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THE�,
Town of Barnstable *Permit
'b Ex�rres 6 mor t�rs from issu e
' Regulatory Services Fee
saxxsraste,
Mass. 8 Richard V.Scali,Director
s6;y. ♦0
Building Division
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PEPMT APPLICATION - RESIDENTIAL ONLY
��n D Q� Not Valid without Red X-Press Imprint
Map/parcel Number C/ `� C) /�
Property Address 70 0 /�`7 G �A /ZtJ F#9, 1/l 3
'Residential Value of Work$ �2. C� Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name ;Nk/#/ht.t_ C(IVT7>' Telephone Number
Home Improvement Contractor License#(if applicable) l /Z( ! Email: CO n 7-1?4qCI Y)
Construction Supervisor's License#(if applicable) 0 otlfh Z �Z_ L-OW?CAS!a IJ4
❑Workman's Compensation Insurance
Check one: ry � 1
El am a sole proprietor a1 .1��,~ 1 *►?51;%. ;
VIF_1am the Homeowner , 1
have Worker's Compensation Insurance DEC Q 3 2016
Insurance Company Name /- '`� 1 G c f r A h i lw l A t f 441F,W 1\1'_z N�, 41 � � y
a,
Workman's Comp.Policy# . c
Copy of Insurance Compliance Certificate must accompany each permit. .
Permit R u check box "71
Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to A/-43 ;/A4R/r—
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A cop of the Home Improvement Contractors License&Construction Supervisors License is
ed.
SIGNATURE: e"
Q:\WPFILES\FORMS\building permit forms\E SS.doc
06/20/16
Ile CommoTnveakh of assadruseft
D•epar'tmetit-rf rmhu rW Accidex&
Off"Of hTW-*afiGM
600 Wasliarigion street
-- Boston, 02111
-- witTtumas%govIdia
Workers' C'mppensaffan Insurance AfdavrL gmlders/CoIltr-actEi3s/ETtctrmmus/Phun hers
APTMC Tmfa matiGn Please Piint
Address:T�az /zk
City/St 0 Phone
Are you an employer?Checkthe appropriate bar: Type of project(required):
I_❑ I am a employer with 4 ❑I ttm a ge4-eral contactor and I 6. ❑New oons[�cEiaa
arnologees(full or part-time).* have hir'ed1he sub coabmcfos
2. LT-Ian a sole proprietor orpartuer- listed onthe attached sheet: 't- ❑Remodeling
ship arui 1 ve as employees 'These sub-contiactars have � ❑Demolition
waiting forme in any capacity- euaployees aEulhave tvark�ss' 9-.❑S.uildiag addition
INC wudoew COW.fimx;mce COS-i us=11011
required-] 5- ❑ We are a oorpomfion and its 10-❑Elecidcal repairs or additions
3.❑ I ama homeowner doing all wodc officers have emt'.rcised their 1L❑Flmabingrepaim or additions
myself[No warkere ootnp_ rightof esempfio per M(M a have no
Roof repairs
insurancerequired.11 § (�
employees.[No wads' 13-❑Other
Comp-ksur xz required_]
��rcp appEicsv�d;st clecltssbos�1 mast slsn fiIlootthe se�ctia¢heSatvslxcrtfiug iheawo�cels'comp��fi�+*�pnIicgiaEnrnrsucn_
l ameoaraeisthto sahmitt F3714 [IC in g they xredoing BllWDA=Admhim autsdeCDntM ft=wmst snhmkanewaffidaeCa'd�mcb
ICa lE t chectRhis box mast stt ch Ssddiifo 21 skeet s wjngthemeof the sub-c sad stile whether.oraotthare eutitieshmm
employees.Ifthemib�tsctioe knm mplogee%1heymustpmui&&&sra&EWcomp•poliynumber-
IT am as euiplayer that isprauidirz-�vrrrkers'canrpertsatt�n irFsrirarrce,�nr m}�eirtPFn3�ees $eNv is fiiR pa£iey and job site
infornzat arr. n
Insurance:Company Name_ 90 U-L-
Toficy 4,cr €--irts_71�-- * F-kpirationDate:
Job Sit�Ad� � �2 Cityl5tatelz�pr
Attach at-copy of the workers'compensationpolicy declaration page(shoui tg the policy,number and expiration date).
Faiimm to secure coverage as required under Section tit!of MGL c�1572 can lead to the imtpositioa of criminal peaalges of a
flue up to$1,5aa OQ andfor one yeirimpdsvnment,as well as rivril penalties iu the fora of a STOP WORK ORDER and a fime
-of upto 0:00 a day against the violator. Be schised tb2d a copy of this statement maybe fzvarded to the Office of
1mvestigations ofifie DIA for insurance coverage vedfic a icn.
T da hersiiy T ruttier•tke pains dperiazties ofpzd�u}'thatthe informatim>•prmi&ff abmra fs trus artd carrect
Sitmature_ Date- >2 D
Phone Irk
QJ al um only. Da not wrRe in this area, be crrlripieterl by cftp artown afjidat
My or Town: PermitUcense:9
LwaingA.apsarftp(circle one):
L Board of$ealth Brag Department 3.CitytTowa Qrzk 4_Fdectrical hapector S.Plumbing Inspector
6.Othiw
Com#act Person: Phone it:
orm�ation and Insfinc ons '
m c�easation for fbeg employees. '
�c��];,.ee:tis decal taws I52 reuses an employees ode
Purmmmttn ibis sty,m enVIvyee is defined as=e=ypmsonmfbe service of under amy mart ofhae,
express or iiaplied,Dial orb"
n Is deiimcd as ran m 1,Pa ,association,oorporafion uf=IegaI ems',or mT two or more
of foregonJg Vgcd in.aJoint ,and inchzrTmg the legal of a deceased employer,or fhe
receiver or trnsf-ee of an fildiV deal,patamship,association or of m legal ,euspl oylag employees- However fbe
owner of a,dweIIi4 house bavingssot more fbm three apadmechs and who s therein,cr fhe occupant of the -
dWPlImg house of a�5zer who employs persons V do m", -on or repair w�on such dwelling house
or oa the grounds or appurfauar¢thereto shall not because of emplayme be deernedi�u be an employer.'
MC3L chapter 152,§25C(6,).also states f -,&¢every state or local agency sfiall withhold the t crrauce or
renew-al of a Ticease or gemit to operate a bIIsiaess or to contract dings is the commonwealth for any
applicant who o has notproi ced acceptable evidence of compM-m with the insurance coverage razju "
Add�onally,MGZ chapter M,.�§_25CM s�frs¢NM'h=flie nor�y ofifs political Subdivisions shall
enter jab any contract for the payIDlm.an ee ofpublic wo3k u3I a ccet le evidence of compliance wif-h file fi=map_
req=ements of this chapter have b n presented•o the co—acting oiity.
A-PPlicaat�
' ensation affidavit co le#ety, �ec3ang the botes�apply to yov n r sitnatio and,if
please fill out the worlo'as comp mP,
necessary,supply sab I{s)name(s).x—,S4
dres (es)and ennmber(s) aIongwitiltlicir cer[ifrcat s)of
„s -ance. L=itedLiahiI4 Compames(IL ) susstedLsab P rps( )WtTino empInyers other tbaathe
members or partia=sa are not rogimed to . Y e& comp josurance_ If an LLC or 11
.P does have
employees,apolicy is required. Be advise-dtisat afftdays be sabmjdfedto the Depa-Ement of Indnsfxial
Accidents for confamation of m mr,U=coverage. a be a to sign and date-the aftida4it The affidavit should
be returned to the city or town that the application for flit p or license is being req not the D ep amtment of ;
Ti�rTrrefriai�J:cidenfs Shouldyou have any questions the Jaw or ifyou are requsedto obtam a woEk='
compe,osation policy,please call ti� e Dparfineotatthe hf�d sbelovT Self-instiredeompaniessboulde rtheir
s elf-i su ce license nuaber on the appro Ime.
City or Town Officials .
Please be sure tb at the affidavit is complete and legibly. The D has provided a space at ti=botfnm
of the affidavit for you to frj out in the event the ce oflnvtinT to collf actyou regarding the applicant
Please be sore to fill in the pen aWlicease msm-ber . vill be used as a re co number. Ia-addition,an applicant
fhat must sabmiL multiple pennsFllicense appIi' in any given year,need D mbmit one affidavit i n�--�i'T'a cnn-nt
policy infb=nation(ffneoes�y)and mmdea`mob 1��"the applica* rho wrhe"aII locations in (may er
town)"A copy of the-affidavit that has bey o stamped or nm iced by the or town maybe provided to the -
appIican#as Froo�t3sat a Valid affidavit is on for fatal permits or licenses A day mssst be Med Dist earls
or comsncerccial be
year.Where a home owner or citizrn is o a license or or parm not related to any b - e
(ie.a dog license orpem it to buzcn leaves )saidperson is NOTrcqcdredto complete affidavit
TIIa Office oflnv e s t wDuldIi m to, you in adaince for your cocperafion.and sbD you hate any questions,
please do not hesitate to give nits a Call-
Me Deparfsueuf's address,falephmc and/fax ac: i
cammmy i of Iassachu -
Deparfinmt of T n Ed Acaideuta
Offi=of Ime&Vkkfio=
f Bas YA 02111
Ta.4 617-727-49W 4-06 or
Fax 617 727'749
Revised4-24-07 - Maass,aagfdim
16/DEC/07AED 14: 26 FAX No. P. 001/002
A� CERTIFICATE . 12/07/2016/2018 OF LIABILITY INSURANCE `YM "
THIS CERTIFICATE IS ISSUED AS A MATTER OF INPORMATION 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), AUTHORVED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A 6tatement on this certificate does not confer rights to the
certificate holder in lieu of such endorsament(s),
PRODUCER NANTACT John LYnchIV
PAIL PETERS AGENCY INC. PMO(Aic,NE N 508 477-0021 FAX Na:
DDREs - linday@paulpeterSagency.com
680 FALMOUTH RD. INSURE S AFFORDINGCOVERAGE NAICA
MASHPEE MA 02649 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 26614
INSURED INSURER B:
RYAN HOLMES CONTRACTING INC INsuRERc:
INSURER D:
180 NINIGRET AVENUE INSURER E i
MASHPEE MA 02649 1 INSURERF:
COVERAGES CERTIFICATE NUMBER: 109369 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 ADOL UBR POLICY EFF POLICY EXP
LTR POWCY NUMBER MMIDDNYYY) IMMIDDIYYYYI LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR PREMISES occurtence $
MEO EXP Zg one person) S
N/A PERSONAL A ADV INJURY $
OF.NLAOORWATFUMITAPPLIESPER. GENERAL AGGREGATE $
PoUCY❑PRO- n LOC PRODUCTS-COMP/OPAOG 5
OTHER: $
AUTOMOBILE LIABILITY Ea eCradent $
ANY AUTO BODILY INJURY(Par person) S
AAIL�LL OWNED SCHEDULED N/A BODILY INJURY(Per accident) S
TOS NCN.OWNED PROPERTY DAMAGE $
HIREDAUTOS AUTOS OW accidaM
S
UMBRELW LIA6 OCCUR EACH OCCURRENCE $
EXCESS UA9 CLAIMS-MADE N/A AOOREOATE I _ ..
DIED RETENTION
WORKERS COMPENSATION XP RR
STETTUT :" y
AND EMPLOYERS'LIABILITY
ANYPROPRIETORlPARTNEk&XECUTIVH YIN E.L.EACHACCIDENT 5._1.000 0001
A OFRCERlMEMBERFXCLUDED9 NIA WA NIA 7PJUB9F41829516 12/21/2018 12/21/2017
(Mandatory In NH) F-L DISWF= 6MPLOYEE 8 1,000,01V
6 OF DE5a ON OPERATIONS Below - EL DISEASE=PGUCY LIMIT $
N/A
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is reputred) r—
Workers'Compensation benefits Will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is g en to pay
claims for benefits to employees in stales other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was Issued(Unfess the expiration date on the above policy precedes the
issue date of this certificate of Insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.gov/Iwd/Workers-compensationriinvestigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
TOWN OF BARNSTABLE BLDG. DEPT ACCORDANCE WITH THE POLICY PROVISIONS.
200 MAIN STREET AUTHORIZED REPRESENTATIVE
HYANNI8 MA 02601
Daniel M.Cro ey,CPCU,Vice President—Residual Markel—Vt/CRIBMA
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD
r
' Town of Barnstable
Regulatory Services
Richard V. Scab,Director -
► Building Division.
Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize ' r IXU� `'d�� /` fir' �� to act on my behalf,
in all matters relative to work authorized by this building permit application for.
i3OV4(, �A &�2�a 6--
(Address of Job)
**Pool fences and alarms ate the responsibility of the applicant Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature-of Owner Signature Applican
Print Name Print Name
Date
QTORMS:0VNERPE RMISSIONPOOLS
Town of Barnstable
Regulatory Services
p�FTNE Richard V.Scali,Director
Building Division
Paul Roma,Building Commissioner
163,.q. 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
1
Office: 508-86 ;�4&8 Fax: 508-790-6230
HOMEOWNER LICENSE MPTION
Please Print
DATE:
w
JOB LOCATION:
number �' street village
"HOMEOWNER":
- name home phone# work phone#
CURRENT MAILING ADDRESS: �
city/town state zip code
The current exemption for"homeowners"w extended to incj de owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire vy o does not p9ssess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which hel he residep or intends to reside,on which there is,or is intended to be,a one or two-
,ssory�fo such use and/or farm structures. A person who constructs more than one
family dwelling,attached or detached structures�ac
home in a two-year period shall not be considere a hbme caner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shll be ®�onsible for all such work Rerformed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsbili for pliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she rstands a Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will c pl with sai(hrocedures and requirements.
Signature of Homeowner
Approval of Building Official •.4
Note: Three-family dwellings containing 5.000 cubic feet or larger will be•required to comply with the State Building Code
Section 127.0 Construction Control. .
HOMEOWNER EXEMPTION
The Code states that: "Any homeowner performing wok for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of\thhnt
struction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeownhall-act as supervisor."
Many homeowners who use this exemption are unaware they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing Construction S pervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires licensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supdrvisor. The homeowner acting as Supervisor is
ultimately responsible.
To ensure that the homeowner is fully aware of his/her respons bilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands he responsibilities of a Supervisor. On the last page
this issue is a form currently used by several towns. You may care to am-nd and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doe
06/20/16
09/14/2012 23:04 15084775774 RVANHOLMES_ 74719 P. 002/002
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GEORGE H RYAN
180 NINIGRET AVE.
MASHPEE MA 029A9
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o 1'2a.12018
o/A
Office of Consumer Affairs and Business Regulation
10 Park Plaza.'- Suite 5170
Boston, Massachusetts 02116
Home Improvement.Contractor Registration
Type: Corporation
Ryan Holmes Contracting Inc. Registration: 1
180 Ninigret Ave. Expiration: i 163 0/2 26/2018
Mashpee,-MA 02649
I
3
-,A 6 ;qW-:W„ Update Address and retu card. Mark reason for change.
n sane. l n a �_
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
"''•; Type: Corporation before the expiration date. K found retu to:
Office of Consumer Affairs and Business Fl
l�tlstretfon Expiration � egulation
10/26/201 B 10 Park Plaza-Suite 5170
Boston,MA 02116
Holmes C ig ft.
G,Porge Ryan. .
1W Ninigret Ave.
M shpes,MA 02049 ° ~
Undersecretary Nof alid v6b6ut signatt re
i
Town of Barnstable *Permit# 6 6 Co ?5
Expires 6 months from issue date
Regulatory Services Feed
Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
�V
www.town,barnstable.ma.us
Office:' 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number Z 20 '-7
Property Address ---3��
4 tD
®Residential Value of Work Minimum fee of$25.00 for work_under$6000.00
Owner's Name&Address P,6 `
Contractor's Name Y- Telephone Number
Home Improvement Contractor License#(if applicable) `
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
OT-I am a sole proprietor
❑ I am the Homeowner p^�
❑ I have Worker's Compensation Insurance . p`
Insurance Company Name A& SEP 2 8 2007
Workman's Comp.Policy# TOWN
OF BARNSTA5LE
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
9-Re-side �7- )e u-)Iv, -f, end<.1— eA+A AA1,-0 J;:)o"4 67/41d)
Replacement Windows/doors/sliders. U-Value (maximum,44)
*Where required: Issuance of this permit does not exempt th other town department regulations,i.e.Historic,Conservation,etc.
;
***Note: Property O must . roper Owner Letter of Permission. -
A copy o e ItSme " ro Contrac rs License is required.,.,:
SIGNATURE:
Q:Forms:expmtrg
Revise061306
=f
The Commonwealth of Massachusetts
Department of Industrial Accidents
r Office of Investigations
600 Washington Street
Boston,MA 02111 ,
www.m ass.gov/dta
Workers"Compensation lasurance.Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual):, l
Address: 4. D , 1 nw
City/State/Zip: Phone.#:
Are you an employer? Check the appropriate box: -Type of project(required):,
1.❑ I am a employer with 4. [] I am a general contractor and I
employees (full and/or part_time).
* have hired the stlb-contractors 6 ❑New construction .
2.9I am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• ❑Demolition
working for me in any capacity. employees and have workers'
insurance.$ 9• []Building addition
[No workers' comp, insurance comp.
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 11.❑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.
ZContracton that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
employees. If the sub-contractors have employees,they must providb 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. �p �
Insurance Company Name: (PCs'
Policy#or Self-ins,Lic.#: Expiration Date:
Job Site Address �A ® -City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date),
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to$1,500.00 and/or one-year imprisonment•, as well as civil penaltim in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against olator. vise t a copy of this statement may be forwarded to the Office of
luv.estijzations of the IDIA fo urance c era e v ati n.
16 hereby certi an the pains•an p per' ry that the information provided above is true and correct.
Sienature: 22 Date: 0 Z
Phone#:
Official use only. Do not write in this area,'tb be completed by city or town qfjiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
.1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspecto155.
6. Other
Contact Person: Phone#:
_r
�of 1HE 7,
Town of Barnstable.
a s
Regulatory Services
• 9ARNSTABLE, •
9 MASS. Thomas F. Geller,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
wvvw.town.barnstable.ma.us
Office: 508-862-4038
Fax; 508-790-6230
Property Owner Must
Complete and Sign This Section
If using A Builder
as Owner of the subject property
herebyauthorize �` �CiF -(,4�'J to act on my behalf,
in all matters relative to,work authorized by this building permit application for: ,
44 .
(Address of Job)
nature of Owner ate
Print Name
Q:FORM S:OwNERPERMIS SION
Board of Building Regulations"d Standards:
�f License or registrafiou valid for ind►vidul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
I Registration 1,00390 Board of Building Regulations and Standards
Expirat on 6%16/2008 One Ashburton Place Rm 1301
i x Type ).dividual Boston,Nla.02108 r —�
STURGIS ST:'PETER ' x
Sturgis St.P
9 . s
1 65 Cindy Lane/P.O.Bq 372 =G�
B3rnsta6leMA.`Q2630" bepur � lmm straforrZ N t v id without signature
:, .
a
zoo
Town of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services Fee 0Z
dlo
Thomas F.Geiler,Director �7
Building Division
Tom Perry,CBO, Building Commissioner �,�, 07
200 Main Street,Hyannis,MA.02601
www.town.b arnstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number L cr l o q
Property Address C 60 PL-4f. (,FA
[Residential Value of Work :5t_� Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
3L�� 2e obi 2 2
Telephone Number c7 �- J
Contractor's Name 1
Home Improvement Contractor License#(if applicable) l (SG
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one: FEB 2 ® 2007
I am a sole proprietor
❑ I am the Homeowner TOWN OF BARNSTABLE
❑ I have Worker's Compensation Insurance
��Zsurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box) CD
i in old shingles) All construction debris will be taken to _ -
s
0 f(stripping g ,
❑ Re-roof( Pp g .R
❑Re-roof(not stripping. Going over existing layers of roof) CQ
CD
tv...
❑ Re-side
2&Q _ maximum.44
Replacement Windows/doors/sliders. U-Value ( )
*Where required:. Issuance of this pe i.does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Pro 'Ovine must Property Owner Letter of Permission.
-6py of the o ovement Contractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
The Commonwealth ofA assachusetts
• Department of Industrial�ccidenfs
Office oflriyestigations
600 Washington street .
o Boston,MA 02111'
w>- wan ass,gov/dia
Workers' Compensation Iusur�nce Affidavit;.Builderg/Cotitractors/Eleetriclatts/P,tt�ers'A licant Information Please Priint
Name(Business/Organiiati'mvfndividual):, � � Dow ux,A '
C,� .
City/State/Zip: u"1 - OZ6 'v:a Phone
•Axe you an employ er?'Check the appropriate box:
1;❑ Iamaemployer with 4. am ;Type of project ire Hued ;❑ general contractor and T q ..
"employees (full a�.d/or part time),*. .have hired the sub-contractors 6 ❑New constru,ction .
2. I am a'sold proprietor ox partaer- listed on the'attached sheet; 7. ❑Remodeling
ship,andhave no employees These sub-contractors have
ivorlang for me in any capacity. _ enaployeeo and ha 8. ❑Demolition'.
[No workers' CO Ye wOtkerS
mp,insuuahce comp. insurance.$' 9, ❑Binding addition
3.[} �e4uired] 5. ❑ We are s•porporation and its 10,❑Electrical r_......--_... -_ repairs ox additions
-I am a homeowger doing-all:ys,ozk ,— officers hate exercised their 11:❑Plumbing re
myself,[No woilcers'comR, right bf exemption per MGL' pairs or additions -
insirance,required,]t 12,
c,152, §1(4),and we have no ❑Roof repairs'. .
employees, [No workers' ..13.0 Other '
c03p,insurance required.]
Any applicant that cheeks box#1 must also Ell out the section below sbovm their workers'compensation policy information,
t Homeowners,who submit this affidavit indicating they are doing all work and then hire outside contractors mint submit a new affidayitindicatin au$Contractors that aback this box must attached an additional sheet sbawing thename of the gub contractors and state whether arnot those entities have
empieyees, If the sub-contractors have employees,theymust provi db their workers'comp,poHdy number.
I ant an employer•that is providing NorkersI compensation Insurance for my employees. Below is the policy and3ob site'
information.
Insurance Company Name
•Policy#or Self-ins.Lid,#;•
Expiration Date; ILEy�
Sob Site Address: 1'�
City/statemp;_ b 36'
Attach a copy of the workers' comtpensation policy declaration pa
ge'(showing the policy number and e
Fallure,to•secure coverage ag required under Section 25A•of'MGL c. 152 can lead to the imposition of c ' $Pu ation date),'
fine up to$1,500,00 and/or one-year' p nmtnalpenalties of a
y imprisonment,as well as civil penalties in the faint of a STOP VORK.ORDER and a fine
of up to$250.00 a day against the Violator, Be advised that a•c of this statement maybe fozwazded to
opy Y the•Office of''
Investi ations of the bIA for nsura ce covera a verification '
I do hereby certify unde he pat pa tie of perjury that the in prgvided above is true anti correct, _
5i tare: T Date• ,UZ� �p
Phone 9 Z 3 •
Ofj t lal use only. Do not write in this area,to be c1-1 fed by city or town official
City or Tdwn: ' -Permit/License# .
Issuing Authority(circle one):'
1,Board of Health 2,Building Department 3., City/Town Clerk 4,Electrical Inspet:tor 5, Plumbing Inspector
6.Other
ContactPerson: •
Phone#:
Massachusetts Creneral'Laws chapter.152 requires all employi rs provide '''orkers' compensation for j�hau employees.
Pursuant to this statutz, an employee is defined as"..,every personinthe serv�li e of another under any.contract of hiie,
expres s or implied, oral or written" T
An Employer is defined as"an indiyiduil,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engage in a joint enterprise,and including the legal repiesentatives of a'deceased employer, or the
receiver or trustee of an' ` ' ual,partnership,association or other Iega1 entt ,employing employees, However the
owner of a dwelling house ving not more than three apartments and who resides therein,or the occupant of the
dwelling house of another wh employs persons to do maintenance,construction or repair work on such dwelling house
or onth.e grounds orbuilding ap urtenantti ereto sballnotbecause of such en sloymentbe-deemedto be an employer."
IvIGL ter 152, §25C also sta s that"every state or local licensing a �ency shall withhold the issuance or
renew a license or permit to'op ate a business or to construgt burl gs in the commonwealth for any
applicant who has not prod uced•acce table evidence of compliance with he insurance coverage required.".
AdditiomIly,MCrL ohapteL.l52,§25C(7. fates`TIeithei the commonwe'a1 nor any of its political subdivisions shall
enter into any contract for fhb perfasmairce f pnblic.work aitii aceoptabl eru;e of compli iiae�gitlxtbe in e'
requirements of this chapter have been prose ted'to the contracting au,
Applicants ,
Please fill out the workers'compensation affidavi mpletely,b checking the boxes that apply to your situation and,it
necessary,supply sub-contiactor(s)name(s),address )and ph e number(s)along with their certificates) of
insurance, Limited•Liability,Companies'(LLC)or L' 'fed Liab 'tyPartaerships(LLP)withno'employees other than the
members'or partners, are not required to carry workers' omp ation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affi vi may be submitted to theDep'artment of Industrial '
Accidents for confirmation of insurance coverage. Also be ure to sign and date the affidavit, The affidavit should
be retw:sted to the city or town that the application for the p t/or license is being requested,not the Department of
Industrial Accidents, Should you have any questions reg g e law-or if you are required.to obtain a workers'
comp ensatic n'policy,please call the Department at the n ber ed.below. Self-insured companies should enter their .
self-insurance license number onthe appropriatn'lind,
City or ToWn officials
Please be sure that the affidavit is'complete'and printed egibly. The\Dentmalit has provided a spacq at tl ea bottom
of the•affidavit for yay.to fill out in the event the Offic of Investigato contact you regarding the appbcant,
Please be sure to fill in the permit/lieense number whic will be useererice number: In addition,an applicant
that must submit multiple permit/license applications'applicationain any given year,aeedNRnly submit onp affidavit indicating r-=Mt
policy' rm infoation(ifnmessaty)and under"lob Site A ddress"the applicant skpuld write"all•locations in___. (city or
town);'A copy of the af.davit that.has been officially,tamped or markddby the city or town maybe provided to the
applicant as proof that a valid affidavit is on Me for I ire permits or licenses. Anew affidavit must be felled out each
year.Where a home owner or citizen is obtaining alicease or permit not relatedio\any business or commercial venture
(i.e, a doglicense orpemmittobrimleaves•eto.)said pai s6nis•NOTrequired to completo this affidavit,
.The Office of Investigations would like to thank you in advance.for your cooperation`and should youhave.anY questions,
please donotbesitateto givens a call.
The Depaxtumnt's address,telephone and fax number:
Qf of Ira�e � �
4t=4.MA 02111
617-7n2 4 k eat W or l- -h-fA St B
Revised 11-22-06. 49
WWWM 86v'idi&
�efi► r Town*of Barnstable
Regulatory Services
Thomas R:Geiler,Director
FD;%+p`� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
ffice:. 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, � u'1 , as Owner of the subject property
hereby authorize IST,YJ A CN-- to act on ray behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
�fl �iZ(ci tq rl� C�•DL�
Print Name
Q:FORMS:OVINIERPERMLS SION
j
BOARD O�BUILDING
License IONS CONSTRUCTION SUPERVISOR
Number C
014501
Birtae�,Cg319950. ;I
ExPi es, 8123/2067 j
Tr.no: 12003 `I
RegtrQ
STURG�s STPET e �qq_
PO BOX 372
SAF2NSTABLE mA "E
74
r.Boa►•d of
y Building Re
HOME IMP- gulatiOM and St _
20VEMENT CON OR r
Registrations T RAC
00390 T 5
t
u lrsb't'"/16/2008
j `- .�6
STURGIS ST•P , "' ividual
E
Sturgis St.Peter ! it
65 Cindy Lane/P. ` o�. a ;
Barnstable;MA 02630 '?
=r j
trator
Deputy Adminis ,
A ssor's map and lot nu_tuber . .
i
... C THE C
_ Ce,../o.G.,,,,1' F t�O
Sewage Permit number ....... ...........
Z BJHBSTAIILE, i
House number ......
9........... OO 2639. \0�
MA A,
TOWN ;OF BARNSTABLE
`- BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .................... .................. ........ 5..e-4).........
i
TYPE OF CONSTRUCTION ............... ./1.4..1..?......../.:65�/y1...................CC?h ) C;o ...................
�! ........�.: .. ........19. �.. �.
TO THE INSPECTOR OF BUILDINGS:
The undersigned
p hereby applies for a permit according to the following information:
Location .........1. ..TG.......!!.- ....................
/...........e ...............................................................................
1
ProposedUse .............. 4..,0..0..........G..U. ......................................................................................................... f
Zoning District ............ ...............................................Fire District ..........`tit ...Wvr. .......................................
Name of Owner /f4P,�i171XV.e 7.Y...........Address .......... q Fu�GE,f� �i.�...........�1it�vc�,t��,?
� ,
Name of Builder .....................SA.... ............................................Address ....................................................................................
Name of Architect .....:Yi9!0!PY........ .....................Address ..b11-Y.... ..............A4-.x.A(,W..1........
Numberof Rooms ..................................................................Foundation ..............................................................................
Exterior ........: ......e—.JA v o.................................... ................Roofing ................�L�'%. .....................................................
Floors ...................iWAPA......................................................Interior �,f5
Heating .......... ............. ...............Plumbing .:........./, /In7,4�
.<a
Fireplace
...........�.....................................................................Approximate Cost .......... ..��..... ... ........................................
Definitive Plan Approved by Planning Board -------------------_-----------19-------- . Area . ... ...6.,. .. ...._ ...........
Diagram of Lot and Building with Dimensions Feet/.............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
P ,
-,'OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..... .C...'q ..Lem�.................................
f
Construction Supervisor's License ... .......
N i
RAVEN BROOK REALTY A=299-7U4
+ €�jt 24644 REMODEL/CONVERT
f!l E................. Permit for ....................................
-OBLDG./ CONDOMINIUM
...............................................................................
Location „3400 Rte 6A
..............................................
West Barnstable
. .............................................................................
I, Owner Ra.ven. ...Brook. . . ...Realty. . ..............
r
..... .... .. .. .. .... .. ..... .... .....
Type of Construction .......Frame
...................................
................................................................................
Plot ............................ Lot ................................
r'
Permit Granted ......December 15, 19 82
...............................
Date of Inspection ....................................19
Date Completed ......................................19
f
I `�
FROM
TOWN OF BARNSTABLE
BUILDING DEPARTMENT
Town Clerk Francis Lahteine 367 MAIN STREET HYANNIS, MA 02601
To
Phone: 775-1120
L
SUBJECT:
FOLD HERE
DATE
September 19, 19 4 MESSAGE
Work has been completed under Building Permit #24198 (Wianno Trust) .
Please release- Bond.
SIG D
DATE
REPLY
SIGNED
N87•RMI RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY
PRINTED IN U.S.A.
VICTORY SIGN INDUSTRIES, LTD.
P. 0. Box 5423
Ft Oglethorpe, GA 30742
(404) 375-6612 �
5! r\5,- p�p--f n,An 4-p \J,l cAo c�, :Si-rs, RA -
------ .Sold ' ✓�l�
FORM IIZ33 RAPIDFORMS,INC,BELLMAWR,N.J.08031
,woe TOWN OF BARNSTABLE Permit No.
Building Inspector Cash
uea
,ego•
'MI( ' OCCUPANCY PERMIT Bond
Issued to Address
ven tsruo�: RcHitti'
it #5 3400 il'oute. 6A -irnstable
Wiring Inspector a�� � r.er-- r;� Inspection date
Plumbing Inspector f: Inspection date
Gas Inspector - .,..___._.,,� Inspection date
Engineering Department Inspection date
Board of Health Inspection date
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
_.:.. _.. , 19......_. ....................................... .............................._........................................
Building Inspector
i
o� TOWN OF.BARNSTABLE Permit No. ----246r+r4______________
Building Inspector
san�ra Cash -----------— -- —
w� i
OCCUPANCY PERMIT Bond NIA
Issued to Raven Brook Realty Address
Unit #9, 3400 Route 6A, Barnstable
r
Wiring Inspector / /o Inspection date
Plumbing Inspectortl� e' b. Inspection date
Gas Inspector Inspection date
Engineering.Department - Inspection date
_Board_of-.Health �� Inspection date
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL'
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND. IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
C'.:. ..�..�..... 19 .f�, , 'i� f!l 1
f Building Inspector j�'�/
1� 9r �� ;=sor7�
Assessor's map and lot number ........................... ............... �/ �C'G�!®L *THE Tyr
Sewage Permit number WQ
�- ......�d.�4...,��... ^.............. SEPTIC MUST BE
e
T M
,N LC SYSTEM _ AHHSTODLE. •
c, INSTALL B
House number ...:.................... . ED IN COMPLIAN 90 1ABa
.................................................
_ ,; WITH ARTICLE II STATE
�.. O i639• 9
i c r4
OF BARN5TA1&1 E1 - TOWN
Yr BUILDING ,INSPECTOR
APPLICATIONFOR PERMIT TO ..... ......................................................................................................................
TYPE OF CONSTRUCTION ......../.'i.�.rPN.f..:�..............::......................................................................................
Jin
fJ a� f.................................................19..
.e
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...........&.41.T.. ..........r. t�?,C �`�TA,� ........ �. .............................................
re
Proposed Use ................ '�� .�� ....:: ... !t .! ...............................................................................:......
Zoning District .................'e
.......................................................Fire District ..............................................................................
Name of Owner :.4..t....�R.B.4,..7- !/ �........Address `�5�OG7 i(�/ ✓ T . W S 7W,& f'
f1
Nameof Builder ....: /. r/ .... �1�� ...................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ..................................................................Foundation ..............................................................................
Exterior .........��! 14�1.��.��.. ...............................................Roofing ...........��4.R,,P..4.T.......c.1 ...........
Floors .............0�,4 . .✓ �. ........................................Interior .......v�f �'. ,7......:e.o x'..<...............................
Heating ..................................................................................Plumbing .......................
/ ®o
Fireplace ..................................................................................Approximate Cost ............./............................................
Definitive Plan Approved by Planning Board ---1_--------------_-----------19________. Area 7'U
Diagram of Lot and Building with Dimensions Fee /"...��:.............
SUBJECT TO APPROVAL OF BOARD OF HEALTH
z6 '
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name . .... .. ...
c
Arb�utbluwtv W. D.
. ^
'
. -
'
' to
� ���5� permh �v ...........
-- '
. .-- -.y---- ---- --
°
.............`^^-^'--................................................
` n&oio ' -
Locoik�� ..�.����-.^--..��.-.^----- ---..
...................Agr*etob+s......................................
' W. D. Arbuthnot
Owner ---------.--^--------._
'
- - �-~.�`
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TOWN OF BARNSTABLE
ZONING BOARD OF "PEALS
NOTICE AND DECISION 794 31 p ,3 1
Special Permit- Conditional uses -
Appeal No. 1994-23
Summary Granted
Appeal No. 1994-23
Mary Giuffreda
Address: 3400 Main Stre__et__, Rt_e�. A
Barnstable, MA 02630;
Assessor's Map/Parcel: 299-092
Zoning: RF2 (Residential F2 District)
Applicant's Request: Special Permit to section 3-1.1 (3A)
Conditional Use Renting of rooms to no
more than six (6) lodgers in one (1)
multiple-unit dwelling.
Procedural Provisions: Section 3-1.1 (3A) : special Permits
Background information:
According to the Assessor's Records the lot, located in Barnstable
village is 0.52 acres. The lot contains a four bedroom, four (4.1)
bath single family dwelling with 4,036 s.f. of gross floor area (GFA) .
The structure was originally built in 1870 and is now served by public
-water, gas, and on-site septic utilities.
The site is located in the old Kings Highway Regional Historic District
and the Route 6A Historic District. No change to the structure is being
proposed. The present use is a bed and breakfast inn, know as the
"Bacon Barn Inn". According to the sketch plan submitted with the
application, the lot has parking for up to six (6) cars.
Procedural Summary:
The petition was filed with the Town Clerk and the Zoning Board of
Appeals on February 9, 1994. A public hearing was held on March 23,
1994 at which the Board determined to grant the petition. The petition
was heard by Board members; Acting chairman Ron Jansson, Rick Barry, Rob
Thorne, Dexter Bliss and Gail Nightingale.
Summary of Public Hearing
Mary Giuffreda representing herself as owner of the Bacon Barn Inn
stated she has been renting to six people since 1989 and now finds she
needs a permit and would like to obtain one.
she provided all Board members with a booklet for this hearing. Said
booklet submitted to the file, included:
A. Photos
B. Parking information
C. Floor Plan, First Floor
U. Floor Plan, second Floor
E. Access Easement (Powder Hill)
F. Access Easement (Bacon Farm Condo)
G. Legal Notice 3/10 - 3/17
H. Abutters
I. Board of Health Permit 1994
J. Data from Historical Records from Town of Barnstable
R. Permit for Signage
L. Hosted by Cape Cod Chamber of Commerce
After questions from the Board including reported parking spaces being
adequate with six spaces and room for more if necessary as seen in
attachment B of the booklet and stating that the property is owner
occupied and that the driveway easements are in proper order as are all
considerations.
The public was invited to speak. No one spoke in opposition or in favor
of the petition.
Finding of Facts:
Under Zoning Ordinance 3-1.1 (3A) the renting to six lodgers is
permitted. This property has three bedrooms to rent to a maximum of six
lodgers and it is allowed by special Permit. This use is common and
exists throughout the Cape Cod area. The applicant has indicated
parking for six cars and has provided evidence of Board of Health permit
for 1994. The applicant did try to determine the procedure for a bed
and breakfast in 1989 and was misguided but was operating in good faith.
when she found she was not in compliance she did come before the Board
for approval. The use is not detrimental to the neighborhood nor does
it derogate from the zoning ordinance.
The vote was as follows:
Unanimously in favor.
Decision:
Special Permit number 1994-23 for a conditional use of Lodging up to six
persons to Bacon Barn Inn is granted as per plan and as requested.
The vote was as follows:
AYE: Acting Chairman Ron Jansson, Rick Barry, Rob Thorne, Dexter
Bliss and Gail Nightingale.
Nay: none
Order:
Special Permit number 1994-23 for a conditional use of Lodging up to six
persons to Bacon Barn Ian is granted as per plan and as requested.
Any person aggrieved by this decision may appeal to the Barnstable
Superior Court pursuant to MGL Chapter 40A, Section 17, by bringing an
r�
action within twenty (20) days after this decision has been filed in the
office of the Town Clerk.
3 3a q
Ron Ja s n, Ac 'ng Chairman Date Si ned
Appeal 4-23 - Bacon Barn Inn
I Linda Leppanen, Clerk of the Town of Barnstable, Barnstable County,
Massachusetts, hereby certify that twenty (20) days have elapsed since
the Zoning Board of Appeals filed this decision and that no appeal of
the decision has been filed in the office of the Town Clerk.
Signed and sealed this CQ( day ofV 19 under
the pains and penalties of perjury.
0,0
Linda Leppanen, Town Clerk
Distribution:
Town Clerk
Property owner/Applicant
Building Department
Persons Interested
Public Information
Zoning Board of Appeals