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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel l SCE Z d Cc,/ Permit# � 3
i
Health Division i'U C OZ ` Date Issued
Conservation Division r �o Z7 10 Z Application Fee
Tax Collector !�R 00' d k pZ40 Permit Fee 00
A� 1
Treasurer I`z�-- �7 f 0 0z SEPTIC SYSTEM,FAUST BE
Planning Dept. INSTALLED IN COMP *?NC
Date Definitive Plan Approved by Planning Board WITH TITLENVIRONMEN9TAL C® �
Historic-OKH Preservation/Hyannis TO�WI4 REGULATIONS
Project Street Address 9 a C,¢J E!Z h` ZZ_ Re/ 64 l C_
n Village
Owner 4414 S O 9 C_ Address 3 4 TO G</<—_�-2
Telephone
- Permit Request / E/l'I c) E_ t- A L 2 < 1-3
lzlz
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatior3. o. O (7 Construction Type
�Q1 Lot Size Grandfathered: El Yes ❑No If yes, attach supporting documentation.
i—
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) 1:
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
R
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing new -
2 Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool: ❑existing '❑new size Barn:❑existing ❑new size
Attached garage:❑existing Cl new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
'f Cortmercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use -
BUILDER INFORMATION
Name Telephone Num r
Address License# d
Home Improvement Contractor# .12 3C�
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 71,0,dla 2-
i
i .
FOR OFFICIAL USE ONLY
PERMIT NO.
N
L•
DATE ISSUED '
MAP/PARCEL NO. ' 4
ADDRESS VILLAGE -'
OWNER
DATE'OF INSPECTION:,"
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH-.I FINAL
PLUMBING: ROUGH :::j a FINAL
GAS: ROUGH ' : FINAL
FINAL BUILDING
DATE CLOSED OUT r
ASSOCIATION PLAN NO.
—____ ITh Commonwealth of Massachusetts
i
—�` Department of Industrial Accidents
600 Washington Street
Boston,Mass. 02111
Worker C ensation Insurance Affidavit
name:
location:
city phone#
❑ ' am a homeowner performing all work myself
I am a sole proprietor and have no one worlds in ca achy
I am an e 1 er_ roviding workers' compensation for mp employees working on this job.
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❑ I.am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who _
have
the following
owin wo
rkers' c o Pens ation o4ces:
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Failure to secure coverage as required ender Section 25A bf MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years,imprisonment as well as dvII penalties in the form of a STOP wORK ORDER and a fine of 5100.00 a day against me. I undersfand Chat a
copy of"statement maybe forwarded to the Office of Investigations of the DIA for coverage verification
I do kereby certi�r,,,r'Trthepains and pe of-perjury that the-information praud ideubnveislrr ._an�cotrect
Signature Date 1/ a
Pont name "' _ !/' i Phone# ' L
official use only do not write in this area to be completed by city or town oilicial
city or town: permit%license# OBuilding Department
❑Licensing Board
❑checkif immediate response is required ❑Selectmen's Office ,
_❑Health Department
contact person: phone#; ❑Other
(fevieed 9/95 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 Departiment.of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. Ile.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 requiredto obtam.a workers' compensation policy,please call:the Depai tin ent 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 suie to fill in the.p imrtjlicense auinbei which willbe used is a refeience number. 71i-affidavits may lie'ieti AsirCtf? .
the Departure bymail:or�FAX unless othei arrangements have been made
The Office of Investigations would like to thank you in advance for you coIFF
operation and should you have any_guestions. .
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
0111ce of Investigations
600 Washington Street ` ;t
Boston,Ma. 02111
fax#: (617) 727.7749
phone #: (617) 727-4900 ext. 406, 409 or 375
°FINE r° Town of Barnstable
Regulatory Services
r •
BARNSrABM ` Thomas F.Geiler,Director
9 MAW. g
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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.
i
Type of Work: F„f��� C �'� 2) F CK Estimated Cost O O d 0 0
Address of Work: -Q 6.e. c/ i
Owner's Name: AIA C d .W A-
Date of Application: 2
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
El 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 agent of the owner:
Date Contract Registration No.
OR
Date Owner's Name
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MA 117 �- -• GOLF COURSE FAIRWAY
lA P 17� , f EDGE OF DECIDUOUS TREES
` EDGE OF BRUSH
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. . .......... EDGE OF WATER
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PARCEL LINE**
MAP 110 �_ __MAP#
�'- - 21 -<—PARCEL NUMBER
/ \ 4 { —� #18e0 —HOUSE NUMBER
L,� C + 2 FOOT CONTOUR LINE
/ ; i 49 10 FOOT CONTOUR LINE
1,147 . 1 i� Elevation based on NGVD29
/ `,1 J ,✓ 1_ }/4.9 SPOT ELEVATION
0) 440 STONE WALL
i ✓ /T \ -X—X- FENCE
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RAIL ROAD TRACK
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DOCK/PIER
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T O W N O F B A R N S T A B L E G E O G R A P H 1 < I N F O R M A T 1 O N S Y S T E M S U N 1 T a SIGN ® STORM DRAIN
a PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetria(man-made features)were interpreted from 1995 aerial photographs by The lames
1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topographyand vegetation were interpreted from 1989 aerialphotographs 6 GEOD 0 UTILITY POLE TOWER
F - 9 P Y
W E 0 p 20 n 40 National Mop Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetria,topography,and vegetation were mopped to meet National Map Accuracy Standards LIGHT POLE O ELECTRIC BOX
�i� I INCH=40 FEET* enlarged scale. on the mop. at o scale of 1"=100'. Parcel lines were digitized from FY2002 Town of Barnstable Assessor's tax maps.
Board of Buildinq Regulations
One Ashburton Place, Ism 1301
Boston, Mai`& 108-1618
License: CONSTRUCTION SUPERVISOR LICENSE e.Birthdat • 06/03/19 58
Number: CS 059348 Expires. 004 _-==
_ P .__r�_—.. Restricted To: 10
z � I %
MZ
THOMAS S ELDRIDGE
138 SPRING ST
ti
HYANNIS; MA 02601 r
Tr.no: 26029
Keep top for receipt and change of address notification.
07-1
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Home Improvement.YC_ontractor Registration
Registration: 123067
Type: DBA
Expiration: 12/02/2002
THOMAS EDLDRIDGE CONSTRU;CTIO`N
THOMAS ELDRIDGE
138 SPRING ST.
M.
HYANNIS, MA 02601
Update Address and return card.Mark reason for change
Eldress E] Renewal n Employment Lost Card
✓`ce i�omv�noouuea� o�/�aaoac«uiaek2
= Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registrat'ion.' 123067 Board of Building Regulations and Standards
•Expiraion:. `.12/02/2002 One Ashburton Place Rm 1301
Tgpe: .INQIVIDUAL Boston,Ma.02108
THOMAS EDLDRID.GE CQNSTRU'
THOMAS ELDRII)C;E
138 SPRING ST: �G
HYANNIS,MA 02601
Administrator Not valid without signature
P�OFTHE The Town of Barnstable .
9AH.N'STAeLE. - Department of Health Safety and Environmental Services'
9¢ MASS. 0
PTEo Mai Building Division
367 Main Street,Hyannis, MA 02601
f.
Office: 508-862-4038
Fax: 508-790-6230
PLAN REVIEW
0 T
Owner: Map/Parcel: // 7 I -Q aG U
iP- o aao✓
Project Address: Builder: r&o
s
The following items were noted on reviewing:
c f e /� 2
Reviewed by:
Date:
Qa
q:building:forms:review
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