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1gineering Dept. (3rd floor) Map D Parcel Permit#
House# Date Issued — CD. Q
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) �
Planning Dept. (1st floor/School Admin. Bldg.) - �Tw
Definitive Plan Approved by Planning Board 19 SEPTIC SYS . BE
INSTALLED 1 ' ; � NCE
Preet
aTOWN OF BARNSTA RRaM�TA
L CODE AN®
Building Permit Appli_c�a_tio�n��, 'OWN REGULATBONS
ddress / �6e o ru)C�n o<) Ave , 6� �y�-�tC
Village Steil,
Owner T6M Ke"C,1�1?9
Address p,p.J'11,1.) F,4 &M rv1 H(1
Telephone 106 S
Permit Request 2ee1a.CQ. ie)CZff /n
First Floor square feet Second Floor square feet
Construction Type WOA
Estimated Project Cost $ ?n�(
Zoning District /P��;, Flood Plain / o Water Protection AA)
Lot Size Grandfathered ❑Yes p No
Dwelling Type: Single Family Two Family p Multi-Family(#units)
Age of Existing Structure ' Historic House ❑Yes Uio On Old King's Highway. p Yes A4140
Basement Type: kFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing 3 New Half: Existing / New
No. of Bedrooms: Existing New 15
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fue : � &Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing / New Existing wood/coal stove ❑Yes ❑No
Garage:)-Detached(size) /OaX Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization p Appeal# Recorded❑
Commercial p Yes bNo If yes, site plan review#
Current Use Proposed Use es
Builder Information
Name Abe2f V, (// gale Telephone Number 1(9-u ° ITO
Address /10 'Peas k)T' ee � n �/ License# OQ 36
/qQ�Sf OYI M � ��S 1 A '�l A 00%19 Home Improvement Contractor# ll�94
i . /
Worker's Compensation# A/
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
&Vndw)C "Do m
SIGNATURE I DATE G I dAn
BUILDING PERMIT DENIED FOR THE FOLL WING REASON(S)
FOR OFFICIAL USE ONLY
31 Z -3
PERMIT NO. -
DATE ISSUED `
MAP/PARCEL NO. r
ADDRESS s o VILLAGE
OWNER `
DATE OF INSPECTION:
FOUNDATION —
FRAME
INSULATION - J
FIREPLACE
ELECTRICAL: ROUGH .., ' FINAL '
PLUMBING: Wojl H w. FINAL
GAS: RE)VMft S FINAL
FINAL BUILDING
DATE CLOSED OUT n
ASSOCIATION PLAN NO'?
r
• �sue r�
The Town-of Barnstable
• e�' Department of Health Safety and Environmental Services
Building Division
. 367 Main Street,Hyannis MA 02601
Ralph C=V1
Office: 509-790-6227 Building Commis
Fax: 508-790-6230
For office use only
r
Permit no. ,
Date AFFIDAVIT;
HOME MOROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation,' repair, moderniation,
conversion, improvement, removal, demolition,et one but
no�moreon f an than addition
dwelling units pre-existing to
owner occupied building containing
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements
Type of Work: to(-S— Est.Cost
14 6a,, npai2�1�4ew_Vl l
Address of Work•
Owner's Name
Date of Permit Application:
[hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
_Job under S1,000.
Budding not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING 'THEIR OWN PERMIT OR DEBT . WrM W� DOEGISTEREb
HAVE
CONTRACTORS FOR APPLICABLE SOME IIViPRO
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL r- 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner. /
Jaik R lion No.
' Date Contractor Name ��
I
i
•�' +` T/rc• CIIIIrlllumi-culth of Massuc'husctts
Dr�urtllrc•Irt n
f Industrial Accidents
^- �:_=-1•�_
.3 �. '�;�•-. OfficPolltrye.:tlgallotts
rx
6(W if ushiur;turn Street
- �: Brlsturr..11u�s: 03111
Wurk-en' Compcnsation lnsurnncc AlTdavit
rilic ntinforntatinti _Plc^�e PRii'�1'T'it eittly
Inc nn- me
ci v M-A nhont:
I am a homeowner performing all work myself.
E. I am a sole proprietor and have no one working in anv capaciry
— —
t� I ar,; �n en;niover providin_^workers' compensation for m. empiovees wort;inc an this 'ob.
rnmwinv n•t^ty-
ltic!rrcc•
IV 714-�
ctn•• nhnnc e-
incur-ttrr rn nnlin-ti
7.
zr-. z=oic procric or. -cncr:il contrrctor. or homeowner�ctrcic onc) and have hire—the cont,:.c:ors listera
:h� :oilowing workers' :em-e^sation poiice=:
1 ti:!rr,
Aj
ct••..
nhnnc a-
in—r-^rr -� nniir�•= __ _
rlrt' nhnne
nnf iev
incur-arc rn, —
Att:c:: addi tion at sh[e:tf me c!s'tri ----.:•e. _.;�'.•..,a.:i .. ._......— ,......._. _.��...+.�..—.—.�•. �....--��:�.:--:r►)
F:,:Iurc N )CCLfr cU\•cra-.0 ns required u ucr:ectton_`A of 11G:. 1S3:an lead to the imposition of cnmtnal penaiues ot'a line up to SI_70.UU:nux.
unc clrs' imprisonment as %I-cil:ts ciyii penaities in the form of a 5TOr WORK ORDER and a fine urS100.00 a daV against me. I understand thct-
copy , i this,uticmcm rant be furs nrdru to the Oboe of Int•estit:cuons of the DI.\for coyeraFe vcriticanon.
I f:'o ,ere.^r cr -r;i :_11111'rr fire pttitrs njtn pertRiliCS nrperjun•:hot the iniormarion provided above is true and correct.
_.... l< � - � b Oatc //0 p ��
Phane>*�y <f(gV s 0�
IotTictai lisp unty do not pyrite to this area to be compicted by city or town olTciai �
t pin .ir town: permitificense# r Buiidin_Dernrtrtert [
CUccnstn_ 3ourd
caccx if imtncciate respunce is reuuired G
selectmen's Office t.
C11c2ith Dcnartmcr.t
phone F• ^Uttter.
ncr.nn•
information and inst•rucrinas
sa.!:use:;s General Laws chanter 15_ _'
section 5 requires all employers to provide workers' cn III
pens::uutt
e::: irn ecs. As aut�ted lrom the cfjrpfi rce is defined as ever , person in the sen�ice of :uic�the:
cc:: ctf hire, express or implied. oral or wrincn.
An einpinrcr is dcfincd-as an individual. partnership. association: corporation or-other lc_--al entity. or.any IWO cr
the :urc,_cirt�_ en,_nued in a joint enterprise, and including_ the legal representatives of dec=cezi empiover. or:!:_
rc::_:VC.1 or:nrstce of an individual . pnnnership. association-or other legal entity. employing emplovers. Ho«e•. _
rn+::era af.;dwellinu house haN•ing not more than three .apartments and who resides therein. or the occunart of
d\% !louse of another who employs persons to do maintenance ;construction or repair work- on such .c.....
or :.rat :Ire __rounds or bui ldin% .appurtenant thereto shall not because of such employment be deemed to be :-n'=
section also states that cvcn• stntc or local licensing ngency shall witlrlrold the issu nnc:
l of., license or hermit to operate a business or to construct buildings in the commun"ealth for ::..^1
.c.:rtt n•1to itns not produced acceptable evidence of compliance with the insurnce cover;c require—'.
.!%.. :tcither the commnonwealth nor any of its poiiticzl subdivisions shall enter into any contract for tl:e
of public work until acceptable evidence of compliance with the insurance requirements of this
zrC:2::;e,4 to the contrac:inc authorin'.
:iii in :he workers' compensation affidavit cotnple:ch by checking :he box that applies to your situa::c:: c:
address and phone numbers as all affidavits may be submitted to the Departmcr.: o•"
;cciac::ts for contirmaion of insurance co%•err_P. Also be sure to sign and date the affdavit. Tire
tcui:; be returne to the cin• or,own that the appiicztion for the permit or license is beinc revue=:ec.
ccc aiet of industriai .-accidents. Should you have any questions reg�ding the "law" or if you are race_:
XC,_KCrs* cornpe::s�:ion policy. ple2se czil the Department at the number listed beio��.
C:,y 7r :uN ns
aura :h�: the �ffida� it is compie:e and printed legibly. The Department has provided a space -t the -c::�-
rite`: ooti;t :or ou to fiil out in the _rent the Office of Inve=igations has to contact you regarding the cppiic:.r:•
^e _ = :o ;iii in the permit license :lumber which will be used as a reference number.�Tlte affidavits may be
by mail or FAX unless other arrangements have been made.
i,e -ce cr ivestications wouid like to thank you in advance for you cooperation and should you have stty c::es:
-o not '.tesitate to un,e us 1cell.
iJe -„rrs address. teiepiione and fax number.
The CommonivenIth Of Massachusetts
Department of Industrial Accidents �.
Office n-f Investigations =+
600 Washington Street
Boston. Ma. 02111 ;
fax 1: (617 "27 49
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