu tu t7-' ri 70% z z LOW 74 c-, 49- 00, k F TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map . Parcel Fl Permit# Health Division - �� c�w� ° Date Issued Conservation Division o�� Fee �� Tax Collector SEPTIC SYSTEM DUST BE Treasurer I Z��q�' INSTALLED IN COMPLIANCE Planning Dept. WITH TITLE 5 ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address ,1 ki n Village Owner ` Address v7 it Kd Telephone �� [p ,1 7 Po r t Permit Request Li Q �t� ��D r acre-en coam cp n Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost l (000• Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size , • Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family M/ Two Family ❑ Multi-Family(#units) Age of Existing Structure 22 Historic House: ❑Yes U<000' On Old King's Highway: ❑Yes Basement Type: ErIll'u*11 ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new D Half: existing 0) new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: }-Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes O'I�lo Fireplaces: Existing ✓ New Existing wood/coal stove: ❑Yes a-Nu- 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 0 oY l rl Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO A) s SIGNATURE DATE _ y o?(p " f ' r' — FOR OFFICIAL USE-ONLY An _tc PE MIT NO. DATE ISSUED! MAP/PARCEL NO. , ADDRESS a VILLAGE OWNER_ r � � +.. r�• r J: w DATE OF INSPECTION ,: FOUNDATION 7 FRAME '' 1�� cf 1 - 's INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL S_�•- l C PLUMBING: R0 UGH. `= RZ FINAL Il! GAS: ROUGH;,` FINAL FINAL BUILDING . .. DATE CLOSED OUT a `+ ASSOCIATION PLAN NO'" ".� rxt 7+1 t J f A..e4- . .-- -� The Commonwealth o Massachusetts .- _=� of Massachusetts -= Department of Industrial Accidents ON=011MOS998t/0OS . 600 Washington Street --` 4I 'Boston,Mass. 02111 . — Workers' Com ensation Insurance davit FIN name: t1 /l a QL location: J ci `In hone# . /v T I am a homeowner performing all work rhyself. ❑ I am an employer providing workers' compensation for my employees.working,on this job.: ::::::.:::: toMDany name. :....,:::: ::;:`:;:>;:::::::;::>:::':?:' ::::>::::::::>::>::;>.:::... :': ::::::>::>:: ::::>::;:;:..::>:::::>:::>.>:: "'::::>::: ..... ........ .... ....... ......... .. :.:::.>::»::>::»::::>:::::::i::i:::.:.ii: ..::.::.:::... :•:::•;;:;.;::. :.::::i:.::::::::: address. .... .:.:..:.............. ::: :.: ;.i:i;i:;::.i:.:.;::..::...::. :.::.::.:.;:.:::.;;::.;:.:;.;:.::.;:.;:.;:.;::::::::::...:::. . .:::::..:..:.::: :::.::::.:::...::.....::.:::::::.:.::::.::...:... crtw::: Dane#::':':: <>;`.'>::: ;::.;::.;:.:..;.;:::::.;:.;..:;.:':.;:.;;;:':.::.::.;.::: :.:.:::..:::.::::..:::.::.:........::.::.:::::.:.::. ::. insttrance.ca ...,. olirv'#...<::::, :>: >: :.; <` :>:` %/ I—] I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices. .................................. ............ :.;:.:;.;:.;::;:.;:.:;:.;::.:;.;:.;:;;:,:.%.:.;;:.;:.:is i:.i:.:.<.ii:::..:.;::.ii:.::.::............ :.:.:.;;:;.;;;;:.::.;;;:.::.;:;:.;;::.::.;:.;;:.:...;: .....;:......i i:. anv name ::.::::::::;:>.:.;: tbMD .::.::::::. �.:::. ;::if:f::?:<•:;::i2:'Ci i i''i Ci» .* :i.::.......r:....:: i Y.i i i...:i i`:::Ci i:'Ci'i.:.i''?.'i:i i Ef%? ??:<:><: ff>:<:?:?'.::.'i:' '•'3::i<i'ik::t4:f:'ile:n:ii: :::::::::.:...::..::::..........:.::.::.::.-:::::::.�.:....:..::::::::......-:....:�.�:. ...... :...................................::...:.........:...:::..::.:...:. .. .........:.:...::..:: ......:::::.::::.:...:: ............................................................................................................::............... ...........v:.v.:v::+::r:::rr::::nv:::w::::::r::::::.:.:N::.�:...:.:..:m::�::::::r::tw::::::.:.:.:.:::.......:: .........:.rC......... .':viiii:•i:•ii:4iii:•i{:::.ii}iii:J.'.. 4iiiiii::v:.. iY:::•if*,*:'�i}:....:'i:'::viii:.:}iiiiiY?:vYiiiiiiiiiiiiiii.....i'•i'wi}iiiiY:•i?.... ..••..•..•.......•••..••••...............•.•.....•..•...•.........•..•..•.••.•....••.••.•••.••••••. ...................::..........................:.::...::..:.:..........:............;...::�:::::::::::::::::.�:::::::•::::':Y.�:::.�.�:::.�::.�:::::::::::.�:::::::._:::•:::w::::::.�:::::::::::::v:.�::.�:.�::::::: ::•:::w::::::::::::.�Q.•3:...<.n ............... ::M•:r::::ww:::.vv. �Liiii JiiY::L:Y:::::i:i:::i::Y::iiii::iiii::i:ii?i::i:{i:ii}i?i:.:::iis':y�ij'iii>::(:: {:!:il::::::::iiii:....:i:i:::isti:'i'::•::::::::::::::::::::::n:�::::::::::::is•i'{irryi:: _ __ :y:j:�i:1'.'ii::ii:::::::.i iii::^i:..t..^.ii:.ii}i:.::.i:.iiii:iiiii?:{ryXL:ipi?iiii v::•:::•`:•ii'•iY...i:::'.iii:is i'.vi:{•i:^:j;:.i::ii'riiii:<::t vfi::ii'iii:i..:;•iY;:;::ii:2::::i::::i::i:.i:::++i}:..:ii%:{.i::i:ii::3i:i:i Yi?:: ................ ............... ................ . ... r ........ .. ........ ......... .. 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I. :.:::::::..:::.:::::....:::::.:::::.:::........:.. :...::.::.:. ::. :.::::.::.;:.i:.i::.i:.:::'.;......; �..... ci . ...._............_............. ..........._._... ... . _..... ..... .__. _.............._.......... .......ti one.#.....:,...::. iiii:••i:.;:.:.;:•:;i:.;;:.;i;i::::;;:•;:::::. i:.i:.i:.::.i;:::::::::::::::.:.::::::.:.::::.:.:::::. .::.:::::::::.::..:.::. .::::::::::::: > +=>:w>:... :<::::>:;:;;.::>.:::,•'t;:::.............:......: :.... :»::> :::: ::: ::>::>::»>:>%::<:>::<::<:>:«:: •ii:•:•iiiii::.;;:.:•i;:.i:.i:•i:.:.i:.i:.; asnrance:co� ... :: oli "#<: ::: >:::<:::::::`:>:: ;:.i::.i:.ii<:..: :.i:.,.i:.ii:>..:.: F a to aecm a coverage as required under Section 25A of MGL 152 can had to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verifleation I do hereby certify under the pains and penalties of perjury that the information provided above is true.and correct SignatureVvuvt_ Date ` a(,o r �9 _ _ Print name d Phone# 3-1 5 0 official use only do not write in this area to be completed by city or town official . city or town: permit/license# I ❑Building Department ❑Licensing Board ❑checkif Immediate response is requited ❑Selechnen's Office • ❑Health Department contact person: phone#; ❑Other (Fred 9/95 Pltq Information and Instructions f ' 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,neitherthe 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 permut/license number which will be used as a reference number. The affidavits may be reburied to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a'call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents ltfice of lwestl adons 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 The Town of Barnstable ,*TP1E , o Department of Health Safety and Environmental Services Building Division ' BABrtsrAB14 ` 367 Main Street,Hyannis MA 62601 MAss. 9 i639. ��tED MA'I a Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION Please Print DATE: 1-0 l0 JOB LOCATION: number street village "HOMEOWNER,,:_ q— Pl d `. ,5 name home phone# work phone# CURRENT MAILING ADDRESS: oar-m©� (Path, o-&V7S'' [o©� 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"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said prce ures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMPTN ,OF TFIE Tpy,_ The Town of Barnstable Department of Health Safety and Environmental Services pTEDMo►'�A Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. O� r� Type of Work: Estimated Cost Address of Work: �`� Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): �Wo k excluded by law [ db Under$1,000 RBuilding not owner-occupied �wner 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 of the owner: Date Contractor Name Registration No. 9 Yt A4%w ` OR l 46 Date Owner's Name q:forms:Affidav /01/99 01 HF0.x� CoV " Shy- m i u Ile u' yow' rY��.at - to � ila4� �� the flat plan u�d � 1-00� ^9 ��-1a• � 4ov rceded Ab J Aw, bu, 1d1 � PerM?t }or o_ fees porch . T� joy � c� �Q(Y��� � U 315 - 1045b- , °FKHE The Town of-Barnstable • anxxsrns�, • Department of Health Safety and Environmental Services 10rEc +" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner PLAN REVIEW Owner: Map/Parcel: � Project Address: I I V V"l 1T-) �'S L 1 l� Builder: The following items were noted on reviewing: Please call 508 862-4038 for re-inspection. l by: p Date: U� q:building:forms:review I `K �a 09/01/99 07:16 v 0000000000 Harding [a 02 ti i I 1. r a 1� 1 c� C, 7K, . / l I I I i !1�1 �I�'1;(..;`�!'l t.•�N 1''1,iJU.IJ ZlJN; 'N, t� 4'�, J (,),� 'r i\ .'Ii�til� /,l� ,�:IIlr 1 1! )Cl 11 i) REV. V. ''7 14\3 l v l f�I � 1 I J 1 /`� ''� �' ,.,,1 N R li:l�; --1,..C:' �t,c'f.1 '�' . •,I. , ,` 11 A 1, 1 I .i'. I If',',f;,,l,l' (;f,l�ll.�•'r 1C> ,�dd.',..,j9::.CJ�'.. >l.'.�',' 1!.'..L'I�. ��! �t� °�s•,,.a,, 'A }';F �[i 'VI''v� N lC... Y i 1Yt4 ON 'I'['iJS WEAN IS LOCATED ON THE GROUND A3 � pAUI. 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