HomeMy WebLinkAbout0149 LAKEVIEW DRIVE 1
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UPC 12543 � �
No.53LOR
HASTINGS,mN
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel (Ig Permit#
Health Division QAr
r ?17-1 ��tl Date Issued _Z
Conservation Division Lx 1 Qom'' Fee 3 ,6 n
Tax Collector -a 11462461 04,
SEPTIC SYSTEM MUST BE
Treasurer ���( �� I_ / I I f INSTALLED IN COMPLIANCE
Planning Dept. WITH TITLE 5
ENVIRONMENTAL CODE AND
Date Definitive Plan Approved by Planning Board TU N 9 GULATImis
Historic-OKH Preservation/Hyannis
Project Street Address I g g L.Avc�Vtsc.w
Village l _IFE✓)T`-0-i Scis—
Owner C4P _,,q 5 r Z,41r\CM4-_ tvll�sTGS Address S 2
Telephone 1,5O -S75 c1 aGY
Permit Request STQQ✓AGc,_- C_,�lA`cn ��� )cAc11
Square feet: 1 st floor: existing� proposed Aq ��5nd floor: existing proposed Total new
Valuation (P(n. Zoning District + Flood Plain '70y\f_ C Groundwater Overlay Construction Type Type 00oa Or,-FAQ 0,,000,.AZ)
Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(#units) ,
Age of Existing Structure Historic House: ❑Yes 0 No On Old King's Highway: Cl Yes 0 No
Basement Type: ❑ Full ❑Crawl ❑Walkout 0 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 0 Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage:0 existing ❑new size Pool: 0 existing ❑new size Barn:0 existing Cl new size
Attached garage:0 existing ❑new size Shed:Cl existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded 0
Commercial ❑Yes' ❑ No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name- P-GES �PSS Telephone Number
Address 1-46✓�Ac,-o Lnf� License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FRO THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
r
} , FOR OFFICIAL USE ONLY
A
S' 1
'PERMIT NO.
i
DATE ISSUED
MAP/PARCEL NO.
t A
s ADDRESS VILLAGE
OWNER,
DATE OF INSPECTION:
FOUNDATION
FRAME .
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH' FINAL
} GAS: ROUGH "FINAL
FINAL BUILDING _
DATE'CLOSED OUT
f{b ASSOCIATION PLAN NO.
Y M1
1
The Commonwealth of Massachusetts
1 = •L Department of Industrial Accidents
600 Washington Sheet
Boston,Mass. 02111
Workers' Co m ensation Insurance davit
name 1 A 21�� Y"�4SSSC�
location _
city phone# Off'37 •�i
I am a homeowner performing all work myself.
❑ am a sole netor and have no one woridri in any achy
I
WIN -
an em 1 ravidin workers' co ensation for my employees working,on this job.
I am pP g ......................mP..........:.:::.,.::::::::.::::::.::.:::::::.: ..:::::..:.:::::::::::::.::,:.:,:.::..::.::::::::::::::::.::..::::.::::::::::::::::::::::::::::::::::::::::._:
COm 8nY nam
�94»`are
..... ..........
.....::....::..
:"on
t1
i2`i2' � ?iii%ii>"i
>� of
nsuranc //.
❑ I am a sole proprietor,general contractor,or Homeowner(circle one)and have hired the contractors listed below who
have
win workers' co ensation polices:
the folio g .............mP.............::...:.:..::::::.::::::.:.:::.::::::::.::{:{{.:.�:::::::::::::::.::...:::::.:::::.::._
NOW
WIN
low
SURE won imo,"
We
i�i`•vnam
�'an
• `>:<�:%?�>�><� �'�> <?>� �>«'����>���<A�r>�;>::}:>i;::»i:so:ass»::>:��;«: :�>:�:�>:>>::s
"`ddres 8
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rid=sisce /
Failure to secure coverage as required under Section 25A of MI,I.152 can;lead to the i-maddom of 01mbu i pemaltie+of a One up to sl Jo oo and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and aline of$100.00 a day against me. I understand that a
copy of this statement ma o ed Ottice of Investigations of the DIA for coverage verification.
I do hereby certify t p penalties ofp�Jw!' �tht-urformadon provided above is truce and coned
Signature Date . 1 —
Print _ Ct�►'t�-�S Pc9 SSJA S Phone
offldal use only do not write in this area to be completed by city or town official
city or town: peradtNcerue# []Building Department
❑Licensing Board
❑Selectmen's Office
❑checkif immediate response is required ❑Health D0arriment
contact person: phone P — ❑Other
MEN
oc and 9195 PLu
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract
of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of .
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or
trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the-grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
Applicants
your the box that applies to situation and
Please fill in the workers' compensation affidavit completely,by checking pp
numbers along with a certificate of insurance as all affidavits may be
applying company names, address and phone
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
big requeS Department have an questions re the"taw"or if you
not the D ariznent of Industrial Accidents. Should you y qu ��
are required to obtain a workers' compensation policy,please call the Department at the member fisted 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 permitMcense number which will be used b made.number. The affidavits may be rearmed to
the Department by mail or FAX unless other arrangements have
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
Office of lavesduadolls
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 eat. 406, 409 or 375
f
FjME r,
: . The Town of Barnstable
8A1N `�'g Regulatory Services
i639• �`0 Thomas F. Geiler,Director,
eft)MA'S
Building Division
Peter F. DiMatteo., Building Commissioner
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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: �(�`�� ax �� Estimated Cost
Address of Work: I y°l LAVCc!
p
Owner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
FlWork excluded by law
OJob Under$1,000
QB O 'ng not owner-occupied
caner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTOHE ARBIT FOR RPLICABLE HOMEATION PROGRA IMPROVEMENT GUARANTYWORK Do NOT FUND UNDER M I�142A.
ACCESS TO
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date
on ac r Name Registration No.
OR
i t.
Date Owner's Name
q:forms:Affidav:rev-070601
RESIDENTIAL:
SHEDS - POOLS -DECKS-OPEN PORCHES- GAZEBOS
DETACHED GARAGES
FEE VALUE WORKSHEET
ACCESSORY STRUCTURES >120 sq.ft.(Sheds,detached garages,gazebos,etc.)
>120 sf-500 sf $35.00 $ �;2t
>500 sf-750 sf 50.00 $
>750 sf- 1000 sf 75.00 $
>1000 sf- 1500 sf 100.00 $
>1500 sf—USE NEW BUILDING PERMIT APPLICATION
DECKS x$30.00= $
(Number)
PORCHES x$30.00= $
(Number)
IN GROUND SWIMMING POOL $60.00 $
ABOVE GROUND SWIMMING,POOL $25.00 $
RELOCATION/MOVING $150.00 $
(Plus above fee if applicable)
PERMIT FEE $
a
Q:formsAkcost
eff:082301
r
The Town of Barnstaaie
• ces
: .�r+sr�Bi.t:. • Regulatory Servi
HAS& Director
t639• ,. Thomas F. Geiler,
'�Fo►u►� Building Division
Peter F. DiNlatteo, Building
Commissioner
367 Main Street.Hyannis MA 02601
Fax: 508-790-6230
Office: 508-862-:1038
HOMEOWNER LICENSE SIP ION ..
Please Prtnt '
DATE:
village
JOB LOCATION: t4 �— stress
number
C ass o
~HOMEOWNER":
home phone# work phone#
a=
�
CURRENT MAILING ADDRESS: no code
state
city/town.
does not possess a license,arovi� d
The current exemption for"home_e�"was to include
o � uyied dwellings of six touts or
less and to allow homeowners to engage an individual for hue
the owner acts as supervisor. DEFDCMON OFHomEoWNER
s who owns a parcel of land on which hdshe resides.or intends to reside.on which there is.or is
Person( ) accessory to such use andlor
intended to be:a one or two-family dwelling.attached or detached stwo-Yea
A person who constructs more than one home in atwo-yew period shall not be considered
farm structures p Official on a form acceptable to the
a homeowner. Such"homeowner'shall submit to the Building
' o Official.that he/she shall be res onsible for all such work erfotmed under the buiIding errrtit.
Buildg
(Section 109.1.1) " , o Code and
The undersigned"homeowner"assumes responsibility for compliance with the State Building
other applicable codes,bylaws.rules and regulations.
The undersigned"homeowner'certifies that he/she underst
ands the Town of Barnstable Buildingsaid
Dep
e t inspection procedures and requirements and that helshe will comply
prose ments.
store of Homeowner
Approval of Building Official
c feet
Note: Three-family dwellings containing 35.000 cubir larger will be required to comply
With the State Building Code Section.127.0 Construction Control.eamt is requued shall be exempt froth tht
HOMEOWNER'S�'I'ION
�e��starts ; "Any homeowner performing work fS which a building dped that if the homeowner engages a
provisions of this section(Section lo9.1.1=Licensing of construction Supervisors)*pro
sor." supervisor(see
person(s)for hire to do such work.that such Homeowner shall act assl are assuming the responsibilities of a
Many homeowners who use this exemption are unaware ast the
Appendix Q.Rules&Regulations for Licensing Construction Supervisors.section 215) This lack of awareness often results to
persons
In this case.our Board cannot proceed agai
App responsible-
serious problems.particularly when the homeowner lilies trn"censtd P as Su ervisor is ultimately rap
WnG acting P �of the pertrttt
unlicensed person as It-would with a licensed supervisor. 'U homao on r,,ties.many conununiues require.as P e of this issue is a
To ensure that the homeowner is fully aware of hidher rap responsibilities of a Sup On the I our�ommuntiv.
application.that the homeowner certify that he/she understands the reap
form currently used by several towns. You may tyre t atstead and adopt such a formlcertification for use in y
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Storage Sheds - Garden Sheds - Pine Harbor Page 1 of 2
Standard features on our sheds Available Options:
include:
• Change 3' Door to 4' Double Door
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5C9hU -ru eq-�) 0 Ghan able-Boor
• 5/8" CDX Plywood Floor
• Door Ramp
• Upgrade to Opening Windows
• Post and Beam Frame
ed-VA-Rdows
• 1" x 12" Board and Batten Siding
•,-Addi-tiop al-Ogenirzg-Widows
• 36" Rough Pine Door
•—LGn,g€f-R-afftp
• Extra Heavy Duty Hardware
• Sona Tubes
• Handmade Oak Door Handle
a
• 2" x 6" Pressure Treated Floor Frame
16" on Center Shing}es7-
• Stationary Windows of h Gf-bitch
• 10' x 12' and larger sheds Come With •—R-�'��Glapbomd
Two Windows
•_ ingles
• Shutters
Pressure Treated Plywood Floor
• Flower Box
• 2 - 8" x 12" Aluminum Louvers For
Ventilation •Smoot4t-T-ritn-With-3'-V=-Groove-Door
• 20 Year Asphalt Roof Shingles - 7
Colors to Choose From _
Larger Sized Custom Post and k `
Beam Buildings, Barns, and Garages
Available Here
http://pineharbor.com/sheds.htm 11/21/01
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RES. ZONE.' 'RD-I This MORTGAGE INSPECTION Bank Plan
1UseoOnly FLOOD ZONE.' "C" �
THE DISTANCES AND MEASUREMENTS ON THIS PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY.
TOW :, — REGISTRY OWNER: —L�KBLAS�III,pIIYGSQMf_'AN� _ —
DEED REF: — — — BUYER: —CHA&ES T _&__FJ?A9CIAL P-A SIOSL
'DATE: _11 ZZQ0_ , _ _ — PLAN REF: 55,2/3_ ._ _ SCALE:1"= 50 _FT.
I HEREBY CERTIFY TO PBQyII? Z�S/1YI�1H�liBQ1lP c>ti C4 44t,. '
IN_C. _ _____________ ______THAT THE BUILDING ♦���"��� YANKEE SURVEY
SHOY�I ON THIS PLAN IS LOCATED ON THE GROUND AS , / PAUt. `�' CONSULTANTS'
SHOW-N AND THAT ITS POSITION DOES _-_- CONFORM '�� V;II�� y` 40B (SUITE 1)
TO THE ZONING LAW SETBACK REQUIRI.MEN'I'S OP 'rill? '� Y'+�IMf
TOWN OF ---RA8AISM& ____—.--_____..-AND THAT }� �"� INDUSTRY ROAD
F-
IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD +.' ~' �� MARSTONS MILLS, MA. 0264u
AREA AS SHOWN ON THE H.U.D. MAP DATED 8_1B,/B_5-_ TEL: 428-0055
Co , unit - anel # 250001 D005 C FAX: 420-5553
THIS PLAN NOT MADE FROM AN 1NSTRUMENT SURVEY
P L A. MER1 PLS NOT TO BE USED FOR FENCES. BLULD1NG PERMITS, ETC. 26504 CB
Inclusionary Affordable Housing Fee
property Owner's Name �JH 1 / Mp rh' �._
Project Location
Pro'ee -Value..' ®P� �: i <Permit iAnb'�er
J .
Planning Dept. INCLUSIONARY h(Jc),-;i G
FEE $ I 0�oo PAID
PLANNING, ffARTMENT
j INITIALS GGii DATE Cc4 7 ljgq
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TOWN OF BARN-STABLE
CERTIFICATE OF OCCUPANCY
PARCEL ID 000 000 158 GEOBASE ID
ADDRESS 149 LAKEVIEW DRIVE PHONE
WEST BARNSTABLE ZIP -
LOT 3 BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT
• t
PERMIT 45044 DESCRIPTION CERTIFICATE OF OCCUPANCY
PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY
CONTRACTORS: Department of Health, Safety
ARCHITECTS: and Environmental Services
TOTAL FEES: �TME
BOND $.00
CONSTRUCTION COSTS $.00
756 CERTIFICATE OF OCCUPANCY 1 . PRIVATE Pl d1 n STABLE,
MA83.
i639. �
• BUILD L SI �1
BY
DATE ISSUED 03/27/2000 EXPIRATION DATE ��
M _
4 TOWN OF BAR9S ABLE
BUILDS PERMIT
, ^r^e`•a
PARCEL ID 214 058 GEOBASE ID 13247
ADDRESS 149 LAKEVIEW DRIVE PHONE
W BARNSTABLE ZIP -
LOT 4 BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT WE
PERMIT 40809 DESCRIPTION SINGLE FAMILY DWEL Nq. SEPTIC NO.99-561
PERMIT TYPE BUILD TITLE NEW RESIDENTIAL BL FMT
CONTRACTORS: NICKULAS BUILDING CO. Department of Health, Safety
ARCHITECTS: a4Environmental Services
I
TOTAL FEES: $.45 THE.
( BOND $.00
CONSTRUCTION COSTS $145.00
101 SINGLE FAM HOME DETACHED 1 PRIVATE P'4"
�M s
0.19•
D � FD INI�►�
BUILH G
BY - -
DATI 08/31/1999 EXPIRATION DAT'
!
APPROVED APPROVED
TOWN OF BARNSTABLE TOWN OF BARNS TABLE
' ,�As
❑ V�t�}G ICKO-_LUMBING-- BUILDING
❑ PLUMBING ElG
r -
Ron
_c �APPROVEDZ�`'��
TOWN OF BARNSTABLE APPROVED
❑ TOWN GAS ❑ WIRING ❑ GAS OF BARNSTABLE
❑ PLUMBING 'fill-DING WIRING
a/a( �t4 ❑ PLUMBING ® BUILDING
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;�
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4 TOWN OF ARSTABLE �• �' ► � _
BUILDINI +,PERMIT
PARCEL ID 214 058 GEOBASE ID 13247 ^`
ADDRESS 149 LAKEVIEW DRIVE PHONE .
W BARNSTABLE t ZIP
;,LOT- 4 BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT WB
PERMIT _ '. 40809 DESCRIPTION SINGLE FAMILY DWELtqiG SEPTIC NO-99--561
PERMIT TYPE' BUILD TITLE NEW RESIDENTIAL BL PMT
Department rtment of Health Safety
CONTRACTORS: NI�XULAS BUILDING, CO. . _
ARCHI'�ECTS: 1 i andl\Environmental Services
TOTAL FEES: 45 Th1E ;
BOND ! i $..bo -'
CONSTRUCTION COSTS145'.00 , Q�
101- SIT10LE,FAM HOME_ DETACHED 1 PRIVATE P-i1'. //IrrQ�AQQB
I U
i �'�� �.��� ED Mp'►l A
. _
BUILD �� S
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DATE ISSUED. 08/31/1999 EXPIRATION DATE
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY'OR PERMANEATLY.'EN-
CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR
ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS
PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF FOUR CALL INSPECTIONS REQUIRED
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS N THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR
2. PRIOR TO COVERING STRUCTURAL MEMBERS\ HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH-
(READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS.
3.INSULATION. ,OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE.
4.FINAL INSPECTION BEFORE OCCUPANCY.
i
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
1
L,6 -ZZ-Tq 1 Oda
2 2 2
�,
3 1 HEATING I ECTION APPROVALS ENGINEERING DEPARTMENT_
2 �.0 BOAR OF LTH
3 Z Zc'PrJ 3 Z
OTHER: SITE PLAN REVIEW APPROVAL
� v
WORK SHALL NOT PROCEED UNTIL PE MIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS
THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA-
TION. NOTED ABOVE. TION.
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map L Parcel f=J, Permit# _ 0 0�9,0
Health Division —.J l6�4�,�i.,��`" -r C� ..: >�� date Issued _
Conservation Division ENV� WITH
ZNITAL COp Fee
,Q f�J i np A-r Ali!®
Tax Collector G�`''�' w
Treasurer _Yi !
Planning Dept.
Date Definitive Plan Approved by Planning Bo d 7—�� _ f (¢'✓" )
w ��nnisP� C4 X P�
Historic-OKH Preservation Hyannis
Project Street Address .e % 1 Jos (Dev Lo T
Village
Owner �� !r �1 , �2 Jr Address V
Telephone G 2
Permit Request
�4 eA
Square feet: 1 st floor: existing proposed/Q 7� 2nd floor: existing proposed Total new
Estimated Project Cost �d Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size . �o to Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes kN-o On Old King's Highway: ❑Yes No
Basement TypeXFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) /�A_% 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 Aiy'�Qes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
l
Detached garage:0 existing ❑new size Pool:0 existing ❑new size Barn:0 existing ❑new size
V_S�9-6
Attached garage:0 existing Xnew size ZYX Shed:0 existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes >(No If yes,site plan review#
Current Use Proposed Use /I ice'?
.04
BUILDER INFORMATION / G
Name G Telephone Number �3 b
Address License# IQ d tt 1-✓ ,
C Home Improvement Contractor# o a a,
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY ;
IT NO.
DATE ISSUED' ,,
MAP/PARCEL NO. '
ADDRESS VILLAGE
OWNER' ;
DATE OF INSPECTION
FOUNDATION
FRAME
INSULATION t
FIREPLACE
ELECTRICAL: r ROUGH FINAL _
PLUMBING: ROUGH FINAL.: �
GAS: ROUGH FINAL;J t
FINAL BUILDING
DATE CLOSED'OUT r
ASSOCIATION PLAN NO.
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WesternSuretyom ane
e
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LICENSE AND PERMIT BOND
For County,City,Town or Village Only-Not Valid for Bonds Required by the State.Not Valid for Contract, ;
Performance,Maintenance,Subdivision,Agent to:Sell Hunting and Fishing Licenses or Utility Guarantee Bond. e
KNOW ALL MEN BfTHESE PRESENTS: r BOND No. L& P4 2 2 0 5 8 0 7 '
. e
b !
That we, Ni ktil as Buil ding Co . , Tnr
of the V'i l l a gP_ of W e s t R a r n s t a h l P , State of Ma c c a r h n c P t r c , as Principal, e
and WESTERN SURETY COMPANY, a corporation duly licensed to do business in the State
of M a s s a r h n s P t r c , as Surety, are held and firmly bound unto the
Town of R n r n A r n h 1 P , State of M a s s a c h u s e t t s , Obligee, in the amount
(Valid only when a County,City,Town or Village is named as Obligee)
of Six Hundred Fart and 0 1 �(1****************�, Q-/ DOLLARS ($ 64 0 n n******),
(NOT VALID FOR MORE THAN$25,000)
lawful money of the United States, to be paid to the said Obligee, for which payment well and truly
�r to be made, we bind ourselves and our legal representatives,jointly and severally.
THE CONDITION OF THIS OBLIGATION IS SUCH, That whereas, the Principal has been
licensed. to rnncrriirr a gino1P £n rni1y dtoaIlina at 149 T.alraviesa nr.ive
WPSr Rarnctn 1)1 p , MA Q 9 A 6 8 160 f_t froutaae by the Obligee.
NQ,ye,% f4 -t FORE, if the Principal shall faithfully perform the duties and comply with the laws and
or zed°:(at uc`rr�g�all amendments), pertaining to the license or permit, then this obligation' to to be void,
s to erna 'gin full force and effect for a period commencing on the day of
Augtt+��r,9 19 9 9 and ending on the 3 1st day
�iug u s t �unless renewed by continuation certificate.
V*1'hi bone nay� �rminated at any time by the Surety upon sending notice in writing to the Obligee and to
thy,`-''r cr l�. `p5gf the Obligee or at such other address as the Surety deems reasonable, and at the expira-
�31?i) days from the mailing of notice or as soon thereafter as permitted by applicable law,
whiche�exol � et'this bond shall terminate and the Surety shall be relieved from any liability for any subsequent
acts or omissions of the Principal.
Dated this 3 1 s t day of August 1999
Principal
Principal
Counter ' ed. WESTERN SURETY CO ANY
T
By Reside' gent By President
G
ACKNOWLEDGMENT OF.SURETY ,
STATE OF SOUTH DAKOTA i ss (Corporate Officer) G
County of Minnehaha f
On this day of ,before me, the undersigned officer,personally
appeared Stephen T.Pate ,who acknowledged himself to be the aforesaid officer of WESTERN °
ISURETY COMPANY,a corporation,and that he as such officer,being authorized so to do,executed the foregoing
instrument for the purpose therein contained,by signing the name of the corpo n by himself as such officer. ;
IN WITNESS WHEREOF, I have hereunto set my hand and official se .
+J. RHONEg.NOTARY PUBLIC �� pSOUTH DAKOTA SI �I' •P.�. otary Public, South Dakota My Commission Expires 642-2004 Western Surety Company • 101 S. Phillips Ave. °
Form 849•A—12.97 `'`'°'`'`'`'`'�`'"'�'�'�` '��'+ Sioux Falls, SD 57104 9 1-605-336-0850 '
r
` A
v ` F
p ACKNOWLEDGMENT OF PRINCIPAL ;
(Individual or Partners)
STATE OF
ss n
County of 1
G °
1
F °
On this day of ,before me personally appeared
F 9
' G 1
G °
F 1
G known to me to be the individual_ described in and who executed the foregoing instrument and
G 1
acknowledged to me that—he_executed the same.
My commission expires
Notary Public
-� ACKNOWLEDGMENT OF PRINCIPAL ` -
y (Corporate Officer)
STATE OF
ss
County of
On this day of ,before me,
personally appeared , who acknowledged himself to be the
of , a corporation,
and that he as such officer being authorized so to do, executed the foregoing instrument for the pur-
poses therein contained by signing the name of the corporation by himself as such officer.
My commission expires
4 Notary Public
t G v
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✓�ie �oauonaruuea`l� a`��l`tctdcccicueCC
OEPARTNENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number: Expires:
Restricted To: ae
LARRY O NICKULAS
`O4 'BCiOMiq BOX 570
WEST BARNSTABLE. MA
92ee i�auvrnanweall�i a�-l�aa ac�u eCF�
�- HOME IMPROVEMENT CONTRACTOR
Registration 1000"
Type - IINDIVIDUAI-
Expiration O6/18/00
LARRY NICKULAS
Larry 0. Nickulas
G� o HUCKINS NEC; RD
• ADMINISTRATOR CENTERVfij.-; MA 02632
4
The Commonwealth of Massachusetts
= - - ( Department of Industrial Accidents
'_-- Office 0118yeafgaUoos
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
location: / Z / t G Ci
phone#
I am a homeowner performing all work myself. /
I am a sole proprietor and have no one working in any capacity iF 7 S
I am an employer providing workers' compensation for my employees working on this job.
comnanx name•
address•;:
cove phone#•
insaraticcco: poli #
IIIIIIIEW
I am a sole propri f,general contractor homeowner(circle one)and have hired the contractors listed below who ha,.:
the following workers' compensation polices:
comnan.xname: C c, C _�
o ZJ "lJ
,
`cc'rl�/ �!///�� � �.UI
'000 /. . . .. ...: ..'00" �i �-
/ Ge.:..:. ..1-e c
Yr, � a phone#• Cf U
h c �� I' # C) d C'J U C
Failure to secure coverage as required under Section 25A of MGM'!can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/w
one years'imprisonment as well as Civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 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.
Ida hereby certify under t pains and penalties of perjury that the information provided above is true and correct f
Signature Date �// 5�/�
ell /11
Print name Phone#__ 7C Z Cc=, 2 jamMMMMMMIN
Cc.nt.ctperson:
ly do not write in this area to be completed by city or town official
permit license q -Building Department �
oLicensing Board
mediate response is required oSelectmen's Office
Health Department
phone#; -Other
R
(Mind 3/95 PJA)
780 CMR Appmdix J Trade-Off Workshe t IEEnforcementAgenc- l
1 c� Permit#
Builder Name Date I I
Builder dress �, �� Zone# I Checked By I
Building Address a L` G A'<U I
Date
Submitted By A P -� �� I �0 Phone Number —
F
REQUIRED
PROPOSED
Ceilings, Skylights, and Floors Over Outside Air
Insulation Required
UA U-Value x Area = UA
Description R-Value U-Value x Area I
ft2 `/ ,3 !� b Y/d Its
Ceiling
Floor Over Outside Air tt2
Skylight — ft2
ft2
M
Ceilings:Total Area ( tt2
Walls,Windows, and Doors
Insulation Required
U-Value x Are = UA
Description R-Value• U-Value
x Area UA -4 m {0— I
Wall Q M 0 tt2 �� � 7 ;!IJ
r -Window — 0 ft2
Door — R 7% ft2 ,
Sliding Glass Door — • b tt2
ft2
ft2
tt2
Wails:Total Area
Floors and Foundations Required
U-Value or Area or
Insulation Insulation U-Value or Area or UA F-Value x Perimeter = UA
�� `�
Description Depth R-Value F-Value x Perimeter 1 ft2
Floor Over Unconditioned c �y / d 71m D� tt2 t
Basement Wall t12
tt tt �
Unheated Slab in. tt
Heated Slab in. tt
ft2
Total
Total Proposed UA
Required UA
Total Proposed UA must be less than or equal to the Total Required UA.
Statement of Compliance: The proposed building design represented in these documents is consistent with the building plans,spe
cifications,
and other calculations submitted with the permit application.
_A�
Company Name &ate
BuildedDesig r
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