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HomeMy WebLinkAbout0650 CEDAR STREET 1:77'40 UPC 12534 o No. 2-153LOR HASTINGS, MN �i Cw _�.a.•ued.. ..:.1.:.:: ..:'....-..ae..:�..:.u.Yasyy.�.rr�..v.:.:tiLr1..r�v.L._.'� -��-�edJ��.x•.�.v..--.ruLa_,i:�.-a._,..aiir.�a....a.. ............w�_:: .v...�.L..�.�..'�_-..w/a:L.fl.�,J_:. .�:...::_.__ .. .:-_v ��...__� _..a '~�i[?LL'Yi�.. _ _1'.•A.F:.':a..-u� TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION Map Parcel Application#` Health Division Date Issued Conservation Division Application Fee Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board �. Historic-OKH Preservation/Hyannis Project Street Address MV Village �tle�f 0?.66 Owner Address WV C 4ft 4_ Telephone �J�6 3��— y� S6 un sms Permit Request l r t Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay I � Project Valuation 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: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other o Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Ti Number of Baths: Full:existing new Half:existing neV Number of Bedrooms: existing new ^a Total Room Count(not including baths):existing new First Floor Room 'aount ry N t7r1 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 ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use _ Proposed Use ' a BUILDER INFORMATION q,L Name_ �l�l Telephone Number $ '1 Address License# 4°►I+� Home Improvement Contractor# 161113 Ir' OE6W Worker's Compensation# Wj ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �""VULA5=� SIGNATURE DATE 7 D �. I FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ^i• MAP/PARCEL NO. , ADDRESS VILLAGE ' OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NO. 6 The Commonwealth of Massachusetts Department of Industrial Accidents Ln Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ��JJke", Address: City/State/Zip: Phone#: Are you an employer?Check the propriate box: Type of project(required): 1.N;I am a employer with 4. ❑ I am a general contractor and 1 6. ❑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. t �• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t ' employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 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 contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �kw Insurance Company Name: n Policy#or Self-ins.Lic.#: ' �l/ p'C Expiration Date: 2 n ,6�'!/ Job Site Address: 650 WPA J City/State/Zip: © V Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.0 day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatir of tY DIA for insurance coverage verification. I do here y cWfyu r the pains and penalties of perjuty that the information provided ab ve is t ie^anrd correct. Sip-nature: p� ff� Pe Date: Phone#: 44V 500 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ACC> 09/09/CERTIFICATE OF LIABILITY INSURANCE DATE(M /2011 Y) 011 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: Mark Sylvia Insurance Agency PHONE FAX 771 Main Street c o E • 508 428-0440 AC No: 508 420-9227 E-MAIL ADDRESS:mark marks Iviainsurance.com Ostervllle,MA 02655 INSURERS AFFORDING COVERAGE NAIC# INSURER A:Farm Family Casualty Insurance INSURED INSURER B: Niall Hopkins Builders,Inc. INSURER C: 118 Lakefield Road PO Box 231 INSURER D: South Yarmouth,MA 02664 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDrYYYY MM/DD/YYYY A GENERAL LIABILITY 20011-6275 10/30/2010 10/30/2011 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGES(RENTED PREMISES Ea occurrence) $ 100,000 CLAIMS-MADE ❑X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PRO- LOC $ MBINED A AUTOMOBILE LIABILITY 2001053575A 6/25/2011 6/25/2012 COEa aden.cci.dentSINGLELIMIT $ ANY AUTO BODILY INJURY(Per person) $ 1,000,000 ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS x AUTOS 1,000,000 NON-OWNED PROPERTY DAMAGE $ 1,000,000 HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ A WORKERS COMPENSATION 2001 W6459 9/8/2011 9/8/2012 7 WC STATU- I x OTH- AND EMPLOYERS'LIABILITY Y/N ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED'? 7 N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Carpentry,Electrical CERTIFICATE HOLDER CANCELLATION (508)790-6230 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE j ` ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD _.;_. •'1'u�catchnsctits DepaiYment of Puh Slic iNA Board tit`i3uildim:L Rc Aulation,and�tam[urt13 !Construction Su.pervisOr License, Lic.$gse: CS g491677 NIALL J HORKINS' BOX 231 SO�YARMOUTH;MA 02664 Expiration; 4/212013 Trig: 14504 �:'.��nvn�s�iuisiii�' • Al Office o onsmner �qs b4 Bness7icgulHio c ~License or registration valid for mdividul use only HOME IMPROVEMENT CONTRACTOR t before`the expiration date..7ffound returnj(o a Registration 1ti1773: Type! Office of Consumer Affairs and Business Itegulahon.. t , e YP 11 .- `t E;xpiratron: j 1/20120i2 P..iiVate Corporatloii l0 Park•Plaz� Sprte 5170 ifHOPKINS BUILDERS INC, Bosto4%V1A 02 y'6 F MALL HOPKINS 1.% y+ 21"G FRUEAN.AVE SQUTH YARMOUTH MA 02664' h: Undcrsecretar�r' I - -- — �"n �Yol v it"` withou.signature OWNER AUTHORIZATION FORM (Owner's(Name) owner of the property located at C'e r (Property Address) �- (Property Address) hereby authorize t Hhr, (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. lJolu U, Z Owner's igna re I lit Date 1D { J A6' O O 7- 88 . O -sue c) 3-3 f 4 C CERTIFIED PLOT . PLAN F OR : Z y✓�f?v ` Jvy Ro G ,�N 10T 88 TO W N 0 F : SCALE : / " = -40, GATE .1 CERTIFY 'THAT WHAT IS SHOWN :ON TH.13 PLAN ; IS AS IT. EXISTS ON THE GROUND AND CONFORM TO THE TOW REGULATIONS D LE ASSOCIATES FALMOUTH.., MASS. OY .a .w „�•'"`*• TOWN OF BARNSTABLE -- Permit No. _-------- _ s,a.n,u Building ZIISp@CtOr Cash OCCUPANCY PERMIT Bond _No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without 'a Building Permit therefor first having been obtained from the Building Inspector.No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." , Issued to T, & J Rorp-arl Address Irt ,,`8 F;� redar rtD;C-L!t; �-`eat lmrnsta' 9c Wiring Inspector 4! f r, Inspection date - Plumbing mspector,fl .!� -,'" Inspection date Gas Inspector f Inspection date Engineering Department ` Inspection date 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. `r! 1 Buil g Inspector 5'a�d5 Off' w � ` i t 7- 8g 0 o _ : Z/S�BQ op O• - W.�-sr�v�a-� f� CERTIFIED PLOT PLAN F 0 R : Z ,zioGE,vN LOT : 88 TOWN OF : SCALE : OATS a: tta ,,. I CERTIFY THAT WHAT IS SHOWN SON THIS PLAN . ' t IS AS IT EXISTS ON THE GROUND AND CONFORM TO THE TOW REGULATIONS DOYLE ASSOCIATES FALMOUTH , MASS. ,-Assessor's map and lot number 0.. ..-. .....�.. � ` FTHET p SEPTIC SYSTEM MUST Sewage Permit number . .. / ....3.: INSTALLED IN COMP! fin..`? U -tea r WITH T!T ,. Z HAHB9T11DLE, House number .......... ..................................... IL r ENVIRONMENTAL CODE ; M6 9• TOWN Rr TIONS OMAI TOWN OF BARNSTABL� - � r BUILDING INSPECTOR t ,� APPLICATION FOR PERMIT TO ..... %� L.l.......° /��/c/��!c ..............F.... , ..................... ',. ll........ ✓ . TYPE OF CONSTRUCTION . l100,0...................................................................................................! ................................................19V 4 � + TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for ranpermit according to- thefollowing information: Location ... a 1,.l/9/ !Y 1.rd� .s J..�<.11.................. ................................... /��uFl1!41`.... t J... ProposedUse .....�• ; .......................................................................................................................................... ZoningDistrict ...........t�,.T:t.................................................Fire District .............................................................................. Name of Owner ... ........................Address ....z/0.. /`�Cb1/!C... GfJ;.t/�/Q.066 l...... Nameof Builder .........6W1.1A4Jr.�'6WA44....................................... ..................��............................................................. Name of Architect ... ........................Address .... ': /��............... / .......................................... Number of Rooms ..............................................:................Foundation .......�o/y��'�� . .... ?........ ............................................. Exterior ................11,.)oi^ ................Roofing ........le;e5. / 5" /�les....................... Floors ..............��/.1��...................................................Interior ........ 5 �� �fJ�:.l.... Heating /.//' i�� ....... ..' l g , ... !l.T��-t..l..FU Y... ...Plumbin )........................ Fireplace ........../.�t./................................................................Approximate Cost .......... . J. d ..................... Definitive Plan Approved by Planning Board ----19__U. Area .....1.. ..................... Diagram of Lot and Building with Dimensions Fee ® � �d ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH S RofloO y I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name✓t'•••..LGI!r ......................... I ROGEAN, E. & J. i `fro ...2aU.a. Permit for .Qna...1/.2...s�tp �. s Single Family Dwellirlg Location Lot #.. 650 Cedar West Barnstable ............................................................................... Owner .E'...&...M....Rogean............................ Type of Construction ...gra4.me......................... ............................................................................... Plot ............................ Lot ................................ Permit Granted March 11 ......................c 19 81 a Date of Inspection ..................� ... .......19 Date Completed T to PERMIT REFUSED i'� ................................................." .. . 19 s, ��. . ... .... ............. . . �-.�.s........................................................ ..... ..c. ................................................................ . ................................................................ Approved ................................................ 19 ............................................................................... v�/ ..U .... . .. . �!I�/f1�' .. V.Y../...... Assessor's map and lot number . ® .....: ..� .....:. `® THE T �o� o� Sewage Permit number .`..: ?° '....:`?.................................. _= Z BABH9TADLE, i House number ..........'.........:..'.......'. ...................................... s Mb e �O 39• �0 �'0 YPY M• i TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..... ........ ... ...................... �.. ...:. .:,................. ......................................... TYPE OF CONSTRUCTION .......... ,f r.... 6�........................................................................................................ ................................................19.' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: . .................. r . ..... .. . . . ... .... .... .... .. , .............................. ....................................a .....: � ......,Proposed Use ............ ...... .: :y ✓................................................................................................................,......................... ZoningDistrict ........................................................................Fire District .......................................................................0...... Name of Owner ... ....... p. . .�....' ........................Address ...................y ........................ Name of Builder dot ...........................................................0...... Name of Architect ..................: .:... ... . .........................Address ......:.. ?..... '.:� ............................................. IJ Number of Rooms Foundation Exterior ................:.. . .......::....... !�iL . ..:.................Roofing .........° "y6 .' Floors ..... .......... ................................................Interior ......... .:...... . ........ Heating ... ......... ......... ......................................... ✓ Plumbing r � F ... ........................................................ Fireplace .,y . ..............................................................Approximate Cost t:....d:... '.......:...................... Definitive Plan Approved by Planning Board 19 Area . ..................... Diagram of Lot and Building with Dimensions Fee ` SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ...............:..................... .......................................... . . ROGEAN, E. & J. �330O One l/2 Story ' ^ No -----.. Permit for .................................... - ___.S ' -l!�..Faod' ..Dvvell.i���___. Location St?�eet- West Barnstable � ----.---~.------.:............ ~----- ` E—.— 6 /T. �ogean— ' Owner — --..._— ---------.---. ' l7ranua Type of Construction .......................................... ' ----.---------------------- ` ` Plot ---------. . Lot ................................ ' � | MarchlI, 8I . | Permit Granted .,----.—_-----.lq Dote of Inspection . ~~'^ Completed - . '~ - H ' ' . lg------ -.. . / .-------. ~.---------------- ' ` � � —'-----^'.[--^-------^^------- \ ........ -- —...^--.. � ,�� � ,—.���. ...R.���—.----.— ' � . ` ^ . - Approved .................................................. lq ' --------------......-------- ` ` . ' . . ................— ........ .................................................. ' As �(/� Parcel de. Permit# /cam / 7 e Conservation Office(4th floor)(8:30-9:30/1:00-2:00) 1 D1�'I�(�� 1 Date Issued �o?� Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) l Engineering Dept.(3rd floor) House# � . -- SEPTIC SY Mr BE P _ INSTALLED HC 19 WIT ENViRONME ^o r TOWN OF, BARNSTABLEF-- Building Permit Application Project Stree Address Q7,/,�' Village 1. e— _ 6 1—14 .5'�c� Owner — To e A &1 Address Telephone Permit � Request D I77 Req 11 � 2 � First Floor 1 l 2 square feet Second Floor square feet Estimated Project Cost $ �� d� 1) 0 Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use cslr 1h Q� Construction Type _4 1-) I Commercial Residential 'Dwelling Type: Single Family _ Two Family Multi-Family Age of Existing Structure I Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths Dz. No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces h � Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information C �,+ Name Q / / Telephone Number (J Da 5,7 2 Address 3�3 8' Pd Sd ��yr (/License# D..2 / e 1/7 4-.o1� [/'i` y(-e AA, A Home Improvement Contractor# 1290 / 0 S Worker's Compensation# _ /Z O 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 d� G. SIGNATURE GLc-• DATE TU BUILDING. ERMIT DENI FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PE MIT NO. o • DQ ISSUED MA /PARCEL NO. - RESS VILLAGE OrNER 4 DATE OF INSPECTION: FOUNDATION FRAME; > ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL _ PLUMBING: ROUGH FINAL GAS: f ROUGH FINAL { FINAL BUILDING DATE CLOSED OUT Y ASSOCIATION PLAN NO. + DEPARTMENT OF PUBLIC SAFET! CONSTAUCTIUN SUPERVISOR LICENSE TNgsber — ,;Expires: ` 4 ==6EOR6E ] ALLAIN 38 PLEASANT PINES AYE CENTERVILLE, MR 02632 05 OVEIIE�i-CONTRA&10R�' 7� �• T i ' �q� �ur.V•lj • , 4 �1 t • � A ♦ r ,� . � ♦ I, � fir.► I � , y :. i� `` -_-t=�•� Department of Industrial Accidents A If MCC V11fiYVSfigJfi9,7S �'.� ' '• y, 600 if ashing;ton Street Boston,111ass. (1 111 • Workers' Compensation Insurance AMdavit ppnu.. Ma MI ion, flease-Vitf 'ie—elluly 33 P/•e -JL— q° ,) .n/7 4,Pir UI/1 -e M , i nhonc it �� S I am a homeowner performing all work myself. 0 1 am a sole proprietor and have no one working in any capacity ri I am an employer providing workers' compensation for my employees working on this job. n 3 1 rt • ed d t C/ rih•• Cei 14e UI r-Ae l 1' 1 nhonc tl• incur,ince co policy 0 r. 1 am a sole proprietor LIFeneral contracto or homeowner(circle one)and have hired the contractors listed below who have the following workers co en n polices: '4' 1 .•,dress• 332 yl 1'/—P cit%-: C eg �'-P4- l/[mil �-P lY I fl �D Z S O�1' I phone#! 1 - �P -�'- 9-6/ •, I zeco. 1 C0 JJ0licx# C .2073 !� � ^f+ :�, ':,T. _ _ :/�ry.:.�p,4'�7!'7,^.,• .R� :F ���+M•• 71?"^!Cn:•9.•.. '�4�'�.'�":r'*�S company name: address: cirv: phone#• insurance co policy!! .Atiach add1tfonal'shiit if uee .-►�Y.:=:..�;�-�• +:;h*r v'+ter •,-�.: :T:.a.•... . '.;,�r„^ .. = — :, »�-• - ;; Failure iu secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or unc •ears'imprisonment ac well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. 1 understand that a copy of this statement mad'be forwarded to the Once of Investigations of the DIA for coverage verification. !do herebt•certify der die pains and penaUies o peduq•that the information provided above is true and correct. Signature Date _ r1 �A Print ameD7�f Phone official use oniv do not write in this area to be completed by city or town official city or tows: permit/license t! nliuilding Department OLicensing Huard O check if immediate response is required OSelectmen•s Office Olicalth Department contact person* phone,', nUther 1 Irem cd 19!P)A) j . The Town of Barnstable M& Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508 790-6227 Ralph C.rossen Fax 508 775-3344 Building Commissior For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruaron,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 strncmres which are adjacent to such residence or building be done by registered contractors,with certain aocepdons, along with other requirements Type of Work: s� G Est.Cost v• d Address of Work: S 0C Q ja = cl Owner.Narne: Q Q e Date of Permit Application: T4L I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000 Building not owner-occupied Owner pulling own p=4 Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH i1NRE6I5T =D CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO TIC ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner•. p� A CU, el Date Contracor name Registration No. OR _- (limner's name Application to .7 1 [� n I f 6 4 Old Kings Highway Regional Historic District Committee in•the Town of Barnstable fora 4. CERTIFICATION'OF EXEMPTION Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 cf-Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo- graphs accompanying this application. TYPE OR PRINT LEGIBLY. ` DATE v 4 y ADDRESS OF PROPOSED WORK rd S O �10 AASSESSORS MAP NO.. . OWNER ASSESSORS LOT NO, fa ,kt.. HOME ADDRESS (� D CP a>^ TEL. N0. �LO " Z[ AGENT OR CONTRACTOR ADDRESS TEL. NO t hit: . '',- '; .. 4..x...- -yt '- .. 't:• !' ..'. sit ,,•. • This application is for exemption of proposed-exte'rior construction on the ground that. "'r' % `' ' ti 'y'`'•r`' ❑ (1) It will not be visible from any way or public place. ❑` 1 (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commis sion.,; �fi ^{ (Check applicable box) PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot,and,.if en addition is involved,show• ing location of existing building z t �Hk 444{1� k fL r 4>. ..i"P'"`'� - ,.r i�.'r r. ;,i- n N y Lt! y:. -. '; ; ••r , .� J aac•11A�-'IL8'T" fir.. 'vt f f _ t!Z f :, ;- 3 , t ' ' SIGNED r Space below line for Committee use ti fK 1 ; t° t , ;°•'' nor e- Contractor-Agent D ce d y The Certificate is hereby ���`� ' ByTOWN OF 13ARNSTAFtiDate' Y Approved t 'The categories of work entitled to exemption are listed on Disapproved',; ❑ the back of this form. Al `✓, Er•' ` w`� 1 •'�C ` J�-"Lam .+. i r... '' skd�' •r '�'`r ai3x a;�. . Y .. I ! Ie, ' i