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160 ✓� :a r i �' N t i i a f Town of Barnstable *Permit'/Q0 / �Z(00_7-7 ExpE R M IT Regulatory Services Fee e 6 m n ho issr<e� • aexsresrE • Yip MASS 2013 Thomas F.Geiler,Director Building Division TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 , Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address /10 O r�w (, Pe. ✓1 1`''�-P S Residential Value of Work$ �?P90 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name � �<. ���.� Telephone Number S d8 3C1 •-29 7/ Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) c—❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ® I am the Homeowner ❑ I.have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ® Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to� ,.ems vw ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows i #of doors: ma's 0 Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. 'where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. i ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: I Q:\WPFILES\FO S\building p �'t forms\FMRESS.doc Revised 06051 Email. ~ Town of Barnstable Regulatory Services Aa A71RT�i[iR M,SS. Thomas F.Geiler,Director � Building Division Tom Perry,Building Commissioner 200 Maui Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print t-DATE: 7 vCc7l� JOB LOCATION: I G C� C It,v c1t�, I t /,i,, i?C,0, A—r7gs r number/1 I street village "HOME h OWNER": JO w `�J�t•�dam. > o�- ?�2 a�T� name home phone# work phone# C CURRENT MAILING ADDRESS: Po city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures an requirements and that he/she will comply with said procedures and requirements. CA'atum76eovner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit'application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in. .your community. _ C:\Users\decolllc44ppData\LocO Microsoft\windows\Temporary Internet Fles\Contmt.Outlook\QRE6ZUBN\EXPRFSS.doe Revised 053012 IHE Town of Barnstable Regulatory Services • RLAA7.C1LRiR ASS. Thomas F.Geiler,Director 16.19. � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Usi= A Builder as Owner7theect ptopertyhereby authorize ct on my behalf, in all matters relative to work authorized by this b emit (Address of Jo Pool-fences and alarms are the responsibility of ` applicant. Pools are not to be filled or utilized before fence is,installed and all final inspections are performed and accepted. Signature of Owner ' Signature of Applicant Print Name Print Name i Date Q:FoxMs:owrrMERbMsIorrnooLs 6/2012 ;a �`Ite�amm'opnt3t o�Massaclrust�#s I#e threat gf'1Fu&YmW Accidents - t'1KWe rrf tigatic'ns 600 Waskington Street Bestan,MA 02U1 wtt mmassgmaldia Workers'Compensation Insurance Affidavit Buagders/Contractors/F,leetricians/Plumbers Applicant Informatian Please Print 1&%ibly Name Address: /L o CitytSta&Zip: la f3c w J-4. I ke Phone i1-. S-O 5r7 - 3 G z --z�-d 71 Are you an employer?Check the appropriate bo= Type of project(required): 1'__❑ I am a employer with 4. ❑I am a general contractor and I 6. ❑New camstraction employees(fall andlorpart-time)* havehired the 2.❑ I am a sole proprietor orpartuer- listed on the attached sheet 7- ❑Remodeling ship and have no employees These sob-contractors have g_ ❑Demolition d have wo&ers'employees an vvodting forme in any capacity- 9_ ❑Building addition [No work=,camp.insurance comp,msuranteI mod] 5. ❑ We are a cotporatiemand its 10.❑Electrical repairs or additions. 3.® I am a homeowner doing all work officers hnve exerdsed their 11-0 Plumbing repairs or additions myself[No workers'comp- right ofexemption per MG- 12-0 Roofrepairs insurance required]1 c-152, §1(4} and we hone no- emplopees-[No Warless' 13.❑Other comp-insurance required] *Piny appHomt that checks box#1 mmst also fM a=the section below sbovitn5 flea vuskers'cmVe=afitm policy iaf=wfHm. T Homeowners wbo submit this affidavit iadscat kZ they are doing alival and flea hie outside caetactnrs such. :k-An—ctoa that check this boot mast attacled as additional sheet showing the name of the sub-cm'xacma and state whether wmt these emfities bzm employew. iftbe sub-contrauais have emp7ayee-%they mmst pamide their wmkeW comp policy mnabm .ram an employer thatisprovitiYrrg iiwrkets'compnmdian insurance for my etnlydnyirm Belau is diepaHey and job site information. Insutsnce Comp myName: Policy#or Self--ins Uc.#: ExpirationDate: Job Site Address: City/State/zip: Attach a copy of the irorkers'compensation policy declaration page(showing the policy number and c ratio-n date). Failure to secure coverage as requitedunder Section 25A o€MGL c. 152 can lead to the imposition ofcriminal penalties of a fim up to S 1,500.06 and/or one-pear imprisasament,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250-00 a day against the violator- Be advised that a copy of this statement maybe fnrwarded to,the Office of Investigations of ilse DIA€or insurance coverage owification_ T do hereby ce fy rtitdar the win s andpenalties ofpedwy that doe information providad above is hue and correct Q::N" ttae Bate: Phone#: 01kial use only. Do not writs in this area,to be completed by city or town officfaL City or Town: PermitUcense# Fssning Anthority(drele one): L Board of Health 2.Building Department 3.CitpTown Cleric 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute,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 budding appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insu once t;overage. .Also be sure to sign and date the affidavit The affidavit should be retuned to the city or town that the application for the permitor 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town O ffi ais 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 pemiit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out.each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etr,.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your 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 Massachuse t Depat$nent of IndustW Accidents Office of kvestig,ations 600 washingtan Street Boston,MA 02111 Ta#617-727-4M at 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass_govldia y j, Town of Barnstable *Permit# co 26)8 PROF rOtgy Expires 6 months frorn issue date Regulatory Services Fee BA"STABLF, ' X-PRESS PER IT y� MASS. 9 `Ch Thomas F. Geiler,Director MAY Division -- 3 2010 Tom Perry, CBO, Building Commission6 OWN OF SARNSTASLE 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid with orrt Red X-Press Imprint Map/parcel Number Property Address 0 c ,", S7 (�Residential Value of Work 2DO 0 `Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address A,0 C L/4G 4 S7 Contractor's Name y" �L w Telephone Number 2 b 7 1 Home Improvement Contractor License#(if applicable) 2 /y9 Construction Supervisor's License# (if applicable) Oo f Ye7 9 ❑Workman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# 2001 kd)Q l Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to AKA-met"jl�- ✓ CJA- I _r Going over existing layers of roof) © Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License & Construction Supervisors License is required. SIGNATURE: n I c�N The Commonwealth of Massacltttsetts Department of Industrial Accidents Office of Investigations 600 YYashington Street Boston, MA 02111 >vww.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le i bly Name (Business/Organization/Individual): )6 hw Jc.� Address: 4 City/State/Zip: L tM Ss Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hued the sub-contractors 1� listed on the attached sheet. 7. ❑Remodeling 2-® I am a sole proprietor or partner-ship and have no employees These sub-contractors have employees and have workers 8. .❑ Demolition ' working for me in any capacity. 9. ❑ Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.K I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of exemption per MGL 12• ___.Roof.re airs........... . -- _ srrysel#,..[No.work�vs.._coznP,..... -4_.........:........_.:.......-...-:..__....._..... ... _._.__._...__ _ ...... ❑ P Y insurance required.] t c. 152, §1(4),and we-have no employees. [No workers' 13.❑ Other comp. insurance required.] *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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors'have employees,they must provide their workers'comp.policy number. 1 am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: 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 tip 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the ains andpenalties ofperjury that the information provided above is true and correct. signature: Date: ,,_ 3 av Phone#: 36 2 97 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 r+,,.......a 1D...- Phnna#: l Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for.their employees. Pursuant to this statute, 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, §25C(6)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,MGL chapter 152, §25C(7)states"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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s) of . insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the ^..T_ members or artners,are not ri.e uired to c workers corn ensation insurance.' If an LLC of L P-does have employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials 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 munber. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your 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 Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia Town of Barnstable o Regulatory Services r Thomas F. Geiler,Director • anxxsrasr.e, MASS. 1639. � Building Division DIEDr A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:_ 7 2O /D t JOB LOCATION: A,0 C 4.� �4 � � ' �`L" 7�number street village "HOMEOWNER": L�� N dU 4/t/so SO'i^'i C 2 name / / r home phone# work phone# CURRENT MAILING ADDRESS: (/,4,.. k.h,r city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requi ments. Si lure of Hom er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC oF�ME Tom, Town of Barnstable Regulatory Services BARNST^BLF- ' Thomas F. Geiler,Director Mass. n M,.,b. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 wwvy.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder. I , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) i i Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the,reverse side. Q:FORMS:OWNERPERMISSION TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel (105 Gam""' r. Permit# Health Division ''/� «'" Date Issued �n Conservation Divisionw Fee DO Tax Collector SEPTIC SYSTEM MUST BE Treasurer (� INSTALLED IN COMPLIANCE D< 1i4,'ITH TITLE 5 Planning Dept. ENVIRONMENTAL CODE AND Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis ' Project Street Address O S r .Village Owner �o w �� ^'s Address Telephone 73 L- — 2 S -7 Permit Request ��%� /c. k 4�l - �.o� a S v Square feet: 1 st floor: existing 3/ 5 S proposed 2nd floor: existing o proposed Total new Estimated Project Cost Sf60 Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size �c>_l boo s/, 14 Grandfathered: a Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(#units) Age of Existing Structure /t 7 3 Historic House: ❑Yes Cl No On Old King's Highway: ®Yes ❑No Basement Type: ®Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 600 Number of Baths: Full:existing new Half:existing new _ Number of Bedrooms: existing 3 new 0 Total Room Count(not including baths): existing new First Floor Room Count s 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 Cl 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 -��� I?o v w BUILDER INFORMATION Name Jd�^' J ���o^' Telephone Number `�� Z 'z`a-7/ Address G a e6y&,4 S% License# ODIC' �✓e�� r �a�• /f Home Improvement Contractor# 0 2 44 � Worker's Compensation# ;20 OI y, 0 201 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE _�N /7 l I FOR OFFICIAL USE ONLY 5 • r . 1 • PERMIT NO. DATE ISSUED r' MAP/PARCEL NO.- ADDRESS VILLAGE = OWNER °" . DATE OF INSPECTION- FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH' '- ; - FINAL PLUMBING: ROUGH M FINAL GAS: ROUGH FINAL _ FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. ` The Town of Barnstable MAM �0 Department of Health Safety and Environmental Services 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 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: 6v6 o l-wq Ac-44 ff'o Estimated Cost Address of Work: �� o l..-K-C� 4 �-- Owner's Name: Date of Application: C Y i c 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 H"ROVEMENT 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 the agent of the owner. Date Aontractdr Name Registration No. OR Date Owner's Name q:forms:Affidav - --_- The Commonwealth of Massachusetts ± =- Department of Industrial Accidents Olfice olloyresff9atioos 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: ticl IV N a 4--rQ � location: /00 C city "Cr `e-p-A—A--c tc, Sl c phone# ® I am a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in an, ca acity ❑ I am an emplover providing workers' compensation for my employees working on this job. comnnnv name: address: :.. city phone#• insurance co. plies# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloitiing workers' compensation polices: comaanv name• address: dtv phone#- insurance cm. ...... company name: address: city- ... phone#' in.uranceco. ::.:. .:::.::. ..:. plies# 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 51.500.00 and/or one years'imprisonment is well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the 011lce of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature/ is Date �-. ! y / �l _ Print name . o �'h �`-f ' Phone# C a - 2 Y?J official use only do not write in this area to be completed by city or town official city or town: perndt/ilcense# 7❑Building Department ❑Licensing Board ❑check if immediate response u required ❑Selectmen's OPflce ❑Health Department contact person: phone#; � ❑Other (mmea 9195 PIA) 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 co=--= 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 receive:c: 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 contacting 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 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 retiuned io 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 8MC8 0110Y8sugatl00s 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 ectionam, rg, 1 The Massachusetts State Building Code (780 CAM) includes provisions to ensure that houses and house additions meet energy efficiency standards. This supplemental CONSUMER INFORMATION FORM is to be filed as part of the building permit application when a builder/contractor or homeowner, constructing/installing a house addition with very large percentage of glass to opaque wall, seeks to utilize a special energy conservation exemption option for "sunroom" additions to an existing house (780 CMR, Appendix J, Section J1.1.2.3.1). This FORM is not intended to prevent a homeowner from selecting a "sunroom"of any size, configuration,orientation, form of construction or percent glazing, but rather is only intended to assist homeowners in becoming aware of some of the important energy conservation and year- round comfort considerations involved in selecting and utilizing a"sunroom"addition. The connection of "sunroom" structures to residential buildings may create comfort and energy consumption issues due to uncontrolled solain or uncontrolled radiation cooling of the main house. In the selection and construction/installation of"r:gasunrooms", included below is a non-required, open-ended list of product and design considerations that a homeowner may wish to consider before actually constructinglinstalling a"sunroom". It is recommended that consumers carefully review these options with their designer, builder, or contractor, in order to minimize potential energy consumption and/or house discomfort issues. In addition, the qualifications and reputation of the company or individuals to be hired are important considerations. PRODUCT AND DESIGN CONSIDERATIONS RELATED TO"SUNROOMS" • Solar Orientation and Natural Shading • Type of Glazing • Insulating value • Solar heat gain • Frame materials • Glazing to frame sealing and gasketing materials/seal durability and/or weather tightness of the sunroom • Adequate ventilation-Operable windows and fans • Applied Shading Systems • Insulation level in floors,walls,and ceilings • Possible Sunroom isolation from the main house via a wall and/or door or slider • Heating and Cooling Methods: Efficiency,Zoning and Controls Homeowner Acknowledgment The Massachusetts State Building Code, Section J1.1.2.3.1, requires that the actual proQerty owner(not the owner's agent or representative)acknowledge receipt of this CONSUMER INFORMATION FORM prior to issuance of a Building Permit for a project that includes "sunroom" additions to an existing residential building. In accordance with this requirement, the undersigned hereby acknowledges that she/he has read the information in this document concerning sunroom comfort and energy conservation. Signature o ctual Building Owner Date tif0ti ./60 s ( . Print Name Address of Permitted Project 2 - -2K? Owner Address(if different than project location) Owner's telephone number i Fv Hill a e o9: - rov0 <o s v ... d > 9r 8 g jm LLJ 1 f 1 1 \ a V LT / 77 C•, \ i ' i ' \• \ ,, ------ Ln cXD p ---- t \ / L(0 \ % \ fie �o,�r�;r�museez� o����aczr`u,�aeC�a HOME IMPROVEMENT CONTRACTORS REGISTRATION I _ Board of Building Regulations and Standards i One Ashburton Place — Room 1301 "`! Boston Massachusetts 02108 �I ------ -HOME IMPROVEMENT CONTRACTOR -'----------------------- Registration 102149 Expiration 06/30/00 Type — 'INDIVIDUAL r A_ �- . `• HOME IMPROVEMENT CONTRACTOR JOHN JOHNSON • , y I ,Typestration INDIVIDUAL49 John .J . Johnson }' ... r izpiration -06/30/00 i i k i«:'i PO Bo.x 118 160 Church St �, Ti k y c °I + •4 W . Barnstable MA 02668 � _" ' JOHN JOHNSON e• n J. Johnson d� ADMINISI MR ru Box 118 160 Church St � - W. Barnstable MA 02668 DEPARTMENT OF PUBLIC SAFETY I ' CONSTRUCTION SUPERVISCR LICENSE Number;=r===-- Expires: _ Restricted,T_oc- 00 JOHN J 4J6HNSON VINy 160 CHURCH ST _ .W BARNSTABLE, IA 226;c i utl i t.b a II � � i UI I i li • Yj J� I } f d �I i • i I I I � { I 3 , I ii I a a r: a I. J� i I � i i Za L- u b 0 i s ; I . `J 1 � I ; it aD TO Li .� 1 Application. to Old King' Hi hwa Re ion Historic District Committee g g Y g . in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application. Is hereby made, id triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building Addition ❑ Alteration Indicate type of building: ,® House ❑ Garage ❑ Commercial ❑ Other 2 Exterior Painting: ❑ 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4: Structure: ❑. Fence ❑ Wall ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE '' ADDRESS OF PROPOSED WORK �f,0 GI<�w�� S f ASSESSORS MAP NO.15 _ OWNER � f" ()e 60 A..ct L, �J I�WJ S o w ASSESSORS LOT NO. 0O � HOME ADDRESS to G V FLC k. • S T TEL. NO. 3h2-ae 71 'FULL,-NAMES AND ADDRESSES OF ABUTTfNG OWNERS.- Include name of adjacent property owners across-any public street or way. (Attach additional sheet if necessary). © �iy DoLv dc9.v �`y G�vV/►-G� S1' Z✓- P3�wns �4 _-1 O '13o,v well Jr rri AGENT OR CONTRACTOR y 'y S•o'er' TEL NO. ?6 Z 71 ADDRESS 0 C• SL. Gya-s-e OZL h DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done(see No. 8,other side), including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). r S'.e t 0� ��-3�c�z`.c Y �v�w�.e yp '� ��-�C� G•JI.' �T-f� �t.{, R /n. /c-ss.,c a t° K o S u rye �i'rv�owS kt.w?A_ ned 1�•. �: ,:-�� i f z I �,�,:: r f Owner-Contractor A nt owl r'f O US De v b at Cer ' ' ate is hereby xxavr Date ,,�xf- Ti 0 iss� a me ,. TOwN OF )���AxABA RN NWgyly Approved ❑ IMPORTANT: If Certificate is app ved,approv is subject to the 10 day appeal period provided in the Act. Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION C'�n.r►��.f't. n`c ti-$ SIDING TYPE CC)d s�i., 1 COLOR CHIMNEY TYPE / )A COLOR ROOF MATERIAL AO =1Z, J D /��.cli;c7". COLOR wwyj _ PITCH WINDOWS -/tAW1cwt-.,COLOR ".-rr SIZE Y 304'z 17-o-v�Pt�t.-fti.r. TRIM' COLOR w i 1 �/u C'JC 5�� . .. ds e_ 8,.. :DOORS Y': � w��• : �G�X ��.�ti 3 y��iiDa.aCOLORS ;• RPd SHUTTERS. l,c . : . COLORS i✓ko, -r.< GUTTERS w �. COLORS (,� i rY DECKS MATERIALS GARAGE DOORS AI:4-- COLORS SKYLIGHTS-2 t lyx SIZE 2 'k I COLORS &o,., SIGNS A. COLORS FENCE NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of this form are required for submittal of an application, along with Four copies of the plot plan, landscape plan and elevation plans, when applicable. SPECSHT Revised 11/98 \ ------- /C51 �- j I Jo/� W V sill! LA Z n< a ° o o m 1y fl ( •1; ':"� ,_ i 1 ��� i'`r n fr D 50 Ri 66§e� $ i '_-S =S _ '' s 3 EY)gineering Dept. (3rd floor) Map , Parcel Permit# 9 7�-v r House# (o o Date.Issued s Al Fee e) P-Le fti-m .Q11p - & +i`chAnl Admin Bldg 1 SINE 19 , AWL �Y' g BARNSTABLE. 6 .� TOWN OF BARNSTABLE Building Permit Application / P oject St` Addre g LT l Villa , �� v�r� s�4. 14 Owner . 7�6 L, Address A,o c 4- LMC C sr Telephone 3 Permit Request & 0 ; M First Floor /0 Y'D square feet Second Floor square feet Construction Type 4-0 c Estimated Project Cost $ 25`0 Zoning.District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 2 *L�c Historic House ❑Yes [YNo On Old King's Highway ❑Yes ❑No Basement Type: ,)Full El 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 3 New Total Room Count(not including baths): Existing l New First Floor Room Count Heat Type and Fuel: U Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) 0 x 3v 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 9 / Builder Information Name d= (� J,) ` ,__1 o Telephone Number L 2 -ZQ Address A D r 51, License# 60 -1Y® Q Home Improvement Contractor# /b 2 /1/ y Worker's Compensation# 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 // n C% SIGNATURE 0C fz DATE f��y 21 97 BUILDING PER IT DEN [FOR THE FOLLOWING REASON(S) 19-- Milli- Im FOR OFFICIAL USE ONLY a PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS = ' - VILLAGE OWNER met DATE OF INSPECTION: FOUNDATION , FRAME ;yz INSULATION C FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ` GAS: ROUGH FINAL FINAL BUILDING oy-a7- DATE CLOSED OUT ASSOCIATION PLAN NO. %THE TOWN OF BARNSTABLE A BARBS ABL 3 a r MAM 1639. BUILDING . INSPECTOR M;"f APPLICATION FOR PERMIT TO ..... . .................................................................................................... ...............��.w �,k/ ........................... ...... .. TYPE OF CONSTRUCTION ................... .rZtq ........................ ............................... .............................. r.............. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information. . . . . . 16 c? '�6 n .......... 1 -ty Location ......��r. ..........�,&................................................................................................................ ProposedUse ............ .......................................................................................................................... Zoning District ......... ..............................................Fire District ...... P-)C)-F-C. ......Wass................................... ....................... Name of Owner ....4: ....................Address .......... eow CA- ................. ....................................... Name of Builder ........ ........—f .e........Address ........... ............................. .............. Nameof Architect ....................... Address .................................... . . .......................................... ............................Foundation ..... ................. .... ............/C).. Number of Rooms ...................................... Exierior ..... ................................Roofing .................... -d t.................. ............................... Floors ......... . ed/c .. ......... . ..........................................................Interior ................................................... . .................... Heating ............. e......................................................Plumbing ........................ �I—. %- ........................................ Fireplace ............... Ae............I.............................Approximate Cost ..................... .0 ........................ Definitive Plan Approved by Planning Board --------------—-------------- I A Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF'HEALTH q 0 _j < LLJ Ll- 10 ^l :,� 3 L 0 z < > LU I LJJ > 5 0 < Q: z � 3 LLJ CL 00 La 0 (r) < o >: 0 -j CO < :C CL LLJ 0 0: CL cr,.N- I-- M LLI z U) a Q Ld Of U) 7�� "*,j NU 0 Cr > LLJ 0 12 U Cq Jl I ------------- X rc- Jj LLI tad I,hereby agree to conform to all the Rules and Regulations of the VT,.ownofT..Bar st7ablirding the ..,above construction. Name ......... .......... .......................................................... A. D. , ( 15089 one story �� ................. Permit for ... � single family dwelling � .-----.--..-------------~—.—,. {hzrch. 8treet Location ^ � —'^'--'-----'-----------' / West Barnstable —.--.---------..------------. A. D. l�ombIio uvvnar -----.---_.------_____—. � V � _ frame Type of Construction .......................................... . ................,.........,''.....................'..................'......'' � Plot. ---------. Lot ................................ ` ^ � . . e 72 . Permit Granted ...... .. � I!! 19 Dote of | ' � uune Completed v . .^x � � l PERMIT REFUSED � lV � ^ -----.-.»:^—.`--------.--. . � ^ � .-----.^—.—...---,~-----------.. Y ' � ^---..—.—..—.--.-----.^..--..—~,—.. [ —,--._--.-.---....,~.---...--'_.,— \ � � -------.—.—.—.---.,—.^----.---.' � �. Approved ........................................ lA ~------------------`------- �v , . Y / ' a e7olcl ��; co S'`we�. !4 �� � �c.,voc✓ le c o y THE . : . The Town of Barnstable �►xxsTnBi.$. 9 B \ �' Department of Health.Safety and Environmental Services &639.rEc ram" - 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: I/fe Ayll Est.Cost Address of Work: A 6 C 4,&r_,_4 Tt- 4�, /Sa.w,w s 1/r /IV S s 411 Owner's Name J4 4 n�� Date of Permit Application: C/__/ 7� I hereby certify that: Registration is not required for the following reason(s): Work excluded by law _1 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 apply for a permit as the agent of the owner: v 6 Z v rc. Qo J-r o y Date Con ctor Name Registration No. i OR -w- Date Owner's Name ' V. +� The Commonwealth ofMassachusclly Department of Industrial Accidents 011iceollavestlgations 600 If'ashhi,ton Street Bo oit. A1ass. (12111 Workers' Compensation Insurance Affidavit �lpnlic•tnt information• _..-_Please PRINTaeb ]y_--,__...._........ name: Jd �iK- yd k A-ro Ioc,ition• lG U GAj Sr, cilx' G<7 6 4 !/V(T_r nhone "•2 7 I (' I am a homeowner performing all work myself. ❑ ^ I am a sole proprietor and have no one working n in any capacity ._�... .-.ew•.-.�__P_..._...........n...—._yNvar.i_rws4�i T"'wMt"/'1�?.�:.:f� +�!!!lT.i��� �.T""�'�•� — _.... —...... [) I am an emplover providing workers' compensation for my employees working on this job. coumany name: aticlress: situ: nhone t#: insurance co. police.# [) I am a sole proprietor. general contractor, or homeowner(circle otte) and have hired the contractors listed below who have the followin! workers' compensation polices: comnam• nnrttc• address: nhone##• insurance rn nolics•t# ... .,_._ .._.. ..,:_- -- -;�->-,.:_- ;T••,-.psi. —�,;•::-.-;...._r.....•,�.. :-�--i_• commmn%, nnmc• address: rite•: ahnne#!: insur•nce co policy t! .Attach additional sheet if necessary, u.�.i..et��—•+•— �. .... �. y=,--w,w. ri4�Y��.w..i._.-:-��.lY!'�wL.�iE•.L.ic'wrA F:iilurc to secure coverage as required under Section Z5A of 111GL 152 can lead to the imposition of criminal penalties ol'a line up to 51.500.00 andior one-'cars*imprisonment a. ell:IS ciVil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that n copy of this statement mas' be forwarded to the Office of Investigations of the DIA for coverage verification. do herehr ccrtijr tdcr tern pr 't and penalties of perjury that the information prorided above is true and correct. xs�E! nawre Datc �`" `� 7 7 Print name Phone# '•ofrtciai use only do not write in this area to be completed by city or town o(licial city or tn�n: permiUliccnsc I tl3uilding Department Licensing Board I]check if immediate response is required ❑selectmen's Office . [3111ealth Department contact person: phone#!: rj01her S.: Information and Instructions Massachusetts General Laws charter 152 section 25 requires all employers to provide workers' compensation for the employees. As quoted from the an enrpl( ree is defined as every person in the service of :mother under any contract of hire, express or implied. oral or written. An emplorer is defined as an individual• partnership• association. corporation or other legal entity, or anv two or►nor the foregoing en aged in a joint enterprise, and including the legal representatives of a deceased emplover. or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However th owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the d\velling house of another who employs persons to do maintenance , construction or repair work on such dwelling ho or on the urounds or building appurtenant thereto shall not because of such employment be deemed to be an employe: MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or rencival 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. Additionallv, 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 been presented to the contracting authority. ��-.�-.ram..-.--......�� ....-.�.�..•- 7 .7 �-7•..�� �..i.lw .-....._ I 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. 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 requires to obtain a workers' compensation police. 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 o. the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie: be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned - the Department by mail or FAX unless other arrangements have been made. Tile Office of Investi=ations would like to thank you in advance for you cooperation and should you have any questior please do not hesitate to _Live us a call. 7-1 -- ... The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 «'ashington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 Assessor's map and lot nurlbvr .... ;,��.�! �oF THE t01� Sewage Permit number /.. ./ ` �.�.......... .......tc..A . ................ House number 14.0.......G. f t � BaaPAZ& r ..................................... 00q,t639. 'F0 MAY a. TOWN OF BARNSTABLE BUILDING . INSPECTOR APPLICATION FOR PERMIT TO ...490 ./a...::... 'Z1.: ........................... TYPE OF CONSTRUCTION .........4.,b? ?A 6:a4'fng;...................................................................................... ....../Vo v.../�......................19. . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ��i vot`� .c�� /�c�rt r�. t fti.E?.l1' Si l s.....................................................................................Sr......... ............ . y. ..mx ............. ProposedUse ..... 4....................................................:.....................................................................I......................... Zoning District ...f. -./.:.(/ ..................Fire District ...�` ?s... t ................................................l, !e ..................................... ........ Name of Owner ......... ...... ........................Address .. Sf Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms Foundation ... ................................................... Exterior .....4. 00!O ....f..4r.`.^yhr..........................................Roofing ../�s ��. ... .`��.�5........................................... Floors ..... e."'!. ..............................................................Interior ....Allf..................................................................... Heating ?!00��...57`4Y........(f ! �-).............................Plumbing .. .. ........................................................................... Fireplace ............................................................Approximate. Cost 3 0bo �Z7 Definitive Plan Approved by Planning Board ------------__—-----------19_ _ . Area ............ ..... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH ----------------- I - C�ivl�-c4 S���er 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. oName .. .............................................................. Construction Supervisor's License ..v�........................ ....... - = JOBNSDN, JOBN 35775 Qaxage,�-- ' No ................. Permit for ---.-----�--- Single Family Dwelling ' .- ..---------.----------.. Church Street Location ----~------'---------- Weot Barnstable --.----------------,------- ' Jbho Johnson ' Owner ---------------------- ^~ - Frame ',F~ ~' ~~ ' -------------- ' ' ' ^ ........... ........ ........................................................... ' ` + Plot -_-.��----' �t ................................ . ' November l6' - 83 Pe,mh Gronxyd ------------..�]V ~~ ~ .~ Date of Inspection..-----. ^ ..-]A . ^ Completed ................. -.]A ` � ' r . . ' � ` ^ ` ^ � ` � ' ` . . . . . ~ � ' . ' . Assessors map and lot numb r . .......✓.. THE ro L � .,_ /IJ i � Qy �,► Sewage Permit number : `..�1-� ........ ............... .........: Z SAR33TABLE i f t - rasa _., House number ....1�.. ....... .....!!.2: ..............:.................... 9oa 1639. \0� mi, { TOWN OF BARNSTABLE BUILDING INSPECTOR Pa . APPLICATION FOR PERMIT TO .......�si,p,�v....... ....!2.`^�.�..:�:..............................................................:.......... ; V 4,'.A �✓ �=it,f M ...................................................................................... TYPE OF CONSTRUCTION ............................................... /�/�v l�.......................19. s. .... . ................. TO THE INSPECTOR OF BUILDINGS: <s The undersigned hereby applies for a permit according to•;the following information: Si" .�. ..f..!,Location v ProposedUse. ... a.1c.. ?............................................................ .................................................................................... Zoning District ... `............................................................Fire District .... `.s ... ............................. t; Name of Owner .........Azn ......�q Nr4.X. Address ..C61.4 c4.....s¢......................:............................... r' Nameof Builder ..................................................... ...............Address ............ .................................................................... Nameof Architect ................................................. ...... .Address .................................................................................... q Number of Rooms ..................................................................Foundation ...Ar�K?qt;s.................................................... a ..a� sG, . Exterior �O ...!?/r ...............................Roofing. ... ra,`�.�Y Floors Interior ' �w.e�`'....... t .. ..... . ........ Plumbing ..................................... Heating Plumb'n Fireplace ............ �.............................:.r..:.....`...................Approximate Cost .....j000.................................................. r t Definitive Plan Approved by Planning Board -----------______-----------19_______. Area Diagram of Lot and Building with Dimensions Fee 7Z:............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ILI � 5rP 1 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. ., Name ..... ......... a. Construction Supervisor's License a O S q Q r• , JOHNSON, JOHN A=153-5 25775 One Sto No ................. Permit for .....................X.Y.......... g....................... ........ .... .1bo Location ....Church Stree.............................. t.......................... .. . ia West Ba nst ..................................... ........... Owner ......!T9�1h..Johns.on ... ............................................... Type of Construction ........Er.dme...................... ................................................................................ Plot ............................ Lot................................. Permit Granted .....N(Rvemb.6.r...1.6........19 83 .......... .. .. Date of Inspection .....................19 Date Completed ....................................19 1 S-D��t�, _ Tu /?e-s e vv e-e p�" e W�%C 0' IV 4 a / SCALE: '� • APPROVED BY: DRAWN BY DATE: REVISED �St DRAWING NUMBER l i \ i t 414-- 44r- lz- ti o 3 � i Gtastst _- - 30 vi 00• 41 SCALE: I# APPROVED BY: DRAWN BY DATE: MIL ,Q Q� REVISED DRAWING NUMBER i