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HomeMy WebLinkAbout0068 BAY ROAD oil G } t 0o0 i 4 � Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION _ Map 007 Parcel d 7_ Permit# Health Division l " NE 3 3 3Rt�WA Date Issued 3 —03 Conservation Division �� /�/�o� ��77 3� � 43 Application Fee _ Tax Collector 1 Permit Fee P7pX/ oZ Treasurer s l�lSlOtd SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE Planning Dept. V=TITLE b Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address apt, Village Owner Z212 t 6i&R Cfvg Address ��it� �m�v -T- �r 4ZG j5 Telephone Dom— ZD !Z.8 2— w. jV 6--r- / i`,V ed� Permit Request kaPn®al 6eLY'/ k-06PA" k�-��4-,-;-Tt �detir� `g5 Square feet: 1 st floor: existing proposed 2nd floor:existing I- rio proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Z1164 ®Ov Construction Type Lot Size 9 Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family K Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: El Yes ANo 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 L new Half:existing new Number of Bedrooms: existing new � .: +^emov� I ��^ - P r•� �'�"' �• Total Room Count(not including baths): existing ��new_ 4irst Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑ Electric ❑Other Central Air: ❑Yes No Fireplaces: Existing T New Existing wood/coal stove: ❑Yes J�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 CNo If yes,site plan review# Current Use 47,05"c Proposed Use BUILDER INFORMATION Name �-e �/ Telephone Number ON,d-F,*X Address 16,0 7z 3 2-"Z— License#&'S OZ/<-;9 7 Z ` alyv►S /"C Gi t Home Improvement Contractor# D L lO4,e; Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6r,ai IVe 4 ble— SIGNATUR DATE 3 Z 'D3 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. /113 ADDRESS VILLAGE OWNER o DATE OF INSPECTION: FOUNDATION FRAME {C 'fl INSULATION ' . IA ��6 �Ta3� 7003 r, FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH`I FINAL FINAL BUILDING 7j.v 9 DATE CLOSED OUT ASSOCIATION PLAN NO'.- �� u - ca r The Commonwealth of Massachusetts Department of Industrial Accidents Office of/nest/9JIMNS 600 Washington Street yBoston,Mass. 02111 i Workers' Compensation-Insurance Affidavit name: 7` ke i 4A .' location: )OP, n _ ' cityS� 1/-PA/i(/.`s J`��c , OZl©�9© phone# (] I am a homeowner performing all work myself. [] I am a sole proprietor and have no one working in any capacity19111 _ I am an employer providing workers' compensation for my employees workutg on this fob / rt. .:'.., 1.,r'd ijS�M'.' ;, 'i �A Y.3^��k t,^OWER., ?t3 S u;- '�.. R,• ., e...e :., t c!'r-5- r1J t �f• b+a..�4 .� ���i St :::ssstititi,,,��%� { 7 i -'r s tFe x _* r+, e.- a�'w. v.'' .u,y',d �5�1 p7r'7 f f "x'6 Si. 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SiYn'surance.co.,�»' `�•.... - Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of criminal penalties of a fine up to$1,500 00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pain and penalties of per' ry at the 'nfom ration provided above is true and correct. Date 3 Signature � Print name Phone# t�y��Z� 0-3 official use only do not write in this area to be completed by city or town official city or town: permit/license# r-1Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; nOther (revised 9/9S PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the-"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you.have any questions regarding the"law"or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out.in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406 INE lokti Town of Barnstable Regulatory Services Thomas F.Geiler,Director MASS. 9`bPrED 39. 01 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. ,,��jj 0 Type.of Work: (f _e,Val®u l Estimated Cost /O V,9 O Address of Work: �2 h �+C.( • ��. � Owner's Name: \T,_017 1i— �J 4 0'i �s+^ Qi ii°�s-s N--Z Date of Application: 3-- 2. F D 3 I hereby certify that: 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: f.YorS- Date Contractor Name Registration No. OR Date Owner's Name RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings_Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSBEET NEw LIVING SPACE square feet x$96/sq.foot= x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE Z®s`O square feet x$64/sq.foot= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming-Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee �Q�= r � ''•� fie 7° ;� i. BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Numbe� 046972 BiItdate�.;,QB(2$l�961 \ (�e1INN -=Ezp08X28 Q03— Tr.no: 2880 Resfrict�d;�00- STEPHEN M WH i PO BOX 322 S DENNIS MA 02 '0 Administrator 'j i ✓fie �i°mihzO1� a�./�aaoac/zccaett Board of Building Regulations and Standards HOME IM IROVEMENT CONTRACTOR Registration:, 110650 lug Ez ration- EW2004 vi YP YI STEPHEN M WH` ' gLE�•REjv1.pLD §TgPHEN WHALE.CC` 77 EISENHOWER COTUIT,MA b2635 Administrator I - / x 1r,9v�./ors /r�Dmn���r,Y C o y � Ile AN S c9 rr�0000 ,��' �0 P /®"v /'/j Co. ex yy(�rAruia,sT,� �'-3 ,?/U,rr z✓v /UA�v L�T,g�vo . v a )W41V A4 7'Ug4TS G o cv�/a,�id-��/�.��i� Ali 4,4 4-rZ /noN614�V Z7IYZ/scoff ,4vE .Sa•y4,rm0IVN 3 00 7 L0 3DV8 hNTI1l4i?JINfl1N?IHIJM -nn�nrnnnr ram. r _ _ oo�9t SMOKE DETECTORS O.K. "EW SMOKE DETECTOR REOUIREMENTS ARE NOW LAW. EVEN THE ADDITION OF A r NEW BEDROOM WILL TRIGGER AN LE B DEPT. UPGRADE OF THESMOKE DETENSTAB �D:NGDETECTORS j FOR THE WHOLE HOUSE. YOU MUST PLAN ACCORDINGLY AND HAVE YOUR ELECTRICIAN TAKE OUT THE APPROPRIATE PERMIT AT THE FIRE DEPARTMENT. UL r , 1. 0 Izo�a \/, lou Q,7Jj �ho4 d�7�Z4 IOYJ� ' o � h� zuul9 Nn -Olr Folz �1�v_ProfessiounlB 3gDesigiler RO B 53 ow - So Yarmouth, o, 2 NIA02G61 , (5(5)394-5296 O���, �• , f - - -' -- oo 22 c4) oS"�V I s•o cc ca— mi j •-' c 3s 1 � I I� S I ivJ i1 s�� I 41 4 C I Lill i � T❑C � �� —,��.J,��n ion/`/� _«I �� Ili � � � I•_ i �1� T � & ..� � a _h_�; �" I , �, �•c' rn—rl cc i ITT i ! c (: J!�.,...e wAaranses�.wdwxaa;a arrav3.xw 4i 1--;!2 o fm =? &Z ti �3 :z ih 2�7 r Mar--29-03 1? : 10P P.01 UJ/_O/_VV., U.J. JU VY�VVJ•lV .+.� r r�r •• ..r t Town of Barnstable Regulatory Services Thom m P.Cdler,Director '''" Building Division Tom Perry, eutid(pg ComWRe9oner 200 Mab Strw4 }lyumis,MA 02601 Office: 509-862-4038 i Fax: 508-190-6230 -- Property OwncrMust Complete and Sign This *Ction If LJain&.A Builder i A M e 5 �.� (4 r<A ' l ,as Oeuacr oflt6e subject property J�'- �r�C-r.! 1A A L� �herebyauthorv� to act on my behalf, in all marten rrlative to work a u OnZM by this building pmxit a p ' aeon for(uidress of job) . �� i Signature o Date Prim Name i i The Town of Barnstable BARNSTABLE. Department of Health Safety and Environmental Services v Hwss. m 67q. �0 "fEOMp�°" Building Division 367 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: Ji rr, Lr\ «rr, Map/Parcel: C- oaS Project Address: Builder: UJkclen The following items were noted on reviewing: i ►-hcve -frgeme r, d �m�ke_ r)ek-eC-Or5 -be_ us�0.(GdeA --rn CV((Ce\* COA-- ® �b t,%,X 4, e M"SA- rrv.tc-+ Cuccen+ code• Wi erg �ss�ble. r i { I Reviewed by: ,� 0 Y Date: q:buildinglorms:review , Y p,�pTHE�ati The Town, of Barnstable BARNSTABLE. - Department of Health Safety and Environmental Services 9 MASS. 0 f6}q. �0 Building Division 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection ,R1 nos u Location 42 60o'/ RCS I Permit Number Owner Builder 1jACA) P V\ RM-5 . One notice to remain on job site, one notice on file in Building Department. The following items need correcting: - 1`� nsu. ce�T ir5LJa"-'0A �or CC � � , hG , < -�6 /Y1► ✓► P- I3 -�nf Please call: (508-862-4038 for re-inspection. Inspected by l L m" Date ��810 bU r� • Assessor's Office(1st floor) Map �� Parcel d ��t# 1'T S7 7 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) �°r �o� • O� Engineering Dept. (3rd floor) House# �S Planning Dept.(1st floor/School Admin. Bldg.) BARNSTABLE. MAB& Definitive' an Approved by Planning Board 19 � �`®� ` TOWN OF BARNSTABR OMM���� a Building Permit Application �8VfV �� COD, ,,V. Address Village Owner �fL, /l�,gt/,p/G� /��" ��j�/ Address Telephone yzf� -�Scg y3 Permit Request ,A&�P7i>id cJ Ty �X.si iiY� .�fo'ys� ,%=d/1 /G x/7 8. )f aw First Floor square feet Second Floor square feet d+ Estimated Project Cost $ 02 0, vaa Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Ziin'�ing$oard of Appeals Authorization Recorded Current Use Proposed Use Construction Type lr"Z> -/-'b /Y� eX LSi/NG Commercial Residential t. Dwelling Type: Single Family 1-__ Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway />/ Number of Baths No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name AA Telephone Number Addres VeLd?rWAI ?3 License# 0S70 3 Z Home Improvement Contractor# /447400 : lZ.7 T72 2.y Worker's Compensation# 08 u/"oJ 93yP 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 1. PERMIT NO. DATE ISSUED - MAP/PARCEL NO. - ADDRESS VILLAGE LAGE + OWNER DATE OF INSPECTION: FOUNDATION ' FRAME ✓ INSULATION FIREPLACE ELECTRICAL: ROUGH - a FINAL - - PLUMBING: ROUGH FINAL GAS: t ROUGH FINAL - FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. i HOME IMPROVEMENT CONTRACTORS REGISTRATION oard of Building Regulations and Standards j -One Ashburton Place — Room .1301 • -Boston, Massachusetts 021.06 HOME IMPROVEMENT CONTRACTOR -Registration 100740 Expiration 06/23/96 • Type — PRIVATE CORPORATION • I •1N1ME.lNRRIfYEMEIIT CONTRACTOR..•, � .Capizzi Home -Improvement , Inc . i Type --.'-PRIVATE CORPORATION•• Thomas Capizzi , Sr . i -Eeplrltion ••-06/23/96 1645 Newton Rd . Cotuit. MA 0263S..• i Clplltl Hole 11provomelt, In • Tho11e Clplul, Sr. ' ���+���jd448 Newtol•Rd. I . I e •Cotult NA 02631 y leslrided To: 10 DEPARTMENT u 11PARIA11I or PUBLIC SWIT ONE ASHCUR 10ISIRUC1I01 SUPLIVISOR LIC[IS[ I 10 - loot COS-rUN, luber: . [spires: Id e: If - lesoorl CS 166111 W21/1111 10/21/1168 16 - 1 1 ,Dill loots VSTRUCTION SUPERVISOR LICENSE leslritled To: 10 nber.: Expires: Biri[idaLe OIVII Q11 057042 09/26/1997 , . 09/26/196 I,stricted To; UU "' CooeMrssioemt 1 lUl HOLL01 10 6 [ 1111091H, $A 11536 CIAL-.SECURITY Jl: 030-58-7. 494•-. :::::.'{:`:,.:' rIn ZZI JR . 'C I --~X AP OMAS� 0.'; C .VAL`•b PER I •-- BARNSTABLE, MA 02660 ; : ::: ..................;..................:......:v;•.}i:i:::.i}•i4ii':.i:4:;}}ii''ii}:4}}.;}i}}}:4:}4:;}4:4'r....:.•.�..x.;:.v•,:.;..}}}:..::::.::::.::::.}}y::::::n:•}.}:•}v:::::::::::::::::.iw.�::::::.:.yw.}}..}'..:}:..:{::::::....:......:..........:......:v.•..?.}v.}�.:::...};in:.:i/:•?.�'??.}::}:::?:::4:4:v:::4:j4:i4:4::v}}::?.}}}::r:??^}i}:^:ii::4:•}}}}}:i•:Y:•:}}}::}v':?}:'.y{':iY} D..: TE PRoouCER THIS CERTIFlCATE IS ISSUED AS A IIIATTER OF INFORMATION NORCRO�S & LEIGHTON INC 1 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFlCATE DOES NOT AMEND, EXTEND OR ! !L! CELEBRATING 150 YRS ! ! ! ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW. 437 STATION AVE COMPANIES AFFORDING COVERAGE S YARMOUTH MA 02664 COMPANY A MARYLAND HOMEBUILDERS INSURED COMPANY CAPIZZI HOME IMPROVEMENT INC a ITT HARTFORD COMPANY 1645 NEWTOWN RD C COTUIT MA 02635 COMPANY D ...........::,.:............................................................................................,..................................,..............................................................................................,............................................. S 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. CO TYPE OF INSURANCE POSY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTA DATE(MMMO/YY) DATE(MMMDNY) LIMITS GENERAL LIABILITY TD P 1318 8 0 5 8 0 4/O 1/9 6 0 4/O 1/9 7 GENERAL AGGREGATE :2 0 0 0, 000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG s2, 000, 000 CLAIMS MADE 7 OCCUR PERSONAL A ADV INJURY $1, 0 0 O 0 0 0 OWNER'S 6 CONTRACTOR'S PROT EACH OCCURRENCE $1, 0 0 0, 0 0 0 FIRE DAMAGE(Any one fire) S MED EXP(Any one person) S 10, 000 AUTOMOBILE LIABILITY. ANY AUTO COMBINED SINGLE LIMIT II ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS A (Per person) HIRED AUTOS NON OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT E AGGREGATE L S EXCESS LIABILITY EACH OCCURRENCE _ RUMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM = WORKERS COMPENSATION AND 0 8 WEBW 9 3 4 8 0 4 01 9 6 4/O 1/9 7 X I STATUTORY LIMITS LIABILITY THE PROPRIETOR/ EACH ACCIDENT = 100, 000 PARTNERS/EXECUTIVE INCL DISEASE-POLICY LIMIT = 500, 000 OFFICERS ARE: EXCL DISEASE-EACH EMPLO S 100, 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEMICLESOMCIAL ITEMS FOR VARIOUS CONTRACTED JOBS ATE 8..........................::::.:::::._:...............................................:..::..::::::: :....:::::::..............................:.:::::::::::::..........................,....................... . ................... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF PLYMOUTH EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MALL BUILDING DEPARTMENT ID— DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, TOWN HALL BUT FALURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY PLYMOUTH, MA 02360 of AM KIND UPON THE COMPANY,,.WS AGENTS;PlIt:REPRESENT TIVES. AUTNORDfD REPRESENTATIVE 1......................... Robert H Lei htori,``' ` C3 .:::.:.:.:::.:.:.:......:..:.:.:,.........:::::::::..::.::::::..,.:::::::::::::t.,,... v:.:::::.:::::: 9 :. ......................::.:::::::::::::.:.:�::::::::::::::::::::.:::::::::.;:.}:.}:.:.}>:.};:.}:.}:.}:.}::?.:.}}:.}:.}:;?.}::.,}•.:.:;.};:;:.}:.}:.}}}:.}:.}:i.;:;?<.}::::::::::::::>::<:::>':;•}:.}:.}:.;}}:.}:.}:.:ter:>::::::>::>::>:::�: �':> -• ---- , .The Commonwealth of Massaeh latsetts a;ll -_=_�•3e Depa-kMent,of Industrial Accidents r �' �Ol/Icsll/orest/osdhis . �- - �_� : 600 Washingtoh Street Y}�% Boston, Mass '02111 Workers' Compensation Insurance Affidavit location: 3 ohonc O ! am a homeowner performing all work myself. 1 am a sole proprietor anJ hase no one �%orking in any capacity_ - I am an employer pros iding µorkefs' compensation for ms' employees working on this job. company name: ddre : T / _ phone d: tnsurance co��/ ���/ iX�s�72�-, _ . oolicv g Q8 L(/fec�lf� 9�i3�� I am a sole proprietor. general contractor. or homeowner(circle one) and have hired the contractors listed below who.have the following workers compensation polices: m anx name: ' address: i . phone a: insurance co ooli cv q •,., -- - companx address: —.-- ohonc p• policy N Failure to secure coverage as required uoder�Sccnoa 25A pf MCL 152 no lead to the imposition of crimiul pcnatdes of a age up to S1.SOO.00 and/or one years'imprisonment as well as civil penalties in•tbe form of a STOP WORK ORDER soda nne of s1ta.00 s day egainat me. I■aderstaad that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verificatioa. t do hereb}•cerrif)-under t s and penallies perjury that the information provided above is true and eorred Signature au —� Phone t Z Print name official use*only do not write in this area to be completed by`city or town official • i city or town: _ _ _ permitAicense 0 rlBailding Department pUcensing Board psclectmen's Office ! check if immediate response is required Health Department :4� '�eOntaet ptr on:- - - - phone N:_ -_ _— r'tOtber _ C. . ? :ram -��9�t%`n+_.:•1V/t�:'c »; a+:-._..•.Yr'�`i Y, ;q.:: o•r.`ia :J: F Al� 'c;:?'� ^ .. - ' .t ;:�-•1;;�:;;. _ - �y Yam'!. i"� ti.•' J1�,.- } _ - 4� ychx •?#:'sa~. ,_.-.::!tG!^i:: ^'�•r7.2:%S'; .. .. .�%.F-. { . The Town of Barnstable s Department of Health Safety and Environmental Services Building Division 367 Main StnCC4 Hyaaais MA OMI Ralph Cross= OT1= 508-790-6=7 Bmwiag Commissionc: Fwc 508-775-3344 For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c 142A requires that the"reconstruction,aiteratioM renovation,mgair,modernization,wa""4 improvement,.remotial, demolition. or construction of an addition to•any pre-das�ng owner a ed building containing at least one but not more than four dwelling units or to S=C=rs which are t to such residence or building be done by registered contractors,with certain C=Ptions, along with other requirements o �s Type of Woric:�/G X/7 � oNEst -Cost Address of work: L 9 z:3 x e�� Owzur.Name- i3O�4 i ST� Date of Permit Application: y— /7— -�L I hereby certify that: Registration is not required for the following reason(s): _Work caduded by law Job under S1,000 Building not owner-==Pied ownerpuftgownperm# Notice is hereby given that: CONTRACrORS OWNERS PULLING THEIR OWNPRE R DEALING N�E�' ESS TO THE FOR APPLICABLE HOME �P WORK DO VE ACCE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MM c 142A SIGNED UNDER PENALTIES OF PERSURY I hereby apply for a permit as the agent of the owner. � aa7yo Date Co names Registration No. Ch'T OR ��� - Owner's frame '1 s 0 `a y 3 i - --r � 1 9 _ _. ......._ srnt�q • .s� �x�J �C . I o S�S/n�orros � -� T r� u< jrra� roo7.ag;!, - ) 4k ' . I Liu— } pill . -�� C6 a i -r•- Vz I - w . a ' 3 � � I -Q, O 1 Qf f3AY POP ONE S S ETT . SETca SET i 1 }�?� 'id�l' ��� d.':r� P� '� } lt•... �i ltV�) .f•9 t�l1f Y.ffi i �.t i�a�/ � ��:4 ?a��� � SPC 1t N .., } y�r �I fir[ x:si�i, S .t• ._•ifr s 4�`�x W;`s§•..'�i�4r.�-"�.`+��,,��i�Ytx..'z - -� 3 w16 ' k 0 ' 1 fVT 1 4::✓i • SET ti ?O " .ca ;•:;. ►/oTr -rH ION 'PLAN SNows Lor4ziA �FAIU- OF' L•oT Zo/a AS SH—,WN C•N PLAN OF LA /i�►,°N -OF -ERTY of Ro;F=RT' I ;;. : .. :T•Fov4/l kR REGoR�Eb't(� Thl E COTU IT. BaRNSTA��:�- B/IRNSTA�Lt T �ISTrcr OF Fok. t"'!16E /A. L C O T.T, • "DRAWN r_�. CALG* IN':=30 �:, di:;•rv5 n ry h NCK 2&1 . . 1 CHARLEs N• S^d p Lei. �...:.'.'. . .y R6►GISTERfcD S'. i• .. uRveyoe... HYANNIs;,• s CAPE,:Cau