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'THE 2012 Town d Barnstable Permit#
Tpw °k%y Expires 6 mon hsfr nr issue date
Regulatory Services,. Fee
BAMNSrA
MASS' Thomas F. Geiler,Director
1639.
�lFD Mp't A
Building Division
Tom Perry,CBO,.Building Commissioner
200 Main Street,Hyannis,MA 02601
www.t o wn.b ams t ab l e.m a.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number i Ll
Cf
Property Address s 3 l UJ4 py' e"i k— •1�C<<S
P �
residential Value of Work Minimum fee of.$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name :T)A u 1t:1 Telephone,Number S'��'ZllU-may
Home Improvement Contractor License#(if applicable) I (`I 5101
Construction Supervisor'.s License#(if applicable)
❑WorkFa
' mpensation Insurance
e:
sole proprietor
❑ -lam the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy.of Insurance Compliance Certificate must accompany each permit.
Permit Request check box) _
Re-roof(stripping old shingles) All construction debris will be taken to Loci
0 Re-roof(not stripping. Going over existing layers of roofl
Ed/Re-side
#of doors
❑ ReplacementWindows/doors/sliders.U.-Value (maximum .44)#of windows
*Where required: Issuance of this'permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
ontractors License&Construction Supervisors License is
A copy of the home Improvement C
required
SIGNATURE: ��L �.
Massachusetts
Department of.Public Safety
Board of Building Regulations and Standards
Cunstructiun Supcn•isur 1 &2 Family'
License: CSFA-057540
217 A TMEB19
SV MA 02648
MAggTON _ y
-r p
V'%%%a Expiration
Co1r►missioner
1212812013
i
I _
U registration valid for ind vidul use only
��iLe � Bf � es ` Y License orxp
Office , o �$� .. :� before the expiration date. If found return to:
HOME IMRROVEMENT.CONTRACTOFt:_` •... ;,,;:. Office of Consumer Affairs and Business Regulation
i. Registration: 114561' TYPe $ 10 Pik Plaza,-Suite 5170
• •DBA
j Expiration:-'�i,Qt ;2013 Boston,MA QZ116
C... - i
GADY CARPCNTR-` = I
David Gad,
F
i \' Undersecretary" 1 Not Wid it sig ure
Marstons Mills;M'A 026d8:-,
F
p -
I • 1
,r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
d00 Washington Street
�. -et`1 Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ':t�> Cjyyt.K C 1r NT'iZ4
Address: 2t- —TwAj e,. L ,
City/State/Zip: 02&Lf Phone #: see"
Are you an employer? Check the appropriate box: Type of project(required):
1.Ell am a employer with 4. ❑ I am a general contractor and I 6. ❑New.construction
gx5ployees (full and/or part-time).* have hired the sub-contractors
2. I a sole proprietor or partner- listed on the attached sheet.. T ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
'
working for mein any capacity. employees and have workers 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or addition
3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or addition
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.)
'Any applicant that checks box fit must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: —
Policy# or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fin(
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 D1A for insurance coverage verification.
I do hereby certify under th ains and penalties of perjury that the information provided above is true and correct.
Signature: Date: I/ i
Phone#
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority.(circle one):
1. Board ofNealth 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
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 employee's. 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, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a,license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the conunonwealth 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), addresses)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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASS
Fax # 617-727-7749
Revised 4-24-07 www.mass.gov/dia
f
_ f
�YHE r- Town of Barnstable
BARNSTRegulatory Services
"B' Thomas F. Geiler,Director
Y MAE& �*
y0. Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 5087790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
VMe_C6t as Owner of the subject property
hereby authorize qJ 6L')/Cy e�37c d to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
ig ature of Owner Date
T
Priht Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
' I
Town of )Barnstable
f(}tE)ph
Regulatory Services
• Thomas F.Geiler,Director
aaatvsrAXLE,
9�a 116 9S. p�0� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8A4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: , village
number street
"HOMEOWNER": work hone 4
name home phone I; p
CURRENT MAILING ADDRESS:
city own state zip code
The current exemption for"homeowners" as extende to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individua for I& who does not possess a license,provided that the owner acts as
supervisor.
DEFI 4,TION OF HOMEOWNER
Person(s)who owns a parcel of land on whiche/ a resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detach d structures accessory to such use and/or farm structures. A
person who constructs more than one home a two-y ar period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building/Official on a rm acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildin ermit. (Section 109.1.1)
The undersigned"homeowner"assu -es responsibility for co liance with the State Building Code and other
applicable codes,bylaws,rules and egulations.
Y
The undersigned"homeowner" ertifies that he/she understands th Town of Barnstable Building Department
minimum inspection procedur s and requirements and that he/she wl 1 comply with said procedures and
requirements.
Signature of Homeowner /
-Approval of Building 07cial
Note: T/ee-family dwellings containing 35,000 cubic feet or larger ll be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The ode states that: "Any homeowner performing work for which a building permit is req 'red shall be exempt from the provisions
of this section(,Section 109.1.] -Licensing of construction Supervisors);provided that if the homeowner ngages a person(s)for hire to dp such
work,that su'�Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibiliti of.a supervisor spr(see Appendix Q.
Rules&Rygulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often.ruu in serious problems,particularly
when.the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed p �son•as it would with a licensed
Supervisrs. The homeowner acting as Supervisor is ultimately responsible.
k 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 t amend and adopt such a form certification for use in your community.
....�.mri CMCr1D�A C\r,nm>vvrmnt nnr.
�„o•`"`'�., ,r TOWN OF BARNSTABLE Permit No. -__20232_ _^
•� -
Building Inspector
: swrrAU Cash ------------------
o�aWO OCCUPANCY PERMIT Bond X --4h
No building=nor structure shall be erected,'and no land, building or structure shall be
used for a new, different, changed, or enlarged use without a Building Permit therefor
first having been obtained from the Building Inspector. No,-building shall be occupied until a
certificate of occupancy has been issued by the Building Inspector."
Issued to R. Arthur Williams Address Box,55, MArstons Mills# MA
lot #24 153 Timber Lane, Marstone Milis
Wiring Inspector V � �j)�� / Inspection date 717/1 —�"
Plumbing Inspe t r� 1��.. Inspection date
Gras Inspector r, Inspection date
/Engineering Department ���� .-- , 0� Inspection date
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.
17 `
.................:..................................., 19......__ ............................................_...................._..._.... ......------.------.------------_N
Building Inspector
tti10 ON
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Assessor's map and lot number ................................... O�� �C�1st- �f /�- 78
SEPTIC SYSTEM MUST BE
Sewage.°Permit number ...............2.:` , .. INSTALLED IN COMPLIANCE
cV W j
WITH ARTICLE II STATE
TOWN OF ��BARN Y�Ell TOWN.
Q CF TH E t0� x
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to �w rj
" t,;E�airsTsnis;
9 BU
}q• ILDING INSPECTOR .
`�0 N :]
f;
. APPLICATIONS FOR PERMIT T4 ........ f'.1.........................................................................................................
o ' TYPE OF CONSTRUCTION ...........4-.r. .. ..�-� r�.�.M.........................f ' y. Q.
oa ............... . � ... .............19�.U...
=t/53
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
u
,.,() `T '`o�� ax .........�./f�.�:�`.�?c��S.. ..1'./a.!/ .... .1�//!'..,..
ProposedUse ..... ...........................................................................................
Zoning District Xna..A...............................................Fire District .. ..Ct'1s1 .��-1!�1�... .,. �. ,.d/�<!t�F.t.,,......
Name of Owner ....... .. r4�41.r'...I/1l i. .........Address ......11VA.r.-�s.l.Pith.S....J!Vi.//x............................
Name of Builder 4/4: ....Address ...... ...............................................
c� / r ��j Address c �IXQ //�1
Name of Architect ......�....�e..�... ..t.?z.✓.. . ........................ ....... . . ..1��'��'. . ." ..................,................. i
Number of Rooms .......��Qa.E,d ..........................................Foundation ..��, ...../.Q. i" c./.... .�'�.,r..........................
Exterior ... i. L'...e4r4 x:7.. /" I/Roofing .....
Floors ......L.cti:,-7 . ...................................Interior .........
f k
G& ..6'4!. ��ce . ...............................:
..ter...�.... � /[•-� ��.
Heating "/ . ic' .c; ........... Plumbing ...�iY�...!��.w�....`....t ?a �� ..�--'.lk .F.�..
Fireplace .....�..... .....�l�.tPs r.�.�c`1 ...�C16 ..? -,;.Approximate Cost ....... .............................
,ll ------19 7�_. Area �i�.O 'S
Definitive Plan Approved by Planning Board ----7___��_-____ ........... ................oQ....
Diagram of Lot and Building with Dimensions Fee ...... .............. ............
SUBJECT TO APPROVAL OF BOARD OF HEALTH J�
4 . I
S1/N�IP lad— !ice ueSE -" ,
d► 4
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. /v e--
Name X �. JeQ• :��,1.. ..............
- y
Williams, R. Arthur
i� 20232 1 1/2 story
No,................. Permit for .................................... 4
single family dwelling
...............................................................................
153 Timber Lane
Location ................................................................
Marstons Mills
...............................................................................
R. Arthur Williams
Owner ..................................................................
Type of Construction
frame..........................................
................................................................................
Plot ............................ Lot .....................
.....................
May 19 78
Permit Granted ............. ..........................19
Date of Inspection .................................. 19
Date Completed ..... .........19
PERMIT REFUSED
.... 19
...............................................................................
...............................................................................
...............................................................................
Approved ................................................ 19
...............................................................................
r,'Y'� .r..- .r .�- .l " � - .-•�.�- .r �--•-- �.�..Y+.-.s .,�.•`�,^....--.^"`..+ --�..r-- v. �..• .--. :" '�_-y_•_.�, •�-w�.+-'.w'--a-.'y^vF"^a^. _ ,
p� ,�j
.� Assessor's :map;and 'lot 'number '� ../.... .......? `;' i D�l�' �C✓�t� Ste;./r/- 79 '
o Sewage Permit number
. � L
TOWN OF BARNSTABLE
1i 33JHH9TODLIf i -
ri "3` - BUILDING INSPECTOR
t: 01)' r!
L: 'y M
ra APPLICATION�FOR PERMIT TO ....I v i I ...........................................................................................................
u,
TYPE OF CONSTRUCTION ............ ................../ .� .........................................:
J
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Locrtionr/l."�- ��2� �a// /i.�._s�� /4�2.../i�rahwr' /,.q.✓G. �y�l1rS<o.cJS../�/�/�l ....
t
sk ;- .. ............................................../. .......... .. ... . .......
ProposedUse (-, " � �� -�� � '''*�'°�''� �"......... ......................./.................................................................................................................................
Zoning District ., ,...1 ( . . �.or✓i .......
Fire Distract ..........................................
Name of Owner �,�.- ��� /�s� ..�.<.........Address ...... 4�-s/ . � .... i/fs...........................
........................,.................................
Name of Builderr •, /./1� s...�.�c> Address ........... �...r.��/ p_..............................................
.......... ................
Name of Architect ,........ .................................
Number of Rooms ........ ........................................Foundation
..............................................................................
/,v clr...(„f: ✓;,.•- �y, l ;(' � Roofing .....2V11) bp�."NU...... ................�►'
.....
,Ixle,ior
Floors .. 7n 07 ar ........ .........Interior ......../�� �4?.:....... �................
/....... .................. ..........
..... :.,. .....
�— --•mac
Heating /�./ .,L Plumbing .... N� ! Iv�%.� /vf e,
�.A^................. .....w.'..........................✓
Fireplace Approximate Cost ....................................................................
Definitive Plan Approved by Planning Board '_--------19_1. Area �(l0 0 S
....... .................c..y..........
Diagram of Lot and Building with Dimensions Fee .4__& — 3.......................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
1 1C/N 1/!A el f' �i•I�I `
�'.ro� • `y UO
sr Qv0 s'F
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above.-
construction. jj;/;./���- ��/�a�,�� /v v
�' Name ..w........ .................. �!`..........` ......":`..............
Williams, R. Atthur A=149-49
20232 1 1/2 s tory4amw-
No ................. Permit for .....................................
single family .dwelling
. ...............................................................................
153 timber Lane
Location ................................................................
Marstons Mills
...............................................................................
Owner ........R..........Ar....th.....ur.....W..i..1.....1i......ams...................
..
Type of Construction ....frame
..........
.............. ....................................... ..................
................................Plot .............. ............. Lot
t #24
Permit Granted ............May iq� 78
............................19
Date of Inspection ...... .....................19
Date Completed .'400<.......................19 '
PERM) REFUSED
......................... ........ .... 19
. ....... .. .................. .........
f.fi ............k...............................
.................... ..........
. ...............................................................................
Approved .............................................. 19
............. ..................................... ...........................
................ .................................. ..........................
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Assessor's office(1st Floor):
Assessor's map and I f-number I y 9 -�yq g I�. V70M SYSTEM MUSS
Conservation
Board of Health(3rd floor): n WITH TITLE 5 •
Sewage Permit number Chi sec ENVIRONMENTAL CO�„ s�,'�T�i�
Engineering Department(3rd floor): tL 1 s3 �`�J �lv TOWN REGULATI®N
House number �' Y1v
Definitive Plan Approved by Planning Board 19
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BA'RNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO e,.Ve tic,f
TYPE OF CONSTRUCTION W�oud
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
L/��� a
Location �'S,3 � �.����" o:�c r, e M C:,v S :'�-•,� S ?ii-r .'�� S• �1 y d[
Proposed Use
Zoning District A. 0 Fire District C
Name of Owner C',X A�2 (J)ck✓✓ AI Co-j Address 1 3 Ti wi d-e /u
Name of Builder U Address 1110 X d 7" t
Name of Architect Address
Number of Rooms �� Foundation .0 j C,.
Exterior wo Roofing d
Floors ck,-dtr. Interior
JJ
-Heating /r� � ww�{ � � r Plumbing
Fireplace Approximate Cost
Area )�V-CA 0k)4.tisr
Diagram of Lot and Building with Dimensions Fee
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 q,
Construction Supervisor's License
McCOY, CATHY WARREN
No 35140 Permit For Remodel T)w,- L 1 in
S_i:.ng.le_..nF-am .l_y._Dw_e_l 1 i na
Location 153 Timber Lane
Marstons Mills
Owner Cathy Warren McCoy
Type of Construction Frame
Plot Lot
Permit Granted June 18, 19 92
Date of Inspection 19
Date Completed 93 19
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