HomeMy WebLinkAbout0143 CAP'N SAMADRUS ROAD l�3 Ca�,-) S�,mcc�r� S���
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Town of Barnstable *Permit 0�� �—� " (�
Expires 6 monthsfirom issue date
�� ��-r Regulatory Services
r� P. .� Thomas F.Geiler,Director
x� i
AUG 2 9 0006 Building Division , QCP
Tom Perry,CBO, Building Commissioner A
TOWN OF BARNSTASLE 200 Main Street,Hyannis,MA 02601 g
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
[ap/parcel Number
roperty Address i q, lc04CO3 -
]"Residential Value of Work 1p�t�1`� Minimum fee of$25.00 for work under$6000.00
owner's Name&Address
a
.ontractor's Name ���4f /�oK /!✓� y Ft�f�V_Q J/b/Aft Telephone Number 3 �� 776 "Xv
[ome Improvement Contractor License#(if applicable)
's License#(=ftpphcabie)
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ the Homeowner
Ejj/I have Worker's Compensation Insurance
asurance Company Name
Vorkman's Comp.Policy#
'opy of Insurance Compliance Certificate must be on file.
'emait'Request(check box)
Mf Re-roof(stripping old shingles) All construction debris will be taken to 't�l
❑Re-roof(not stripping. Going over existing layers of roof)
❑ .Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission,
A copy of the Home Improvement Contractors License is required.
;IGNATURE:
1:Forms:expmtrg
:evise061306
• t he t.ommonweatrn uJ lnussucnusecw
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA O2111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Bluilders/Contractors/lElectricians/Pluitalbea-s
Applicant Information Please Print lr,ezibly
Name (Business/organizaton/Individual): �r
Address: :3 r
City/State/Zip: ,P,� �--`���l�_Ab _ Phone #:
Arree,yo n employer? Check the-appropriate box: Type of project(required):
1.LAN!am a employer with�Q_ 4• ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t T ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work-' right of exemption per MGL 11.❑ P umbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no 12,BRoof repairs
insurance required.] t employees. [No workers' 13. ][_ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill cut the section below showing their workers'compensation policy information:
t Homeowners wbo 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 their workers'comp,policy information.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and,yob site
information.
Insurance Comp any Name:
Policy#or Self-ins.Lie. #: Expiration Date:
Job Site Address:_ �7`3 A �i7�/ 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 Qf MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to.$250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify u the pains a penalties of perjury that the information provided above is true and correct
Signafore: Date: ;?0
Phone#: Y_ 7 7A F/
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*lisp ester 1
6. Other
IL Contact Person: Phone#;:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees
Pursuant to this statute, an employee is defined as"...every person-in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual,partnership, association, corporation or other legal.entity, or any two.or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling hous a having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or .
renewal of a license or permit to operate it 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 commomvealth 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 permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that.a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would hike 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-MA_SSAFE
Fax# 617-727-7749
Revised 5-26-05 WWW,mass.gov/&a
i
Town of Barnstable
Regulatory Services
BAMSTAASS. s Thomas F.Geiler,Director
pIE1639. `e� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, v vl� , as Owner of the subject property
hereby authorize �V /v� to act on my behalf,
in all matters relative to work authorized by this building permit application for:
ce, _ r 0 V
(Address of Job)
Si ature of Owner Date
Print Name
Q TORMS:O WNERPERMISSION
i
Q :::. :.:. :. :;.:: .:
=UCFA [ALTER
IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
LY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DWARD A GRAZUL INS AGCY LDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
0 BOX 337 THE COVERAGE AFFORDED BY THE POLICIES BELOW.
ARSTONS MILLS MA 02648 COMPANIES AFFORDING COVERAGE
COMPANY
28Y2K A HARTFORD UNDERWRITERS INSURANCE COMPANY
URED COMPANY
R L T CONSTRUCTION INC B
31 MANNI CIRCLE COMPANY
CENTERVILLE MA 02632 C
COMPANY
D
.....:.:.:....:.............................................:::•:::::::::•:::.............................::.:::::::..................:..::::..............
....... ................... ....
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
VDICATED, NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
:ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
XCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DATE(MM\DD\YY) DATE(MM\DD\YY) LIMITS
GENERAL LIABILITY
GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
CLAIMS MADE OCCUR. PERSONAL&ADV.INJURY $
OWNER'S&CONTRACTOR'S PROT. EACH OCCURRENCE . $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Any one person) $
AUTOMOBILE LIABILITY
ANY ALTO COMBINED SINGLE $
LIMIT
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per Person) $.
HIRED AUTOS
NON-OWNED AUTOS BODILY INJURY(Per
(Per Accldeni)
PROPERTY DAMAGE $
GARAGE LIABILITY
ALTO ONLY-EA ACCIDENT $
ANY AUTO 1 OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
EMPLOYER'SUABIUTII (UB-1051C04-5-05) 12-24-05 12-24-06 STATUTORY LIMITS
iE PROPPEOR/ $H :
PARTNERS/E(ECUTFVE INCL DISEASE—POLICY LIMIT $
OFFICERS ARE EXCL
OTHER
DISEASE—EACH EMPLOYEE $ 00
r
CRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COV RA
...................:::::::::.::::..:::::::.................:.::::::.::.......... .. ::::::::.:..............:.:::.:::.::::::................::::::.:..:............:..:..:.....::.:......
;;:.;::.:;0/kfi�i�: .
:.....................:.......::::.::.::::::::::::..;:::::.:::::::.::::::::::...tA kO f.: .:::.::.:::::::.:::::::::::......::::::::::::::::.::::: .;:.::.::::.:
. .............::
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
4RNSOF BA BUILDING DEPARTMENT 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
)WN OF BSTREETBLE LEFT, BUT FAILURE TO MAIL SUCH NOTICE.SHALL IMPOSE NO OBLIGATION OR
)O MAIN STREET
I'ANNIS MA 02601 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
2 :s..46.3......................:.:.::::::::::::.::::.:.::::.:.::: ............. :::::::.:::::::.:•:::::::::.... :,.:::.::..:::::.......
' I
y.;
r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map- t Parcel Permit#
Date Issued 041`
Feed-S`�,cly
i Tax Collector lYC 7�� yy
Treasurer
�7t.
R�.ut� � t hnnina R.,.,.i�_ • c
lavj
s
5
Project Street Address _ A P OBI 2LA P (3 Ya-()
Village C 64 �A i
Owner c�1�ry02 A �A2�'��1\ Address ORP N SfAMcn aus �C
Telephone 60 �3 y a 4 -
n i
ermit Request 1 e ,QL;A CC C=-X 1: G, &84i-C H Q 0 }�
kA ax,iE,
Square feet: 1 st floor: fisting proposed 2nd floor: existing proposed Total new
Estimated Project Cost Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: 0 Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Fami1y--iA Two Family Cl Multi-Family(#units)
Age of Existing Structure r S Historic House: O Yes __dNo On Old King's Highway: 0 Yes _,"M No
Basement Typed Full 0 Crawl ❑Walkout 0 Other 1
Basement Finished Area(sq.ft.) _iZ5- Basement Unfinished Area(sq.ft) q�C C)
Number of Baths: Full:existing Ck new Half: existing new
Number 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 DC Existing wood/coal stove: ❑Yes 0 No
Detached garage:0 existing O new size Pool:O existing ❑new size Barn:0 existing ❑new size
Attached garage Q existing ❑new size Shed:0 existing ❑new size Other:
Zoning Board of Appeals Authorization O Appeal# Recorded❑
1✓ommercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Named ' Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
VS�IGNATU`RE �������
DATE
( � FOR OFFICIAL CMMNLY ,
�.- ► t
DATE ISSUED -
MAP/PARCEL NO.
z r• ,
ADDRESS',
,- VILLAGE '
r
OWNER'
r
i• i �
DATE OFINSPECTIO ,
FOUNDATION t
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL -
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING �I 1
r
DATE CLOSED OUT
,
ASSOCIATION PLAN NO.
r
The Town of Barnstable
• • �arrer�ara. _
Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
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
sa, requirements. '
J
Type of Work: Ji4zF— PLAc e, anza-ma Estimated Cost
Address of Work: 635
Owner's Name: OW1�2� �A�t. LC I ll
Date of Application:
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.
Date Contractor Name Registration No.
OR
to Owner's Name
q:fomis:Affidav
I .
i
The Commonwealth of Massachusetts
{- Department of Industrial Accidents
Office ollnsestiosaans
600 Washington Street ,
�- f
Boston Mass. 02111
Workers' Compensation Insurance Affidavit
name: (<
location: ( H sprmporLw
city (. .•' 1 ® hone b O
• I am a homeowner performing all work myseif.
❑ I am a sole proprietor and have no one workin in any ca acity
❑ I am an employer providing workers' compensation for my employees working on this job.
compnnv name:
address: ::•....:::::..::.:: ....:
city phone#•
insurance co. policv#
❑ I am a sole proprietor, general contract or homeowner(c le one)and have hired the contractors listed below who
have
the following workers' compensation polices:
com anv name: ®� °
Ll
� : '
address: LD
city:
insornnce co. .. Cy�Q C� :...:.:..:. olicv#
company name: :;...:
address:
city phone#'
FaIIure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Me of S100.00 a day against me. I understand that a
copy of dUs statement may be forwarded to the once of Investigations of the DIA for coverage verification.
1 do hereby certify under a pains and penalties o perjury that the information provided above is tru<and co re
D'
gttature Date _
15,0_ 60
Print name 1da4Aq ;_/mil d2e_77.-f 7`7-- - _ Phone#
official u:oniv do not write in this are:tobe mpleted by city or town official
cito or t permit/license# ❑Building Department
` ❑Licensing Board
❑checdiate mponse is required ❑Selectmen's OtHce
❑Health Department
contact phone#; ❑Other
(revues 9/95 PJA1
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 co=-"z
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 receive:c:
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 renews:
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 this the application for,the permit or license is
being requested, not the Department of Industrial Accidents`'Should you have any questions regaiding the "law"of 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 maybe returned io
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 Imlesugatlons
600 Washington Street
Boston;Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 eat 406, 409 or 375
i
-� The Town of Barnstable
Department of Health Safety and Environmental Services
' Building Division
BARNSPABI.B. ' 367 Main Street,Hyannis MA 02601
NAM
��FD MA'I a
I '
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
L� Please Print
DATE:
JOB LOCATION: 1`13 �'A�M S �aa2Us �Cl �6Tu, l ►�� WIAl
number //�� street -lige
"HOMEOWNER": �K'jD P�4 �A�1'lrls'11 s Q� uag I (o RS
name home phone# work phone#
CURRENT MAILING ADDRESS: Iy3 \ .t\P ''1 Sgrmp%(-)QjAs Rcj&r�,
; '
Oa( s�
city/town a state. zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less
and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building ep rmit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requiremen
ign cure of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control. .
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the
provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for
hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,
particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would
with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used
by several towns. You may care to amend and adopt such a form/certification for use in your community.
QTORMS:EXE IPT
6 22
/ -
AAssessor's office(1st Floor): 2 p� �
Assessor's map and lot number O✓_ 8` y�' !�773 IBC SYS o-ALLED IN
Board of Heal*(3rd floor): Q ` d
Sewage Permit number %4 - MTH-nTLE
Engineering Department(3rd floor): _ —43 �o S AMAUSAM tc I
House number Y ls'� eo +6yq
7C'MNI RiEGAU EI
Definitive Plan Approved by Planning Board 19 ],%- r�r
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BAR.NSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO !1/e�J !� / �p ^� / ��.,,Xl ,
TYPE OF CONSTRUCTION U)O
i
Jv w-P 19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit a ording to the followi g information:
Location N 5 5 a
Proposed Use e .w
Zoning District Fire District eorTb l
Name of Owner
oL,ev�J J od t -P Address 7G n-P /�. Qe�..wi �s-5, 6zG39
JoCX Ic-P C4V' lov21 �� Address TC 1Z4Yf �, /�atiwl�/ 451. O2G36
� Name of Builder �-
Name of Architect Address
Number of Rooms Foundation (/o�H P c� C°"'C'f
Exterior e C'.0-A t' S�` J(, S Roofing z r
Floors C2t" �� �`� Interior
Heatin 2 5 Plumbing
9
' o
Fireplace Approximate Cost o0
Area
Diagram of Lot and Building with Dimensions Fee
Uv
_ CAS
i
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
+"r Construction Supervisor's License 6660 3
1 �
3 ,
JODICE, LEON
No 3399 2 Permit For 1 Story
Single Family Dwelling
Location 143 Cap'n Samadrus Road
r - f
r Cotuit
> OwnerV Leon Jodice
Type of Construction Frame
s
7 Plot Lot
Permit Granted September 2 8 ,19 90
• `Date of Inspection 19
(Date Completed �(�� 19
t
IIA7Q/
�.
C
a+v Nf^M.v%.t..•• .'i.f1M T.T ;I w aw�„i1a•L!'�,,
n :Tv
ff, t�•'T'T17Ma �,}�
All wl
TOWN OF
BARNSTAB
1 " ' ` ` BUILDING DEPARTMENT Permit 'No..3,3992
I �A,n T
•���.►• TOWN OFFICE BUILDING Cash (.$5 4 7,00).
•„'_. ..
H.YANNIS.MASS.'02601 •.
I Bond
' • --• ----•�-�,- • 'CERTIFICATE OF
USE AND OCCUPANCY ^
Issued to
. ::Leon: Jodice t ..: ..
Address °1'4.3'`Ca n
•'1 F li'jh C:;
p Samadrus Road
Cotuit; Mss
• b
USE GROUP
FIRE GRAD
lNC OCCUPANCY L OAD }' "t ?
THIS PERMIT.-WILL NOT BE•,VALID, AND.THE BUILDING
SIGNED BY,'THE BUILDING 1NSP,ECTOR'iUpON SATISFACTHALL.'NOT BE
REQUIREMENTS AND IN ACCORDANCE:WITH.SECTION 119a)OF- A'
OCCUPIED U(VTILL
BUILDING.CODE ORY COMPLIA'NGE,..WITH
SSAGHUSETTS STATl4 '
e , i-
Janud
rY' ,
1
• ... 19
• � ' J th�;icj y ,�
I Y `nspector
Bu}1Ing I�
• I
I' 2. PRIOR To COVERING STRUCTUR AL QUIRE HOB
MEMB ERS(RE ADV TO LATH1. D
OCCUPANCY. SUC
�TLb7NC5HACt'?C tiT}-•
3• FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE -o�'t.ttJ�-�c_�.-�,
PO T THIS CARD SO IT 1S VISIBLE FROM STREET. ��4
TOWN OF BARNSTABLE
BUILDING COMMISSIONERS OFFIC t {, . i,,+� � . -.iu �
DATE ;REFUND TO `; � +' � w
!l 8I9/ y p r 1ilrit yy � 7� �
,, 'E �?'�' rj' "1,h..tzar�5'7�T�1 `+
ACCT.;�' �"O/o?/Ooa0�0 a }}lu; Jodicey
S I, op,He"Lane rtaM°i +' y, Is s4 w K �> 1
VENDOR# ya yr ,ill 1 ,z �5•. �' } '� 'IF � ���t 4 . 1
AMT. �0��— Irk
PO NIP
APPROVED BY
A/C��f♦y�*�� ,i ,�-�.E�.�.'iT��/k'� bl,4t� 'fit✓t�')'-�� � �..+rt�X'
Y rt ZNM
S
FF
5i�y�'��". � � •" ,taw t�`a fiia�r. 4 s.�'`+�- � '.:n }
A �y sir
jtIM
Ae-41M
ti ly 4'S1iR.fij'y{�a!�`�j� �j 't 1 •., ��'
i A;,r
J`f�i�+'�y%`�'+y`I�+,��+�1;}?�;��ir+�'.! ��•' •��,1`'� F'����� � ""7i�� s 4 . �f���� ° t'�w'�x �S :. + .. �����
TOWN OF BARNSTABLE Permit No. ,33992
I BUILDING DEPARTMENT� ($54. 7 00)TOWN OFFICE BUILDING Cash ! .
7 ■M�
.ego•
HYANNIS,MASS.02601 Bond ................
CERTIFICATE OF USE AND OCCUPANCY
Issued to Leon Jodice
Address 143 Cap'n Samadrus Road
Cotuit, Mass.
USE GROUP - FIRE GRADING •OCCUPANCY.LOAD
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.E OF THE MASSACHUSETTS,STATE
BUILDING CODE.
:..January..7" r9...9.. ... ....................
Bu;Ifling Inspector.
p t _�F._ ..�,.�...,�R..e�.,��san+•r�r:r.,.,;-,.. •..•.tia.\a^'. :, :. ♦: ,�� \ ... ... a 'Rs+c.^ro."713v.:,.
TdWN Ot BARNSTABLE, MASS;4CHUSETi� '4� BUILD 1 N G PERM 16
A-038-052 =
DATE �evtember .Ltd 19 90 PERMIT NO: T
APPLICANT_ Indlep Corpotarion \ ADDRESS lb HopeLane•. Dennis MasB. 06039
! y;\•,�;:' (NO.) (STREET) —�ICONT R'S LICENSE)
PERMI�TO _guild Dwelling (. 1�1) STORY S4h le FamilyDw#lling DNUMBER OF
WELLING UNITS ,
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
AT (LOCATION) 143 Capin Samadrus Road, Cotult � ZONING Rg
(NO.) (STREET) — r DISTRICT_
( BETWEEN \
AND
I (CROSS STREET) .. (CROSS STREET)'
SUBDIVISION LOT
LOT BLOCK SIZE` •1'
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT, IN HEIGHT'AND SHA-L'L'•,CONFORM IN CONSTRUCT)(
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
4
Sewage #90-281
REMARKS:
Jodice Corp. ($50.M)
76 Hope Lgne, Dennis, 02638
' AREA OR 17•04 sq. df..
VOLUME ESTIMATED COST $ 50:,000.00 FEEMIT'•$ 85.25
(CUBIC/SOUARE FEET)
OWNER Leon Jodice
ADDRESS 76 Hope Lane; Dennis, MA. BUILDING DEPT.
BY
THIS PERMIT"-` ONVEYS NO RIGHT TO OCCUPY: ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY C
PERMANENTLYENCROACMMENTS ON PUBLICL E
'MUST BE Al
PROVED BY.THE JURISDICTION. STREET OR ALLEYGRADESOASSWELIL SADEPTHFICLLYEANDRMITLOCDAT ON OFUNDERTPUBB CI LDING SEWERS MAY,
BE OBTAINE
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIOP
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL --APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR� PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN
ELECTRICAL, PLUMBING AND
I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
i' 2. PRIOR TO COVERING STRUCTURAL QUIREO,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MEMBFINAL INSPECTION
TI TO BEFORE
FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION BEFORE
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
P� . 0/
)
22.-
7 2
fA
3
HEATING INSPECTION i"PREIVALS NGINEERING PART NI
2
OTHER SITE REVIE�VA� p _ ' R(IARE)Of I IF. 11114
' ��D- I
y pr
WORK SHALL NOT PRO ED UNTIL THE INSPEC• PERMIT W!LL BECOME DULL AND VOID IF CONSTRUCTION
TOR HAS APPROVED T E VARIODUS STAGES OF rPOE:MIT
E.K IS NOT STARTED WITHIN SIX MONTHS OF DATE THE INSPECTIONS INDICATED ON THIS CARD CAN E
CONSTRUCTION. iS ISSUED AS NOTED ABOV ARRANGED FOR BY TELEPHONE OR WRITTE
NOTIFICATION.
7\ -
I HEREBY CERTIFY THAT THIS FOUNDATION IS LOCATED ON THE LOT AS SHOWN AND
CONFORMED TO THE TOWN OF SARNSTABLE ZONING REGULATIONS, REGARDING
SETBACKS FROM STREET LINES AND LOT LINESAT THE TIME�IT WAS�SE
ONSTRUCTED.
PT. 20 1990
R98ERT E. RAM .P.L.S. DATE
133. 00
N 38-44' O"I✓
PA RCEL 52
23768 f sf
+
N W
b ti N
~ ti ,
F0U10A7101V o GARAGE,
41.5'+° ig•i• 1 o N
d 26 a
to
i
- N
J/ S4
'per U S
F� p D`
30 15 0 30 60 90
SCALE IN FEET
'r THhS''-PLOT PLAN WAS MADE FROM AN INSTRUMENT SURVEY AND IS FOR THE
"USE"OF THE BANK ONLY. UNDER NO CIRCUMSTANCES ARE OFFSETS TO BE USED
FOR FENCES, WALLS, HEDGES, etc. .
FOUNDATION LOCATION PLAN
OF MAP I
ROBERT y°�� '.PARCEL 52 CAP'N f SAMADRUS ROAD
RAYME.
OND y COTUIT ( BARNSTABLE ,), MA.
No.21583 9 ARROW ENGINEERING .INC. FLOOD ZONE
s%y ���sJ 10 CAPE DRIVE, SUITE; B COMM. No. 2500010018 c
-'� - MASHPEE, MA 02649
EFFECTIVE DATE AUG. 19, 1985
SCALE: /11=30, DATE: SEPT. 20,'/990
'; -- `•f_ . 777.
_ f ; _. ._ ,+.'mil /�/ _-
PAAnw-
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I W . .
_ Coo -
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� ^V^�1. r - �, -ate--'=------ 'y71 ,� - `�' ��. �\ro-`.-•
�y '.-'T�'�L� (��r•�c�y�Ys�•I�.^ T- .t �`:`w--��{1.tj/f1�/f/��_-� - � � � jy� _�.ow wry`" f�V�YF.-:_ tt ..ww•• y�` ' �L/(r�6p(J�i�/� �p�-�y�} Z ` 3 •
_ T c6
............
{
-:iV!_�-:ter' ='.�-sT`=t'.:.."e...-•
l �aoyI Po
10a i 9
�Z ► � 4
•, 1 -.. 'I � I stew-ors — � �vra.Y I �§ �
J i LAG--.-. _ 1
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I
. I
Law oSFICES OS
JEFFFm-v D. Wrr.r.Tal%�xs
219 EAST KAM STREET
B43I,b ORD;M A C,ACSUSV_=01757
IEURT792W D_w3mi.r AMC AREA CODE 508
LA.URA y M A n-IT• T MXPH01SE 478-1777
FAX 50847"1.45
June 15, 1990
TOWN OF BARNSTABLE
OFFICE OF- THE BUILDING INSPECTOR
397 'Main Street
Hyannis,- MA 02647
RE: MR. LEON TODICF,/-AROLD and =ITH H. BLE,THEN
To Whom It .May Concern:
This 'letter will confirm that since August 18, 1980, the
owners of the property described as Lot 32' on a plan of land
recorded with the Land Court Division of Barnstable County
Registry of Deeds as Flan 34623-B, 'said land being located on
Capin SamadrusRoad in the Town of Barnstable, have not owned any
contiguous lots to said Lot 32..
I have relied on Transfer Certificates of Title No. 82560
and 9869.1 duly filed with the Barnstable County Registry of Deeds
in rendering this opinion.
P ease feel free to contact me with any questions.
ty ve
yl
_aura A. Mann
r
LAM:dj h
Asses,rar's offiA(1st Floor):
Assessor's map and lot number 43 0 5, SINE tp
Board of Health(3rd floor): 1?19 -)-q,(
-
Sewage Permit.nuffAr
1 , "ISTAX LE
Engineering Department(3rd floor): DMAAL
Hobse number 639.
Definitive Plan Approved by,Planning Board C24 — 19 70 us"I
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 e- 4c-"
TYPE OF CONSTRUCTION C).
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information-
V0 _4 e-
Location V),) J
Proposed Use
j
Zoning District Fire District
rt Name
of Owner Address
Name of Builder 1.)0-el c-' Address
Name of Architect f 11006,V 41 Address '5$e
Number of Rooms Foundation e-(-e
Exterior C 1-9 At-_ Roofing AS 14 z It
FI oors e Ir Interior
i
Heating Plumbing
Fireplace Approximate Cost
Area
Diagram of Lot and Building with Dimensions Fee
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.
c ".9
Name
Construction Supervisor's License
JODiCE, LEON
A=038-052
`No 33992 Permit For 12 Story
Si�;ig1e Family Dwelling
Locatiqj 143 Cap' n Samadrus Road
Cotuit
Owner Leon Jodice
Type of Construction Frame
Plot Lot,
Permit Granted September 28, 19 90.
Date of Inspection 19
Date Completed 19
• t
PERMIT COMPLETED 1/1/
TEST PIT #1 TEST PIT #2
ELEV. 49x5 0' . 50x0 - 8'-f'- -- - -- - +; ,^\ UENL AL_ NOTES
TOPSOIL TOPSOIL
a -- _ 1. ALL ELEVATIONS SHOWN ARE BASED UPON AN
SUBSOIL SJBSOIL --
- n ASSUMED DATUM
3' r- 3 - — -- "_ �/ 2 P - I-; ALL LINES A MINIMUM OF 1/811 /FT. UNLESS
N —
I -, -, OTHERWISE SPECIFIED.
C�
-0, �- 00h ) O 5 C- ! 3. ALL PIP
ES TO AND IN THE SYSTEM SHALL BE CAST
IRON OR SCHEDULE 40 PVC
_4 _ i_ - OOc , 1 CJ C n � �
CLEAN CLEAN ` 0 i 4. ALL SEPTIC TANKS DISTRIBUTION BOXES AND
MEDIUM MEDIUM �----__--�- �' 000 :� '� O r LEACHING PITS SHALL BE DESIGNED FOR H-20 WHEEL
I SAND SAND 1 rt I
-� i I LOADINGS WHEN UNDER PAVING.
000
-r-- --- — — �� � O C C 00
00 0 O C 00 c' 0( ! 5. REMOVE ALL UNSUITABLE MATERIAL BENEATH THE
r� pp 0c _� o p) 016 TYPICAL UIS T RICaU ON BOX I OOCC O00� p A DIRTANCEVOFO OFTF AND BACKFIINL WITH FOR
AY -
EE ' F
_. __. REE SAND 81 GRAVEL HAVING A PERCOLATION RATE
! � NOT TO SCARF -F;' r-, - -- -� OF 2 MINUTES PER !NCH 0R LESS.
NO WATER ENCOUNTERED NOTE DISTRIBUTION BOX AND 6 THE TOWN OF BARNSTABLE BOARD OF HEALTH MUST
GAL. REINFORCED SEPTIC TANK BY BE NOTIFIED WHEN THE SYSTEM IS NEAR COMPLETION
OBSERVATION PIT TYPICAL 1000 ( AL St—PTIC TANK ACME PRECAST OR EQUAL TYPICAL_ LEACHING PI j AND PRIOR TO BACKFILLING.
7 UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS
PERCOLATION RATE 2 min/inch NT T TO SCALE NOT 7-0 SCALE SHALL BE INSTALLED IN ACCORDANCE WITH TITLE SZ
OBSERVATIONS BY PAUL ANDREWS NOTE TANKS REINFORCED THROUGHOUT WITH OF THE STATE SANITARY CODE AND ANY LOCAL
TOWN OF BARNSTABLE BOARD OF HEALTH ELECTRIC WELDED WIRE WITH 24-1/2" RULES WHICH MAY APPLY
ENGINEER ARROW ENGINEERING INC EMBEDDED STEEL RODS IN TOP 81 BOT- trAV �w1AV olsr� 8 CONTRACTOR IS TO NOTIFY ENGINEER, PRIOR TO THE
DATE JUNE 14, 1990 TOM. CONCRETE IS 4,000 PS.I. TEST. s N 39 44 ,0O a 23.00 INSTALLATION OF SEPTIC SYSTEM , OF ANY DiSCREP-
P-7613
ANCIES BETWEEN TEST PIT RESULTS AND FIELD
CONDITiONS.
9. ACCESS MANHOLES TO SEPTIC TANKS AND LEACHING
PITS TO BE BUILT UP TO 12 INCHES BELOW FINISH
GRADE.
J40.00 23-0O TOP OF
N 38. 4.40 M Lt FOUNDAT"-)N
ELEV = 51*25� r-- , il% ,SH GRADE FINISH GRADE OVER LEACHING FINISH GRADE �' �� r
I
FINISh GRADE OVER 7AN�<. OVER "D" BOX AREA ELEV 50,0
ELEV.= 50+25 ELEV - 49+5 _EV.= 5
PARCEL
8 3 - - r - 13 -4r F...t4. Q l° r ---- X -1%tl A ��
- __ __ ° -_ . __j_r ' _ 12' 4-P� l0.50%_ r- - r;:; '-�
___ -�=WASHED STONE
23�6 ± f I N v = 47+3 i I NV - 46+83 - - __A -_ - ___ -
492
.INV. 46+66- F G /.\ - 47+,5 1000' G4dL INV 46+90 DI;T BO °�
RE iNFORC, [ X °o
I
24 3/4 1/2r
(TO BE FVEL
.....
... WASHED STONE
l'-,1V -- 46+60 ii' enoo`Q�t• • . . .. ... BOTTOM OF PIT
E:LE'V.- 40+60
°R°A3e SEWAGE TYPICAL S.... SYSTEM PROFI LE
F � PRECAST LEACHING PST
y o F< s�+�Nc° I3349.r 'TO BE LEVEL E3� STABLE)
NOT TO SCALE
33- 49 ti /co 2
,F LEGEND
_.
1000 GAL ��- e 4s.e 30�o F X i`;T C,ON TOUR _.__ __. ____ .___ $ MAP S CT fON PARCEL _ LOT _ _ADDRESS
38 52 32
SEPTIC TANK. ! y
u
PROPOSED CONTOUR 8 i _-- __1_________.___ ______-_-�--�
s R N �W EXIST SPOZ ELEVATION 8 X 0
fd►� � 3Q � 49A
PROPOSED SPt�T ELEVATION H 0 _ _
z _ __ --
•st, LEACHING Pi o` / PERCOLATION TEST y ZONING DISTRICT FLOOD HAZARD ZONE
50.e f, �,` P#i ,"BSE RVAT ION PIT f►i - ---- - - RF— -- - - - -.-Cl. -
co
a j TPn2
e
CIVIL
�� :9� DESIGN CRITERIA alp PROPOSED LOCATION OF DWELLIN
c4pl �• 49.E , -- t� SEWAGE_ DISPOSAL SYSTEM
N - NUMI BE R OF` BEDROOMS
L�tol.P9 . ON PER BEDROOM I �rON:� ;
A M,� —�9� - �:�ALLor�s PER PE RSON PER SAY 55 � ° ,►�'• �! � PARCEL 52 CAP'N SAMADRUS ROA
" l v i_ EaC,H+tiG F�E;QUiREU 330 d
S 9p COTU
R � IT ( BARNSTABLE l MA.
A D
LEACHING PROVIDED 549.7gpd
�71SPOSAt. NO
APPLICANT ENGINEER
SEWER DESIGN LEON JODICE A,RR ElvGir� El�!n�r
76 HOPE LANE 10 CAPE DRIVE Sl'
DENNIS, MA. 02638 MASHPEE, MA 024
D
S1EWALLti 211x6x5x2.5 - 471.2gpd aI ,�"r� r�
- nx52x1.0 = 78.5gp BOTTC M d "1 � :,.z�s � , ' SCALE SHEET
30 J5 O .910 61D 91D .*n• %'rs r w5
7C)TAL. 549.7 gpd Mfi �A A�; .tli ._ DUNE 15, 1990
PLAN SCALE � � i�."FCKED SY AF`PD e. r' A
� � T SJR /HP GLT A-E