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Engineering Dept. (3rd floor) Map rcel ,, '�d_6;;(Permit#
House# 'Dale Issued
Board of Health 3rd floor 8:15 -9:30/1:00-4:3 r�D
Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
SEPTIC SY
QjLd19 ��° d a'�f A SCE
TOWN OF BARNSTABLE-
Building Permit Application
Project Street Address (' /a 2 Ln 77c,
Village CG'TU c `
Owner A S, J6^, zC ,�/,N o Address
Telephone
Permit Request &C1L
First Floor square feet Second Floor 2-f!,ps, square feet
Construction Type
Estimated Project Cost $ S ��
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure S, Historic House ❑Yes ❑`No On Old King's Highway ❑Yes a No
Basement Type: IU/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 3 New
Total Room Count(not including baths): Existing s New First Floor Room Count
Heat Type and Fuel: ❑Gas U Oil ❑Electric ❑Other
Central Air ❑Yes Ulo Fireplaces: Existing New Existing wood/coal stove ❑Yes Ingo
• Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) 1
❑Attached(size) ❑Barn(size)
f�None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Proposed Use
II - Builder Information
Name Lo, (yr2z yY, �GV�2�,1(�� Telephone Number 112 0 �313
Address 2 cl ( �t 1 License# Q 1
J.1 V.-S`Z'C!U75 M��5 Home Improvement Contractor# I I C(o 6o b
U a•G +IE� Worker's Compensation#
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 BETAKEN TO '7t w 43 cs t
SIGNATURE (Q, DATE Il Ca
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
PERMIT NO.
a
i
DATE ISSUED a
MAP/PARCEL NO.
ADDRESS VILLAGE ,
1 i
.OWNER
DATE OF INSPECTION:
s f
FOUNDATION
FRAME.-
INSULATION r `
FIREPLACE`-
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUTS
l F r j
ASSOCIATION PLAN NO.
4
i
Lonunon.ctlealtA of 171wjach.adettj
�aPa�f.,:eRf n��'•nduafrcal r�cc
600 1/ whinyfoa Sty
James J.Campbell (3oJEon, Masad.,u a 02f f f :
Commissioner
Workers' Compensation Insurance davit
(aoeasedpQmiase)
with a principal place of business at: =
- c�i►•�zTa�
do hereby certify under the pains and penalties of perjury, that:
() I am an employer provid'mg workers' compensation coverage for my employees wort
this job.
�,USUf�,g ti.I✓L C• CIF /), AZANC a C4 / 4q .39S'
Insurance Company Policy Humber
() l am.a sole proprietor and have no one worsting for me in any capacity.
() I am a"sole proprietor, general contractor o homeown circle one) and have hired
contractors listed below who have the following workers compensation policies:
Contractor Insurance Company/Policy Nu
Contractor Insurance Company/Policy Hu
Contractor Insurance Company/Policy Nu
() I am a homeowner performing all the work myself.
;--. ccc�of ri< S_:e-:Ent wil!be fb:-4-reed to dw OM CC cf investiruors of d:e OTA for=Trm verificatier. and tint�iluc
ce�t,4e rEe_:Ed enter Sec cn 2:A of MGL 152 can lean to L IM esition of criminal penalties eorsisan¢of a fine of u:. to S 1,SOO.G
Years' im�ri<c-^ent wen as dvii ;enact' n e fes-cf STOP WORK ORDER and floe of ST00.00 a dr-vy arzi2t me.
Signed this day of
Ucensee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department
r U-. co rE r.cT 11FORM--'C? LL: 6 � -72^ =900 X4 3, 404 4a9,
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LOT LOT 24
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CHARL o TTE A VE
FLOOD ZONE: C. RES. ZONE: RF
THIS M0F2TGAC;E� -1 NSFPFC_' I ON PLAN IS FOR
BANK 'USE ONLY
TOWN: coTuTT REGISTRY OWNER: GARY & BETTY O' NEIL
DEED REF: 2773737 __BUYER: JAMES & SANDRA DANNHAUSER
DATE: - 9 2I 88 PLAN REFi9%39 SCALE: 1 '= 20
ere y certify that then ui inb
shown on this plan is located on p`AN Of ' � `rANKEE SURVEY
the ground as shown and it , / SSG CONSUL'7'<,NT'S
position does conform to the' PAMA. �, 70 RASPBERRY .LANE
zoning law setback requirement of o �O CA MASS
MILLS
RARNSTABLE _—. NO S MASS 02648
and does not lie within the special �4finzck �P�
flood hazard area as shown cn (gtiDSU
the h. u. d. flood nap dated
C'. 5 .,,, - - ;) e nr, not made from an instrument.
Paul A. Merithew, RPLS -V , not to be used for fences . etc
4673
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HE R POOLS / �� & HOME IMPROVEMENTS ,
P.O. Box 751 • Marstons Mills. MA 02648 • (508) 420-5373
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C*ck t'T
. The Town of Barnstable
• BAMSTAB
��g Department of Health Safety and Environmental Services ,
59. Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-775-3344 Building Commissioner
For office use only
Permit no.
Date
AFFIDAVIT
HOME E"ROVEMENT 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.
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Type of Work: kCO Rc,� Est.Cost
Address of Work: -1 � r%' R—La T7r- �� ` Cj/�—
Owner Name: J/;1 D,71.,JOL)/1 x1 U.-�;zi< -
Date of Permit Application:
I herebv certifv that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S 1,000
Building not owner-oa'upied
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.
6 J,
Da a Contractor name Registration No.
OR
Date owner's name
I _ .
'COMMONWEALTH DEPARTMENT OF PUBLIC SAFETY
OF ONE ASHBORTON PLACE
MASSACHUSETTS- BOSTON,.MA 02108 � �_;.= t > ►c-Kk�a 6•!137 F
LICENSE CAUTION
EXPIRATION DATE
CONSTR. . SIJPERVISOR
'
05 /
2 2 9 S 6 FOR PROTECTION AGAINSt t
RESTRICTIONS EFFECTIVE DATES LIC-NO. THEFT, PUT RIGHT THUMB
NONE �q'. 02/28/1994 042838
ON LI NSE.
A�64 -•a WARREN . F. SCHERER
(� ° 224 sq A R I °�E R C I R.C L E BLASTI p RA}T
', m CaTUIT MA 02335 - i
GAGEDINTHISOCCUPA110N.
y.
Fife&mxft�00!uaoaac�f� a
HOME IMPROVEMENT CONTRACTOR j
Registration 116666 {
Type -. INDIVIDUAL
Expiration 07/05/96
WARREN F SCHERER
_ WARREN F. SCHERER
MARINER CIR
ADMINISTRATOR COTUIT MA 02635
,Engineeripg Dept. (3rd floor) Map Parcel Pe_unit# 1 �
House# ,JE� Date Issued -3— q
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) trg e Fee
Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) 6
midlo
19 V .
TOWN OF BARNSTABLE
Building Permit Application
Project Street Address zt�",!5 -&, Abe-- r
Village
Owner L kl m o,S 104)/j/9 Address
Telephone �K 20 S/4.: �'/¢-'33 '7 Sn 9C-,
Permit Request ,�sf->>Z, 720
/il
First Floor / ���T' square feet Second Floor square feet
Construction Type Ze)aqz2 - STC/C
Estimated Project Cost $ ZZ22 /56n
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
I
Dwelling Type: Single Family !Zr Two Family ❑ Multi-Family((##units)
Age of Existing Structure /Z S-:O s Historic House ❑Yes 2'1 o On Old King's Highway ❑Yes
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other C7
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing Z New Half: Existing New
No. of Bedrooms: Existing 3 New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas d it ❑Electric ❑Other
Central Air ❑Yes ulf o Fireplaces: Existing y� —New Existing wood/coal stove ❑Yes & 1To ,.
Garage: ❑Detached(size) Other Detached Structures: ElTool(size) (4 2<�D-F':)
❑Attached(size) ❑Barn(size)
D'1Vone UShed(size) x
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
i Current Use Proposed Use
Builder Information
Name W , fR eo .('`,�� Telephone Number -A-QO
Address P,n { &k License# d1 2 82
'(N1.✓�d2 ,.sz-q-0v3 S Home Improvement Contractor#
/M Worker's Compensation# /- QU JR — 2_ X I Fj3- IV
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING XISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE _ DATE A-4
N-1
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
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I C ' 71,
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oT LOT 24 -
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L o T '2
Dear
a Deck
m Deck o
14 a 361 Q
L o T rn 35.9
15 2.9 77 5 O
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CHA L o T TE A VE*
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IFLOOD ZONE: C. RES. ZONE: RF
THIS M0F2TGAC:l� i r.iS>F, C-I- I ON PLAN IS FOR
BANK USE ONLY
TOWN: CnTr7TT R-EGISTiRY OWNER:_GARY_&_BETTY _O' NEIL
DEED REF: 2773 37 BUYER: TAMES & SANDRA DANNHAUSER
DATE: . 9 21 SS PLAN REFi9/3-3 SCALE: 16= 20
hereby certlty t at the, u—ll-dine /--�
shown on this plan is located on �� OF ' y�� �InNKEE SUF2VEY
the ground as shown and it I �o�' � CONSUL-T'sc�N-F
position does conform to thei PA►ULA. . 70 RASPSERRY .LANE
� � H
zoning law setback requirement of a E MARS 0NS MILLS
No.32096 MASS 02640^
R A R NHSTABLE _....__—.
and does not lie within the specla! \ ��OFESS���PQ
flood hazard area as shown on I \.4ti� SUPS
the h. u. d. ' flood map
�. — — +i:. ;� : ..r+ynot made from an instrument.
Paul A. Merithew, PPLS v riot to be u_erf for fcnce�et -
The Commonwealth of Afassachuselts
Department of Industrial Accidents
I•.i Y _ 1
t
Officeollnoest/gat/olts
"•' ''f' 'r;�'` 600 ti'ashingtr�n Street
Boston. A1ass. 02111
Workers' Compensation Insurance Affidavit
,5105t tnformatton• Please PRINT le� j
0 1 am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
_.�a•..• ..,.^-�---r..'.:�.",are-�.,�•p.:�+.r•..c+v�ss•,-L.*`.�..,.�rv?;�-► - --^!,�..+r-•-',•-h-.•...��..�...,n.......--Y-...*T+.-�-•—.-.�•.,,�.
I am an empi yer providing workers' compensation for my employees wor'•ng on this job. �—
am gym• n•i e- A.
�.
address:
phoneCit -
#•
37J
��. insurance co, #
I am a sole proprietor beneral contracto or homeowner(circle one)and have hired the contractors listed below who have
the followingwort• c • n polices:
cam 11 nm•nnmc•
I idres •-tit� t
ta: / VIA- e#• O>� i
insurance c . U licv# tl
++[!\t:.' ':7;t�ati'3-•r,!•:':�T'!tTaf�.t_ .f••-•ra�it��.1;<'Z7'.r,�7w••••�d,•:rlr:.^,`+..;�..i1 .�..:�:�,• ..:^Ri:'.�'C�r..�^i�
cempnnv name:
i
iddresc•
city. phone#•
insurance co nolicv# _
�Attac_h addi_tional•sheef if tieeess> � wT — — mow• :.:
.. � ;,2:-'a.�:j^q...ti^Y:npretseo`w—�. ..:r=t..�:. rC•.•--•'"._'.` �•"'•.r'•�' _� ...,.. �.
Failure to secure coverage as required under Section 25A of A1GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or
one%cars'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do herebr certij under the pairs and penalties of perjan•that the information provided above is true an corr/t.
Si_nature t ). r Date
Print name Phone
it. �warr - e`►'
official use only do not write in this area to be compacted by city or town of icial
city or town: permitAiccnse# riBuilding Department
OLicensing Hoard
O check if immediate response is required OSelectmen's Office
(:1licalth Department
contact person: phone#• I••IUthcr
VY.._�._ .�.-.••��:N'a'�.�., _ .VMS - - - - _-
frmistd,:()s rrA)
Information and Instructions
Massachu,�actts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an camp!►free is defined as every person in the service of another under anv
contract of hire, express or implied, oral or written.
An en►phover is defined as an individual. partnership, association, corporation or other legal entity, or any two or more of
the foregoint! enLagcd in a joint enterprise, and including the legal representatives of a deceased emplover. or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
owner of a dwellina 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 _rounds 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 -svho 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 boa that applies to your situation and
supplying-company names. address and phone numbers as all affidavits nay be submitted to the Department of
industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tlie
affidavit should be returned to tiie 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.
r
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'Ciry or•ro-,%'ns
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.
Tile Office of Investi=atioils 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.
r-a....-n...•--....,............—:-..,..,.-: --�...wv'-.`.+•ve��•.�...v.�.m-ate.!.. - ....-�..._ _ _
The Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 NN'ashinaton Street
Boston,Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
s
The Town of Barnstable
�
Department of Health Safety and Environmental Services
1"9. Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227 Building Commissioner
Fax: 508-790-6230
For office use only
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.
Type of Work: Est.Cost �l • V v
Address of Work•LT_� VV `
Owner's Name
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
_Job under S1,000.
Building not owner-occupied
—Owner pulling own permit
Notice is hereby given that:
EGISTERED
OWNERS PULLING TM� HO PERMIT OR _ME I PROVEMENTG WORK D WITH URNOT HAVE
CONTRACTORS FOR
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I her y a piy for a permit as th agent of th caner. /
(D
L
Da a Contractor Name Registration No.
OR
Dace Owner's Name
✓1 e �a�t�aancveall� v,'�.���JJr7C/�.JnlrJ
HOME IMPROVEMENT CON 1 RA(. TORS pF7 I 1 po 1 1 r)l l
ovws
oard of Rullding
One Ae lthur toh Place -' Room 1 :301
j f3osk.on , Massachllset.t.s 02108
I'10ME IMPROVEMENI- CONTRACTOR
Registration 116666 Expiration O7/O5/98
Type — INDIVIDUAL-
WARREN r- SCI.IERER
WARREN F . SCHERER
224 MARINER CIR
COTUIT MA 02635
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Restricted Tot e0 57833
DEPART!TIT Of PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE 00 - Nme '
Nusber: - Expires:
1G - 1 6 2 easily Roses
Restricted To, 06 failure to possess a current edition of the
Massachusetts State Buiildiag Code
WARREN F SCNERER is cause for revocation of this license.
224 MARINER CIRCLE'
COTUIT, NA 02635
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! Lot � I
LOT 24
23
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LOT 8 ; 17 Decor Q!
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CHA/Mi'll. 0 T TE A VE.
FLOOD ZONE : C. P.l--. ZZONE: RF
THIS MOF2-T-C<�C�;r-= T (`1�[�C=t=-I- - PLAN IS FOR
BANK USE ONLY
TOWN: ColuTT _GISTRY OWNER NARY & &EI-f= - EIL
DEED REF: 2773 37 81JYER: JAMEE & SANDRA DANNH! USER
DATE* - 9 21 88 PLAN i<E i-9_/3a__ - -- SCALE: 1 ' - 20
hereby certify that the Eau i irk I
shown on this plan is located on /�,p�N" Of VANKEE SURVEY
the ground ns shown and it ` o� �G CONIsUL_T'ANT"S
position does conform to the, �� PAUL 70 RASPBERRY .LANE
zoning law setback requirement of 0.32 11 N MARSTONS MILLS
9ARi�]S 7AB .F. __.--- __--- fro 320ee` MASS 02648
and does not lie within the .���ecfsl �OFESS%
flood hazard area as �hc:.rr, or' �\4,vD VE���
the h. u. d. flood map dat ,?�!
a. riot Wade from an instrument
{ Paul A. Merithew, RPL.`. - :urvc• , not. _o be used_ for forces , etc___ _
- — — ��73
)r's Office(1st floor) Map Lot ermit# q?7�f
.� AA
ation Office(4th floor) V \— off-aft., ctJ Date Issued
d of Health(3rd floor)(8:30-9:30/1:00-2:00) e • D�
. gineering Dept.(3rd floor) House#1 C SYSTE BE
Planning Dept.(1st floor/School Admin. Bldg.) - INSTALLED IN WITH�, �` � L.E.� ���
Defi 'tive pproved by Planning Board 19k�"�iBi� RliE�l�' , � � � ✓
TOWN OF-BARNSTABLE.
r
Building Permit Application t
j
Proje S Address ' �.�.��47)77-C / tle,- ,
Village C,Tyj 7—
`
Owner y ,n.►y c Via t 1 sJ �►AU� ✓Z_ Address w►C_
Telephone Aoo (.4
Permit Request t 9 t L� S CC, e IX Q
Total 1 Story Area(include 1 story garages&decks) -/��a uare feet
Total 2 Story Area(total of 1st&2nd stories) square feet
Estimated Project Cost $ A t S''OO • ��
Zoning District Flood Plain Water Protection
' Lot Size Grandfathered?
Zoning Board of Appeals Authorization - Recorded
Current Use Proposed Use
Construction Type b)OGO 4�cAw`Q
Commercial Residential
Dwelling Type: Single Family ►// Two Family Multi-Family
Age of Existing Structure ` T1 2< , Basement Type: Finished
Historic House Unfinishe 1L 3-02 Ip
Old King's Highway
Number of Baths 2 No.of Bedrooms 3
Total Room Count(not including baths) First Floor 3
Heat Type and Fuel 1 Central Air Fireplaces
Garage: Detached. Other Detached Structures: Pool L 4 8 t K)Grco i 6D
Attached Barn
None Sheds
Other
Builder Information
Name W r lZe'l�, &,kt° cp— Telephone Number
Address `acy Z� (� �r�S ,((S License# 0 A Z 46 3
Home Improvement Contractor# 1 r
Worker's Compensation# c 11 4 4 3 Q S'
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 BETAKEN TO
w rt1 ,
SIGNATURE DATE ( S
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY -
PERMIT NO. #9874 � t
L
DATE ISSUED August 23, 1995 '
MAP/PARCEL NO. 018.092
ADDRESS 5 Charlotte Avenue ' VILLAGE Cotuit, MA 02635 !
OWNER Sandra Dannhauser '
DATE OF INSPECTION: _
FOUNDATION
FRAME '
INSULATION
- w
FIREPLACE
ELECTRICAL: _ , yROUGH FINAL -
PLUMBING: _'.'.'ROUGH FINAL
GAS: ,'ROUGH FINAL . '
FINAL BUILDING-
r
DATE CLOSED'.OUT;
ASSOCIATION PLAN NO.
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The Commonwealth ttf Atassachusetts
� i� •'__.y:�;_w Department of Industrial Accidents
",•.\' #;• y', 600 N ashinl;ton Street
,�� • �'' Boston, A1ass. 02111
Workers' Compensation Insurance Affidavit
.-_.,-.,ter .-...`..,..-._... -._..r,,.•- ....... ..-,._�i__. .�� ._-.�.•. •:avi^n+Vwr.�n».art.;:"c•,•!+��"�^.!wry-�,-..-.-••:•• -
Annitcant information•••• •' Please PRINT leetbly ,� ,
name;
locition: 4/
phone it
I am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
• .75.. _pw�.��+c'��''�;%.T•::rR:L? ismavr.!a�p'�7.'!47T•V9t,.:" *"'•iP!.T.!!gSAY.+"^f. Pl^. �"�"�°•�tT""',!.' h� '�'T.•e='�', r. •r,.+v.•,�wt..
S.w....:ti..::.• '..:�:+:i/�.c31's •-._..r:, sarii<w:+w-��. _.�,Yi�-'--...:.,.�' •'".r�:r�C..W....:: .'.:,-d�Ry-.Y:. .:.;:.�::_+.. __ _ .�.-.. t::.G�.'���f'..�...�.._....:..:.�
1 am an employer providing workers' compensation for my employees working on this job.
company name-
address:
city: phone#•
insurance co policy#
,..».ow.:...-�.,..s+ ........wv-.^ r+••�
1 am a sole proprietor, eneral contractor or homeowner(circle one) and have hired the contractors listed below who have
the following workers compensation polices:
company name:
address:
may• phone#•
insurance co policy#
._.....R'='::.. '.a.::.::�•;.;.. - ,a)ry a.��ov-a:�r,•r'•.'.�•"Y�..aL+.'�+ �•!;�T.^:�:.,r ::.r..w�•;:�TR' :p_r•r{++• +^..-..-^sue
! ...� _- - - .._ - -s;"T^•c�T.._.^.�t�,y7;:f,r.�p1n7'�jTT." ,t ��.e .:.ti;;ii ti':��'
...».__,..._...�._.. .,..-.. .•. ^n: ._ — ..fir r8', - :a.raz::cc
ctimpany name:
address:
city Phone#:
insurance co policy#
i6_n' , ......_, ,_.._ r.,.._ _�. .. ..
:Attach addtbonal sheet dnecessary:_ Y�e T`ssr rR,.' .;-- ;tzrs ''c•.' +• y '� ,, ;� z�;
Failure to secure coverage as required under Section�25A of INGL 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 NVORK ORDER and a fine of S100.00 a day against me. 1 understand that.a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
1 do hereAv certify under the pains and pe tallies of perjury that die information provided above is true and correct.
Si:nature Date
Print name �A� alpf,- �r.�,e Phone# Aa S-2 1
official use only do not write in this area to be completed by city or town official
city or town: permitAicense# nBuilding Department
oLiccnsing Board
check if immediate response is required OSelectmen's Office
C3I1calth Department
contact person: phone#; r'IOther _
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(revised 3195 P1A)'
Information and Instructions `
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted tom the "law", an e►nploree is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An etnpinrer 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 emplover, 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 emplover.
MGL chapter 152 section 25 also states that even,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 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 tite 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. Tile affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
Tile 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.
rtwaorr+.. .............-.._•.-..,,r.•.-.._.-•�. .rrw.. .u.+R-;s:tc�:'- _ ..>-.vsiw_+s+!!�T.,...f.,o� F..!+v.+rt,�o.m.rw—n—w.e....f.—"'•_+.�w+n—s..a -rr.•,=.wi..w�•y,�vs.y.
The Department's address, telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations :..
600 NVashington Street
Boston,Ma. 02111
fax #: (617) 727-7749
phone #: (617) 727-4900 cat. 406, 409 or 375
Fv
•0.,�.f* :W Y-'r�v..:px�gc ``-.,•cam F'0`S'S '.
+WINONE.IMPPROVENENT CONTRACTOR t
'Registration 166 I
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r :T ea°INDIV �•'
P
IDUAL M7,
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, u 'EXPiraion 01/05798
t�X� WARREN F SCHERER
WARREN F 5W§E—R r f
(���e��', .••. �lIARINER��CIR�' . � �"�"�_;��
ADMINISTAATOW TUIr 02635
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,p� �ie Uarwmonaea�c o�./�aaaar,�ivaetla��
DEPAk! '�ii� OF PUBLIC SAF-71Y
CU\STo{!C"_itk SuP"kVISQP,-�IC_VS3
• CS<'.':.�_@428I8`� 0i(%2/19°3
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�` o Town of Barnstable
The T° mental Services
• 1 d Environ
• ' N"s Department of gealth Safety an
see¢ Building Division
367 Main Street,Hyannis MA
02601
Ralph Crosses Building Commissioner
office: 508-790-6227
Fax: 508-790-6230
For office use only
Permit no.------
_ Date AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
onstrnction, alterations- renovation, repair, modernization+
wires that the "T� preexisting
MGL c. 142A requires demolition, or construction of an addition to any
units or to
conversion, improvement, removal,
building containing at least one but not more than four endwelling
ed 110 gractors, with
owner occupiedadjacent to such residence or building be done by registered
structures which are with other requirements.
certain exceptions,along
Est.Cost
Type of Work:
Address of Work:
Owner's Name /
Date of Permit Application: l (�
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under SI,000.
Building not owner-occupied
Owner pulling own permit
UNREGISTERED
Notice is hereby,ULII�IGha TIMM OWN pERNIIT OR DEALING WO�RIC DO NOT HAVE
OWNERS
FOR APPLICABLE HOME IMPROVEMENT FIND UNDER MGL c.142A
C �B�TION PROGRAM OR GUARANTY
ACCESS TO T� `
SIGNED UNDER PENALTIES OF PE&MY
I hereby apply for a permit.as the a °f ° .
1. Registration No.
9 — Contractor Name
Date
OR.
owner's Name
TI�rP