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HomeMy WebLinkAbout0008 BANFIELD DRIVE a A ' o 9�7 n �•e.r t �p e oQPGP— ifi�s— i �a�iy�o4 (,vr4lc.�d/NG Fv1� CoN�'�� r s i 6 d a: oF� > Town of Barnstable . Permtt# �Y 0 Expires 6 monthsfroni 'ssue date Regulatory Services Fee awartsraaLs, v MASS. g Thomas F.Geiler,Director . 1639.TFO MA't A Building Division Q Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.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 0,3)-3 Property Address esidential Value of WorkD Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name c_�+3—Ij t_—L— Telephone Number Home Improvement Contractor.License#(if applicable) �(1 Construction Supervisor's License#(if applicable) �' Q ❑Workman's Compensation Insurance . -PRESS PERMIT Check one: / am a sole proprietor Q C T 15 Z 009 ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance 'TOWN OF BARNSTABLE Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ( e-roof(stripping old shingles) All construction debris will be taken to }QCU ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department r6gulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is �req�uiir .. SIGNA Q:\WPFILES\FORMS\building permit fo 4sXP�RESSc Revised 090809 as V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 E�4 sy www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): ( 1J t�J A—�--L— Address: �� a N (1 o 112 City/State/Zip: Phone M D'— 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 sub-contractors 6. ❑ New construction 2. 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.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have. employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year 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/aereby unde a pal n enallies of perjury that the information provided above is true and correct. Sin Date: V ( � Phone#: 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#: r+ 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,constriction 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-contractors)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 pen-nit of 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 pen-nit/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. I 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 r . Owners Authorization Form is e 639 Please print or type Statement of ownership Authorization and address �- �� ZC �c 07 Name of Authorized Agent / Contractor ��ta.. AiiC1�A- Cam, Owners ignature f Date A separate letter from the owner with the above information and an original signature is acceptable A faxed copy is acceptable for the issuance of the permit but the original must be forwarded prior to any inspections. Phone number: 508—760 -6157 Fax number: 508—394 -6289 vlassachusetts- Department of Puhlie.Safet� Board of'Buildin- Regulations and Standards Construction Supervisor License License: CS 45408 —-- _ Restricted to: 1G MICHAEL A BINNALL 25 GENEVA RD E ' S YARMOUTH, MA 02664 Expiration: 4/22/2011 ('ununissiuner Tr#: 13640 ( ,P� ✓lze V�ay�nwm.�uea.�//z a�✓�aaaac�uiaelta I .___ �\ Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registratxoi n� 105530 Board of Building Regulations and Standards � One Ashburton Place Rm 1301 - Expiration=7/17/2010 Tr# 271194 Boston,Ma.02108 Type==DBA ! MICHAEL A.BINNALL ADDITIONS REMOLDi Michael Binnall j 25 Geneva Road f South Yarmouth,MA 02664 Administrator i Not valid wit h .gj tare t` Assessor's offioe (1st floor): SEPTIC SYSTEM MUST B7 Assessor's map and lot number ...✓o� "...(>a�1..�/( '�tT�#�LEC IN COMPLI�►t �` ,,o`T Board-of Health (3rd floor): WITH TITLE 5 Sewage Permit number ......--5'J..542 ...........'...........::111RONMENTAL C®C� t�� L BAB33TABLL, �gineering Department (3rd floor): 11`01,' N REGUL�"„T�CaA,"a 'oo 39• House number ........................................................................ o rar a. APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P,M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .........A...... ...... ^. ................................... ..................................................... TYPE OF CONSTRUCTION �� . (/ ................................................................................................. .. .5"........ 19 �1 )TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies f r a oermit according to the following information: Location ............8.......'G/........... ....................... ........... �.l ........................................................................ ProposedUse ......... ....... ... .. L� ..................................................................................................... 13 Zoning District ....... .........................�OS............Fire istrict Name of Owner ./ " ......... . ....."e' 1......Address ....A...., r........ .................. Name of Builder '� Ld1lJ .............I...............................Address .......................... .....!Wi t............. ...—k*-4­*... .............�.. Name of Architect ....1:................... `.....t�.. ....................Address ..... ///� ..... ........ .... Numberof Rooms ..................................................................Foundation ..�... .. ............. ... ..,......�............................ Exterior ..... ..�.//..... �.�3!�� .....................................Roofing ....... .... ;....... .. ................................................ Floors ...............................................................Interior ................. .�:� . Heating ....../.Ado...................................................................Plumbing ........./V.Lv.............................................................. p , O .........---Approximate Cost ............t���Q�::................. . Fireplace ......... ................ . .............� .... ...... Definitive Plan Approved b Board _ -------------------------19------- Area Diagram of Lot an Building with Dimension4 `Fee `.......... J....`V............. SU CT TO AP O L OF BAD OF HEQLT1 A OQ 1 s•� '1 I P�tPos�R. � 1 -Aim Pit, o"'S CCUPANCY PERMITS REQUIRED FOR NEW i on►�- I ereby agree to conform to all the Rules and Regulations of the Town of Barnstable rega g the above construction. Name ........... ................................. ................................... Construction Supervisor's License .........0 4 ....... Y.t.... Secor, Peter & Dorothy No 30749 Permit for .....Ad4...0'K4M...M. ......Single faT.i.1 v..d we.1.1 i na................... Location ...........8....B..a..n...f.i. e...1..d....D..r...i.v...e.................... Cotuit ...................................................... Owner ............Peter .............& AU9 hy S e.......jcoK........ Type of Construction .............. KALMP.................. ............................................................................... Plot ............................. Lot ................................ ......... Permit Granted ..................M......ay...1...5 19 87. Date of Inspection ........... Date Completed ............ ............. 9 7 -0 Assessor's offioe (1st floor): o�TMETo Assessor's map and lot number ...� '... .9.. Boafd of Health (3rd floor): d kSewage Permit number 5'��R� .. i BA"STABLE, ! Engineering Department (3rd floor): oo rb 9- ♦� House number ........................................................................ o rar a� APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .........A......0 .......�.........." �-........................................................ TYPE OF CONSTRUCTION .................1•Jo o 4V .................................................................................................................... /..5--........ 19. 1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the fo lowing information: yy ' n I.Location Q.......�..........�:......................`:�!!�:•.e...................... ..... . .. .e.......................................................................... ProposedUse 1........'"`` "........ ! ...........................................................................I......................... D`S'� Zoning District .................................................................Fire District ��/ ...........................................-....... Name of Owner .��� .......Address y....... _....... tl........................................ I.......... Nameof Builder ........... Address .... ........................................... ......................:............ Name of Architect ...I ...... ....................Address .. ....... ........ ...........///t<.r......t 7 .;..........,' i Number of Rooms Foundation ..��.... ... ............. .. E% ................... Exterior .....�..:ff......57LA,.'.��.....................................Roofing ....... .. ,.............,...,............................................ V . .:..........:............................................. Floors .Interior - ` I' Heating ..................................................................................Plumbing ......... J..).............................................................. hA I Fireplace .....6/0................._..................................................Approximate Cost O�C7. Y 4 Definitive Plan Approved by„Ptann g Board _ ______________________19_______ �Area ..........lU Diagram of Lot and Building with Dimensions Fee V -� _. _ ._ - - - -- ............. ............... SUBJECT TO AP�P,O'VAL OF B(Y9PKD OF HEALTH Q 04 �.. � 1 1 p Pr�poS�� LYr p, � S y OCCUPANCY PERMITS REQUIRED FOR NEW DWEL'LIN.GS� I1thereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ........ ......................................... � � Construction Supervisor's License ...®Ov...�©. !... . Secor, Peter & Dorothy A=023-029 No Permit for ...... add garage to .......single...f.a.mi...l.y dwelling g................... Location .........-.8...B.an.f.i.e.ld...Drive................... .........................Cotuit ...................................................... I Peter & Dog�hy ��qqxOwner ............ . . . ... ... j ... ........ Type of Construction ...............fraM.e................. ............................................................................... Plot ............................. Lot ................................ Permit Granted ..................Ma..y...1....5 ..............19 87 Date of Inspection ............................. ......19 Date Completed ..................... .................19 Assessor's offioe (1st floor): 0.23 a,cy SEPTIC SYSTEM MUST ?N E TD` Assessor's map and lot number ................................/...........C�, 1"STALLED IN COMP ` 0 Board of Health (3rd floor): Sewage Permit number' ....................... �. ..�........ WITH TITLE 5 t EARBSTsnLE, Engineering Department (3rd floor): ENIVIRONMENTAL COD 3 9. House number ......................................................................... TOW-N REGULATION APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only TOWN 'OF ."BARNSTABLE BUILDING' , INSPECTOR APPLICATION .FOR PERMIT TO ..... .. .............�... ............................. ............. ........................................... TYPEOF CONSTRUCTION ....:..... . ....... ...... ...... .. ......................................................................................... .....�.....-�� ..............1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applie o permit according tote following information: � 0�.635 . �2. Location .......... V.......... ......... ............................... 1........................................................................,................ ProposedUse ............�............ .. ...............................................:............................................................................................. ZoningDistrict ................................ . .......... ........................Fire District ................. ........ .......................... ..........4............ Nameof Owner .�1 "k...... ............ ..........................±......Address ..I.?.... . ..... ..... ............. :.... ............................. Nameof Builder ........`.......!.. .. .............................................Address .3`5. .... ..: ... ..... .......J............... ......... .. Nome of Architect ...P4..................................................Address ..... .... ......... Y'[.`...................•...... Number of Rooms :. ?Y1S...CO(? .... .........Foundation ........1...........(..rl.. ... .. .............. ..J..... Exterior ../.......... 'P- ............................Roofing ........ ...`.'`'r ..!....,.... ................. ................................. Floors `..........Interior l�l ...... Heating ' ........ ,1 ..lT�'...... :'Plumbing /'�� . ................. ................................... .............6......... Fireplace ..................................................................................Approximate Cost .....31 Definitive Plan Approved by Planning Board ________________________________19-------- . Area ... 5 ...... ..: . Diagram, of Lot and Building with Dimensions Fee .C�,�--'' L.1 . ..........................:.... SUBJECT TO APPROVAL OF BOARD OF HEALTH '� �/ lob OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstab regarding the above construction. Name ..... .................... ........ ......................................... Construction Supervisor's License .................................... . SECOR, PETER & DOROTHY UA 'No ..29983 ... Permit for .....Bu;Uld.Aiditioxi ............. .......... . ....... .................. Location .........8 Banfield Drive ....................................................... Cotuit . ............................................................................... Owner ......Peter & Doro.t .q hy..� i�qK.............. .......................... .... Type of Construction ....Frame............................ .......... ............................................................................... Plot ............................ Lot ................................ Permit Granted .. September 29,......................................19 86 Date of Inspection ............19 Date Completed .........Ae"7............19 4 L Wb tv Assessor's offioe (1st floor): Qo7� Qo� q ` Assessor's map and lot number Cie— Board ...... .................. ........... Q f Board of Health (3rd floor): o� Se4oge Permit number ............................ ...�! i BaaasTnncE. 0 Engineering Department (3rd floor): oo rb 9. H se number 3 `e " APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only, _ TOWN OF BARNSTABLE BUILDING INSPECTOR . ��APPLICATION FOR PERMIT TO ..... .... ............................. .......................................................... TYPE OF CONSTRUCTION ..........1 .... ...................................................................................................... 9 _ �? ...............................................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies(,o a permit according to the following information: _ Location ........... ................ .......... ............................... ............................................................................................................ ProposedUse ................ ....................................................................................4.......................................................... ZoningDistrict ................................n...........,.........................Fire District ..................................................................?............ i<. A� Name of Owner '}.R... ............ ..........................,......Address .....� .... �. .... .................................... 13 p.� Name of Builder .. .. ................................................Address ..�5. .... ...`! ..... :�....................... .. Nameof Architect ............... ........ `" .....................Address ..... .... .......... ........f..... ..... �.......................... Number of Rooms �.` 20aM..s..C?f)1.... .........Foundation ....... .........t;.�. ... ..... �...............�..J...... Exterior ....`' .. ..Q.....................' "............................Roofing ........... ........... ..... ................................. Floors 7/ �w" .....Interior c Heating �y ,./P�(° ilc / .... . .,•..... Plumbing .................�Y.�..................................................... ... ... ..... ... Fireplace ..................................................................................Approximate Cost ......t_.....�� � Definitive Plan Approved by Planning Board --------------------------------19-------- . Area .... Diagram of Lot and Building with Dimensions Fee ..��-�... .._... ............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH '� �/ r OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS G I hereby agree to conform to all the Rules and Regulations of the Town of Barnstab regarding the above construction. Name ......... Construction Supervisor's License...........�� DECOR, PETER & DOROTHY A=023-029 2'y983 Build Addition No ................. Permit for .................................... Single Family Dwel1.ing' .......................................................................... ra Location 8 :Banfield Drive ................................................................ Cotuit ................................................................................. Owner Peter & Dorothy Secor Type of Construction Frame Plot ............................ Lot ................................ Permit Granted ....September. 29; 19 86 Date of Inspection ..........................:.........19 IC Date Completed ......................................19 r y i i i A s, 3 C (A cJ4r o ILI • J • I , i c ngineeiing Dept. (3rd floor) Map O o7,3 Parcel O,;7, Reppermit# ,9-6 A-3 2— House# n� Date Issued ( ' ` 3' Board of Health(3rd floor)(8:15=9:30/1:00-4:30) pro J Conservation Office(4th floor)(8:30- 9:30/ 1:00-2:00) 7 1C SYS Planning Dept.(1st floor/School Admin. Bldg.) IN$T1► ` Definitive Plan Approved by Planning Board 19 ENO. HS YOwN• t �° s� //) V /\\/ TOWN OF BARNSTABLE Building Permit Application Projec treet Address ���=/Ff✓� Village Owner /��. TE2 sr �o�Zd7i1 ��CD Address Telephone /11Z(— 1-fxf".3 Permit Request fZ Ale l 04,0 First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 1760 Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 24o If yes, site plan review# Current Use Proposed Use -�-� Builder Information Name M L" �,zZ/ �//�._ Telephone Number 7 -Address v i' License# e I d 3 Z— Z' Home Improvement Contractor# 14V 7yeG Worker's Compensation# 6W WFAal 3t/5r NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE.FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUEDif ' MAP!PARCEL NO. , ADDRESS t VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME t r INSULATION - FIREPLACE ELECTRICAL: ROUGH FINAL - PLUMBING RgGH FINAL GAS: H FINAL FINAL Bi �G DATE , ASSO N NO. • 4. • t 0� & •eald t t ;� .TOME . IMPROVEMENT CONTRACTORS REGISTRATION j ' /. Board of Building Regulations and Standards t One Ashburton Place - Room 1301 t t Boston , t•tassachusetts 02106 t t -�CH—E IMPROVEMENT CONTRACTOR -�------------------------------- - Recstration 100740 Expiration 06/23./98 ,.���r••_-:�,_- Ty?� - PRIVATE CORPORATION HOME IX°ROYL110 C10,CTOR • F � � Re;istratiort !OOi40 CAPIZZI HOME IMPROVEMENT., INC.. I i;p2 - FRIYAic CO2?ORAT:0y . Thomas Capizzi , Sr . ; �� E:�irati�rt t;bl3/48 1645 Newton Rd . Cotui t MA 02635 CA?:ZL HOME 11"10HYUDT, INC • I .•- � i�a:ifs Capri, Sc• . DCPARTMENT - I DOSTUN, 1 is ; PENVISU LICENSC t3ir'thdate 03j0 2 ;09Iz6�1997 ;, - 09/26'/196 iclecl:zlti: :UO - • . - ,L�SECURIT:Y:5'�4v. 030-53- •494 GAP.IZYI:tJR: - ?45 ABI�E���tiA` .026ba • • .� .-- 22 :-_ :L - . The 6nrn onti-ealth of Afassac•husetts -';h, ;; 'i:_=::'1:°,�a Department of Industrial Accidents 600 Tf ashhtgion Street c V - Boston,Alas. 02111 - _ Yorkers' Compensation Insurance Afridavit lican inf'rm pt�a a i ocati n: Cit% C�O7z//T i GZG 3. rhone° I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capach tY C•�,.�s-.__.�:,.. .... �....z.a..:.aw.�,.[:r..'a'�,,.,,>.<-__. ...iJ�;�:•�i^�R-..._,..:�r:�.,_ _.-.�:.•,.:-�,.,:..:rY ..,•.•-�,,,ra���-ram.-;.,,.•.^•:�-a�o�.�- I am an employer providing workers' compensation for my employees working on this job. comnany name: address: cih[ hnn k• insurance co. ,�> %i'��4� tSG(� 1l 3�Y I am a sole proprietor,general contractor,or homeowner(circle one) and hav:hired the contractors listed below who have the following workers' compensation polices: company name: nddress- cih•• hone R: insurance co. olio. .. .� ,.+ ..;'r._.:::_ii.•-fir:`^- - t.bt�il:i comnany name: address city: ne insurance co. eolicv L �.�tt tidditional sficet T -A'N� _7 - a,�5 �:;•.Z_:.-... _-r�:�::+K�SJ� Failure to secure co%-cra-c as required under Section 25A of 1\IGL 152 can lead to the imposition o'criminal penalties or fine up to St 500.00 and/or oneyears'imprisonment as well as civil penalties in the form ora STOP NVORK ORDER and a rite of SI00.00 a day against me. I understand tltnt a copy of this statement m:i% be roraardcd to the Orrice orinvestigations orthc DIA for covcragc rr_ification. I do hcreht•cerrift•turd Vlaillsand Jralties of perjun•that the ittforntatiotl provided clot-cis trite and correct. Signature 114 f — Print name Hone orrciai do not write in this area to he completed by city or torn official _ cih or town: permitfiiccnsc 9 Guuilding Department f., oLicensing Huard check irimmediatc response is required pSclectmcn's Orrice C]Ilcalth Department contact person:P phone -Other _- — - tr_ • r OftHE�y The Town of Barnstable • anRxsrm�, . 9� � �e� Department of Health Safety and Environmental Services ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date /—/O— � AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. A/ Type of Work:_ .rev i Est. Cost_ /-706 Address of Work: - P ��n/C/_PZJ7 ��°�1Y 11_1W Owner's Namee7ze .�y r—�Z��,,;7 Date of Permit Application: /— /0-- �2'7 i I hereby certify that: i Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply,for a permit as the agent of the owner: Date ontractor me Registration No. OR Date Owner's Name