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Home My WebLink About0039 TOWER HILL ROAD (22) q +Tocv�r r}; 1 oQ, tniversial one. wwwnyuniversalop.com phone:i W—w-We UI03 UAM tuuM i 1 1 �. 0 I d 4 6 )` J t■ P L Y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map J l P rc I .. d 2. O Permit# / .3 7 Health Division fd o-- e, F� �T Date Issued /G � a 2 Conservation Division S, 9 Z7 Application Fee ��Tax Collector D �—" //�� Permit Fee 30. Treasurer `— L= —C1 �o� SEPTIC SYSTEM MUST EE Planning Dept. INSTALLED IN C NC Date Definitive Plan Approved by Planning Board WITN TAL Q o ENVIRONMENTAL C� L TOWN REGULA T NS Historic-OKH Preservation/Hyannis ;, 7� ,�/Project Street Address G cv�/� 17 pal Una , q3 Village Owner ,/�C l < ` Address Telephone Permit Request o-!/�'— �D Z14 C l2 /3 SE'C vSquare feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay oProject Valuatior 0 O d, O O Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: O Yes ❑No On Old King's Highway: ❑Yes ❑ No 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 Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas O Oil ❑ Electric ❑Other Central Air: O Yes O No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 0 No Detached garage:❑existing O new size Pool:0 existing ❑new size Barn:❑existing O new size Attached garage:O existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded O Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use y BUILDER INFORMATION / Name v Telephone Numbe(Y-ll Address �� FSPr A, License# Home Improvement Contractor# Z Q .36 Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE G FOR OFFICIAL USE ONLY — PERMIT NO. 15ATE ISSUED MAP/PARCEL NO. s ADDRESS VILLAGE Y OWNER `S DATE OF INSPECTION: FOUNDATION s FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH--, FINAL PLUMBING: ROUGH) k' FINAL GAS: ROUGH _ ?� �'� FINAL FINAL BUILDING � a e °a - DATE-CLOSED OUT ASSOCIATION PLAN"NO. P w. __•�__—, The Commonwealth of Massachusetts • Department of Industrial Accidents -= _ - Olfice of/n�est/gat/ons - i _ 600 Washington Street 3 Boston,Mass. 02111 Workers' Co m ensation Insurance Affidavit name: location hone# city ❑ I am a homeowner performing all work myself. ❑ I am a sole movnetor and have no one worku in ca achy workers' co ensatin for my em�logees worlang on this job.:::}i>:.>i:.J:.ii:.}}:{::>;:.}:!.J:;r.i::.}:.JJ,} :?.):.>:.•.:.};}:.J:::!:}:.:{; e 1 r providing mP.............a..........:::.::::::::::.:........::::::.�::::::::::::::...:........::::::::::::::::::::.�........:::::::::::.::::;.}}}:.J:.}}:;.>}:;.}t::>::�>'�<:�:«:�::::{�»>: y `. e ' t%`'' '' f ;?' r1 :'::�:`:?: `: 4:?:':::<:::%::t an <:nam . t•::.:: .:j:�''•:•: �t l\ .... .................. ::::...................... :ln9titr ce:co«<i:;<z;«:::}��'z<:}:.<:>::.:;s::;.;;:<}:.};}>:.,;:•:••}:,:<.:;:;:>}::•}'�::::):z:»:<:>:«:::;;<>:•>:::;>::}:.:•:�: I am a sole proprietor, general contractor,or homeowner(circle one) and have hired the contractors listed below who have workers' co ensation olices: the ......................:::::.::::.:............::::.::::::................:.�::::::..................... t......:.ti:......::>.::}.�.t..�:. ::::.........r...:::::.................:...................:::..:....................::...................:::.... ,.. .tom __...:.;::::;............... ..:::>::.:..............::.::.,................,.�.:::::.....t.........,.r::w.:::.:,.......t....... .. :}r,,:::: :::.::v;:i.::::w::::.::::::•:4:Ji:•i is J}}i}}i:'• .:..,:r..........:.:... ................................. w::.;, ..........;;................:.v::.•:: ............:::J}:;.i}}:SSiii;{4:i?!jiiij;Ji Yiiii'r'v.:v.... :..v.:.:.,.w:..........:.............. ....... ......... ..................................:..........................................v. •\!tiro .. ..... .... ..... .... ..... .................:•:......................... ..........niii�:v:4i:t^)).;.:•.::::4i}iti;^i;;;J••: ntv,tl:.tv::..... r:?•:'•: :�::.. •v:4i}})})YJ}}J:::S:4:;!v)iSJ:4SJ:•J}SSv:.�:.J)''}S:'::::).i}i':` ....:..... .:::...:::v::•:w:•:::•:?{!•SY?•S}S}>:):???v::vn.....• ...:. v..:.:?{•)}J;:•):?v}J})::J:;•i}:;•}}::::•.�:.:::.v:v:.{;•J};.}}S}:hJ:?,•:::v,v:v::.::::•::::::.............. ........ ........ .....................::::::::•;{::::::::::::nw:;..,..."':::}::v:i;:?•5:;4}:?;.S}:•i}Y{^:i}:i::ii:�i:i}ii}i'•..... 4.. 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Oli E TI]II'8llCe:. �� gaffmre to secure coverage as required wider Section 25A of MGL 152 can lead to the imposition of criminal penalties of n Sue np to S1,500.00 md/or one years,imprisomnent as well as dvfi penalties in the form of a STOP WORK ORDER and a One of$100.00 a day against me. I w►derstaod tLat a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby cert:f�aeder the pains mid pen es of perjury that the information provided above is truo d correct ' Date { Signature Print name o a r Phone official we only do not write in this area to be completed by city or town official permit/license# __ ❑Buflding Department city or town: ❑Licensing Board ❑Selectmen's Office ❑checkif immediate response is required ❑Health Department contact person: phone#; — QOther Oeviud 9i95 pJN 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 maybe 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 Permit/license number which will be used as a reference number. The affidavits may be reimmme k the Department by mail or FAX unless other arrangements have been made. i 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 0MC6 of lnvesUgWons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 p1HE� � Town of Barnstable Regulatory Services Z sT"Lz Mass Thomas F.Geiler,Director 1639. ,0 M 04 � BuildingDivision lED PS Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 i 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. �j Type of Work: 2caZAC �� Estimated Cosft� 3 _0 O Address of Work: cl �//L )ed Owner's Name: Date of Application: I hereby certify that: I 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 her by apply for a t as the agent of the owner: ) In 306 ate Contracto e Registration No. OR Date Owner's Name Q:forms:homeaffidav :S- : - • LLJ _.. _ \J . Pd- � i S • c . ... ..... Al ' 60 •f , . 1 t -- _ oc Vt ty .... .... ---- . --- -, --- -. -.- -: - .. - - -- -- - -- :. .. ._ . ._.: : _tom v_ _...•. ..:.--- �--- -- ---__..__. .-_.._- . ------- -- - - - -- -- ---- -- ._._._.....------ . --- --- -- ---- i r ' r : ; i I I 1 LS olJ / J r L 'r I Z ti- rnrn I 1 I 1 � f 1 I 1 aved Pdr In ° 1 �1 1 i o 7 ° ° \ � M I �I ° Board of Buildinq Regulations One Ashburton Place, Ism 1301 Boston, Mwb�108-1618 License: CONSTRUCTION SUPERVISOR LICENSSEE— �''��_ Birthdate: 06/03/1958 Number: CS 059348 Expires:06/03/ Restricted To: 1 G THOMAS S ELDRIDGE 138 SPRING ST -== HYANNIS; MA 02601 ',M sv 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 ImprovemeritrC_ontractor Registration Registration: 123067 Type: DBA THOMAS EDLDRIDGE CONSTRUCTION. Expiration: 12/02/2002 THOMAS ELDRIDGE 138 SPRING ST. HYANNIS, MA 02601 Update Address and return card.Mark reason for change Address Renewal ❑ Employment ❑ Lost Card __.. � Cflze r�omvinonurea/,� o�./�aaaac/zuaP,lld 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: Registration:' 123067 Board of Building Regulations and Standards --Expiration:.,`12/02/2002 One Ashburton Place Rm 1301 T e .INDIVIDUAL Boston,Ma.02108 YA . THOMAS EDLDRIDGE CQNSTRU' THOMAS ELDRIDGE 138 SPRING ST: HYANNIS,MA 02601 ' `� ✓ Administrator Not valid without signature