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HomeMy WebLinkAbout0114 SEAGATE LANE 1 1 Town of Barnstable BufldIln Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept BAWMABL& `. I . MA&K Posted Until Final Inspection Has Been Made. �elr' IlIl� 'as¢ �� Permit Where a Certificate of Occupancy is Required,such Building shall be Occupied until a final Inspection has been made. Permit No. B-20-1464 Applicant Name: DAVID WOODS Approvals Date Issued: 06/15/2020 Current Use: _ Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/15/2020 Foundation: Location: 114 SEAGATE LANE, HYANNIS Map/Lot: 249-033 Zoning District: RB Sheathing: Owner on Record: ARSLANIAN, PAUL P&SHARON R Contractor Name: -,DAVID A. WOODS Framing: 1 Address: 141 PROSPECT STREET Contractor License: C5=035693 2 NORTHAMPTON, MA 01060 "��" Est. Project Cost: $ 10,500.00 Chimney: Description: roof-not over 1 layer-Bros Disposal Permit Fee: $54.00 Insulation: Project Review Req: r Fee Paid: $54.00 Date: 6/15/2020 Final: -�—' Plumbing/Gas Rough Plumbing: ��Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterissuance. All work authorized by this permit shall conform to the approved application and the°approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for,public inspection for the entire duration of the Final Gas: work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Perso ion ng with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). � Building plans are to be available on site Fire Department ' �� All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: BUILDING DEPT. ,� 020 -114tq Application number...... .. .................................. JUN 1`0 2020 Fee ..............�`?�.............................. • ASS TOWN OF BARNSTABLE Building Inspectors Initials..... .............................. SCANNEDDate Issued............. _ .......................................... i' o;2Y- 0 :33 UMap/Parcel................................................................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: �C&4 C- �lfl t4 LA K t A /� � RJ STREET VILLAGE Owner's Name: ! �--�/I S �ti`t c��, Phone Number G/ 13 -32-0' Email Address:eaJlr'Sf C4-14 i V ..L-, Cell Phone Number/3 �3 -[`-� Project cost$ f S V v Check one Residential L, Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building p it ' cc ce with 780 CMR Owner Signature:. �f� Date: Z 2 v TYPE OF WORK El Siding ❑ Windows (no he change)# ❑ Doors (no header change)# ❑Insulation/Weatherization ��1�'J Roof(not applying more than 1 layer of shingles) ❑Commercial Doors require an inspector's review Construction Debris will be going to /Ce � S' lj��esw ❑ Certificate of occupancy with no construction(complete below) . Occupant/family relationship or business name or Existing amnesty apartment(attach a copy of recorded comprehensive permit) CONTRACTOR'S INFORMATION Contractor's name ` Home Improvement Contractors Registration(if applicable)# /3 Z (, / (attach copy) Construction Supervisor's License# Cis. 0 ('� �I (attach copy) Email of Contractor l Yo>d Z!, of hone number sQ j J// 97 42 C ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. r i ,„AP.PLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X �X �+ *'� X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 20 lbs. or> Yes No ; if yes, a gas permit is required. Natural Gas Yes No '", , if yes, a gas permit is required. . If fo d is beingj served at your event please obtain a Health Department approval between the hours .of 8:00am:'-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *+WOOD/COAL, ELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from�combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone,Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date ` APPLICANT'S.SIGNATURE Signature Date S �? All permit applications are subject to a building official's approval prior to issuance. R The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: '43i � -- ?/, / City/State/Zip (• S" �" j== Phone#: r� �� 6. .� Are you an employer?Check the appropriat9111L Type of project(required): 1.❑ I am a employer with 4. a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, 0 Demolition working for me"in any capacity. employees and have workers 9. ❑Building addition [No workers' comp.insurance comp.insurance.; required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �f Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: —City/State/Zip:�� 4 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the paim and pen ties of perjury that the information provided above ' tru and correct Si ature: Date: 0 Phone#: 5"d d 2e� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer" f MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to 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 ` r 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington.Street Boston,MA 021 It Tel.#617-7274900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia r � CERTIFICATE OF LIABILITY INSURANCE DATE(Mo5/M/DDNM/DOlYYYY) 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 have ADDITIONAL INSURED provisions or 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). CONT IODUCER NAME; JIM HINDMAN chlegel&Schlegel Ins Broker AHI No Ext: 508-771-8381 AIC No 508-771-0663 4 Main Street E-MAIL lest Yarmouth,MA 02673 ADDRESS schlegelinsurance@gmaii.com INSURER(S)AFFORDING COVERAGE NAIC II INSURER A: NGM INSURANCE COMPANY 14788 SURED INSURER B: TRAVELERS MARCOS SILVA INSURER C: DBA EMERSON CONSTRUCTION INSURER D 67 SEA ST APT 11 HYANNIS MA 02601 INSURER E INSURER F OVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS . CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. R TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDD EFF MMIDD LICY E P LIMITS. x COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE- $ 1,000,000 DAMAGE TO RERrEIT— CLAIMS-MADE a OCCUR PREMISES Ea occurrence $ 500,000 MED EXP(Any oneperson) 6 10,000 MPT9375T 11/09119 11/09/20 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO ❑ PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY JECT LOC $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPERTY DAMAGE HIRED NON-OWNED Per accident) $ AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ PER OTH- WORKERS COMPENSATION STATUTE ER. AND EMPLOYERS'LIABILITY YIN - 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ B OFFICERIMEMBER EXCLUDED? a NIA WC-1073205 O4I1712O 04/17/21 E.L.DISEASE-EA EMPLOYEE $ 100,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below )ESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) MARCOS SILVA HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DAVID WOOD 43 matthew way marstonS mills ma 02648 AUTHORIZED REPRESENTATI iyanough43@yahoo.com, ©198 -201 I ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACOFfb Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Cons r.fitt�P bojprvisor CS-035693 ,' rz.- ires:01118/2022 DAVID A.WOODS; 43 MATTHEW WAY MARSTONS MILLS,MA``02648 ��� 1OtSti"�l�1A, f Commissioner ✓�% airr�i2rizu,���� cj� lio hoc uelll Otfice of Consumer Affairs&;Business Regulation' t ' F: HOME IMPROVEMENT CONTRACTOR 5 T1fFE.Individual i EXRiretlon �132361 „07/30/2020 i W DAVID WOODS" -fi, F{ DAVID A.WOODSt � 43 MATTHEW WAY MARSTONS MILLS,MA 02648 Undersecretary Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us' Pre-application for Business Certificate Date V' O V�G Map Parcel Q Applicant Information Applicants Name JINN, I k f k W1 n t'/ Applicants Addressll4 Gyi n l mail Address V'� r OU�D�F� (AMh1 >°SSOt�IS Telephone Number W (Q 11 ' I �{ Listed ❑ Unlisted com Business Information New Business? Yes No Business is a registered corporation? ________________________. Yes No If yes Name of Corporation Does business operate under the registered corporate name? Yes No Is the business a sole proprietorship or home occupation? _________ Yes No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business u o Jaws n�tu�irr �e�sos Business Address � 10 M I h �'�1��t;� I VI Type of Business m d i c, `t�S D n S B1111ding Commissioner Office Us Only O nditions U� &W_'U ✓V -b rn Building Commission4 's Date Clerk Office Use Only f To:Robin Anderson Town of Barnstable Building Department 200 Main Street Hyannis,MA02601 From:Jessica LaFlamme 114 Seagate lane, Hyannis MA02601 (603)617-4247 direct info@houseofjammusiclessons.com Dear Robin, House of Jam Music lessons is a music studio where instructor and business owner,Jessica Laflamme,will teach private music lessons to her students.Each lesson is taught to students on a one-on-one basis and occational small group sessions.The number of full time instructors will not exceed two. Thank you, (ii7 ica LaFlamme House of Jam Music Lessons TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# 266 ,!1 1769 Health Division Conservation Division Permit# Tax Collector Date Issued A Vt 1 10 Treasurer Application Fee Planning Dept. Permit Fee o Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner axe Address Telephone Permit Request G�-4 Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 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 t Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Others. Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: 0 Yes _O No tiw Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size f 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 elephone Number ��lf� 7 4�? v Address License# e�20 yy A `7C_ Home Improvement Contractor# /0 �/q Worker's Compensation# Y/gr g 3/5 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE . FOR OFFICIAL USE ONLY, . PERMIT NO. DATE ISSUED 1 MAP/PARCEL NO. ; ADDRESS ' '' VILLAGE ' OWNER. 1 f , DATE OF INSPECTION: FOUNDATION FRAME �2 � -O°'7 ©(/+ c- INSULATION -7 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL ? r FINAL BUILDING r ! DATE CLOSED OUT r - Y . ASSOCIATION PLAN NO. r Town of Barnstable Regulatory Services 8AR1' AD MAS& Thomas F.Geller,Director Building Division Thomas Perry, CBO,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.maxs 'Office: 508-862-4038 Faxe 508-790-6230 PLAN REVIEW Owner: L (G¢r� Map/Parcel: 14 o � Project Address i S C G0-TE Builder: X/.Z-T— a C___C,--b r-F- The following items were noted on reviewing: C 4 g /Y � Reviewed by: Date: — S —o -7 Q:Forms:Plnrvw The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street . Boston,MA 02111 k ,� °V www.mass.gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl 011 Name(Business/Organization/Individual): . - Address:/lAe ��%� Phone.#: City/State/Zip• � _ Are you an employer? Check the appropriate box: Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and 1 employees(full and/or.part-time).* have hired the sub-contractors 6. ❑New construction . 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling t ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' �� 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10.❑Electrical repairs or additions required.] , 5. We are a corporation and its 3.❑ I am officers have exercised their a homeowner doing all work 11.EIPlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12:❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy'information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: t�/^ 3/ ! Expiration Date: � G � Job Site Address: �� l%� City/State/Zip: _ r Attach a copy of the workers'compensation policy declaration page(showing the policy nutrt er 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 flue 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 unde the pains and penalties of perjury that the information provided above is true and correct. Signafore: Date: a Phone#: 9z 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): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions u 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 zecei_yp.r tee of an individual partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until-acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to 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 Accide>sts Office of Investigations 600 Washington Street Boston,MA 02111 TO. ##617-727-4900 ext 406 or 1-977-MASSAFE Fax## 6 17-727-7749 Revised 11-22-06 www mass.govldia �ZMF L V TT AA VA .i-sbLi JAP rra!✓iv ° Regulatory Services Thomas T,Geller,Director 'loss, $ Building Division Tom.Perry,Building Commissioner .200 Main Street, Hya=is,MA 02601 www.town.,barnstable,ma.us ace: 508-862-4038 Fax: 508-190-6230 permit no. Date AFFIDAVIT HOME INUROYEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL c, 142Arequiies that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal, demolition,or constriction of an addition to any pre-existing owner-occupied - bu,7g containing at least one but not more than four dwelling units.or to Structures which'are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work:_- ��°�m`� Estimated Cost Address of Work:. Owner's Name:' -3 Asv_ Date of Application - I hereby certify that Registratign is not rewired far the following reason(s); DWork excluded by law D7obUnder$1,000 Building not owner-occupied []Omer pulling am permit Notice is hereby given that: OYr ns PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMTROYEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PRO GRAM OR GUARANTY FUND UNDER MGL c,142.:X; ; SIGNED UNDER PENALTIES OF PtP URY I hereby apply for a permit as the agent of the owner; A2 Z�d Da Contractor Signature. Registra.LnNo, OR Date Owner's Signature Q y�f�es,forms:homeaffidav Rev; 060606 Town of Barnstable. 1 Regulatory Services MAass.M# snar Thomas F.Geiler,Director i639. Building Division AlfD nnA'�a g Tom Perry, 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 aaz,:,Zz-�,as Owner of the subject property hereby authorize 0--ALZIto act on my behalf, in all matters relative to.work authorized bythis building permit application for: (Ad&ess of Job) 4i&gnature of Owner at riot Name Q:FORMS:OWNERPERMISSION _ ��p "V �a T i 0 ! ^���; � �6ee T�omvrrio�zuiea�t o�,./�aaacfuyae�ta - I4 BOARD OF BUILDING.REGULATIONS License: CONSTRUCTION SUPERVISOR Number CS 004276 ` Birthdate t2�1 1947 I Expires 12ltmt 2007 Tr.no: t4357 Restr�cfed # u3 r i ARTHUR L D.OLGOFF= 19 McCORMICK DR �f W BARNSTABLE, M�1afl2&68 Commissioner C V%(6)L �A VA- -C 4, JA Ly Sw o-36� 41 50 ? 7/ 0 tAA r • 41 UI UI 0 ri -T- f.W4 + S-k V OLD A Feb 21' 07 03: 40p Mary Lou Laurenza 413-545-0220 p. 3 0u�. ✓ �' v I pvi 2� f a- IIUJV IlGNhpV�- 32V,ov - �JCcWI�� i iInf'cvtok,- ,L 1TQ.1 GCt (i Iti T o VA0..4I:QI +d4 vG Owl oaj- 7 � YS t � ! s2 � s N IS vi r a+` 6 c Dov —44 34 v VA y \*V J to c -N Ul t'• �' 'c.-` c.. � t e X'�• �4�-�a� V�C•.w S p j � � T�N���t` o !d of o �1 Eli I '. f� K� CMA 17, - S yr +0 Pu„L(n U.y;vt .� 2xi� b«� . a!/ S ova +1,c- Lv c-�c I Feb 2107 03: 42p Mary Lou Laurenza 413-545-0220 p. 5 --' i O �' i 1•` i t ' 1'{1 7 r r � N O �A Cil a 1 t y a Assessor's Office(1st floor) Map Parcel Permit Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Date Issued /Q - .2B q� Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) Fee D 0 Engineering Dept.(3rd floor) House# �t„E fo BARNS ABLE, ` 1 MA86 19 .a�o ED lAA� TOWN OF BARNSTABLE Building Permit Application r Proje Street ddress sza CA Village / Owner i /i og2 /6 Address Telephone `7 :2 2-- 0,3 Ll-3 -Permit Request f y,rb®-Y First Floor 4g2W ?' �C�a square feet Second Floor square feet Estimated Project Cost $ ��0` Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type r1. JC Commercial Residential [� Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House o^ p Unfinished Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder I ormation Name �6 / /�. 2/N/ W; elephone Number(/ �� Address 01 /.�VIyJ I CI j-�^� License# Home Improvement Contractor# Worker's Compensation# 4 "5- �J NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. J ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO I SIGNATURE - DATE BUILDING PERMIT DENIED FOR THIrFOLLOWING REASON(S) FOR OFFICIAL USE ONLY ' PERMIT NO. • 1 DATE ISSUED . — � t t MAP/PARCEL NO. ' 1 s � ADDRESS " VILLAGE E - # ' � i r •� - i -- , OWNER 4 , DATE OF INSPECTION: FOUNDATION FRAME INSULATION •FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH t FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. t + i r r HOME IMPROVEMENT CONTRACTORS REGISTRATION Board of Building Regulations and Standard: One Ashburton Place - Room .1301 Boston, Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR Registration 119300 Expiration 06/19/97 Type - DBA ISLAND SIDING RONNIE L . TAYLOR 31 MANNI CIRCLE CENTERVILLE MA 02632 The Commonwealth of itassachusetty b___: Department of Industrial Accidents Oflfeeof/Mest/gat%ns »� ►� ?•_-y.a! 600 fi'avhinrton Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit ----r•— •QIZ� ..^s.iaa tnava uanarva■ ., ...._ r S��SS !S"! � S name: locition• citv nhonc# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employeZM iding workers' compensation form employees wor Sing on this job. om nA address: L //2 A,? L34 nhonc#• lJ t C J eel � incur•tnce co policy# I am a sole proprietor, general contractor,or homeowner(cirdle one)and have hired the contractors listed below who have the following workers' compensation polices: company n•tme• address: citx• phone#: insurance co policy# -': r_..•' _ +tn.r;rti.::riven—s ^.':1'•rt{;^fs'*'ij�.'st+rP=•irif '�7CE{�47�i•.;)Azi-R�:waT S�F"!.^��!'.r_' "�4!isT="'^'." S c6mpam•name: — address— city phone#• incurtnee co policy# :Atiachadditiiinal'shi ifrieeess �•...��.: y a.�;,a,t�.H"t^± el :RtYt�., �a .. = ) . i•� 'r' _ Failure to secure coverage as required under Scction 25A of 51GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one years'imprisonment as Well as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Oflce of investigations of the D1A for coverage verification. I do hereby certif• der the pains and penalties of perjnn•that the information provided above is true and correct. Si_nature Date Print name officiai use only do not write in this area to be completed by city or town official city or town: permit/license# rlBuilding Department Licensing Board check if immediate response is required 13Selectmcn's Office (3liealth Department co contact person• phone#;_ nOther _ a (revised 3195 PJA) - The Town of Barnstable �►�,�, . Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosses Ol= 508 790-6227 Building Commissions Fax 508-775-33" For office use only Permit no Date AFFIDAVIT HOME II"ROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"tzconstruction,alterations,renovation,repair,modernization,conversion, od hnprovemern,.mno%%L demolition, or construction of an addition to any pre which t building containing at least one but not more than four dwelling twits or to to such residence or building be done by registered coutrac toM with certain C=ptions, along with other mquircrac= Type of Work: EEst'Cost Address of Work: Osmer.Name• / Date of Permit Application: I hereby certify that: Registration is not required for the folio-Aing neason(s): _Work excluded by law ob tender SI,000 Building not owner-ooetpied owner pulling own Permit Notice is hereby given that: CONTRACTORS OWNERS PtJl-1-ING O�1V1EO� DEALINGERMIT OR WrM ROVE1��Ni' OW RK DO NOWT HA�CESS TO TIC FOR APPLICABLE H 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: MAI Dat Contra name on No. OR rlamer's name ,