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' ..- '..• _ s- �. -. - c -. � - - 9 WOODLAND & 235 WIANNO OST JULY 8TH 2O14 \ Pam• �,� �g,,e�rNr6� as5iz < nst r _ ,�,, Via„ s ��? yrF.�-±� �'rS •y��" ,gam a._ � 1r►yw '��• +t' ;mot �: ,^ f- � _1 . 9 WOODLAND & 235 WIANNO OST JULY 8TH 2O14 r AW IT AL IL t eye 0 0 � L _go-«-s .a.- . .. ..:ram.•:. \ .. -_..�.r�, ��"C�SS'-+.c e e Lat �R„- 1�' ..! '►. ., 'ti. !'� ij�Y� •. '+�'-sa• ;• �'- -,�• ram, �. %� -�l � �J '�'�`' �� • � ` . �`, , lo. r - �- - • �� ', !.. ` + i � ,�-t?W- -- ,•. ice-- `� �,� - '•- - �A•, .. - - ..I is -^- _ .� _. .a. ` y► .�. �I •9i.. m� '� ram`` t. t.;�,:- �_ '�"�V. S�" � >1 � t ^'b t..\ �� -.. rr'i ►'L., ti: i,. ' .- --' �- v r '�� - �� i-! 'T _ wt•"iD4 °� .�'- _ 'v!' ��4 'FY'Sf�� P��' �`s � �' M' , ''� ,) •r� � :�--� �u- �•_ per,?-�: _�'- - �.-� _� '�'. Ao �e 'r iil`\ - , -� ...�;- 'ti„�`p'c.'.«. a ,, x +. � v�y�GJ s k�-i�•= r .� y� _--- - -- - - - `�� _ � r: l'v by i. li �, ,`�.��•�. ~'. ��-. �,��.. _ �. ; �' `�-� •� .'OOODL�,ND � � • NNOO OST JULY NTH ?0 14 � ,��v'i •— .. '. " � k. - fix i i�r - �}r ,..2 ,�� __ e-- ��'�'' •-.. - -�i fA ems: �,�� r _,�.; �y.. -_ r a,^ i ;�� 'L ai - .. Ate"' 1•'" � �' .. � 'i�.'I,A,NNOOOST JULY NTH �'0 14 +: 't• _`ate �. ey , — e. S s �� Z• •' . . J , _ . 'd pis, - _ •+ �� '��' ►. � t• �. 1. ,°>: �;. � .►� y,q' 'b• -" _ .. . �� +.: � � Wit; .. ��"• _ - lk ic 44 y� +yamow Vk ' - n35 WIAN NO J U LY 8TH 2O14 - � ► a rt` .r Aybi / «��F f � .` _ � - yrt I .A n jl fi .. I S` • - -� it .-- ,h. ��.� R._ - r �rK +wt o.r✓.- ,:+t�• YY� r `'�-- -�9 WOODLAND AND 235 WIANNO OST JULY 8TH 21014 Ile. - TOWN OF BARNSTABLE BUILDING•PERMIT APPLICATION Map `� Parcel / 33 7 Permit# Health Division Date Issued _ Conservation Division Fee ' S/ ` Tax Collector • Treasurer �� &12-61zw Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address 9 /,�Jo�� 1�/d VE Village 1 L/ S �f V I Owner Address �� 1�Ulc� �ae- zium Telephone - Permit Request &h)C2(LF )(i5-j�� boo�-S- h,s�1Q /� Q,&17161, b- w � Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size A Grandfathered: ❑Yes O No If yes, attach supporting documentation. Dwelling Type: Single Family O Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes O No On Old King's Highway: O Yes ❑No Basement Type: ❑Full ❑Crawl U 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 O Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: O Yes O No , Detached garage:O existing ❑new size Pool:O existing O new size Barn:❑existing ❑new size Attached garage:O existing ❑new size Shed:O existing O new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded O Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION +�-� Name Telephone Number f Address P6 9, 6 License# a 32l Home Improvement Contractor# Q Worker's Compensation ��7 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR DATE FOR OFFICIAL USE ONLY ' TE44RMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTIpi: r . FOUNDATION A ♦ .' FRAME INSULATION -FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL • r GAS: ROUGH FINAL _ FINAL BUILDING DATE.CLOS_ED OUT ASSOCIATION PLAN NO. • ""-�"� The Commonwealth of Massachusetts "'-- . ,m _fir'., - =h` --- Department of Industrial Accidents .. ONCE of/�est/gadoos _ ' 600 Washington Sheet ; �� Boston,Mass. 02111 _ . Workers' Com ensation Insurance Affidavit =I name: N1 J / location "L /� /�1./�/Il� (, city 0��kptlAl,"-'-,� phone#-0(? E�7* C . ElI am a homeowner performing all work myself. ❑ I am a sole rietor and have no one worlds in any capacity ''///%%%%%%%%/%%%% % %%//%% %%%/ Q-i am an employer providing workers' compensation for my employees worldng on this job.:: :: ::: .:::::::::::::::::::.:::::::::::::::::::. ; at an :I, a � . -- n slue:: co ss'`....`.. .are c . 0 Wh-i,-�.!:.�-:.-"N'i,111-�--1i :....:....I.............'x....::..X-...i..:....-.......:.....-................::::.......:.:...:......*-.-,.N. see# « ,.: ::: »>>;. M... olicv //- -- insurance ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who . have the following workers' compensation polices: to ..�,::::::]:�:::�:i:i:::i��iii�ii�iii:ii�ii��:i::.�.:i.i::.:.,: -; :: : . ..... :...:.: .. : ....,....-,...,........-,..*...i"...-"..'....'.'..= mtany n »: satire .:::''<'d:::v 'f.....' :::i':,.......... ::..h•:::::... ;:;:y yyii:iiiiii:'r:iiiiiiii:'.+iY:}}};{:•i}i: <`:""kon p...................................... ............................. i. ........................................ ...........................:::::.::::::.v....... ..........................:........ ..... .....n..:........ .. ......:.. .. ... ....... :...:M•:ti9\Y:ii}}}}:'}}: .....................:.....:...:............................................x:::v:�:. :::.::.. ...... ... .................}.................:.......................... ......:.:.. ..........................................:::.�Yw:..•••n......?.�i:CvitwhW.... Insurance;ca:::::::::.:.:::.::.}}:;.:.:.}:.::::::;:>:.;;:.;:;:}::.}:::;<.;:;.>:.}:.;:.:::;;:.:.}:.>;:.;:.:;;:;:::>:<;;:;;<;;:::>}:::::}>:«<:::>;»::><:>;:.r;.>:.::.;:.: ::<}: Old :#.:.:.... }:}:......}::;:: t:vi}}}i:::}::i}i;•}X:::%i:;:ti::•;i;:;< •:•;:.:rr?}:?1:<::•._.iititi•}i:;::...'s .%%%%%/% .:.}::.:::.:: .:.:::.:..::.::::::;.}:.}:::}:::::::::.::.::....::::::::::.::::::::::::.:::... c anvname-}:: ><:>s:....e:>.:>:<:>:<.I...... <:>:>:;»:>.>.<:<::::::;:::::»>.::. ..,_: amp ad dress: C�Ly"' :<i::'p�one ? :::...- :::.:::::::..:.......................................::-::•:"�:::::.�:"':'.::: :.�::::::•.�::::::.� ................................ nanranc OI Failure to secure coverage as required under Section 25A of 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 dvfl penalties in the form of a STOP WORK ORDER and a flue of$100.00 a day against me. I understand that s COPY of this statement may be forwarded to the Olflce of Investigations of the DIA for coverage verification. I do hereby eerti under the pauas and penalties of perjury that the information provided above is trtw w' t d_eo at Signature Date �A i ' _ _ I 1. Print name ' I— L- — Phone# Va. I official use only do not write in this area to be completed by city or town official ' city or town permit/llcense# . ❑Bullding Department . ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Ol$ce ❑Health Department . contact person phone#; ❑Other (revised 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. f 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 I 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 returned to 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 0111ce of lavesilgations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 The Town of Barnstable NAM ��' Department of Health Safety and Environmental Services 1"9. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME E"ROVEMENT 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. 00 Type of Work: b�ed Cost490-0 Address of Work: k2l"1 /LJ— al — Owner's Name: 40 �/),d Date of Application: d 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 udpROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I h re y apply for a permit as the ent of the owner. bllQl(y) W Date Con or Name Registration No. OR Date Owner's Name q:forms:Affidav Regulations of Building Boardurton ace, Rm 1301 one Ashb Boston, Ma 02108-1618 j Birthdate'. 1012011959 License: CONSTRUCTION SUPERVISOR LICENSE Restricted To: 00 Number: CS 026325 Expires: 1O12O/2OO1 i PAUL J CAZLAU1,' 1585 MAIN S t MA 02G55 OS'I'L;RVILL[, Tr.no: 7665 change of address notification. Keep top for receipt and _(r� fie ��a�rr�no�ruuea�C� o��.i2�a�toacfir,�seCli l�_ !- = Board of Building Res ulat:ions and Standards One Ashburton Place - Room 1301 Bo i_on . Massachusetts 02108 1-1c)rnr•3 Improvement Contractor Registration l:e�ct:i:-tration: 103714 Expiration: 7/9/02 _1 y p e: Private Corporation - NONE IMPROVEMENT CONTRACTOR Registration: 103114 !=!llal J „ CA-Z AULT & SONS ., INC . �� a a � Expiration: 119102 Ca:zeaul I-, Type: Private Corporalio 2! c_;.Ldd:iah Rd . P .O . Box 2781 or .I.�a..ns MA 02653 PAUE J. CA2EAUE1 & SONS, I Paul Cateault 22 Giddiah Rd. P.O. Box 1 ADMINISTRATOR Orleans MA 02653 Q Engineering Dept. 3rd floor Ma I 0 Parcel 3 3 7 413 g' g p ( ) p `� Permit# House# 9 6 ,, Date Issued -73 '{ 9 Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) 4' 1 / 3 d' Fee e-� Conservation Office(4th floor)(8:30-9:30/1:00-2:00) NQ G > Planning Dept.(1st floor/School Admin. Bldg.) oFtNE DefinitiLPIjanApprove ing Board 19BARNWABLE.MASS t679• TOWN OF BARNSTABLE E° '+' Building Permit Application Project Street Address Village OAK' Owner Address` Telephone 8^ rL Permit Request WZ First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ h, /1B®,Q® Zoning District C, Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes No On Ol King's Highway ❑Yes No Basement Type: 0 Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing 2New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes A No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage:Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes �No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number fin - Address License#I IF ` OK e2& Home Improvement Contractor# Worker's Compensation# ,mo/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 BETAKEN TO 10 SIGNATURE DATE BUILDING PERM D F TH OLLOWING REASON(S) FOR OFFICIAL USE ONLY /� V✓ 'PERMIT NO. � • DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE} OWNER DATE OF INSPECTION: FOUNDATION - ; FRAME 'L INSULATION FIREPLACE 's. ELECTRICAL: : ROUGH FINAL, j PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL ' i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. • _ J i L y N hl Assessor's map and lot numbei, .................................. HE (Sewage Permit number .....�3.'....Y.F&..................... SEPTIC SYSTEM MUS INSTALLED IN COM*PLI rn ....:........................ .........................I...House number .......Y WITH TITLE 5 163 ENVIRONMENTAL CO E A51 oYPYa, TOWN OF BARNSrXRLE BUILDING 'INSPECTOR APPLICATION FOR PERMIT TO 27;0.A..j......... TYPEOF CONSTRUCTION ... ................................................................................................................. 4 • .....................k..yo...................10� TO, THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ....... ....... ......AVZ',.........SJ.7-cw. ...14L.&......................................................... ProposedUse ..... ...................................................................... C..........................................................Fire District .................... ............................................. Zoning District .... ............. Name of Owner Zal4j..7*-)?AT91/4A/.............Address �e-t- eRIV •Name of Builder ........Address Name of Architect ..................................................................Address ........................................ Numberof Rooms ......../......................................o...............Foundation .................................................... Exterior ..................................Roofing ............................................... Floors ... ..................................................................Interior ............. ..................................... ...................................................... Heating ..../ .44)X...../ ..y.... ............................Plumbing .....................e i T 0 .........Approximate Cost ..... .................................. Fireplace .....?V0...................:,**......**...... Definitive Plan Approved by Planning Board ----------—----------------- Area ...... Diagram of Lot and Building with Dimensions Fee ...........✓ ..................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ADO OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all 'the Rules and Regulations of the Town of Barnstab. regarding the above ,rnstab, regarding construction. rding the Name ... ..... . .. .. .............. ....................... Construction Supervisor's License ....................... FERRIMAN, JIM 25280 REMODEL & ADDITION No ................. Permit for .................................... Single FamilX Dwelling ................ Location 9. Woodland Avenue Osterville ............................................................................... Owner ...Jim...Ferriman ............................... Type of Construction ............Frame.............................. �. ................................................. Plot ... ........................ Lot ................................ Permit Granted ..... IAIY....5.r..................19 83 Date of Inspection .....................................19 Date Completed . G r' Assessor's map and lot number ..... ................. .........::.... ETo • Q Aewage Permit number '.....�3 .............5`:..... i 13ABd9TODL6 „House number ................:......................................................... �639 0� �E0 YP-4 a� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....................... ..F.... ............�.... .— .� TYPE OF CONSTRUCTION it)f? .......... ..... .. .'.............................................................................. ......................... j.............19. ,� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..... 9........ .... J •, S/.. '��/��1..�. :........................................................ I„ ��ili��' %G/�J�il;1 L/,.`1.. lJf�,/...7/.1./. Proposed Use .....:... .... .. ....................................................................... Zoning District .... C..........................................................Fire District ................... -��............................................. Name of Owner . / �'i2;7,, ►?/�../..(�j!I !��..............Address .v.....:S L//i ''�.V z— Name of Builder .. .� j •:...�.�J.,%�{,/.,.,/,,et.11 .... .Address f.•�...�GCr'� ................... 4 Nameof Architect .............................. ..................:................Address ...........................................`......................................... ` Number of Rooms .................................................. �l� b� ..:............ .Foundation. . ..... ...... .... ....................................... Exterior ... ....................................Rbofing .:. ..�.`?,.%�G'�G �........... ......................................... Floors ...7 `. .........1..................................... .............Interior ....... 1,?�is2 .......................................... .... Heating !4:?l �&.. !�. t ...../;v, ............... ........Plumbing ....... r.s.. ............................................�....... 19 Fireplace ... /U ..................................................Approximate Cost . S� r:. ................................... Definitive Plan Approved by Planning Board -----------__________________19 Areo �16 ...... dam• Diagram of Lot .and Building with Dimensions Fee 1.....a.................... SUBJECT TO APPROVAL OF BOARD OF HEALTH z 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. f. Name .... .................. 1z Construction Supervisor's License FERRIMAN, JIM A= 410-133 No Permit for ... .. ......del & Addition ....................... ......S.i.n.q.l.e...Fami.ly...P3�f��jjj.n.q............... . . .. .......... .. Location ..9....Wbo.d.15L.aD .AY.QA11e................... . .Woodland I .. ...................Os t.e.r v i.1 .............. ................... .. .... .. ....... .. Owner ......Jim Fer .................. ............................ Type of Construction ......FrAMe....................... ................................................................................ Plot ......................... Lot ................................ July 5, 83 Permit Granted ........................................19 Date of Inspection ............................. ........19 Date Completed ......................................19 JI S N LE, r1ktLFl 6TUGCi Y'IN I�FI � t- 'Z y Z �Oun+r,At)r Et. 0 n n � p[ 0 U . '1 a P.C.G G uA LI I u Gana'( Koot4 In «pll �G OhT ChP � t � l' (/� ' V o Z'(1L6 lit •N -�TII�IGJS G.L. -�.3TwIC> 1 :fj( SSLL W I ABTA III E<I$T I�.VG 641 � ' nGENI�IG �1 •.�9 I7asMv C � S `XISoTII.I(� FGlI1JOAT IU^I 7 I I O ivw j <� ID wtl X � Z FA I- -- I%C�t.11I DftTl01�1 PLAti1 Z � Z Harrel—fan++Lr ellwk�s p n Q1,G01e PClWO-P 1 p "U8.2AFTo f-+6 14.OG 1 6,G 1hor I ' 6E4M Jolsr Hs.,lr�re¢a Q TT T 1! Z � F100(Z FRAMWLe � _ ik: � !�- S Scala Iq•+Iw" ap THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) A , k- I m / LI DATA Y T v J 0 L C A �tow�a l7l Y7l �14nC3' Y ry Z ED '' 7A ry i N o Ua�gsc i �- '�1� � L4AJI) IZI Ld o V (v �9 • 1 � 1 • ��`��. �� is ® l � \ � r �� ` . �,� ► �.' �� ram, �®, `� • I/ ��`t,.�, c*` �� " � �C ire �� 1 ♦ � � �� ® ♦ � �, NIATGrI �Nlra(n�ES �� 1 r'la-e..l—ear-I:,=��s —��—.--_ —q•�.=//, 1 � I ' Ix� LhS I+ILLS � I Al IvaLN 6TUGCr GIN15N ; _ S __--- _ = - �3- EM FM FF--]I '[ �r uTI-I W EroT �LEVPcTI�IJ Q[ 0 Y) L � \n 0 /^ re�L.l.a G,eoLr u eert,ze •� rcr� er��4 _ _ _ _ ' � --�F e P.c.uau p�j PAKILY VCoM In m f G'�TI�IL�G:JS P.C. • QETa1ll Ens Iwo u+si Z � . t (JrEN I,-�G yyµ -�ti9 1"il.{WG h i i �K16TIIJ(� FGU�IDATIU^t 7 ' ' 9 � � X >V C- _-_�J �'Gur-ID�Ttor..t P�Ati1 Z - -77 2 Z A& • - 6 ma tJc[s;�P 6reAAcrum — - - � —- 1 W ('tlarcA.=.KSefio.crdlll.ul•r�s p n �: . t J o4:�-n_vcw� •� I S TittT5L;3=:bTGL�8L`4M J 0,9T NA♦I[,6¢9 T � � Z apnwo,c. 1 THE FOLLOWING � IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M A I / L DATA i U T l�f NIa.�J j�1NRrIx� ❑ r7 /T o � ol a m S 2 n 1� �I S ��I/11A- HT.�e Acx�J�Tc�SI� �TflG �JU�Q��S i1�C�1'�IiI� �-1 znl ia� 6P-Jf•.4 ,S� i—c,�v awl-9.N�wgTn3 4R.a8 Srco�� qHo��c� n OI 3S Vi c�I�OITP.� rHo-irc-ems &LAAJA SrQWN S�sac AI i �J+Iv��Tc�O I 0i f-=� t t '��• +� _ r� A � • • � ®� � it ��•. I v. .I o � ' S H* lfM"Write Registration 125799 ` = Type - PRIVATE CORPORATION Expiration 03/04/00 C.J. RILEY BUILDER INC -.-_._.._._________ _.. CRAIG J. RILEY 67 FIRESTATION RD/PO BOX 382 -7 &pMRVILLE MA 02655 �• oaJa�iT c�., :i FJ°AaJ 0.: , i f•t• U-, J0; a5'le� S, ADMINISTRATOR :rz <;e�s s;aasnyaessee p. I hpo dJuosek - V1 am - ee - 6T0££ fie .,> 66 �,°1 anr�ncon,u"P-ate �DD1?1 e<<rli;8d T*.•; 901 Z0'EIN uoIsog 8 I X 1 w21 a�Eld uounggsy aup:ol ujmw puno3 31 •a3ep uouendxa aiopq Al uo asn jenpin.pui 10) p!jen U013U3sigal jo asua:)i-j 7f r ' 1 ' oFtr+e tayj, .�.� The Town of Barnstable • .URUPWAIM=4 • 9� '& �0�' Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner. For office use only 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. Type of Work: Est.Cost Ad, 064 .0O Address of Work: /� �/� � 4, &1Z;Z1- /i 6 ®r?L 4_< Owner's Name Date of Permit Application: 1 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 hereby appI for a permit as the agent of the own Date pc me Registration No. OR Date Owner's Name f „ - �` The Conrnton wealth of:1 fassuchusctts _-_• 1 1 Dc purttneyd oj111ditstrial Accidents 60 If"us/tiir1;tutr Street Alas: 02 111 Workers' Compensation lnsurance Affidavit _ .. __ --____ ._—_.._ . --• Please PRINT�Ie ---_- �iplic:tnt information: �j��- _ name Ipcatipn� i 61%. phone 0 I am a homeowner performing all work myself. ` I am a soie'proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Conn t:tnv name. address• /°�1� • �9�/ )Q f city' /�/ ✓/9i/ �T� (/D`L7�� nhnne#• insurance co. licv# Ul _ -,.... -.... _..�... ,_._w_..._. .. [I 1 am a sole proprietor. benera contractor, or homeowner(circle otte) and have hired the contractors listed below who have the following workers' compensation polices: l comp:mv name adtlrescr city! •Rhone it: insurancr ro. Holies d .. •'ter •�_ __. _ =..�. -� -_ -1r�_ �. -iT"f�.w• �.T.r,•t•-- -�- w.�...�....-... - _-..__._ .. .._ ...�.—....._. �-• ter..—_._ .a._._...._�. _ - __ _ _rl• � _ �w __ - _ �_•��` ...—__ cornrmn namr addresc� ritvr phone f!• insurance co, nniin tY Attach additional sheet if necessary_ .:%;,�;�; - +___ "� - '�^-"•• • �--y-- ' = y y. :ale•. �•-w. t:n. Failure to secure cuvcraCe as required under Section Z5A of 111GL 152 can lead to the imposition of criminal penalties of a line up to 51.500.00 andiur une tears'imprisonment as wen as civil penalties in the form 0172 STOP NVORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this matentcut mac be forwarded to the OMce of Investigations of the DIA for coverage verification. !do herehr cerrifi•under the pains and p a/ti of perjuty.that the information prodded above is true a,td vrrect. o Signature Date a Printnamc Phone* :�... rofT'iial (citycor use only do nut a rite in this area to be completed by tin or totcn official tt»vn: permit/license it riBuildint:Department C3Uccnsing Hoard o check if immediate response is required 13Sciectmen's Ofrtcc C311c2lth Department contact person: phone tt: nUllter 1 Information and Instructions Massachusetts General Laws chanter 152 section 25 requires all employers to provide workers' compensation for ;1; employees. As quoted from the an emploree is defined as every person in the servicc of another under any contract of hire. express or implied. oral or written. An empinrer is defined as an individual. partnership. association. corporation or other legal entity. or any two or inc the foregoing en�sa_cd in a joint enterprise. and including the le-al representatives of a deceased employer. or the receiver or trustee of an individual . partnership. association or other legal entity, employing employees. However owner of a dwellin" house having not more than three apartments and who resides therein. or the occupant of the dwcllin- house of another who employs persons to do maintenance, construction or repair work on such dwcliinu h( or on the;,_rounds or building appurtenant thereto shall not because of such employment be deemed to be an empioy: 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 commonvealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionallv. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perforniance of public work until acceptable evidence of compliance with the insurance requirements of this chapter 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 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. Tile affidavit should be returned to the ciry 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 require to obtain a workers' compensation policy. please call the Department at the number listed below. City' or I ON'n5 Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investi-ations has to contact you regarding the applicant. P1 be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returnee Elie 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 questic please do not hesitate to anve us a call. . Tile Department's address. telephone and fax number: a The Commonwealth Of Massachusetts Department of Industrial Accidents _.. Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone T: (6I7) 27-4900 ext. 406, 409 or 375