HomeMy WebLinkAbout1855 SOUTH COUNTY ROAD 8� SCUT4 C-Oxj,NTY
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel 6d3 —00, f)w Permit# - 7701"
Health Division /c 1 Date Issued
Conservation Division 12 3 D4k ex.Aft Fee 7
Tax Collector SEPTIC SYSTEM MUST Bl
INSTALLED IN COMPLIANCE
Treasurers` — WITH TITLE 5
Planning Dept. ENVIRONMENTAL CODE AND
Date Definitive Plan Approved by Planning Board TOWN REGULAMPObti.S
Historic OKH Preservation/Hyannis
Project SfreetAddress 1855 South County Road
Village Marstons Mills
Owner Mr . & Mrs . Richard Clarlc Address 1855 South County Road , MM
Telephone
Permit Request An,,kSwirnrning Pool_ Ao X 4d
Square feet: 1 st floor: existing- proposed 2nd floor:existing proposed Total new
Estimated Project Cost $30 ,000 Zoning District RF Flood Plain Groundwater Overlay
Construction Type
Lot Size 5 .45 Acres - Grandfathered: ❑Yes O No If yes, attach supporting documentation.
Dwelling Type: Single Family O' Two Family ❑ Multi-Family(#units)
Age of Existing Structure W`� Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: gull ❑Crawl O Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing 1 new
Number of Bedrooms: existing new
Total Room Count(not including baths): existing 1 new First Floor Room Count
Heat Type and Fuel: QGas ❑Oil 0 Electric ❑Other FfhJ
Central Air: ❑Yes Ga/No Fireplaces: Existing o2 New Existing wood/coal stove: ❑Yes ❑ No
Detached garage:O existing ❑new size Pool:®existing U new size 20x40 Barn:O existing O new size
Attached garage:C(existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization 0 Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Ke51 APA-'f &t__ Proposed Use
BUILDER INFORMATION
Name -E .J -Jaxtimer , Builder , Inc _ Telephone Number 778-4911
Address-48 Rosary Lane , Hyannis License# 00325l
Home Improvement Contractor# 110609
Worker's Compensation# wcA7-6ASO2R
ALL CONSTRUCTION D RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
PERMIT NO. 30ilb .
DATE ISSUED f
MAP/PARCEL NO.
ADDRESS "VILLAGE
OWNER a
DATE OF INSPECT
FOUNDATION _
FRAME
INSULATION
FIREPLACE '
ELECTRICAL: ROUGH' FINAL `
PLUMBING: ROUGH FINAL
GAS: ROUGH + FINAL
FINAL BUILDING
f •
DATE CLOSED OUT _
ASSOCIATION PLAN NO.'
Assessor's map and lot number a ........�.......,.. .
�0F TN E T0�
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Sewage Permit number ..................�..!..: ...... ..
Z AR35TADLE, i
11 B
K House number �' ,j
�0 MA-4 A,.
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .. Ji`�`�,.....t2;SSE':?f'44-.... e... ea,�nS..t.•.::r;?�r. .............
j
TYPE OF CONSTRUCTION ..... .....................:.........................................................
..............................19c :4
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: .
Location ....�^!S. rn... `� ......J.o;�� CnU,..3-�v Q:r�;,:}....(�'�l r�s c-n..ti�c...M�.: 5.�..N1✓a:......... ..................
ProposedUse R4 <<in�r.,.a �. �.-:..............................................................................................•............... ........ .......................................
Zoning District ..........Fire District .... ........•••
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Name of Owner ' C• C . R�a .......................Address .�,C;t 1��}..�:... T ..... 1-?! �y..(''�A::................
Name of Builder �1.: C,"C"�•r�F..i(L.....................Address -E'.:r.a`�. .. .:�.�.4.,�. ........n't✓�............... ......... ................
Name of Architect .17.A �...Ak ...Cc ! �. a�.................Address ...GiQ !'1.. 2: ..�.,.(` ✓1,.................... .......
Number of Rooms .........ko...................................................Foundation ....
Exierior ... ...Roofing .... T' ...........
Floors ................. .Interior ... ..............................
Heating .. :.0: .........C.� c-•: ._...:..... Plumbing .... :...... Q S`i'1. .............................................._
Fireplace ........................:........Approximate Cost ....2-,06, e?nC�.:..........:....:.........................
Definitive Plan Approved by Planning Board ________________________________19-------- . Area ........:... ..
Diagram of Lot and Building with Dimensions Fee ..........:::.......
SUBJECT TO .APPROVAL OF BOARD OF HEALTH
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.
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..�Name ...... ..... . ....................................................
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Construction Supervisor's License ................
R. C. B. CLARK A=98-23-2
No .?7364..... Permit for ...One StorX............
Single Family..P�q-iiqcj
.................................
Location rt
.................................
.................. ..............................
Owner ....................................
Type of Construction ......Frame.........................
...........
................................................................................
Plot .............
............... Lot. ................................
December 31, 84
Permit Granted ................................. ......19
Date of Inspection ....................................19
Date Completed ..... .................................19
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TOWN OF BARNSTABLE
y�' ���•'" BUILDING DEPARTMENT
= aARNST = TOWN OFFICE BUILDING
'639• HYANNIS, MASS. 02601
MEMO TO: Town Clerk
FROM: Building Departmen
1
DATE:�.'
An Occupancy Permit has been issued for the building,authorized by
Building Permit $k... -'-V �'0 , .. , ............._.........
_
issuedto ......_............... � .. .:._. :`�.,1 ..... ...........................................
,t
t. Please release the performance bond.
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Y r' �7364
4 `o• ° ti 'TOWN OF BARNSTABLE "- Permit No. __________=__:._________
,Building Inspector �.-
j ,• Cash
OCCUPANCY PERMIT Bond
Issued to R. C. B. Clark. Address
lot 42 1855 Main Street. Marstons Mulls
Wiring Inspector v/ �r / k /Inspection date �/��
Plumbing Inspector�.. .n� �! Inspection date
Gas Inspector - Inspection date
j/Engineering Department , `Inspection date
Board of Health �r eInspection date ���-7/YJ i
V
THIS'PERMIT WILL NOT BE VALID;-AXD THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
2
...................::p.................. ._.. , _.._ _
/ Building Inspector
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CERTIFIED PLOT PLAN N
LOCATION BA.e,vsrAOGE &V,45TOA/S,
•
SCALE . / .=. .yo. . . . bATE DEc
PLAN REP-ERENCE . .BC/.vc7 [or '� Z
AS e5-NOWAI ON Ll�ti/D Coul?.T 4110E
EDWARD _
KrE 4
O
e FG/STV oe
CERTIFY THAT THE ,.�`��ST/N(7. "GilNDfI770.Ar) �*0 sualk
SHOWN ON THIS PLAN IS LOCATED ON.THE GROUND
AS SHOWN HEREON AND THAT IT-CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
B.geNS7'q$�E . . . . . . . . WHEN CONSTRUCTED.
DATE
c A�
r REOWERED LAND SURVE. R
Assessor's map and lot number ....... -a . . . .c2
EPTICSYSTEM MUST3�
THE
F5q INSTALLED IN COtAPL
Sewage Permit number ..................................... H TiTLE 15re
. ....40
WIT
AR33TAXE,
F MASIL
House number ........ 2! ENVIRONMENTAL 0
............................................
TOWN REGULA t639-
0 MAI
TOWN OF BARNSTABLE
BUILDING INSPECTOR
-APPLICATION FOR PERMIT TO ...............
TYPE OF CONSTRUCTION ..... ....................................................................................
i.
. . ...........
TO THE INSPECTOR OF BUILDINGS;
The undersigned hereby applies for a permit accordin to the following information:
Location .... ....... ........ ........S.
...............................
ProposedUse ..... .....................................................................................................................................
Zoning District ......9,-F..........................................................Fire District .... ...........
Name of Owner ... ......................Address ....ST r .................
Name of Builder .....................Address ._.....(.`:?'.la............................
Name of Architect P.A.Q.�,0... ................Address ....<,#A. . ....In XA..............................
Number of Rooms ..........10...................................................Foundation .... .........................
Exterior ... :.......................................Roofing .....A6?.H.V-
.......................................................
Floors rl y....................................Interior ...soec--m o RN....................................................
-
Heating ...F�.3A,Q. ........ .........................................Plumbing. .....V12 ......QW.r.-A.4..............................................
Fireplace ...�nA 2-06
Q) L V-�.................................Approximate Cost ..............9.000.....................................
Definitive Plan Approved' by Planning Board -----------------------------19 "Area . ......
0 6,*,�
Diagram of Lot and Building with Dimensions F&6 ...........................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
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.
-yy;-4- --a...........................................
Name .. ..........
Construction Supervisor's License ...............
1
R. CB. CLARK
4'No „27364.... Permit for ..One Story.............
.......Single Family Dwelling .r u...
Location Lot 2, 1855eet
Marstons Mills
Fx
Owner ...R....C.'..B-....Clark.............................
Type of Construction ....Frame...........................
Plot ............................ Lot ................................
Permit Granted ... ecembe.r..31.,. . 1.9 84
... .. .... Y^
Date of Inspection ....................................19
... :l '' .......19 Date Completed '
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The Town of Barnstable
'• BARE. Department of Health Safety and Environmental Services
MASS. g
Eo � Building Division
367 Main Street,Hyannis,MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice .
Type of Inspection
Location I (a �` ��� Permit Number � Z7
Owner Builder
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
STD D P,17 JE
G „1 t
Please call: 508-790-6227 for re-inspection.
Inspected by
e
Date _ �' 9
(mot,LG
Tc)oL
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Engineering Dept. (3rd floor) Map J 91 Parcel d�3 QQQ7 �Permit#, y 2-0
House -5 -� 6 Date Issued
Board of Health(3rd floor)(8:15 :9:30/1:00-A+ ) o �rJ
Conservation Office (4th floor)(8:30-9:30/1:00-2:00) Z
9
Planning Dept. (1st floor/School Admin. Bldg.)f Q EV BE
Definitive Plan Planning Board = `19 oiLTrAivLiT ANCE
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TOWN OF BARNSTABL '�'S 4e " AND
Building Permit Application
ProjectStr ss •1855 South County Road
Village 'Marstons Mills
Owner Mr . & Mrs . Richard C .B . Clark - Address 1855 South County Road , Marstons
Vitt s
Telephone 4 2 8-5 2 6 2
Permit Request Build New Pool , House �X n2k` 1
r '
First Floor 532 square feet Second Floor square feet
Construction Type Wood Residential
Estimated Project Cost $ 40 ,000 .00 - :{
Zoning District R F Flood Plain No Water Protection No
Lot Size 5 Acres Grandfathered ❑Yes ❑No
r
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 Slab Foundation
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New 1 Half: Existing New
w No. of Bedrooms: Existing New
Jotal Room Count(not including baths): Existing New 2 First Floor Room Count 2
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes a 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 ❑No If yes, site plan review#
Current Use Proposed Use Pool House
Builder Information
Name E. J . J a x t i m e r , Builder , Inc . Telephone Number 7 7 8-4 911
Address 48 Rosary Lane , Hyannis License# 003251
Home Improvement Contractor# 110609
Worker's Compensation# Vd C 9 7-6 9 5 0 2 8
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
Maco M is Dumpste
SIGNATURE DATE cc
BUILDING PER DENIED FOR THE FOLLOWING REASON(S)
v FOR OFFICIAL USE ONLY - r • .
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: �^
FOUNDATION
FRAME
INSULATION �� �Sy o A. /OL);�i �Uow)
V.
FIREPLACE
- } t
ELECTRICAL: ROUGH FINAL '
PLUMBING: ROUGH 'FINAL a -
GAS: I ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT c�
E
ASSOCIATION PLAN NO.
L� m
153423
DEPARTMENT OF PUBLIC SAFETY 153423
=_ ONE ASHBURTON PLACE, RM 1301
BOSTON., .A 02108-1618
CONSTRUCTION SUPERVISOR LICENSE �x `i
Number: Expires: B r-thd
CS 003251 01/14/2000 =1�5
Restricted To: 00
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ERNEST J JAXTIMER
ti
48 ROSARY LANE o *T —
HYANNIS, MA 02601
^+ `. spa Keep top for receipt and change
of address notification.
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HOME IMPROVEMENT CONTRACTORS. REGISTRATION I
Board of Building Regulations. and Standards I ,
One Ashburton Place 1 71301 Ro t.
Boston, Massachuset 08 i
# HOME, IMPROVEMENT- CONTRACTOR` °' -------------- --,---
------
Registration 1.10609 ExpiratxeTj1,/43/00
Type = PRIVATE CORPORATION
I. HONE IMPROVEMENT CONTRACTOR
4; J Registration;aIQ609
E J JAXTIMER, : BUI'L_.DER , INC. I TYPe - PRIVATE CORPORATION:, jj
�- --_- ERNEST, J . JAXT'IMER I Expiration 11/03%0O- i
,48 ROSARY .L.N i 1
I
HYANNIS MA' 02601 E
1 J.JAXTINER, BUILDER, INC,
ST J. JAXTIHER 4
eeM�o i �e ROSARY LN
ADMINMTRA7bR`
: I HYANNIS HA.
02601 . . rt
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Zr '
----3 The Common wealth ofWassnclr uselts
Depart»tclrt oJLtdustrial Accidents
� -��_�� f-� � OfTce•oll�:�1�eSU.�aUOnS
MAP PARCEL
-�` --' 600 Wash in, Street
Boston, Mass'. 02111
Workers' Compensation Insurance Affidavit
--'—�z----- --- •F..__=L_S,il$c�1...¢titi\ tP�.l!t!t i_ _ ;5.),. ` - __ ::ice-�`�._'n?.°._`-'.=sl�t`�R.�.
E.J. Jaxtimer, Builder, Inc. -
�amc:
98 Rosary Lane.
Incalinn;
Hyannis, MA 02601 �
(508)778- :911
[l I Pm a hone ow-ncr perfornling all Nvork myself.
O 1 and P sole prof.ic:07 end have no One Nvorkin'- in all)'c<'.paCli)'
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1 Pill all CMP10)'Cr pro\'ldlllo\5'Ori;CIS' COti1DCi]SatiOn fof m}'Cn]p10VCCi\VOf};Irl�on di is Job. —'
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I atn a s�!.,proprietor,general contractor,or hot�eo�vner(circle one)and have hired the contractors listed below who have
• the following workers-':compensation polices: � _ .' -
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ncc ura`-'`s �" ...... ...... :.:: ;:<::.;';�::;<.;:-::<:.;::.;'.:;:<::.>::>::::»'.>-%::;;:::>::>❑ Ito�: :::::.;::>:>:;:.�:::::::;::;::�:::<�;.::;.: ;....:: ��.:;,:,•.'...:. ��'::�::.�>:;:.:;.;.:;
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::3 Failure to secure coverage as required under See tion 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/ors
one years'imprisonment as well as civil penalties in the f( m ofa STOP WORK ORDER and a fine ofS100.00 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.
do hereby V'fel
the pains and penalties ojperjury that the information provided above is true and correct.
Signature Date L. -1 Q
Print name axtimer, Builder, Inc.. Phone 778-4911
official use use only do not write in this area to be completed by city or town official -
K
city or town: permit/licensc k Building Department
C]Liccnsing Board
j Q check if immediate response is required Qiclectmen's Office
01-1calth Department'
contact person: phone q; rl0ther
(revised 3/95 PIA)• ,..,, ���. .-i
.. •. :.\1 .. - 1 li i� �99''�c;� �{4 �1'�5,7�.,� �. S!e'v.
1 ;19`8 12:21 5084 0:115 i *,r 1
SUUL_., trJ �.`Ir; PAGE 01
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: . The Town of Barnstable
• ILAaxarnBM •
MASR Department of Health Safety and Environmental Services
039.39�'' Building Division
367 Main Street,Hyannis MA 02601
Office: 508-8624038 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
requirements.
Type of Work: I n CD iAd �w l to rx l b0 L Estimated Cost
Address of Work: cSv• cl ek,t 1/ ed, / t aly �f S
Owner's Name: �/L �Q ue<4/C
Date of Application: L 31 l�l
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 theagept of a owner:
0
Date 71Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affldav
we work closel Wth you . . .
y
from planning.. . through c&ws -� . . .
Once having decided to enjoy the pleasures of owning a swimming pool,a
family must decide what type and size pool it should buy.
Smooth transition from bare lot to beautiful setting and fun from the first a
day of completion—are the signs of a competent designer and builder.The _
single secret is Ferrari's skilled planning and construction methods R
developed from solid,successful experience. ' S
Because of a perplexing array of sizes,shapes and designs,it would be r.
extremely difficult for the family to make a wise decision alone,but a trained . '
Ferrari Pool Consultant solves this problem quickly and easily.He is a - =mil t _ Ptu,
knowledgeable designer with extensive pool planning experience gained crew
from working on hundreds,perhaps even thousands of personalized pool - heater, n!
designs.From his knowledge and experience he helps each family choose other men
part of th
e(
the right pool to meet its individual needs.Since all yards are different,your
Ferrari Pool Consultant will advise you on the right pool to blend with the
decor of our home,and to fit our individual needs,requirements and `"'d°1."
y y q �'-� Steel-A grid of steel reinforcing rods is
budget'...the ONE exactly right for you! 2 laced together at specified intervals.Just as the
Excavation-After permits are received, the skeleton supports the body, so do these heavy steel
Consequently,the proposed pool location is carefully examined.The size .earth-movers" will begin working. While the reinforcing rods support and strengthen the pool.
and shape of the lot,landscaping,terrain and maximum sun angle must all excavating equipment is operating, your pool is Ferrari always adds extra steel at the deep end and
p g break areas, as well as in the bond beam.
being skillfully hand shaped with exacting detail to
be taken into consideration.Because a Ferrari Pool is a permanent addition meet Ferrari's engineering specifications. The proper
to the home,it must be carefully planned to be a beautiful and integral part piece of excavating equipment is chosen to most
of its surroundings.The shape must be pleasing and practical,simple or efficiently meet the needs of your own particular _ .
elaborate.Do you want to view the pool area from inside your home,or do backyard site. _
you need privacy?Since no two
families are alike,no two Ferrari
Pools may be exactly alike.
Once these decisions are
_ • r<c*
made,the plot plans are - by�r
drawn to scale and templates /
of pool designs are positioned
to determine where the pool "' �y \ pttz
location should be according i ,..
DeckingBecause the deck is such an
to your needs and local `' 1
G important part of the pool's beauty, only
ordinances.At this time a I f the finest quality material and the best
complete plan is drawn and J ° = l: C.el,11 craftsmanship are used. Decking is laid in
integrated with Ferrari C Tile 6 Coping-Now the pool is ready to receive its conformity with individual pool design and
constructions specifications. J first touch of glamour! Every beautiful tile is carefully customer needs. Decks come in numerous
P textures, colors and treatments. (Of course,
inlaid in the pool wall at the water line, and piece by piece, non-skid surfaces are preferred.)
the coping is edged into place. Ferrari is consistently searching
to obtain tile patterns and colors that have won decorators
awards for out-standing beauty, all for your personal selection.
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The Town of Barnstable
HAM Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA M60I
Ralph Cr==
OtI'= 99-790.6= Budding Cammisrc-
Far 30&790-6Z30
For oMce use only
Permit no.
Date AFFIDAVIT
SOME ZWROVEMENT'CONTRACTORZAW
SUPPLEMENT TO PERMIT APPLICATION
h1GL c. 142A requires that the mn=nstrncdon, alteradons, renovation, repair, moderninaon.
eom►ea.on. improvement, removal, demolition, or construction of an addition to any pre-eristiag
Omer occnpied building containing at least one but not more than tour dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors. with
eemin czception&along with iother requirements.
Type of Work:
yp go
Address of Work:
owner's Name_ R IC. IrG�• —
Data of Prx=it Application:
I hereby certify that:
Registration is not required for the following renson(s):
----Work ezduded bylaw
Jab under SI.000.
—Budding not owner-occupied
Owner pulling own permit
Notice is hereby tbat: OWN PERMIT OR DEALING WITH UNREGISTERED
OWNERS PULLING TIMM O�
CONTItACI'ORS FOR APPLICABLE
PROGZAh OR GUARAf=FUND UNVEIL MGL 142A �
ACCESS TO T8E ARS
SIG= UNDER PENALTIES OF PEP-My
I fib,appiy for a•penart as the agent of the owner.
.� .J� -hnu r _
2 Camtractor Name Begisaation Na
Date
OR
Owner's Nume
Date
_ The Commonwealth ofMassachusetts
Depattnient of lndustria!Accidents
_ Met.of1rlYesUg2Uans
-' 600 Washington Street MAP PARCEL
Boston, Mass. 02111
'Workers' Compensation Insurance Affidavit 7
al—E ii l:- nff mot`> c% ;' c`e:dean: 7wti Y.z �l"dC rli. c•:. Tr^ --�` .icy Q,;• a _� ^F� t. a �� yi
-f t77: t1 m� ..:i• r '�. ~�+ (_ '{ t� �I l�t-:i9•.:ts. a., �.Y%;a`.�:,:s�'.���^a =�..a: -.,:�.. x• �:.
E.J. Jaxtimer, Builder, Inc.
name:
location: 98 .Rosary Lane.
�t� Hyannis, MA 02601
phon� (508)778-4911
1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
.;: ... r:.e"L-f".1... .�.<..:a,-r.,_r::,c.:.::`ri•v;:�}r::ca-a aa.�6�.c. +=_n.-i-.1.-•..
(� I am an employer providing workers' compensation for my employees working on this job.
:...:.:..::.::.:...
..... ........... .:. ........ ......
nany.namc. ... ....
:..L:ane
phon
c
insurance::co......... 1~e..:..:::GaSUd: . .,:.:rnSuza 1C2:::C•::::.Y
p }
I am.a sr�!:,proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers'.compensation polices:
;::.:
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or, ar ..
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agar
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l_s _ ous
i
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a(ire up to SI,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement ma` e forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certij the pains and penalties of ury that the information provided above is true and Corr cf.
Signature Z. .. Date
Print name Jaxtimer, Builder, Inc.. Phone# 778-4911 -
s official use only do not write in this area to be completed by city or town official _
city or town: permit/license N -Buildin Q Licensing Boardg Department
i
Q check if immediate response is required QSelectmen's Office
QHealth Department
contact person: phone N; -Other
1'Ui
(raised 3/95 PJA)
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oil .
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�01 PE~Tt:R Nr�l sue+ • pa�l,N o�SE Sl i� Q(AN
r REV{S�D 4a•24 `�
CERTIFIED PLOT PLAN
LOCATION
Q�i;�wsr�
SCALE . �.��.''a'...... DATE
PLAN REFERENCE
�n���i F;��• /�'L'As�/ Loc7o B
ECG•ir .. . . .. . . .. . . . . . . . .. . . . . .
0. 2 A
ICERTIFY THAT THESHOWN ON THIS PLAWli iiCATED ON THE GROUND
:' /"!G �vicDi;yG
LRN'�s�;' AS SHOWN HEREON AND THAT T CONFORMS 70 THE
SETBACK REQUIREMENTS OF THE TOWN OF
. . .. .WHEN CONSTRUCTED.
DATE oXtjg:.�j 1?84 �+
,Q C. B.
REGISTERED LAND SURVEY R
-P 153423
DEPARTMENT OF PUBLIC SAFETY 153423
ONE ASHBURTON PLACE, RM 1301
BOSTON,%MA 02108-1618
M CONSTRUCTION SUPERVISOR LICENSE
Nurribe;r: Expires: B�:.rth.da-te-:-;=-=
CS 003251 01/14/2000
Restricted To: 00
x w
`'1 �!
m
ERNEST J JAXTIMER "� w
ti
48 ROSARY LANE o9 t� Cry,
HYANNIS, MA 02601 �
Keep top for receipt and change
of address notification.
I
� - I
° HOME , IMPROVEMENT CONTRACTORS REGISTRATION i
_- Board of Building Regulations and Standards I
One Ashburton Place Room 1301
Boston , MassachusettS .02,108
: --L- ----- -- -- --
HOME .IMPROVEMENT CONTRACTOR ` ' ----- ------ - _a_
Registration 110609', Expiration,,',._, ,,,
Type- PRIVATE. CORPORATION t
HOME IMPROVEMENT CONTRACTOR
1 Registration, 110609
E , -,JAXTIMER',' -BUILDER, ' INC . Type - PRIVATE CORPORATION II
..ERNEST_ J'.- JAXTIMER I -Expiration -41/03/00
I
48 ROSARY. LN. I
,- H_YANNIS MA 62601 E J JAXTIMER, BUILDER, INC
` ���f�EST J JAXTIMER.•
�''' o ROSARY LN
ADMISTRATOa ' HYANNIS MA-02601
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