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HomeMy WebLinkAbout0340 WEST MAIN STREET /� +� � • �. ;� - - -- � �� 4 I, TOWN OF BARNS,TABLE BUILDING PERMIT APPLICATION 6 ()() . j i 9 0(0 CO Map. '• 7 Parcel Application # Health Division Date Issued j2-1'3-] 3 PP— Conservation Division Application Fee ' • 0 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 340 WeST F'1Q_�V\- Se Village 1"Et��VaVVV11 S % MA o,260( Owner Address Telephone r 4 AI T J 1 Oka &4 01'Permit Request /Z 9-S J ell n.Q IL N-Q, 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, attache pporting: iocuentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) "o u Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' Highway: ❑Yes ❑'No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other �a Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.6) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including bath-:)): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 1 uR�/ .ger�N 1,u S k Q n ALO Telephone Number 6-0 8 MY 6909 Address f7Y YAPS L COCAA.Af 2.02 License# CS ^ yoa6y berm iS,E Q97 , Mat 62 63 I Home Improvement Contractor# R2Y76 I Worker's Compensation # WC 631 S 9(4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO vage-Kou 4h P?4 SQL. SIGNATURE DATE 7• /JQ • AO/S FOR OFFICIAL USE ONLY APPLICATION# s DATE ISSUED Y • M` MAP/PARCEL NO. ADDRESS VILLAGE 3 OWNER DATE OF INSPECTION: ..FOUNDATION ,� r FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL Y. . PLUMBING: ROUGH FINAL—.- GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT � ASSOCIATION PLAN NO. r i ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information __,w�,, Please Print Legibly Name (Business/Organization/Individual): Eek (C✓'0,V\A, �►^ !vtn.p ' Address: 140 Wes-T h't `n'S . MIL t 026a City/State/Zip: Phone#: 5V 9 U*'f 64 09 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 101 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I aril a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling 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$ 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. r r Insurance Company Name:�C�Li �trl-�1/�C71�►'� oo�� — Policy#.or Self-ins.Lic.#: NPP T3W 9 24V Expiration Date: O3. 0.9 •�� 3qo W¢S(� H04 V� S^( City/State/Zip:/State/Zi �/LK r> Job Site Address: tY P� ��' -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 i fine up to$1,50.0.00 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.ce der the pains a enalties of perjury that the information provided above is true and correct Date: •/ . 20/3 Si afore:Phone#: J rn f 36(/ 6 09. 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 appurtenantthereto 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.'-hi 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 applicanYshouldwrrte"all Iota}ions 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 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass_gov/dia y °FTHE l Town of Barnstable ti Regulatory Services MAM Thomas F.Geiler,Director jOrFc 39. A Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder V as Owner of the subject property hereby authorize /3&' / I Sla n �� -1`'�✓� a t y behalf, in all matters relative to work authorized by this building permit. ell (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. \� VJ Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 6/2012 t�� T� Town of Barnstable P� Regulatory Services, Thomas F.Geiler,Director STABLE, � MASS. 1639. .�� Building Division TED MAC A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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 procedures and requirements. r Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly, when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt } fvlassac nusetts - C, 3partr-nen+Of PUu: j:c lie �orr�rw�uveall�i o�../�uaoac�uiaelta Board of Building Pegulations end Si��ndu�c.s, Office of Consumer Affa►rs&BusmessRegulation . N s un�ti u�tu,n 5��ocr�i�a\.. a OME IMPROVEMENT CONTRACTOR.. Registration 172�i;76 TYPe?i� IVAN V IVANIU'SfIENKO I' Expiration 9 2044 Supplement;(] _:� _+« : E'. : BOX 1322 BEL ISLANDS H(51�IE IMPROVEMENT Dennis Port AM 02639 - �•' r , - P IVAN IVANIUSHNKO ` h 29 MILL POND Undersecretary W.YARMOUTH, MA 02673-` C OMM ,SI 01/01/2014 Mas*.Corporations, external master page Page 1 of 2 y.. William Francis Galvin � b D sSecretary of the Commonwealth of Massachusetts HOME DIRECTIONS CONTACT US Search Sec State ma us Search Corporations Division Business Entity Summary ... _ ID Number:043271819 Request certificate New search Summary for: ADRIENNE'S CAPE COD PROPERTIES,INC. The exact name of the Domestic Profit Corporation: ADRIENNE'S CAPE COD PROPERTIES,INC. Entity type: Domestic Profit Corporation Identification Number: 043271819 Old ID Number:000494998 Date of Organization in Massachusetts: 03-16-1995 Last date certain: Current Fiscal Month/Day: 12/31 Previous Fiscal Month/Day:00/00 The location of the Principal Office: Address: 880 WEST MAIN ST. City or town,State, Zip code,Country: HYANNIS, MA :02601 USA The name and address of the Registered Agent: Name: ADRIENNE SIEGLE Address: 880 WEST MAIN STREET City or town,State, Zip code,Country: HYANNIS, MA 02610 USA The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT ADRIENNE SIEGEL 30 RYDER LANE,CUMMAQUID, MA USA 30 RYDER LANE,CUMMAQUID, MA USA TREASURER ADRIENNE SIEGEL 30 RYDER LANE,CUMMAQUID, MA USA 30 RYDER LANE,CUMMAQUID, MA USA SECRETARY ADRIENNE SIEGEL 30 RYDER LANE, CUMMAQUID, MA USA 30 RYDER LANE,CUMMAQUID, MA USA Business entity stock is publicly traded: r The total number of shares and the par value,if any,of each class of stock which this business entity is authorized to issue: Class of Stock Par value per share Total Authorized Total issued and outstanding No.of shares Total par value No.of shares r Consent r Confidential Data r Merger Allowed r Manufacturing View filings for this business entity: 'ALL FILINGS C-" Administrative Dissolution Annual Report . Application For Revival Articles of Amendment `A View filings http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=043271819&... 12/9/2013 Mass. Corporations, external master page Page 2 of 2 Comments or notes associated with this business entity: New search William Francis Galvin,Secretary of the Commonwealth of Massachusetts Terms and Conditions http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=043271819&... 12/9/2013 f A� CERTIFICATE OF LIABILITY INSURANCE °ATE(MM,D°'YYYY' 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 endorsements . PRODUCER BRYDEN&SULLIVAN INS CONTACT NAME: 88 FALMOUTH RD PHONE ,. FAX A/c No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC to INSURER A: INSURED INSURERS: ANDREI YARMOLOVICH DBA BEL ISLAND HOME IMPROVEMENT INSURERC: 29 MILL POND ROAD INSURERD: WEST YARMOUTH MA 02673 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 17327955 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD MMIDD/YYYY LIMITS GENERALLIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea RENTED ) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY FE0.M.1,d.n0 INGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident)AUTOS $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS aracader $ UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ $ $ A WORKERS COMPENSATION Y/N WC5-31 S-384176-023 2/25/2013 2/25/2014 WC sTATU- oET I- AND EMPLOYERS'LIABILITY ✓ TORV LIMBS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 OOOOO OFFICER/MEMBER EXCLUDED? INN/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 If yes;describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,H more space is required) Workers compensation insurance coverage applies only to the workers compensation laws of the state of MA. ANDREI YARMALOVICH IS COVERED BY THE WORKERS'COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF BARNSTABLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING INSPECTOR ACCORDANCE WITH THEPOLICY PROVISIONS. 397 MAIN ST HYANNIS MA 02601 AUTHORIZED REPRESENTATIVE Jeff Eldridge ©1988-2010 ACORD CORPORATION. All rights reserved. . ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CSRT NO.: 1737 955 CLIENT CQDE: 1568030 ➢idi pangds /16/2019 B:OBid2 AM Paga certificates. This certificate cancels and superse es LL previous y lssu �~ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 9 Parcel Application #�� 04 A a S Health Division Date Issued .� 1 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/Hyannis Project Street Address-, -3'10 (gist phi 4, Villa e i►c�A;vlf/t1 � I { GOwne' ' ' -t CA A e, SI-ea rA Address Telephone---- I — Permit Request ne CL-L+P cyan--_ Si 5�a L,,��P c n�rQ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Proms 'ect_Valuation_ .-1 'mod Construction Type Lot Size Grandfathered: ❑Yes 0 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 gount Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other E� v, ^T; Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal;stove: ❑yes WW o Detached garage: ❑existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ newer size. Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: t 0- Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# - Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) P `Nam e�""`��ov.�`� sn,&c`ylt "I-Telephone--N-umber .Address—d, --ems e__ 'S f- 'SMnSStt,2,eE, -_L-icense-# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE q FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED. - a< if MAP/PARCE ,.NO,_.. � .. f� ADDRESS VILLAGE - OWNER ~ DATE OF INSPECTION: ia-FO.UNDATION=. FRAME INSULATION.:'= xY FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL . ` ROUGH ' '"+: GAS �;�;"��`.: � � _� r-: FINAL i ",FINAL SWILDINGP, ,°t: Cl : .. h DATE CLOSED OUT , ASSOCIATION PLAN NO. �L - The Commonwealth of Massachusetts _. Depar-Oneut oflirdustrial Accidents Office ofInvestigations' 600 Washittgton Street Boston, MA 02111 www.mass"gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / n 1, Please Print Leffibly `Name`(Business/O�ganization/Individual):� City 1 ate© CW-0!'KS ' �Aaares�a 5f. • <City/S.tate%Zip�.(1'l�s 02 yg Phone.#: Sao- ??4�-, 5VZto FRI an employer? Check the appropriate box: Type of project(required): a employer with 4. I ama general contractor and I 6. ❑New construction loyees(full and/or part-6me).* have hired the stab-contractors a sole proprietor or'partber listed on the'attached sheet T. []'Remodeling ship and have no employees These sub-contractors have g_ '0 Demolition working for me in any capacity. employees and have workers' 9 .0 Building addition [No workers',comp.-insurance comp. insurance.f required] 5. We arc a corporation and its 10.❑Electrical repairs or additions �3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' eomnp. right of exemption per MGL 1Z.0 Roof repairs insurance required] t c. 152, §1(4), and we have no employees. [No workers' 13.❑Other {{ comp.insurance required-] yAny applicant thatchccks box#1 must also fill out the section below showing their workers'compensation policy information. m t Ho cown=who submit this affidavit indicating they are doing all work and then hire outside contractors must subrnit a new affidavit indicating such. XContrectors that check this box must attached m additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providb their workers''conrp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab 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 crimiriAl penalties of a fine tip 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. Ido hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct: S'i afore: Dat�`�"e`_"' F use only. Do not write in this area, to be comple[ed by city or town offtciaL Town: Permit/License # uthority(circle one): of Health •2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector P y`son u th Massachusetts General Laws chapter-152 re wires all ern to errs to provide workers'compensation for their.employees: - P. q pursuant to this statute, an employee is defined as ,...every p e service'of another under any contract of hire, express or implied;oral or written: Aa 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 ffi steeof 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 at 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 alicense or-permit tdoperateaI 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(n 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 kith 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 essary, supply sub-Go name(s),-address(es)-and.phone ni.imber(s) along with their certificate(s)of nec insurance., Limited Liability Compaaies'(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 pol cyis 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' cos[Pensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insuran4e License number on the appropriate lino. City or Town Officials :. Please be sure that the affidavit is complete printed 'and 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 permidlicense applications in any given year, need only submit one affidavit indicating current policy information(if necessary) and under"fob.S{te Address"(lie apolica it should write"all locations in (city or town).".A copy of the affidavit that has been officially stamped or markod by the city or town maybe provided to the . is o file for future ernuts or licenses. A new affidavit must be filled out each t a valid affidavit n p a licantasprooftha . PP year.Where a home owner or citizen is obtaining a license or permit not related fo 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: < Thy Commonwealth of Mas aGhusel is ' Depa tmz nt of Industri,al Accidents k Office of ru'Yestigat-ia-us, 600 Washington-Street Boston, MA 02l'LI Tel. # 617-727-49-00 ext 406 or 1-877-MAS-SAFE Fax # 617-727-7749' Zevised 11-22-06 www.maSS.gov/dia Town of Barnstable Regulatory Services RAFWSTAsM q ►aa 6 1 9. g Thomas F. Geiler,Director � Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject.property hereby authorizes j��,� ,; 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. (?•F(1R 1vf S•(1 VJIJFR PFR 1,.iTCC1f1N M. Town of Barnstable oaf Yt+e ray o Regulatory Services sAxxsrA MY- Thomas F. Geiler,Director Building Division PrfD MA't h . Tom Perry, Building Commissioner 200 Main.Street,__Hyannis,MA 02601 www:to wn.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOhEEOPNER LICENSE EXEMPTION Pirate Print DATE: JOB LOCATION: number street village "HOMEOWNER', name home phone# work phone# CURRENT MAILING ADDRESS: 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 constricts 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 Budding Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signatiire 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 parfom»ng work for which a building permit is required shall be exempt from the provisions of this scction.(Scction 109.1.1 -Licensing of construction SuperNzsors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowncr shall act as supgvism" 4any homeowners who use this rxemption are unaware that they an assuming the responsibilities of a supervisor(see Appendix Q, Rulcs&Regulations for Licensing Construuction SuperYisors,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 procccd against the unlicensed person as it would with a licensed Supervisor. The homowncr acting as Supervisor is ultimately responsible. _ To ensure that the homeowner is fully aware of his/her rr sponnnbilitics,many communities require,as part of the permit application, that the homeowner certify that hdshe understands the msponrbilitics 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 formlcertifrcation for use in your community. Q:forms:homccxcmpt a 4 �- Massachusetts - Dep,u-tment ot•PON, Safetl Board of Buildin,,, Refulations Construction Supervisor `1nd Standards i License License: cs 105530 ' DAVID SMITH 2 MAPLE STREET MASHPEE, MA 02649 C ununi..,innc Expiration: 4/5/2014 — Tr#: 105530 _ r" . 1 + w r i w s f ,tiY I 41p� a t� i i � 4I1LEO n IC 40 + Tar 1y Y t p � ����,,�,,. i. � �. ,.•,z , � � +III �t�,� I =RIw� -< _ '� a. ti 1 6 w V ti >f: �e if. Dip.9 i ` .,T � •wn '!lp .� _ .Y - � 11 ' ^ }p P.' � � ".,w°�p,.,�'1 ' 'a+�An`r "...c��uc•ma 'stk%c^:"r ..: 4 n 1 om. "� t 4�} ...Art "' a.r •der g}y,,^`f. ^ A, *:��t, 1:6�! ':.1 m A^ 1 J ,I 6 'k �QAh _ .*h,. i, "> j.�1 �1 t�l m..•m x:ti.+.i,r`i..,.n y. .. _ x ,. ` •y:„,x° .: • « ; .. .r /..` t,, F+€ ,.�- _'r,� r� d � y �r- ''k'��7 ram... .`�� ,,.#r..i }� � `z ,. � �• �� '• Al " ►.e _OV. `,y. JN, ;."; ^ ) C',.�t i,� �w4�T '+ ..� ytt '.1,�1 44L, �+^Yw ,�w. ��^,'.;'�. a .tffx..`':1 � ,:�� s+c",wh.. ' --�"�'�" 4�"•�t� w�� 'R :� kr �*�.y. r .., � .r � � �„ • ,. .alb -�,�,ti rs.1 .p 1. 3. 0 estInr71 /10 .,4 Town of Barnstable *Permit# ? ?Q Expires 6 months from issue date s �ABLE : Regulatory Services Fee MAW. $ Thomas F.Geller Director 059.lFo 5+06 Building Division XPR Tom Perry, Building Commissioner ��� 200 Main Street, Hyannis,MA 02601 JUN 4 Office: 508-862-4038 1'0VVN O 2004 Fax: 508-790-6230 V EXPRESS PERMIT APPLICATION ressEIDENTIAL ON PA&/VSr�e'� Not Valid without ReImprint Map/parcel NumberP> Property Address ❑ Value of Work Residential Owner's Name&Address Contrac tor's Name A/147 Telephone Number '°T Home Improvement Contractor License#(if applicable) I S 6 2 a6 - Construction Supervisor's License.#(if applicable) ❑Worlanan's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to U M ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Pro erty Owner must sign Property Owner Letter of Permission. m Improvement Contractors License is required. Signature Q:Forms:expmtrg Revise053003 _ ✓77ee T�omvrrto�zevet� o�,jao�zc,�uraelta OEM Raard.#f.Tuiiding.Iieguiatians and.Standar _ HOME irROVEMENT C64iR: ACo OR ' RegtstKa 6206 200 (` AFT *�livi.duai f }l;, YPRI'CS vi�FtH E p/ �� r��'E�`R� "s���✓�! . Cam... � HYANN;S.MA O260 i Administrator` of tr+s ro,;, Town of Barnstable Regulatory Services Thomas F.Geiler,Director 9� s639• ,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 508-790-6230 office: 508-862-4038 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property I� to act on my behalf, hereby authorize in all matters relative to work authorized by this building permit application for: 340 W&-sz � (Address of Job) Date Signature of Owner . Print Name t� o Town of Barnstable �� o� r BARNSPABM Regulatory Services 11lA.4S. 1639• ,0�' Thomas F.Geiler,Director Building Division Peter F.DiMatteo Building Commissioner 367 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 , N Date: O Name: S' 41 I g- rl �'S G��,� /qJ 6 C �i11A/ Y.L. Address: C3 70 Village: hA Zoning: Current/Last Use Proposed change of use 0� Change of Use Request I, hereby voluntarily surrender the use and knowingly give up all rights associated with its history. At this time I request that a Change of Use permit be issued for the aforementioned use. J Signature Approved G �� Not required Staff notes: Q:B1dg\f6rms\changeuse TOWN OF BARNSTABLE SIGN PERMIT ' PARCEL ID 269 071 OOA GEOBASE ID 17393 ADDRESS 340 WEST MAIN STREET PHONE HYANNIS ZIP - LOT OFFICE BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 57170 DESCRIPTION STRWBERRY HILL REAL ESTATE - 20 SQ FT ( PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of Health Safety ARCHITECTS: P � Y and Environmental Services TOTAL FEES: $25.00 BOND $.00 SINE CONSTRUCTION COSTS $.00 i 753 MISC. NOT CODED ELSEWHERE * * * BARNSTABM MASS. �FD P' UIB LD G 114 DATE ISSUED 11/15/2001 EXPIRATION DATE BY`�y �r v 01 Cis/1995 06:01 918028624926 PA` E 02 Thomas F.Geller,Director NAM i Building Division :yP 1'rlbert C UlshoeQer,Jr. Bnlidiag Co=nJidouer 367 Main Sheet, 11ya1is.MA 02601 Office: 508-862.4038 Fax: 508=90-62= Tax Collector Treasurer Application for SIP Permit Applicant: Ad r i e nne G. Siegel AUCSSors No. 2 6 9 0 71 0 0 A As: ddbadrienne' s Cape Cod Properties, Inc. 508-775-8000 Doing Business : Strawberry Hill Real EstateTelephone NO. Sign Location SbVCVRoa&. 340 West Main Street, Hyannis, MA 02601 Zoning District: COMM Old Rings Highway? YaVe Hyannis Historic District? Ye& property Owner 5 0 8-7 7 5-8 0 0 0 Name' Adrienne G. Siegel Telephone' Address. P. 0. Box 26 YillBge: Cummaq u i d 02637 Sign Contractor Nye: Telephone: Address: Villw' Description Please draw a diagrams of lot showing Iocation ofbuildiags and existing SiSAS with dimensions, location and size of the new sign. This should be dawn on the reverse side of this application. Is the sign to be clecnified? Y03601 (Note.If yes. a wlrimg permit is rnquircP9 I hereby certify that I am the owner or that I Stave the authority of the owner to snake this application; that the information i,correct and that the use and coast action shaA cnnforffi to the provisions of Section 4-3 of the Town of$amstable Zoning Ordinance. Signature of Owner/Authorized Agen . Date: g --L Size: O pmmlit FCC: Sign Permit was approved. �/.-t.� isapproved: �l •.�� t 5 Sgr' PAST SIGKS Robert McDonough ?� ( f ✓',/'f% j.` .!L/;ii.� ;�.�`^ , r,j /v� l� Hemrcrs•Pvun•Huu.-V6.le. ! Imerior Sips•Outdoor Slg.,•Windows .. ..._—.—..__.._..._..—_..._._---_._..... - 71(imn Sl..Nrrwl.MA03601. 7d T15-SS011ru 175-27US Tg_i \�lk�b/(V4 4' ,lam f Oli s I, �r ' I �J r a. i� a� ♦ 1 x r IL �� 4� •f J'r,u i t �� 't y. F V c / w r r i I a I 1 ��gERRy I REAL ESTATE ADRIENNE G. SIEGEL` Principal/Owner 880 West Main Street,Hyannis,MA 02601 (508)775-8000 FAX(508)775-8804 s �LS O 1-800-88278P6 t 1 #: ¥ ` % ..... » �\ d�� � Jim � 3 J &614 4 lfll"1 of-Wo a -_v_'.4�u��✓,,._�:tTi.!'.�Y ;�_iLa TiakA „GG i c-�!ECG-(�:�� L�GZL�G�I��✓ i/ZCGL�(�/l 9 .. _ :/ TfTrfL�+ �'%/'f.•TLj;,�/ter' IL is