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0057 CROCKER ROAD
NO. 152 1/3 ®RA ESS 1 10% . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel DYO Application # g' Health Division Date Issued `:3 Conservation Division Application Fee a. Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address 57 e9yCXEP_ '90 4-b Village WL3j— &RAJ5T48LE Owner 7TM 6z LS Address gag C�pZ.DRc�r!.cP $ � Telephone Permit Request g&J'10yc �� Pt�cC f�a�rxovH FAR 4 GJ q r,USC�411,�(� ,R iuj 7R1M, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project ValuationCoyOD — Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 1 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes 0 No Basement Type: W Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) L Name �'� � �N� �l Telephone Number 5yg - 3L2 - SY5(, Address �3 &0e1"-.51_A kj& License # P9 02&GR Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO lTfZ-4, 17 SIGNATURE ��v '�` DATE r, 17 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED e MAP/PARCEL NO. ADDRESS VILLAGE r OWNER tk DATE OF INSPECTION: , h FOUNDATION FRAME r- INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ,7 f PLUMBING: ROUGH FINAL' s' GAS: ROUGH FINAL FINAL BUILDING ' DATE CLOSED-OUT ASSOCIATION PLAN.NO.,,— s- - I „ Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 116495 Type: Private Corporation .�” Expiration: 6/21/2014 Tr# 226907 RYCON CORP � Y. .. WILLIAM RILEY " 1469 MARY DUNN RD/ Box 212 BARNSTABLE, MA 02630 � - pdate Address and return card.Mark reason for change. SCA 1 ea 20M-OS/11 Address Renewal Employment Lost Card &2e (pom&mwau o Gl&wac�ccaeM ----— — Office of Consumer Affairs&Busifess Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: 16495 Type: Office of Consumer Affairs and Business Regulation xpiration:___6%2.1/2U14- Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 RYC CORP t� = 4 'l=!? --Z' WILLIAM RILEY 1469 MARY DUNN RDF/:,,Boz212;!�9 L �o BARNSTABLE,MA 02630'-':ate f Undersecretary Not vali without si u r Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction supcn'isor License: CS-069004 , WILLIAMAI" �� PBX 212/1469 MARY`i6ws BARNSTABLE NSA 02630 v V i ��� Expiration 05/26/2014 commissioner The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information n Please Print Legibly Name (Business/Organization/Individual): �✓�U `(!�� �Q1JL[� /X>C // LLIAd') Ql Address: r73 Lo e__t 1` fiat City/State/Zip: 'STAQ3 L� , �A � � Phone#: SOUS 361 Z�545(11 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. 0 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ®Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp. insurance t 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.❑.Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] 'My 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverag erific tion. I do hereby certify and ins and allies perjury that the information provided above is true and correct I do hereby certl�rfy and ins and Si ature: Date: 71 30/ /2 Phone Z -545L Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: UtG. A 2UH 1:J5rM A55UGLAILD IMPEL NU. M/ N. 1 CERTIFICATE OF LIABILITY INSURANCE °" ,� 30/20 TBI8 CIRTIPICASE IB IBBUm AB A MUM OF 116MMTIOA ORLY A1® CONFER9 NO RIGHTS UPON TIM CERTIFICATE R=ZR. MO MINICATS D088 MOT AFFUDSYIVSLY OR NEGATIVELY AHEM, EXTM OR ALTER SHE COVERAGE AETMED BY TIM POLICICS DRUM. TBIS CIRTISICLTB Or I1180WCi D088 MO! 0=9t1%Vn A COMRACT BETWEEN TM WM71 1G 120MR(B), AVZRMMM REPMMN!7►SIVE OR PBODO(RR, ATm THE CERTIIICAii 0=91t. ZM ORYANT: It the certificate holder is an AODrnCMAL IZOMMM, the poliaylies) amst hq aedorsed. IE SO MOLTZOM XB MANED, sub3act to the tame and conditions of the Volley, cartels policies may require an andersaaent. A statement on this Certificate does pot confer tights to the certificate holder in lies of such andarsoment(s). t� ,MrZ,v United Insurance Agency Inc PO Boa 1013 1 we.W.I. a+arL Buzzards Bay, Imo► 02532 � cmoo ro•. I.soAw aLm�1A).aA®uis Lvrmaa me. Paul Ganley lWNESAi A.I.M. 10itual Insurance co 33758 mom ae 1137 Long Pond Road Irons ei Plymouth, M 02360 D, slam s� nnvAm s: COMAGr8 CSRTIBICATE NOeM=; RZvI8I0N NOiGM: 7Ni6 8 TO cmnn"a TRY POW098 or IMOUNAD= Lima wxQw am MEN Ise®To TB! am®IOJeD ABOVE cox THE VGLXCr MMOD DM7CATED. S .-I.effl .—.AtR-gOTt$I . TPIWI OR ooaDMOM OP ANr CWInuT OR GIM DOCOMM 11I2s RnMLT To We2Cs rate CSM17CAU RAT!e Is80LD an HAI PERMS, THE »OVIUttCs AATURDEn ST THE FOLICIED IMBED BIIGIa I8 BUBJI T TO ALL TM MM, W=AMWB AID Ge a ragas of BO®PILIc=o. LDUTB OHM" MAY We saga REDUCED ry PAID CLAM. a� nIR or IB80RAWM POL=MMMM WILT EPP POLIcr Me' LnUTB I�Y�Mrr) ?UADlrrrq i LIABILITT lace oecvAAsa ! 13LORQiQAL eO AI LMi LIALM • toGxw= • ,u come [3— •AmmRA.ecwemeq Ps—w • ❑ •ZOOuf.A Aev r1gUt • cu'A AcmmiTA imr Arvuc m: a�L AlaMgls ! QPMJCF 1:11RW Cr ElmAAeovLT•-Qo /••A•• • AOMIMLE LGerurr cma�saott AeQr juo w.wAa,.a • ❑ALL•BW tyros - anal mma rF- ! ❑SCffmrm Avroz !•osir IMP"0.9-WA-M 0 OHim Alne] dm AOVpar! QARM llGcPoD LIM �CAD®Mw oEMMI Le A �ALTLrrIo. s • ODABATADI s may aw ASD 11610TEe6 LYARTLITY t Lnm o TIM PROPRIETOR/PARTHER9/ A EXECUTIVE OFFICMW ARE 94.V11°CXMM • 200,000 ❑ incl ® excl 6009477012011 09/22/2011 09/22/2012 �.z BOLM 500,000 s.s.MWA:.n mioZn� ! 100,000 PWM GAHM 13 NOT CO'V M DT TEE R8r 78ATI0N POLICY. i I I CERTIFICAM HOLDER CANCELLATION ifc—bm COIQSTALJCTION le01HD ANY Ol THe A8o•E De6CRIBYD POLICIeB BE CMXLT29 Sam TM P.O. Box 212 tl�NW20 DAM Musor"Notice MILL HE ULM= a ACeoamm WITH THE PMICr MwisIOes. &MWSTAM, MR 02360 i Client#:20382 2JPPL .ACORN„ CERTIFICATE OF LIABILITY INSURANCE U,%IE(MM10Vt" ) 12MO12011 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(ios)must be endorsed.N SUBROGATION IS WANED,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 :.&I;.Lal.r holder;.)lhi u sf suah aradwm.%v6a!(6). PRODUCE" CMIACI Dowling III O'Neil AI H11 Ea<I:508 775.1620 INC.N :5OBT731218 Insurance Agency E-MAIL ADDRESS: 973 lyannough Rd., PO Box 1990 INSURERS)AFFORDING COVERAGE NAE8 Hyannis,MA 02601 INSURED A:Natiunal Grenyu Mutual Inaureii_c msuNtu James M.Paterson DIBIA INSURERS:The Hartford J.P.Dlumbing B Hooting INSURER C: 42 Jonas Drive INSURER D: Ntashpes,MA 02649 INsuRW h: 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 CONTRACTOR 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 IrPt Or iNsulrAKCt B POLICY EFF POLICY EXP LTR IN&K ww POLICY NUMBER MWD MMIDD/YY LW IS A GENERAL LIABILITY MP023672 =791201111 081291201 EACH OccurmEMcE E 1 000 000 CJ)MMFN,141 11FNFNAI I IARII Ily UAMAr►IOWN Wl' PREMISES Ee ulaaluauas $500 000 CLAIMS-MADEEX OCCUR MED EXr(Am ale ummu1J E 10 000 X PD Oad:250 K-kal)"M A AIIV MOJlply $1,000,000 GE19MLAGGWGATE s2,000,000 (*MAC,1',I&GAII-IIMIIAPMIo-RPfIC PNOInICIS-COMP/n►+Arc. $2,000,000 POLICY wlo- LOC E "AU I OMOUA.!UAtlAJI T C,OMMWI)SUIRI F I IPA I (EU Irtziiad) E ANY AUTO BODILY INJURY Mae amwll) E ALL OWNED SCHEDULED MQun r truuNr AIIIA.R AllIM ft-er.irma n S MHFI14111 OS "ON.OWNI.11 PNOWHIY I/AMAC.F AUTOS elaiJad E S UMBRELLALIAB rM=ttw ►ACM OrrA NNFNCF 3 EXCESS UAe CLAJM34AADE AGGREGATE E IIF11 I NFIFNItONS s_ B WOK t:Ks COMPINSAIION WC SI4t11- DIN• AND NPLOYERS•LIABILITY OBWECLB4885 9107J2011 09/021201 X ANY rROMIET00rARTNERIEXECUTNE YIN t•J.FAC.N M,CJIIFNI $500 000 flt FICA NMo-aplFH F7lCIla)1119 n NIA vam JanaiLe VIRIaI adlory In r1R)If E.L.DISEASE-EA EMrLOYEE MOAN U vs. DESCRWTION OF OrERATIONS beivw rJ.I)ISFAE.T.P!)11[Y t QMII f500,000 ut CHIP I tON OF OPERA I IONS 1 LOCA I IONS I VkHICttS(Aeach ACORD IIH,AAAllanal Kama►IIs Sehaduky If mara spaco Is roqulroo) James Paterson is excluded from the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations end endorsements. Nothing contained in the celtificatB of insurance shall be deemed to have altered,waived,or extended the Coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Rycon Group Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P.O.Box 212 ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable,MA 02630 AUTHORIZED REPRESENTATIVE ®1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(3010105) 1 of 1 The ACORD name and logo are registered marks of ACORD *SB97391M69738 LS1 "MEr Town of Barnstable Regulatory Services Thomas F.GeHer,Director 1659- �� 1659- Building Division Tom Ferry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.tomn.barnstable.ma.us Office. 508-862-4038 Fax- 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby,authorize ��e" C'..'too C eil'I -��IC��to act on my behalf, in all matters relative to work authorized by this building permit application for. �5'y Ceoe6 �e 'RaAb' W, `s .k1 fq (Address of Job) 40 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:O W NE"ERM1SSi0N is ,. i.. ��: ,' �� �`� ♦ Y� 'v r� .� f I ii 1 .- O �� � K i � � � �/` �q,�� ` 1 r ' � � r ` 0 a., T �, �� �4 ` � � tli • C 4 ti1IF ,.! rJ �. 10 9/. S 9) +�t +�e"T Tie r►o�e �o x So 4 14 4?tti� 30 I � 2_ co 4 tzv,l N J • F�' tom. •. � _ 17 , o .+1 Q441 ------------ -ie — �OG in✓l.,l WA L..... rGE(Zrl FY --- N O W E 5 CIS/\D rLTy 6T L� S TAT6M�tiJ 7'J C-er-T I F y -rl,4z-r -Ty.0 v FO e M P>T'-+E B i I t..pt� TH ERGO ffo T �������U�TEQtM�• stor.�+.t_���t�� f N PF—xJ MA�E S ►JOT F,�l l_ wt� iS a. 7 FI-000 =5o00.0 1 V s o►J E F"zt5,� -rO r5 pLarr -7- �o5a<5 9'J s✓Y ,p►.!p,t s N of C�^ ��P. ��T N -T-71 N6q $E l�" ��-r-�. � � -5� . �9 �vwK-�-►n�a o S 3 ZM of �o EDI�VAAD /� '4C7VRF �'7 Ctzo�rcEr-aoo n NE N AQC�9� A. S'�7'c1j, S Mgt_tnloWgK1 � CISTE 6n D..� PEP, Pb, 3 7-R TWKErti Town of Barnstable Regulatory•Services Mass.. Thomas F.Geiler,Director 9�Arfo;�,t►��� Building Division Tom Perry,Building Commissioner 200 Main Stireet,Hyannis,MA 02601 www.to.wn.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Us ing A Builder I, •�/�YIO ✓I �JS � N ass Owner of the subject property hereby authorize &141vo `���� �lr to act on my behalf, in all matters relative to work authorized by this bt"1�permit application for. lRb-414 'Ail. (Address of Job) p cR Cj g J C C> Signature of Owner Date cn co C) E Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 'Q:FORMS:OWNERPERMISSION i vim. =L_ r"..E--�'t; :'r y + .<1'..t r.'.'»; +,+,�{_. -4•t ._ 2 f<'+t 2. • .. j.X. t`." _y .� _' .. ..» -. �:�;k t1 i 1 All 77 I � ICJ —��� ��--- - -12��i�f----�—L 1/I Y� ��— �i�-'�.Jvt.,r`•/.�,= J�i�.cL-�� +- _ . w 1..r.'�/ :. � � it //li...� f-C.•.I/ Y r /' s 'c 1C i/(,ii J 141:.- ;�_r .3�-,/Y%I A;�.,J�•� -'%'t _y I j +f�'•'jG= c'=/t "'�` c%F:�T'i t % ;''� -- r/., .+•. fie.f r �-r r." 2_ /.� �r r ��: r.+. _.[y /�t y_ _ .. ';•y,, r _ g Sj •{�. ; yr;. :r • r s r ,C/ -_ � ��`,a � ,;Ijt�l. Jl��I•';�� �i:��'�"fk:c:1�',7:�iJ�J �r � ��'.t-'.3' i r,rr .r�e��•':ref .-,r�J(//._ r'?/.>r�'J/� � }�// —„ 'f F r , LI r��7irrVY' r + t L•al. •c{.r .�• r{. .,r-.- _ 1 r. i.�.-...-.Fsr.+;.-_._v -.—�.. �+'F 3: i � � 22re•3 I FSKKElaf, Town of Barnstable *Permit# ab(o Expires 6 months from issue date RARMAB E, : Regulatory Services FeeMASS • D rcb , ,e�' Thomas F.Geiler,Director prED"""•` Building Division Tom Perry, Building Commissioner X-PRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 AUG 14 2003 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTRVMRE BARNSTABLE Not Valid without Red X-Press Imprint Map/parcel Number d Property Address C�' �"� �G U"b�: c.7%� e /V A7 V 24!!:�4?' *Residential Value of Work if 93oz�V 1016 Owner's Name&Address Contractor's Nam Telephone.Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑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# Permit Request(check box) t4oeo-oroof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over T existing layers of roof) C v 0__ Re-side b �o- *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. \\ Ho roveme ontractors cease is required. Signature Q:Forms:expmtrg Revise053003 The Town of Barnstable, Department of Health Safety and Environmental Services rED 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: S/ Gu -� / Estimated Cost /Zoe-, , Address of Work: 67 69ocoeCP AD Owner's Name: / Date of Application: C7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law C]Job Under$1,000 Building not owner-occupied �wner pulling own permit Notice is hereby given that: - OWNEMS PULL'ING'THEIR OWN'PERMIT OR-DEALING WITS 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. Date Contractor Name Registration No. Dat4r' e gIbmis:Affidav The Commonwealth of Massachusetts Department of Industrial Accidents • �� -— d � 600 Washington Street Boston,Mass. 02111 Naiir�m�i�i� Worker/Compensation Insurance davit icat:s rrt rus:tuo� //G//////%%%/,//%//��%%F-/FFINQ''""'Oftlif "`K'Y'�/%/%%%%/////%%%%% name: location: �57 ��, 9�'�l�C� 44 hone# 2- E22 fl, am a homeowner performing all work myself. am a sole proprietor and have no one working in ales►ca acitn ` ❑ I am an employer providing workers' compensation for my employees working on this job. comnnnv name: address: .x>:.>:<;::::;::;: •.. city: phone#: insurance co. nnficy# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have . the follo«ing workers' compensation polices: aomaanv name: 77- acidress• . ..` ..... •:i:4: city phone#' .... insurance ca. oltcv#.. camnanv name: :: ... addresr. phone#� tiff ... • / Failure to secure coverage as required under Section 25A of MGL 152 an lead to the imposition of cttn inai penalties of a Me up to S1.500.00 and/or one vests'imprisonment as well as civil penalties in-the form of a STOP WORK ORDER and a Me of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification 1 do hereby certify under h pains a of pe a information provided above is true an correct Sienature Date _ Print name 1 Cam' l Phone# �f* 2- :cont-act se only do not write in this area to be completed by city or town official own: permit/license q ❑Building Department Licensing Board k if immediate response is required ❑Selectmen's Office ❑Health Department person: phoned. _ ❑Other (mmma 9,95 PJA1 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 conrr= 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: 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 renew&: of a license or permit to operate a business or to construct bindings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither.the . commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that.applies to.your situation and=z1_--_- supplying company dames,-address and:phone.numbers=along.with a certificate of insurance as all affidavits may be-- . . submitted to the Department-of Eladustrial=Accideats_for_confirmation.of insurance.'_ verage: Also be sure to sign and "date-the affidavit Tlie affidavit"should be ietuined to the city cr town that-the application for the permit or license is- be. requested, not the Department of Industrial Accidenis—Should.you have= questions regarding the_`law"or if you are required to obtain a workers' compeasationfpolicy,please=call tlii Depamn6d-at the einmbcr 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 Investigatiions has to contact you regarding the applicaeit. Please be sure to fill in the permitllicease member which will be used as a reference number. The affidavits may be returned fo 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 Deparmu='s address,telephone and fax member. The Commonwealth Of Massachusetts Department of Industrial Accidents 0mce of Inyesduaffoes 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 • �, Application to � ®� �•iTC�'� t$�1�$p �i.RE�iDICKY �fst�riG �f�trttt �IOlI�IIiT�)tEP In the Town of Barnstable CERTIFICATE OF APPROPRIATENESS ' �ppiication is hereby made,with four complete sets,for the issuance of a Certificate of Appropriateness under Section i of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on piano,,,., c, irawings, or photographs accompanying this application for. t CHECK CATEGORIES THAT APPLY: r— r•►'t 1. Exterior building construction: l New Addition El Alteration Indicate type of building: 9d House ❑ Garage ❑ Commercial 0 Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 4. Structure: [I Fence El wall [I Flagpole ❑ Other " At% sq TYPE OR PRINT LEGIBLY: DATE ADDRESS OF PROPOSED WORK 57 RD,()Z"8ASSESSOR'S MAP NO. F- OWNER N�t..)A�� KIMR �--'S/ �oC-i�G ASSESSOR'S LOT NO. r1_1 � HOME ADDRESS S 6, 19C20-11e 1,0r 29 TELEPHONE NO. gt-362 ZQ .-o FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, Including those of adjacent property owners across any public street or way. (Attach additional sheet if necessary.) to LWA W141JER 41 P-0 C N 2 �Otl R-0 De}ftp`T ,b C2oGL_&P_ 04C3 AGENT OR CONTRACTOR Ft)6- W_ i AiNet Hy—,6 U/LOaes TELEPHONE N0. ADDRESS �� UX fU�fS �O�JJ �L�, MA DESCRIPTION OF PROPOSED WORK: Give particulars of work tp be done, including materials to be used. Please include locations of proposed signs. .nt 7�0,0>n6A) 6 /'yI i93T$2 � 14 coz---, 644q 5"&/ & D e--)G F-/ti wner on a -Agent For Co tnl *EWA MAR 0 3 2005 ertificate is hereby to . pproved/D T _ Com ittee Members' Signature Town of Barnstable ' Old King's Highway Historic District Committee SPEC SHEET FOUNDATION SIDING TYPE �3(L S 41d�1LO� COLOR GG C�Q_A) ' CHIMNEY TYPE L. — COLOR ROOF MATERIAL 1�_L,►11IL�' i� COLOR S,�/j(� Cxl S� PITCIi WINDOWS Ahro COLOR WI-11 7r SIZE TRIM COLOR �'�?rtiT�JC�1GcT Uvrf/7Z DOORS ` . COLORS SHUTTERS - COLORS Oqi OFB �O.S CpgF�SST GUTTERS G-� �i� COLORS F9liq � DECKS MATERIALS GARAGE DOORS VII � COLORS C�L ��� /''✓� SKYLIGHTS SIZE COLORS SIGNS COLORS FENCE COLOR NOTESt Fill out completely, including measurements and materials/colors to be used. Four copies at this Lo--�����` ti1�F �� � � � I og/s 9J �i�c ✓_c"rT��rw�� �p VII 1100.00 = J�9 2oo�-�- S �9�7J0 J o 61 Peel � a r < ao • J rGEa-rIF`f -T3+C FOL.LOWfdz , STATEM��.Jr<j TO �c74.W r= �T DP-TG.d�E I HEFEBYcr=�IF`( -rF+bT E B o HGP- ROT '�W � �/� A--3 D-TT-1 1I LDt� 'Z'1-�E�O c o N F0 IZ M F-d-I-0 T�'� �►i�1C-, Y-LAw roT rP--u2rH>=c I �eTct"Y-cz --rN' - o l,= 40, � P,oT�off-2-9 5 OtNrU �E5 NOT �AI..L� WZ'4i(�La� l.l4L �MAIr Fwvo Ha:6Atav Avg ,4av D�-- 1 A"TS.r� AS �O►3 s " C, oN FIr �o T`H r5 PLO" s � -- M oR�¢►t `t ( I-�L9 q,)s✓Y ►•►o is NaT SE ,, Q ►�r�w�+; MA.oss�, ^�� � 5 l � �U,� �F At '44 !(Aly 0 3 20 ������j -��„7 CfLOI IGE�L'oA o EDWARDyG�, �5 W. QJr�rz.lSrar3r_s SA. ANE H g 3AR�.� Owl E1�. _ Mir�s�lowSK� `' �'RE STAgLf , F,z�rJo ss CITE E5w z3s' I e6, 3zf ��2- t-�l n.P fob PAS 4-U 1 � ' �V,,�"' i f Town of Barnstable C THE o Regulatory Services E.h. Thomas F"Geiler,Director '�" Bullding Division 9 �• � i639• � •. C �'• plEn t�j Tom Perry,Building Commissioner . ��. 200 Main Street,Hyannis,MA 02601 Fax: ig0:790-6230 Office: 508-862-4038 _REQUEST FOR ELECTRICAL INSPECTION ��. ELECTRICAL PERMIT NUMBER (Permit required in order to process inspection). . 'L• O Requested Date of Inspection Todays.Date 3— o?— a )•7 I, 11A, hereby request.an inspection under Massachusetts General ( tlectridan) Law chapter 143,section 3L and 237 CMR 4.02(3)• installation win be ready for inspection at The •(Property Location) Type o£inspection.requested: on ❑ Temporary Service ❑ ❑ Rough Re-inspection Excavation QService Inspection ❑ Final Re-inspection Ploug'Elaseetion for,sW i�lo i✓ l , 0. -csua Feel /fir ❑ Final Inspection for^ ❑ Other owner or tenant Licensee's name, address,and phone-i G!l/1�2 �� � ° 1W4 Tom' License number E 379f'� Licensee's Signature This section to be comp t d armstable Xnspector of Wires Inspection da t MAR O 2 ZOO? pproved ❑Not Approved This work was not approved for violation of the following Articles and Sections of the MA Electrical code; , Q:WPFil eslorms:electrequest Rer102604 t \ l.omrnonwea&o 0 c' �e O ]� +' l///adaach.c�e� . )JL!/ IN umm cc�� cc77 nC� Permit No. ) �,/, 2epartmed o,131,e Jemicei . Occupancy and Fee Checked > BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL ORS All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 1j (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: &azev S.¢;.;t A CR To the Inspec or ofWires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) S :Z 2D Owner or Tenant `J ft�f 'Fo G L-6 Telephone No. 3021- E228 Owner's Address S D V E Is this permit in.conjunction with a buildingpermit? Yes No ❑ (Check Appropriate Box) Purpose of Building MkYS [_�AT4I CC,066>`AC0.. Utility Authorization No. Existing Service /60 Amps iao/ Volts Overhead Undgrd❑ No.of Meters New Service .Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:.04 eu i Sil�Jlr /J�i� /f' /�eb/►') Completion of the following table may be waived by the Inspector of Wires. No.of Recess id Luminaires No.of Cell.-Susp.(Paddle)Fans No.of Total _ Transformers KVA No.-of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.)of Receptacle Outlets No.of Oil Burners FIRE ALARMS No'.of Zones No of'Switches No.of Gas Burners o.of Dete6tio—n an Initiating Devices No.of RanTotal ges No..of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat um um...,er Tons o,of elf- ontained Total P '""' """""""""""""""""""""""""""" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ unicipal ❑ Other Connection No.of Dryers Heating Appliances KW Security ystems:* No.of Devices or Equivalent No. of Water No.of o.of _� KW Data Wiring: Heaters Si Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wirin : t No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. ' Estimated Value of Electrical Work: (When required by municipal policy:) = Work to Start: Inspections to be'requested in accordance with MEC Rule 10,and upon completion. ? INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless ' the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The j� undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of per'ury,that the information.on this application is true and complete._ F` FIRM NAME: LIC.NO.: ; Licensee: 4/0.✓C, Signatu LIC.NO.: . (If applicable,enter "exemp "in Address the license number line.) Bus.Tel.No.: : /S� �, E SGt Alt.Tel.No.: *Per M.G.L:c, 147,s. 57-61,security w requires Department of Public Safety"S"License: Lic,No. rs OWNER'S INSURA E W I R. I a aware that the Licensee does not have the liability insu�r ce coverage normally required bylaw. B y si a to hereby waive this requirement. I am the'(check one P'owner ❑owner's agent. Owner/Ag Signature i Telephone N. ERMIT FEE: $ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 40 Permit# ! iG'ttIt4 Or PAR!lS lrABLE Health Division R 3 l� I'�SCp 5 Date Issued Conservation Division 11Z 1S U 2005 APR 25 PH 4; 24 Application Fee Tax Collector - Permit Fee t ` o—� Treasurer DIVISIOM SEMCSYMMUSTBE " INSTALLED IN WMPUANCE Planning Dept. WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address 57 CeoCK-6,I_ Izo/i"D Village u/9421\) O�-���} Owner 4 rti1 Address 15,&M6 A1; Telephone 1- <,5_21B Permit Request M a I c &4 7-1 d CA0AU-- 11\J G LOSE-F ADD I'T-70M, G-XISTZ N C, Como W I r,� u� I UA I GC.,y" m3s UL^r o Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay r Project Valuation Construction Type U-9COD Lot Size , 8� A-C' Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family W Two Family ❑ Multi-Family(#units) Age of Existing Structure 2-9 Historic House: ❑Yes O'IQo On Old King's Highway: ❑Yes too Basement Type: mull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Cy Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 3 new Half: existing U2 new Number of Bedrooms: existing new Total Room Count(not including baths):existing new O First Floor Room Count `7 Heat Type and Fuel: e G�❑Oil ❑ Electric ❑Other Central Air: ®'Yes ❑No Fireplaces: Existing —I New Existing wood/coal stove: ❑Yes o Detached garage:El existing El 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 Cl No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name -F�cG 4 1)1P-IG4i` - 6QIQ f5eSL Telephone Number I-EZ)o Address RO,Om VD4S- License# DICE t`,SM�SL A 02-63D Home Improvement Contractor# 13(ai785 Worker's Compensation# )A( 5003183012 q ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 3/12f�?�'i> `TrIrCk2 �vl`�'T'tU►`? SIGNATU DATE 3 FOR OFFICIAL USE ONLY " PERMIT NO. DATE ISSUED MAP PARCEL NO. ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: � FOUNDATION ] fr Off _,. FRAME INSULATION ✓ ok go/, - o FIREPLACE r � ELECTRICAL: ROUGH FINAL' r PLUMBING: ROUGH FINAL \u GAS: ROU"c S FINAL ° `) �Q OZ ® FINAL BUILDING n� O : ' r vimuc = m DATE CLOSED OUT00 S, l ASSOCIATION PLAN NOV:a m 7i no CMR Appendix J , S Table J=b(condaued) Fossil Fuel Prescriptive Paekaga for Oo e and Two-Family Residential Buildings Heated with MAXIMUM MIINIIIIUM Wall Floor Basemeat Slab Heating/CoalingI (1g Glazing Ceiling perimeter Equipment E113cieacy� U-value, R-value' R-value' R-valuLj w� 6 R��� R-value Package 6701 to 6500 Hatioe Degree Days' Normal Q. 12% 0.40 38 13 — 19---- _ __ to ti 6,,.. Normal • Rom. �-12%..•�.;�032-----30--- --'19--- —19—,._..�.--10"d' �ES SUE 6 g 12% 0.50 38 13 19 10 NIA Normal -38 13 23 NIA U '15% 0.46 38 19 19 10 NIA ES AFUE �1 IS% 0.44 38 13 IS N/A 6,— 85 AFUE W 15% 0.52 30 19 19 10 NIArm Noal X 19% 032 38 13 25 N/A NIA Normal y 18% 0,42 38 19 2S NIA 6 90 AFUE Z 19% 0.42 38 13 19 10 6 90 AFUE AA 18% 0.50 30 19 19 10 1, ADDRESS OF PROPERTY: 157 CP—OC4C 02 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: _ 3. SQUARE FOOTAGE OF ALL GLAZING: ' 4. %GLAZING AREA(#3 DIVIDED BY 92): 5. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: 4 ' q-forms-f980303a I 780 CMR Appendix J j Footnotes to Table J$.2.1b: + Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area, expressed as a percentage.Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 fl of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenes`ration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units:center-of-glass U-values cannot be used. 3 The ceiling.R-values do not assume a raised or oversized truss constriction. If the insulation achieves the full -- insulation thickness over the exterior walls without compression, R 30 insulation may be substituted for R-38 insulation and R-38 ihsulation-may be substituted-for--R-49-insulation: Ceiling Rvalues-represent-the sum of cavity--...---... insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing, and interior drywall. For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. 11 The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3;4, or 5.• If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest .efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see.Table J5.2.1 a NOTES: Glazing areas and.U-values are maximum acceptable levels. Insulation R-values are minimum acceptable-levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c)If a ceiling,wall, floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 oFJ"E r Town of Barnstable Regulatory Services h 9BABLE,� Thomas F.Geiler,Director 1639. A�� Building Division lED rA/'� Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Fax: 508-7�90-6230 Office: 508-862-403 8 Permit no. Date AFFIDAVIT HOME nyIpROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142Arequires 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. ' Estimated Cost Type of Work: Address of Work: .7 Owner's Name: Date of Application' - 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 PUt1ING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE PROGRAM R GUARANTY Y FUND UND RMGWORK DO NOT L cc..142A. ACCESS TO THE ARBITRATION SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of a owner: OD Contractor ame Registration No. Date. OR Date Owner's Name Q:fomis:homeaffidav -- The Commonwealth of Massachusetts - Department of Industrial Accidents 6001 Washington Street Boston,Mass. .02111 Workers'. Co en sation.,Insurance Affidavit-General Businesses - • Z �+�Pe-`;; '' � i`dj G'1/7 4,''�l9� l..�r` �T! �'!i ,•,' ., � ,•:iwA>tri ', naive: address: PD �Ux in S rh4y. state M' I ziy o - phone / 42" lL�z" V . work site lomfict(full address): 5 -C'G�(�0�-t�Y�- F-D �` , A_)S ��P.. a_ I 62 ❑ I am.a sole proprietor and h'ave'no one Business 1. pe: 0 Retail❑Restaurant%BaAating Establishment g in any capacity. El Office'[-] Sales(including Real EMte,Antos etc.) am an I en to with em' waft to ees(full& art time.): El Other %/ %% %%/ am a employer providing too keys' compensation for my employees worldng on this job.; !-• r(, r •:lir t �/•_qy`D... �pt.� g] �yg � �:• .•y��'yp;�,"�%��%•.',�'rl.`' y'••°.': i , coin ari'•naniet. ( .a ea��=ens:. .�-�=:::i �. ••�L •.:.:; .:=•::� _ :,:�.. 3's V. : :..'• 'hone,.#r •lIISnratiCe.CLY' .i'•' r1••i+�• - ::y' 'lrw.':k:, 011 •#"' . / 11 I am a sole proprietor and have hired the independent contractors listed belowwho have the following workers' compensation polices: comPany•name= — - ---- addressd. ` ' ' �L'•' ' shy:':'•'•'• C '.1+r•:.•r:..'•'Y.• :1.. insurance co. :4:: - '�>' ov # :•: . compan aan'te .:d.'rr:::. :•:�' -- ,•p _ ,.1._r ��'•' addre'as� - •• .c4. r. ' cijy. '' t' '�:•J� . . :phone#`e Insure cbc "olio:# - 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 civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that 0 copy of this statement may be forwarded to the Office of Investigations of the D1A for coverage verification. I do hereby certify nder ins and RN ties of per' at the information provided above is trued d cor ct • Signature Date t �- Print name e- Phone# 5� ��� / ? J official use only do not write In this area to be completed by city or town official city or town: parmit/license# ❑Building Department ❑Licensing Board ❑-check if iinmedfate response is required ❑Selectmen's Office ❑Health Department coutactperson: phone#; ❑Other (nvised Sept 2003) Information and Instructions Massachioetts Geiieral Lag's.ch4 pter�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 mare of the foregoing engaged-in ajoint enferprise, 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.mainfenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not.because of such employment.be deemed to be an employer. MGL chapter 152 section 25 also-states that every. state'or local licensing agency,shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence'of compliance with the insurance coverage required: Additionally,neither the- commonwealth nor.any.of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this.chapter have been presented to the contracting . authority. Applicants Please fill in .the workers' compensation affidavit completely,by checking the box that applies to your situation.. Please supply company name, 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 perrmt 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:workert"compensation policy,please call the Department at the number h ted.below. . , City or Towns . Please be sure that the affidavit is complete andprinted legibly. The Department has provided a space at the bottom of the affidavit for.you to fill out is the event'ilie Office of Investigations has to contact you regarding the applicant Please be sure to fill.:in the pernrit/licens.e number.which will be used as a reference number. The.affidavits maybe: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 Departrnent's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents . 9tttce of relresdea�ens 600 Washington Street Boston,Ma. 02111 fax M (617) 727-7749 phone#: (617) 7274900 ext:406 oFVAE Town of Barnstable Repl.atory Services vse $ Thomas F.Geller,Director �, 1�,4• ��• Building Division TomPerry, Building Commissioner 200 Main Street, Iyannis,MA 02601 www.town.barnstable;mams Office: 508-862-4038 Fax: 508-790-6230 Property.Owner Must Complete and Sign This Section If Using A Builder (C— ,as Owner of the subject property hereby authorized w21.�.t t3lJ1.L D `> to action mybehaif; in all matters relative to work authorized bythis building pernvx application for: (Address of Job) 02(p(00 i S' afore o er Date Print P1ame RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE , New Buildings $100.00 Residential Addition $50.00 SD) on Alterations/Renovations $50.00 Building Permit Amendment $25.00 FEE VALUE WOMHEET NEW LIVING SPACE �2 square feet x$96/sq.foot= A x.0041= l(O a plus from elow(if applicable) y ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0041= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0041= ACCESSORY STRUCTURE>120.sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf-1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground SiAmming Pool $60.00 Above Ground Swimming Pool $25,00. Relocation/Moving $150.00 (plus above if applicable) Permit Fee Prolcost Rev:063004 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Umber. CS 010366 :e Expires:M6/2 no: 5580 Restricted: 00 WHITNEY P WRI POB 1045/331 OIL JAIL LN BARNSTABLE, MA 02630 Administrator ✓fie Toona�waaru �.�a�sarlreudelld Board of Building Regulations and Standards HOME IMPROVEMENT CO CTOR �tiotic;.:]367W zpiratlon: jW612004 Type: "pB FOELIE+WRI - WRIGHT WRIGHT:. 57 CROCKER RD. W.BARNSTABLE,MA 02668 Administrator 9` I 3 N U X�? Q J � o0 � I FISTIt"i Hous� I Ilf o o K o r o� __....._-Fo uN DA1-Ti oiQ ^_€?(.A N --- ------ f q �0 �or�uG 5 13Ecar v ��-- s�G-G's �a or,- -�a1 V T � u ° � F s N��°• I sOLf ...._�,_. 0.2 C n u N j Ot �} 0 / GO Q � \j ; Fs ot Qj 40 j " xI �-- i %AO� II w � "J 1 — c4 A WA n • Application to Ringo �igbWap Atgirinal �[�tDrit Mi�tritt 1QBTC17Tt )�L'E In the Town of Barnstable CERTIFICATE OF APPROPRIATENESS a \pplication is hereby made,with four complete sets,for the issuance of a Certificate of Appropriateness under Sectiom C' i of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans; , irawings, or photographs accompanying this application for. E, Co DHECK CATEGORIES THAT APPLY: 1. Exterior building construction: l New Addition El Alteration r �? Indicate type of building: 9 House ❑ Garage ❑ Commercial F-1 Other M ry 2. Exterior Painting: N' 3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other TYPE OR PRINT LEGIBLY: • DATE r ADDRESS OF PROPOSED WORK 57 RD,Uz(�(PO ASSESSOR'S MAP NO. C_ OWNER 112,1�p ` kIM6 ga FOCI Lt✓ ASSESSOR'S LOT NO. HOMEADDRESS S'VMt 6-a RL�J� � Z9 TELEPHONE NO, 5U_k=362;0z ' FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across ahy� public street orway. (Attach additional sheet if necessary.) LWA W1169 41 RE) cH & 4v—t Rz C N �bN 21� t �� No C2oc.� P--o AGENT OR CONTRACTOR > la6X4Hr4 ,6 UI L TELEPHONE NO. Sze ADDRESS DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please include locations of proposed signs. .�Yt 7%VOiT76A) 6 r -In lt5J$2 J�5417-1 ��ice-! ��`—� ��/'U�• 14 X/,&'. 510EC-u4tA L GOYS 6411ZI 51)91&�6D GcJG :5H1A1 '!.&;5-r FCC wrier on a -Agent For mite e I /� M �♦ �— his Certificate is hereby Date 2 TO 2005 Approved/D led If H/STWNOFg ORi� pR�s Rtiq B0 Committee embers' Signatures: N f Town of Barnstable " Old King's Highway Historic District Committee SPEC SHEET FOUNDATION SIDING TYPE V3 P0 T& AZ S 4l COLOR CC,. C-�Q—R)� CHIMNEY TYPE G COLOR ROOF MATERIAL GH J C COLOR S,A✓1/j(� '✓fj -XI ST7Axj PITCH WINDOWS ��Ql J COLOR IoO�-// 7' SIZE TRIM COLOR DOORS COLORS SHUTTERS - COLORS GUTTERS D � COLORS DECKS MATERIALS GARAGE DOORS COLORS CJGCY ��5 /� SKYLIGHTS SIZE COLORS CFENiCE.IMIA'Al S COLORS gF MAR 0 3 2005 COLOR t5HRNSTABLFe Fill out e , iaeluding measurements and materials/colors to be used. Four copies of this - ---�- - SMOKE DETECTORS REVIEWED �J BARN TABLE BUILDING DEPT. DATE FIRE DEPARTMENT DATE 5 " BOTH SIGNATURES ARE REQUIRED FOR PERMITTING I i W ; -2 U Q -rJ V CIL aL N IS ot vi , �/ ? w c � f � °L t- %Aop�z a _ C4� � Ir I -- - "y a H� � a N U X�? Q J I I I I . I ° � � � i l l�: �CiST►�iC. Houses � I III I 3 I III 43 o � I i C-' r� 3 4L = - - - - V64T-- - - � - - - i o' v � I _ rl � I Fvu,� L'OnX2E r"� c a& iZ�GTlNG s /3ELorc Jcosr 5/�GyC s Co 577,,cr—L- DOr,JS b N Nt - —� ter.. -�# Y r It,54�bj TOWN OF BARNSTABLE 2639- BUILDING, INSPECTOR TO THE INSPECTOR OF BUILDINGS: The undersigneci hereby applies for a*permit according to'tKe' fo'116\�ind infio'rrhatib6: Proposed Use .....DrAlellincr �� � Fire Diu��� Zoning Districtc, -----------.------------. -------------------------- � . Box 6&- D�uso. � Nome of Owne,'..SEh-LAM ----.---A66,es ---.���������---.���������x--------. � Nome of BuilderSEA � -------'A6J,e» ---.fA0�|---------------------' Nomeof Architect --.-------------------'A66,es ........ -........................................................................ � Number ' Rooms Si�� Fov onlD° 6" ]?�g�� u. -------^-----------_-' '�,^ --===~-~^=�^^~. `'^--'. ----- � � Exie,io `�g �Roofing . � � ----- Fzrw/u'' �»�� G�mo��o � Definitive Plan Approved by Planning Board July 2----------197a Diagram of Lot and Building with Dimensions I;e,-- attached plot -SUBJECT TO, APPROVAL OF BOARD OF HEALTH | I hereby agree to conform to � � � . . . � � � - � ^ � . � � � � � � � � r~ / ' all the Rules and Regulations ofthe Town of,Barrfstable regarding the above � � Nome -.../.����.--..._--�-------__-_..,^ ` J Sea-Lake Corp. AF A - 6 (not plotted) 18193 one story, No ................. Permit for ..................................... 10singlej'amily dwelling ............................................................................... Crocker Road Location54........................................................ We®t Bar)astable ..........................:............... ..................................... Sea Lae Corp. Owner ................... ....... ........................................ .a fkame Type of Construction .......................................... .................................. ........................ .... ............. L Plot................... Ly ro2g) Permit Granted .........IF/br.ary 25......1976 Date of Inspection ......19 Date Completed .... ........................19 PERMIT REFUSED ........................ ........................................ 19 ...................................... ........................................ .................................... .. ........ .. ............. ............................. ..................................................................... ......... Approved ................................................. 19 .................................................................................. . .................. ............................................................ r .: �M ^^.t. ," Xll � ! �'"`� t M _ � t i i - ' _j.' � _I,. � .,. � _. ..�� . �,� fin:, �.�- .;�/j�_'y=: .. - -. -. I t',"-'--cam Cc-:.�`;n�:,% _ .. . � � ! . . /�% ...�. • � �- . • f _ _ � � .1 f/� . .,.. . .� - � _ _ _ :� ':. . . . .. - I _.. . ...: _._. n _. - _ ri I E _� _°�•,- .. � ! • � �f � :- . . .` �� _ . . i ._ .. _ - � - - .. ,�. .v_. . __ .. . -� . . � �`�. ��• t_ -, .:I _ . __ I � I ; .. .. ,... : .: . � .. . . ' _. _ -. . . . . .. ... 1 I - _ �, _c...� ._._1� ----�- --•. —..----- -- '.�'G�.!- / :� - i:�:`-.,.�. :.>Y%•� y:" i. -- �•.�--' .. 1./�c �. `�- �'; !j'ri-• .-r�.fr, a � .-'.l:� iJl� •.a �r_ •AtJ - .. .I. �• �. .✓..• .. _ ... . r •• � _ _ _ _ ___-___ _ _ ____ .. .-ram+•-- .l-,,,fl -,. r ;... •�.~ - )� :� _.--'---. .... ._ . ......_._.. _ ..----�------��-- •--- — _ ' � � `ri�: � ��jl� /r'�-' I 1^� .. .:_ j�.;�{C�...•f�i�'.� '�r-sue'l�:r'.-.�•��� - - r '�ivrFY''� _ ,. :; Assessor's ma and lot number .............� ..................... � p , P1CSTEM MUST�E �W Sewage, Permit number ................... . � a INSTALLED IN COMPLIANCE J c WITH ARTICLE II STATE d 3 tJIIT/ARy l�qn�I- A AA1 TOWN o`T�ETo TOWN OF BARAMA��B.L ; BABBSTABLE. 06 9 BUILDING INSPECTOR ` Construct Dwelli APPLICATIONFOR"PERMIT TO ............................................. ........................................................................... TYPE OF CONSTRUCTION Erm9.:.......................: ...........February..13!..........19.76.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location :...Lot 29 Cr'ocker..Road — ..=LUIEW" - West B xl�i ��................................................................. ........... .................................... .......... ProposedUse ......Dwellinq..................................................................................................................................................... Zoning District .... '................................................................Fire District Name of Owner SEA— � '� .......................Address Box 264-Rte., 6A—• Sandwich Mass. Name of Builder S�—� .O�RATI '..............Address........................ SAME................................................................. — — Name of Architect .......—....—...------..................................................Address ........... —....—---------- ..................................................................... Number of Rooms S�.....................................................Foundation 10" ,Poured••Concrete-7'6" Pour ............ .......... .................................... ExleriorW.C.Shingles w/t7ert. Bds.@Frmr's.Porch.Roofng ?ht..S1g�e -..Sew-Sig................ ................. Garag Ruf-Sawn Fir w/8" o.c. Grooves Floors Oalc except„Kit. & Baths-Vinyl•.sheet........Interior .Dn.W41.7...-....k"..Sheetxw%.................................. ................. ................... Heating Gas Forced..Wam.A r..........................................Plumbing PT-Waste..'...Cappr..Sly........................... Fireplace Yes .........Approximate Cost $4l•,000..................... Definitive Plan Approved by Planning Board --------July___2-----------19 73___, Area 3`�..2.OQ..S .... t............ Diagram of Lot and Building with Dimensions See attached plot plan Fee .....$51r00........................... SUBJECT TR1 APPROVAL OF BOARD OF HEALTH / O�+ ' I I hereby agree to conform to all the Rules and Regulations of the Town of ar st bl egard' he above construction. • ✓ �Name .... . oa ✓ .. ...................... ..... Sea-Lake Corp. t T93 one story, .ter o .. .............. Permit for. .................................... 1 s ngle family dwelling........ ......... ... ........ 3 •zS Crocker Road --. ; Location •• "_� •�� � � , West Barnstable " r; :'' ............................................................................... Sea-Lake Corp. Owner ................................................................... frame t, Type of Construction t ';; . f t r %+............................................... ........ .. #29 . Plot ....................................................... ot ................................ February 2-5. ;:�19 76 Permit Granted .. Date of Inspection ?� Date Completed PERMIT REFUSED r• ��. �' { �' Lj ........... .......................... ...................... 19 i Ci ..........................................:.................................... �� t ....................`............ `... ti rs •� -'1. �' • _ - , � '•'. -ice :} - � .. .... ............. ........................................,......i,. . - n e. As . c ; A roved .......................................................................... ................................................................... ........... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map .- / Parcel 040 Permit# Health,Division 49��s�9 Date Issued 6 -3 —9 T at ision FeeN �d Tax Collector �G �O/3��� SEPTIC SYSTEM MUST BE INSTALLED IN COMPLIANCE Treasurer. l3 WITH TITLE S Planning Dept.. ENVIRONMENTA E AND TOWN LATIO Date Definitive Plan roved by Planning Board Historic-OK reservation/Hyannis 0 ' -•' Project Street Address Village � % ��PA) �77 G G Owner aJ'V'© le_ &'ress e4ne_ek" Telephone - 36 2 — 2 Permit Request �v GcJl�i% Aso ZJi — %d 057 S'P4/^6Q • Co•O �a t�lS 7� �i �� OrJ 5 �) Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new� 4 Estimated Project Cost ells-oz) Zoning District Flood Plain N6 Groundwater Overlay Construction Type Lot Size / Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Dwelling Type: Single Family ,j 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 Basement Finished Area(sq.ft.) -500 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: OGas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes *No Fireplaces: Existing New Existing wood/coal stove: ❑Yes KNo Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:9existing ❑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 BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY ' . PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS - VILLAGE OWNER` DATE OF INSPECTIONS _ FOUNDATION 'F t FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH' FINAL . GAS: ROUGH FINAL t ` { FINAL BUILDING p i= t " DATE CLOSED OUT CY• - •' _ • G y ASSOCIATION PLANzNO" J 1 L . . • , F a c 1 1 t ; 1 l i [ ; _ F i rit ' •'I � � :....:. .. ICI; Al w 4i( I I qi 11j r% tij 4 it :_ .. _ � ;.. •. � i aI } 4: 77 .. .•� a coo m z E pea 17 �. .. - o fj 13 i I t �• S I p: J'a ` r s tJ t { f S it , • r s i i i .� - - .i ail . • ' Illlj • G 1 �� w.. _ .,.,:....,. ...a.:•. ,... ..e:.r.,,, .• r.4:...,.::..-..c,..x.r rr>..:... __...�.__^_'.�' � . .......,.-. ._r.... .,+..+................�.—._.,._«w...�_...._.w. ..... ...� .... .. ......... .... ................ .. .._..... .. .,..... ..., ._ .>�.... _. ,-- .� 1 �__..-__—�._� q ��cril�l�rsgl) 1r1151 .........,� � I-' ti 11 Y f ........ ! ��._--� �-'t Est Al kVI B,A, ===G va _r { Nl- ' 3 .w - 1 _� I it � .5��.6�;aa.",:�� Ic.�).1{'��. 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