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HomeMy WebLinkAbout0083 WHISTLEBERRY DRIVE FO! ,OheY04evVe e 0 v v Eck WAS bLAA-- bre-Gt-t- w ns iss(sQ—, (Su CoLkWhit Town of Barnstable *Permit#ri2o.I I&&3 Expires 6 nwndhs om issue date Regulatory Services Fee • snarrsreata,MASI • Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner /J 200 Main Street,Hyannis,MA 02601 I` www.town.bamstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS.PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number 0� d Property Address d ��.��` f3 t�/�Y y ��/ ,"I��c��G�✓ Ml jk/jA (1 7J 5/Residential Value of Work �T �Q[)d h Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address V%4t Utz q tit) a j1 1 fin/ YG h/fie I d f P- -T IV ew Contractor's Name (41i"Z-L I' .11,0M e M//t/if L/,' /W td/✓�, C e m b 4 TIephone Nuer Home Improvement Contractor License#(if applicable) 00 ,Tl e Construction Supervisor's License#(if applicable) gWorkman's Compensation Insurance Check one: AE„ RESS.PERMIT ❑ I am a sole proprietor ❑ I am the Homeowner[� (�O U 2011 I have Worker's Compensation Insurance Insurance Company Name 4(E f y�e rP� t% -0 dw C45 LI 41 TOWN OF B H R N S TA.B L E: Worlmtan's Comp.Policy# !� w C C 75,lf Y3a Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going.over existing layers of roof) ❑ Re-side #of doors replacement Windows/doors/sliders.U-Value ' '2 g (maximum.35)#of windows •�f/dtt� •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. copy of the Home provement tractors License&Construction Supervisors License is equ. SIGNATURE: C:\Users\decollik\A ta\Local\MicrosofhWindows\Temporary Internet Files\Content.0utlook\DDV87AAZ\ENPRESS.doc Revised 072110 1 ety; Page 7;of7 mpr E� Capizzi Home Improvement Inc" Specifications and,Estimates � ! A STATE OF MASSACHUSETrTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT rt7 WE, ARTHUR&ARLYN SCHNEIDER, OWN THE PROPERTY LOCATED AT 83 WHISTLEBERRY DRIVE 1N MARSTONS MILLS, MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: lk- OWNER'S ADDRESS: 83 WHISTLEBERRY DRIVE,MARSTONS MILLS,MA OWNER'S TELEPHONE: 508-420-1591 LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: 6aah'v RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: Office of Consumer Affairs&Business Regulation License or registration valid for individul use only NO = �HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: = "' Office of Consumer Affairs and:Besiness Regulation _ q,egistration :100740 Type: 10 Park Plaza-Suite 5170 txpirat on_ 312012 Supplement Card Boston,MA 02116 CAPIZZI HOME'IMPROVEMENT?-INC. JACK STRUNSKI.: " `i `• 1645 Newton Rd. Cotuit,MA 02635 Undersecretary if Not valid without signature tiNIassachusetts- Department of Public Safety Board of Buildin, Re-mlations and Standards COr75frtrctiort Supervisor License 1-1cense: CS 64817 :JOHN F yji tS UMSKV L' ,:,PO BOX 861 BUZZARDS;BA1n MA 02532 Expiration: 6/18/2012 ('oLhnicsioriei Tr#: r10573 r � 3 W#1d,1 e I.-eviq The Commonwealth of Massach usetts Department of Industrial Accidents Office of fnvestigations 600 Washington Street Boston,MA 02111 www etas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L2gibiv . Name(Business/Organization/Individual): D zza 44 0 r e •- MP t10 Ue(11eA1-J 71V IL . Address: C �+ City/State/Zip: ca. i MA 6 Flo 3•s" Phone#: "50.,f.Y-Z P- 'i Y>? . 'Are[�IYt' r ❑ Type of project(required):you an employer?Check the appropriate box: 1. am a employer with Li 0 ' 4• I am a general contractor and I New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship.and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' iamrance.t 4• ❑Building addition comp.[No'workers'comp.insurance P• required] 5. [J We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am.a homeowner doingall work officers have'exercised their 11. Plumbing ke❑ g pairs or additions myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no , employees.[No workers' 13-C�other_ .5 comp:insurance required.] •My applicant that checks box#I 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 contmctots must submit a aew affidavit indicating such. �Coatrdctors drat check this box must attached an additional sheet showing the mine of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they atust ptovido their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name: Ace P V O P'e P-7'`( 4 N D C 4 S'i 4 L�y / cc 4 5� �I 3 zoo- Expiration D ate: O 11 Policy#or Self-ins.Lic.#; �1 Job Site Address: -f -e City/state/zip: V1AetvJT,6K M_W1d WM �" Attach a copy of the workers'compensation policy declaration pa,, (showing the policy number expiration date 0�te. 1 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 S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER gad 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 under ains and penalti f perjury that the information provided above is true and correct Sieariature: Date: Phone official use only. Do not write in this area,fo be completed by city or[o)On ofcial City or Town: Permit/License# Issllhig Authority(circle one): 1.Board of Health 2.Building Department 3.City/Towa Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Othee Contact Person: Phone#• Client#:47298 CAPIHOM ACORD. CERTIFICATE OF LIABILITY INSURANCE °6102/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Karen Walther Rogers&Gray Ins.-So.Dennis PHONE F 434 Route 134 tAICAN� F"t:508-760-4630 pIC Ne: 508-258-2230 P.O.Box 1601 ADORE waltherka@rogersgray.com waltherkarogersgray.com DUCER CUSTOMER ID#: South Dennis,MA 02660-1601 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Capiai Home Improvement,Inc. INSURER A:National Grange Insurance Co. Capiai Enterprises,Inc. INSURER B:ACE Property&Casualty Ins.Co 1645 Newtown Road INSURER C: Cotult,MA 02635 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DL UBR POLICY EFF POLICY EXP POLICY NUMBER MM/DD MM/DD LIMITS A GENERAL LIABILITY MPB1075H 06/08/2011 06/08/2012 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $500 000 CLAIMS-MADEI OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY Pau F-1 RO LOC $ A AUTOMOBILE LIABILITY M1 M28044 tt1 06/08/2011 06/08/2012 COMBINED O accident) SINGLE LIMIT $500 000 ANY AUTO (EaBODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ X Drive Other Car $ A UMBRELLA LIAB X OCCUR CUB1076H 06/08/2011 06/08/2012 EACH OCCURRENCE s5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5 000 000 DEDUCTIBLE $ X RETENTION 10000 $ B WORKERS COMPENSATION NWCC45843208 12/25/2010 12/25/2011 X I WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS BANY OFFICER/MEM PROPRIETOER EXCLUD OT ECUTIVE� NIA E.L.EACH ACCIDENT $1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEEI$1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1 000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Additional insured status is provided under the general liability when required by a written contract with the certificate holder CERTIFICATE HOLDER CANCELLATION 10 Da s for Non-Pa ment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE i ©198 -2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S67537/M67480 MEE Assessor's map and lot number ......... ..... r.. i I Bpi THE toy♦ ' P Sewage Permit number ............... ...................... Z BASBSTADLE. • House number ............':. .. ...I ..................................... ro ruea TOWN OF BARNSTABLE . BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..:( ` �G��/ OF .e SiVe/7771-1 L 46W i ................................... ........ TYPE OF CONSTRUCTION .....WhAe?........ ...... ......................................:................................ C. ... .l.l.....................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......... 0 .........../:............C, T/7 . ........ko .:................ ... ........................ ............. . Proposed Use ...: //�g�e �Gi ,,2�iE/P��//l� ................................................................ ZoningDistrict ........................................................................Fire District .............................................................................. oz—o Name of Owner Address ..................... Name of Builder .V.. < ..... L '............Address .........�P� v� � �4 . Name of Architect ...... NC)ZoJ:.Y.............................Address ... ............................ Number-of Rooms ....... ..........................................................Foundation ...................`.......................................................... Exterior ...... 'f/ C ...Roofing ............... `................................... Floors ��%'!.!' eZ..........................:.............................Interior .... ............�� G✓ C r... ��....../.......L".............. Heating �T$..1�......!A'/ -..............................................Plumbing ......... ....�� J.......................................... Fireplace .... ..............................................................Approximate. Cost .................................................................... 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 am t bl e'ar g he above construction: Name .... .................... ............... .............. Construction Supervisor's License .................................... STANLEY, JOHN A=63-88 No ....28021.. Permit for .......V21.5.t;Ory. ........... Sin gle 1AqI'P.X ly..Dwelliag...................... Location --Wt..9.......8.3..WbiZ t lebe rry. ..Drive ................ .I-S............................... Owner .........JObli-Stanley. .......... .................... Type of Construction ......Frame......................... ................................................................................ Plot ............................ Lot ................................. June 85 Permit Granted .......................... . . ....... 19 Date of Inspection .................. 19 Date Completed ............... ..... ..................19 7o' ._..k�'xi+r..'�ie'iw'w+.:*�wr+»-� ...•.. '..�ar3x''�ais�-:.J'rn-<�:nr.A'-:.�n..:.S�a'�rn .�.:>ra.S:.:r,_.'r:,..<:r.s�:..ti=.:...�. . ,. :..- -�....'+"'. ;" �.. i� . � f��x '".. '!il':T..`:,�.-�.:d,^.'�ti' a. 1�l�ti..:. '�,f ' 5 h � '`3,�:•.� .ar��Y erir 3�. ��axi,; •S(' .t t•. :¢_ . .d-.f Win: �\a;,�=•.•<;.,i '�:.t.. t1 }. .1 �t,4 i:'ti Y ` o•TM`'�.w TOWN OF BARNSTABLE Permit No. 28021 Building Inspector cash 16) . OCCUPANCY PERMIT Bond R Issued to John Stanley Address Lot #9, 83 Whistleberry Drive, Mnrstons Mil-Is L Wiring Inspector Inspection date E- Plumbing Inspector Inspection date• _ Gas Inspector Inspection.date gEngineering Department Inspection date Board of Health Inspection date THIS PERMIT WIL OT BE VALID, AND E BUMDING 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. 19 �, .. Building Inspector - - °;�'s l�• -, u i p�1 Y ttvr 9� '4t ��, -- - •, •` MAU� 'M1=.lit A li}�I'If II.A 1 t Uxh#7Ut. UY 1� i�M�t�Mn d I nL A 11'dk&L ..:i FOUNDATIONS OR FOOTINGS. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALLNOTBE OCCUPIED UNTIL MEMBERS(R£ADY TO LATH). I A FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. ' OCCUPANCY. ' POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 2 2 . HEATING INSPECTING APPROVALS F IGERATI INSPECTION APPROVALS 1 1 0� B� STAB TO ' :THER 12 2 . aA�2>�' of F>tTA-------------- o - . // oF.xE,� TOWN OF BARNSTABLE Permit No. 28021 �- BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash ......... �A'Pcriv HYANNIS,MASS.02601 Bond CERTIFICATE OF USE AND OCCUPANCY Issued to John Stanley Address Lot #9. 83 14hist1pberry Drive Marstons Mills, Massachusetts 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 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. s.� ...... 19.. Y!........ ... ...... .................... Building Inspector °°. TOWN OF BARNSTABLE BUILDING DEPARTMENT S ssaaaraat t TOWN OFFICE BUILDING i rua i 39. HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for ttie'building authorized by BuildingPerm' #... .L� ............ ..................................................._............. .................._............... ci* issuedto .......... ............. ............. ............. .... ................................._............................... . . _.�..__... _. ......»»...__w. 1, Please release the performance bond. •oo y\ I -20 b i y VVILLiAM Plo. 19334 G V 7-,4-/A7- THE S,�/OWit,r f,�E,2E0.1�CONl oL YS k//rho SCA L C— �"_ .�O � OATS T�/� S'/OE.0/�G/E.A�/O SETB.4 Cf� P.L.4it/ .2EF'E.eEtiG'E • ,�Ec�l�/.eE�IE•t/TS Off' 7,4/l• Tow�t/aF LOcA 0 W,!! TiS//S .o,L9�//S il/OT BAS // AA1 .eEG/S -ESeE1 L.4A�0 /NST.2U�lE�t/T,$U.e✓EY€ //� QSTE,21//.C.C�a MASS. O��S'E'TS.Syalf✓�f/S,�,bvt� It/oT' e9,C-- AOP.� /C,4lV7' =d7 E SEPTIC SYSTEM MUST SP INSTALLED IN CO Assessor's map and lot number ......................................... MPLMU s,pia T H E WITH TITLE 5 Tc Sewage Permit. number ........ ....... 1ENVMONMENTAL COD" V -GULATION* EARNSTAILE, House number MAO& ................................................... .......... 6,0001- 1639- 0 Mid TOWN : OF' BARNSTABLE BUILDING INSPECTOR ��1Lju(�7- 6.0- -APPLICATION FOR PERMIT TO .... ............... *........./ .......................... ...... TYPE OF CONSTRUCTION ...... ...................................................................... .................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the,following information: Location .......... ....1-0..... 7-...........?......... c// -7 .. .. j- �� zf. ........... Proposed Use .....�-5,6 /e....... �5 ....... ...................................... .......................... ZoningDistrict ........................................................................Fire District .............................................................................. -0 . ..........................OLD oe e4o ..........Address ....../?.� .......................... Name of Owner ...................................................7 T�NG Nameof Builder ........0................ .. ...........Address ......... ................................................. Nameof Architect ....... ...........................Address .................................................................................... 26 tj,< &a C. /0 Number of Rooms ....... ... Foundation .............................................................................. nC4e, . Roofing ..Exlerior ....... W. ... r(................................................................... Floors ...010-,�..W.. .......................................................Interior ......I .......... wllil��C......................... Heating ........�X .............................................Plumbing .......... ................................. Fireplace ..... .............................................................Approximate Cost .......... .................................. Definitive Plan Approved by Planning Board -----------------------------19--------- Area ............. ......... . Diagram of Lot and Building with Dimensions Fee ................115................ SUBJECT TO APPROVAL OF BOARD OF HEALTH AJI) 0 b/3 q OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of rns bl e rd* g t e above construction. the Town of rns bie e4erdg..t e..abov.(Name ....... .. ....................... . ................. .................. ruction S Lc ruc n Supervisor's srs en Cons ruction Supervisor's License ..... ..........I.................. r7STM&-,T, JOHN it 4'No .... Permit for .......1 story........... ........... Single Fcmdjy..p�ling ................................ ............................... Location .....P3 Whistj .,Drive ................ .... iIarstons Mills ............................................................................... Owner ..'..John..Stanley...................... Type of Construction Frame............................... ........... ................................................................................ Plot ............................. Lot ................................ Permit Granted .......''June. 13................19 85 Date of Inspection .....................................10 Date. Completed ............1.9 60 ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map _ Ole3 Parcel G1 U ; -- Permit# Health Division L Date Iss�ue#d Conservation,Division /zG l zoo t l/ Fee o? Tax Collector `4431ol Lk SEPTIC SYSTEM MUST BE Treasurer Z3 7�a INSTALLED IN COMPLIANCE WITH TITLE 5 Planning Dept. EIMIRCRIMENTAL CCD"A Date Definitive Plan Approved by Planning Board 'OWN REGULATIONS Historic-OKH Preservation/Hyannis �. Project Street Address 3 �iJ Il .CsC - LOT Village Owner ,Q `it/2 cfjr�e/�� /L Address O �iA%Py>z/ P Telephone G/ 4'2:� � .Permit Request LC?iJ�d4.P l.FiSz,_.,C 6`�/� /C� bdi/� Square feet: �floor: existing proposed 2nd floor: existing proposed Total new Valuation 7 Zoning District Flood Plain Groundwater Overlay ' Construction Type Lot Size //Z 091C Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. 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 Cl Walkout ❑Other jBasement Finished,Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: "Full: existing new Half: existing new Number of Bedrooms: existing `'` new Total Room Count(not including baths): existing new First Floor Room Count �i Heat Type and Fuel: ❑Gas Cl Oil ❑ Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: ,duck Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name ` r Telephone Number Address 41f- i//01a/4 License# y,::)- a Home Improvement Contractor# Y Worker's Compensation# ALL CONSTRUCTION D S RESU TING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 3 2Ja/ Ih FOR OFFICIAL USE ONLY 4 ' PERMIT NO. DATE ISSUED MAP/PARCEL NO. 6 " ADDRESS VILLAGE OWNER DATE OF INSPECTION: ' s FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL u PLUMBING: ROUGH FINAL GAS: ROUGH 6 FINAL FINAL BUILDING r q DATE CLOSED OUT ASSOCIATION PLAN NO. Y ......... _ The Commonwealth of Massachusetts �.,r� — _ —_ Department of Industrial Accidents -_ Office OURY809080s _ 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit i. name: location: city Ad/9 phone# ❑ I am a homeowner performing all wok myself. ❑ I am a sole purietor and have no one working m' capacity em to r rovidin workers' compensation for my employees working on this job.: :::: ::::am an p ye P g .......................... ::...:.::. :....::::::::::::::::::::::::::::::.:...:::::.:::::::::::::.:::::::::::::::::.::::::::::::..:::::.:::::::::::mom :::::::.::.;:.;;:;.;:.:.......:..........:: ....:::::::.:.::::::::.........:::::::::::::::::::::..:.................:::::::::::.::::::::::::::::::::::::::........::::::.:: ::::::::::.........X. ' < ' ' ::::::<::::::::::::: i:;::;:;::;:S:: :: ; .::::::::::::.:.:;;: :: :.:.. cow an n m X. X . ;;:.;:..:, ::::......:.....::::... :.::: :.:..:. ;'lion x . D c [)IICV nsuran ❑=soler, general contractor, or homeowner(circle one)and have hired the contractorslisted below who ha workers' co ensation olices: the following .................:::::: ::::: :..:::::: ::: :::...::.:::::::.::: ::::::::::::::::::::::::::::::::...:::::::::::::::::.::::::::.;:.:;.:.;:.;;:.:;::.;:.;:.:;.;:. 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'i "o n�ararice� �. gafiure to secure coverage as regnired wider Sectlon ISA of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,N0.00 and/or one yam+irrrprisomnent as w vn penalties in the form o[a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of thb statement may fo ed to the ce of Investigations of the DIA for coverage verification. I do'hereby certify th pen es of p at the information provided above is rue d correct Date Signature Print name /� l C— ' Phone ON official use only do not write in this area to be completed by city or town official city or town: permit/license tl ❑Building Department ❑Licensing Board ❑cheekif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; _.. ❑Other 0evued 9195 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,'or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance.or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and Printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the Pi number which will be used as a reference number. The affidavits may be lettnrned 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 OMce of ImlestlgWons } 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 The Town of Barnstable r • 9 snr MAS& Regulatory Services 16 ;t►`0 Thomas F. Geiler, Director, Building Division Peter F. DiMatteo, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permi no. Date ZL L� 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. / �,/ J/ Type of Work: ���`'`l��° sk/'J 7 Estimated Cost ?61 Address of Work: 63 -Ae A& 1 I' Owner's Name:�/lT��� ) 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 hereb apply for a permit as the agent of he owner: to Contractor Name Registration No. I OR Date Owner's Name g1orms:Affidaw rev-070601 Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration:, 118952. Expiration .-05/08/2003? " ''= =T ti. Individual" ! THOMAS P DAMELIO;BL•DG:B RE THOMAS DAMELIO;'K ; 45 MELBOURNE RD 7�-; `•. ; HYANNIS,MA 02601 Administrator 0 1 BOARD OF BUILDING REEG�LPU00(LA+�TjIONS I` License: CONSTRUCTION SUPERVISOR Number..CS_ 047420 t - Birthdate: 04/01/1946 /-Expires: 04/072003 . Tr.no: 10305 Restricted To: 1G- THOMAS P DAMELIO 45 MELBOURNE RD ( �viol HYANNIS, MA 02601 Administrator ;2 xx4aci15NX.^n"° O :t. ,•.f: i � .30 WILUAM 1 . i fln. 19334 O G ):. 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