HomeMy WebLinkAbout0010 LANCASTER WAY ' e
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Town of Barnstable *Permit
•� ti Expires 6 montkfrqin issue a
Regulatory Services Fee
BARNSTABLL homas F.Geiler,Director
o ���-IS P 9� Building Division L
�g
Tom Perry,CBO, Building Commissioner
MAY 2 9 2008 200•Main Street,Hyannis,MA 02601 Co
�40A BARNSTABLE `"'`�'` .town.barnstable.ma.us (0
Office: 50�%y- Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number i 1 00 "
Property Address 10 W C19 J4��iQ &M Y wE_37- SMIN67467 Z,,E
Residential Value of Work �, "o- 00 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
,o 1-41VC A37,T/1 W4 Y ACST 349N_61r791&,_ &g Oz bt
Contractor's Name L EA1V311_bF_ WC. �,�Ti�"� Z.49P, 'YAE, Telephone Number 6Ok'7-7/-3���
1° Home Improvement Contractor License#(if applicable) 00 / 1 (Y�°�i4ds.�z 4 C_
9W, orkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
VI
am the Homeowner
have Worker's Compensation Insurance
Insurance Company Name Iq wr_,/Z j e4�j N o n?E 143 5 U Q)Uce
Workman's Comp.Policy# W L /7(o 9
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of.roof)
&KRe-side 2
R"Replacemen Windows/ oors/sliders.U-Value os 3 Z (maximum .44)
*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 is required.
SI6NATURE:
Q:Forms:bui ldingperm its/express
Revised 123107
Client#:23059
OCEAINCI
ACORD,,, CERTIFICATE OF LIABILITY INSURANCE 020708'°°
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rogers 8r Gray Ins. Plymouth ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
341 Court Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O.Box 3700 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Plymouth,MA 02361-3700 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Arbella Protection Co
Oceanside Inc
217 Thornton Drive INSURER B: Insurance Company of the State of PA
INSURER C:
Hyannis,MA 02601-8105 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'
POLICY EFFECTIVE POLICY EXPIRATION
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MWDD/YY DATE MM/DD LIMITS
A GENERAL LIABILITY 8500029947 01/01/08 01/01/09 EACH OCCURRENCE $1000000
X COMMERCIAL GENERAL LUIBILITY DAMAGE TO RENTEDPREMISES Me occurrence) $1 OO OOO
CLAIMS MADE M OCCUR MED EXP(Any one person) $5 000
PERSONAL&ADV INJURY $1 000 000
GENERAL AGGREGATE $2 00O 000
GENI.AGGREGATE LIMIT APPLIES PER: v PRODUCTS-COMP/OP AGG s2,000,000
ri POLICY M PRO-CT
JE LOC
A AUTOMOBILE LIABiuTY 58456400002 01/01/08 01/01/09 COMBINED SINGLE LIMB
ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS
BODILY INJURY $
X SCHEDULED AUTOS (Per person)
} X HIRED AUTOS
BODILY INJURY X $NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC E
_ AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
_. DEDUCTIBLE
RETENTION $ $
B WORKERS COMPENSATION AND . WC1766193 01/01/08 01/01/09 X WC LIMIT FR
EMPLOYERS'LIABILITY _ JQBY
TAT
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 000
X OFFICERIMEMBER EXCLUDED? NONE E.L.DISEASE• MPLOYEE $500,000
Use describe under
SPECIAL PROVISIONS below E.L.DISEASE-P &ICY LIMIT sSOO 000
OTHER _
m I
�-C
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS rV
*'Workers Comp information"Included Officers or Proprietors cu
2*
b
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08)1 of 2 #S34158/M34157 DEC o ACORD CORPORATION 1988
f
APR-29-2008 09:04 Oceanside Inc. 508 775 2848 P.02
oy t11E
Town of Barnstable
• anwastABLL `
65
1 � p Regulatory Services
6�p. �QP
Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
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 Using A Builder
1, °" �� '. 1'J n1 L� _.,as Owner of the subject property
hereby authorize EA�J �/y�i. to act on my behalf,
in all matters relative to work authorized by this building permit application for:
l b L4,V e,9,3rE e way- W. 6A1?A5?;V,6 cE
(Address of Job)
4
ignature of weer Date
/l•JNL7
Print Name
Q:Fonns:build i ngperm its/express
Revised 123107
TOTAL P.02
�le {oommzomusea��C o��/�aaacu/u�aelta
�\ Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registrat :\ 100121 One Ashburton Place Rm 1301
EzW4660642010 Tr# 267890 Boston,Ma.02108
(�t� - ,. rn
t i Type—P_r�i to Corporation
OCEANSIDE,ING1 .N t
Richard Clark
217 Thornton Dr �o,w - ,
Hyannis,MA 02601 "� Administrator of valid without signature
I -
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9
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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
ApplicintInformation Please Print Legibly
Name(Business/Organization/Individual): e1e, ,aSi CVP /iu e,
Address ,g/,7
City/State/Zip: h4 4-x/Ae15 /�/� - Phone.#: So-Y-�-77
Ar;ey�y an employer? Check the appropriate box: Type of project(required):
1. I am a employer with /0 4. ❑ I am a general contractor andl .
employees(full and/or part-time).
# have hired the stab-contractors 6: El New construction
2.❑ I am a'sole proprietor or partner- listed on the attached sheet 7. i<=&ling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, employees and have workers' 9 O Building addition
[No workers'romp..insurance comp.insurance#
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 11.0 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.Ck6tther.OE/"
corm.insurance required.] lliCZf/E'�
'Any applicant that checks box#1 must also fill out the section below showing their workers'cornpmso4on policy information.
t Homeownen who submit this affidavit indicating they art:doing all work and then hire outside contractors must sulirtnt a new affidavit indicating such.
(Contractors that check this box trust attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if the sub{onbactors have employees,they must ptwidt: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. /j /�/f
Insurance Company NamE: 11-e Av.-e- C bat i7t�C (tom 7
Policy#or Self-ins.Lic.#: Ul 4�, d 9 77 `f/ Expiration Date: / / ,%
Job Site Address: ��'_ f- ~ City/State/Zip.—
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to socure 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 tip 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 WA for insurance coverage verification.
I do hereby eertcfy r the and penalties o perjury that the information provided above is true and correct
Signature: I Date: �ap/
Phone k �P-7.71'5116 j
Official use only. Do not write in this area,tb be completed by city or town offtciaL
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#:
To
Oete Time
WHILE YOU WE OUT
M
of
Phone
Area Code Number Extension
TELEPHONED PLEASE CALL
CALLED TO SEE YOU WILL CALL AGAIN
WANTS TO SEE YOU URGENT
RETURNED YOUR CALL
Message
Operator
AMPAD 23-021-200 SETS
�� EFFICIENCY® 23-421-400SETS CARBONLESS
-i 41
TOWN OF BARNSTABLE
CERTIFICATE OF OCCUPANCY
ARCEL ID 110 004 011 GEOBASE ID 42085
DDRESS 10 LANCASTER WAY .. PHONE
WEST BARNSTABLE, MA .ZIP. -
LOT 10 BLOCK LOT SIZE
DBA DEVELOPMENT -DISTRICT WB
PERMIT 18412 DESCRIPTION (BUILDING PERMIT .014475)
PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY
CONTRACTORS: Department of Health, Safety
ARCHITECTS: and Environmental Services
TOTAL FEES:
BOND $.00 Ok CIE
CONSTRUCTION COSTS $.00
753 MISC. NOT CODED ELSEWHERE
BARNUMBIA s
MASS.
OWNER, AMEK, HOLDINGS OF CAPE COD
ADDRESS P O BOX 186 EDIN�
e I
W DENNIS MA BUILDI,tNL DIVISION
DATE ISSUED 10/07/1996 EXPIRATION DATE " '
7` >;a,ls tiit'1 'd ...[vTt.!'° ttil'(,3 /�),f�✓,:; '�1 ..}. C .i°+r:n4;i az;)'1 S a;� a4� t a f.r { 15 7. 1 1 J
y�y.. �i•.1.4.a*�•�fi.1
f ' �► �'-. 'G• Z ,,+5'�.ta,.Ty, +-`t s; I sw `ia A, '
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}r' ,�' ,s t�- s •. , •j ay:-. r L: ll nF�i ,l ,�-i! a'f.t7 e zi�� ' �° vF I��Kr'<Y '�.r, � Aft.
1,�
TGWN
P' �tti��4:.�: BIJ.�.1,.L1�.1�11-.7 1".rit�21-►1 F ..c• iiay 4,�y5,�s fl �`� r ' t'f��.r s�:
PARCEL:, ID1tu C>(:3�t ?�1? GQBAaE D ";42085 •`'�� ` ''
ADDRESS -( c5r ;-`Ts'" �c< 1 �. >^crs5-{ y' PHOIvE r
teJeST_3A'R+j 5 I)+A L6, N44 ZIP — ,
1.0 Bul)c LOT SIZE _
DBA DEVEC,OPMENT DISTRIC'.T TiTIS
Ad AMILY 'DWEIIING (SF7.PfT. #95— J35kM T )ESCZ1P1 l :'PE a `
PER:YIIT "-'YPEi BUILD `.TITLE NEW DENTIAL, BLDG PMT
" 9 • Department of Health,'Safeti
co�a'r Ac'r.ORS: E X . ������ItE'i"�' ���. :�.�_ ?� � and Environmental Servicesv
�. t,
l�,l� IIZ�.i:I'�:
_ Im --
TOTAL Ee
< <,t,1ST:�J .r.10N COSTS �s�� ,o��a _oo �;,
< `r,{
1Gi SL dt I1E i�'!Xi"� i�C'r " .l R'.iL:CHED 1 '•'PAIVATE P. *x'' ABLE' •
ti 039.
AMEK, HOLDINGS OF CAPE COD
AUDFZESS Y 0 BOX 186
BUILDING DIVISION
W DENNi M.A BY
DATE' iSS-Q& 0 !12/:L9�6 ` � EXPIRATION DAT „
j THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.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 Oil
FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND 'WHERE APPLICABLE, SEPARATE
1.FOUNDATIONS OR FOOTINGS 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-
PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH-
(READY TO LATH). ANICAL INSTALLATIONS.
3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE.
4.FINAL INSPECTION BEFORE OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS - PLUMBING INSPECTION APPROVALS ELECTRICAL I ECTION APPROVALS
r ► ..�ti V `i s
2 2 t �s irr, 2'
f 1 HEATING INSPECTION APPROVALS i� ENGINEERING DEPARTMENT <'
wN.
2 `2— (. BO RD HEALTH
OTHM s,;
VIEW APPROVAL.
uj
.., r: IC
•-ED 'JNTIL F1jr
ERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS
THE RUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY
�C ,,,�,•� ••� 9%.TcTuc.OF:qu1T IS IccliFn:A.q .,TF_lfE' 1pNE'1RWRITTENNOTIFICA-
•. -
i
`OF�NE ip� The Town of Barnstable
9 BARNSTABLE.g Department of Health Safety and Environmental Services
MASS.
Fo; Building Division
367 Main Street,Hyannis, MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
Inspection Correction Notice
Type of Inspection t %&J
Location (i 1*r-tQ Permit Number
Owner Builder { '
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
ov-\ Acwv- G 6-,k c.--r-.A -Q "'S'-
N
I A ,
Please call: 508-790-6227 for reeinspection.
Inspected by � 1
Date CST
VI
`o L LJ I
• 9
Parcel Permit# J LI q- 7
Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) J)aate Issued '��/ 96
Board of Health(3rd floor)(8:15 -9:30/1:00-4:45)
Engineering Dept. (3rd floor) House / �IK
Planning Dept. (1st floor/School Admin. Bldg.�j1 `� �( ?�
D ve Plan Approved by Planning BoardM a�`F- N dp,o v°,�e eQ 19a-/� o� BARN ABLE.
EM
09
TOWN OF BARNSTABLE
Building Permit Application ENWA AND
JPrJeceet Address �,t� '�'� C� TOWN 1 it riOHS
Village QS-1' `1 vls-}-'a� P{ ', �r
Owner �L_X=>,,IyS en-P Cc. Address
Telephone
Permit Request
First Floor I-ZA Z- S F square feet
Second Floor <q�slo S-r- square feet
Estimated Project Cost $ V:56, 000 .�
Zoning District Flood Plain Water Protection
Lot Size o 7Grandfathered ?
Zoning Board off eats Authorization Recorded
Current Use V 4C,0_04 'col Proposed Use i
'Construction Type wbod
Commercial Residential L�
Dwelling Type: Single Family Two Family Multi-Family
Age of Existing Structure N pr- Basement Type: Finished
Historic House Unfinished
Old King's Highway r S
Number of Baths Z. S No. of Bedrooms 3
Total Room Count(not including baths) 8 First Floor S
Heat Type and Fuel r=kW q of s Central Air ---- Fireplaces t3
Garage: Detached �� Other Detached Structures: Pool -------
Attached tam Barn
None Sheds
Other r
�• er Information
Name _-(� 4 �7. 12.Telephone Number ��- - �
P � i 3 l
Address �t.10 • SS / License# l��2_S09
UV o�S� 1.VLLS �C v Home Improvement Contractor#
Worker's Compensation# 606-C-z4 10 51 C"
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTIO DE RIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR DATE `f cI1
BUILDING PERMIT DENIED FOR THE FOL WING REASON(S)
FOR OFFICIAL USE ONLY
R
L
PI MIT NO.
D ISSUED
M P/PARCEL NO.
IRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION #d r
0 �
FRAME
INSULATION d
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
s
GAS: ROUG FINAL
FINAL BUILDING Lb J
DATE CLOSED OUT
ASSOCIATION PLAN NO.
J.t- ..�^ `. ... + + :I ' lY ° '• ''L.J'+ 1,' ',�.:-',5•tl,l/ r'P:' J .� � �.le
GTE
OEPARTBENT OF PUBLIC SAFEly Restricted To: 00
COHSiRUC'ION_.SUPERVISOR LICENSE I fallrre to possess a errroat
00 - None
::Nu�hec "w Massachusetts asaaeAraotta3taeosr/ld/fw
eirthdatc. 1A - Nasonry only Code/avacca forravocat/on
CS_ ��018863 v:,08/O7/1991 08/O7/1950 16 - 1 8 2 faeily Hoes
:Restricted io Op I
—may
_ GEORGE R RUSSAS
PO"BOX 569
E DENNIS, NA 02641
,
'
ISSIONER
• �"'� The CunrM)"I"'eallli of Atassachuself-
'� • '' ' artinent pe of Industrial Accidents
-- Mel: P
- " � _ -=1� - 0/Jlceollm�estlgalloas -
�?: , ' i';a' 600 «'asiungu)n Street
�de�; Bim-ran.Mass. OZlll
Workers' Compensation_ Insurance.ARdavit
iea-nt nft'erin-iiien' �IEpRiNTle �� --
lec�tion•
gin, nhone#
❑ I am a homeowner performing all work myself.
❑ 1 am a sole proprietor and have no one working in any capacity
I am an employer p viding workers' compensation for my em oyees working on this Job.
comnIny nn �,W-f &..MCI
V
e
rift•• I/UQ S� J 20,1/1 LS - ohnne#t
• #
L....
❑ 1 am a sole proprietor,general contractor, or ho eowner(circle one)and have hired the contractors listed below who ha
the following workers' compensation polices:
tomn•tnt•n•tme•
address:
city: nhone On
-��rance co. nolicy#
I.'�..i+�� «`_�;:_. --..- �._.•o....••Q�•r.—�'rte'nsr:'^y�*r—r = -- �°F'°°'lr°}�y"�''Wit���.e�,'�'"'� '
m v e•
address:
city: nhone#:
incur once co
:Attach additional'shcet if aeeesatt�-•.;�••-�-•+�^_•--°�="'-•---- _- -------•-_ --- - 4- -- — �'�
faiiurc to secure coverage as required under Section 25A of AlGL 152 can lead to the imposition of criminal peaaltin of a fine up to S1.500.00 end/al
one years'imprisonment as well as civil peaaltics in the form of a STOP NVORI:ORDER and a tine of S100.00 a day aping me. 1 understand that a
copy of this stateme ay be forwarded to the ORicc of Investigations of the D1A for coverage verification.
I do imerebr cart •and time it d pe alder ojperyum.r that the injor madon pm ided above is d correct
7
Sienaturc Paime
Print name � v one#
olncial use only do not write in this Mato be completed by city or town oflieial
pe rmitilieeme# rnBuifdiog Department
dtv or town:
C3Liccasing Board
check if immediate response is required C3Seieetmeds Office
(31iesitb Department
phone#;contact person:
r�Other
-Information and Instructions F,
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for thch
empioYces: As quoted from the "law", an empinree is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An empinrer is defined as an individual, partnership, association, corporation or other :,gal entity, or any two or more
the form, 'ng engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
goireceiver 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 hou
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer
MGL chapter 1'52 section 25 also states that ever}•state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonvealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
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 1i
been presented to the contracting authority.
.,�r+..��, yra. .1 i 1 S� a}.w 1- ^i C•.. :.� y 1 y_�t"'�.�i�tY r\�- '1( : .a. .._
_ a' ':;
"' f:. :: }. :!'T�iL'.\:'. �•,;.• :..»_ fir^ i:• w i` c .r.:. �:1,r '�'�., 1�.
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 affida�it. 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.
oai�r•s......o�.ew •_�a -I. :•'-:;='�.r''1'7'�''"y,"5,�,+ML►�•� '!%r' '�'tiJ `r.:?� •.wts,�;s-• . + _
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. Plez
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned t
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 question
please do not hesitate to give us a call.
`'. • .. - �. .. '..•,.,�� -•. - s.i r....j�...�.. �.r �,+ .. •c•sr�%:.w4v:.niv�,.N _�.�..::-ri.. ...:_t.-;.�,,;..
The Department's address, telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
office of inuesUgations
600 Washington Street -
Boston,Ma. 02111
fax#: (617) 727-7749 •.
phone #: (617) 7274900 ext. 406, 409 or 375
QUERY PROPERTY: QUERY END
QUERY PROPERTY
PENTAMATION----------------------------------------------------------- 08/09/96
PARCEL ID 110 004 011 GEO ID 42085
LOT/BLOCK 10 DBA
PROPERTY ADDRESS OWNER AMEK
1-8� C Pd�RY—L E HOLDINGS OF CAPE COD
10 LAojG4b7Z r- W A� P O BOX 186
WEST BARNSTABLE, MA
W DENNIS MA 02670
PHONE DISTRICT WB
DEVELOPMENT ; STATUS C ASSESSOR' S CODE
CAPACITY (NOTES)
ZONING DIST/ZOC SEWER SYSTEM
FLOOD PLN/ELEV. WATER SYSTEM
OKH? # BEDROOMS
ZBA DECISION FAMILY APT
LOT SIZE 30492 OPER/MGR NAME
WET LANDS MULT ADDRESS
USE 130
(N) EXT / (P) REVIOUS / NO (T) ES / PER (M) ITS /
(V) IOLATIONS / (G) EOBASE / (E) XIT
• a
1
Application to
Old Kings Highway Regional Historic District Committee 9 J ,Q 43
in the Town of Barnstable for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, in 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: altlouse Garage ❑ Commercial ❑ Other
2. Exterior Painting: 2,
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 � �c DATE
1 , I
ADDRESS F PROPOSED WORK g s - C-�--) re�-5f•ASSESSORS MAP NO.
OWNER MC t-�O c✓L S U� co
�E ASSESSORS LOT NO. j0
HOME ADDRESS � x rf36t w Sri S, -� nZb TEL. NO. �0
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public
street or way. (Attach additional sheet if necessary).
l a l ��s� a s��'l..-- 3S o_vevc- r s�� �
r✓t � , ">
�n is C�ZCo '�
AGENT OR CONTRACTOR-E—LO 2 `^ `2- `' EL. N0.
� 9�
ADDRESS Py •� v l�(o � s-r s I•-{ 8z �
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). 50 x..(.' I-kvt{-e— —6--=( efl,j t:wv'cis.�
OJ-J 4wz d,n a-- eev-- eP Zvt �.I..DI.e,r-- ���r��`e- c- c -C?,�a P(Qce--
-jO' X (Q( -Ty--SS t.w\AZ-
�q c"k1M 1� 0
Signed
Owner-Contractor-Agent
Space below line for Committee use.
ZR c- ved-bV=H1-9aC.
'' IN 0
Date - 9�Nllj'hje CertificatqAVhereby io
-: iTime �
qy
Approved ❑ IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal period
provided in the Act.
Disapproved ❑
ADDITIONAL INFORMATION FOR MAKING AND FILING AN APPLICATION
FOR A CERTIFICATE OF APPROPRIATENESS
The four categories for which a Certificate of Appropriateness is required are: (application for demolition or removal is a
separate form).
1. EXTERIOR BUILDING CONSTRUCTION (new or existing buildings): . An application is required for any exterior of a
building to be erected or altered including windows, doors, siding, roof, light etc., that will be visible from any public street,
way or public place. The following scale drawings are required in duplicate with application: plot plan (if addition — show
existing buildings in outline), floor plan and elevations. Also required are snap shots of existing buildings, where additions or
alterations are to be made. No plot plan is required for.addition or alteration which does not touch the ground.
2. EXTERIOR PAINTING: An application is required for any portion of a building, structure or sign to be painted that is
visible from a public street, way or public place. Color samples must be attached to these applications. An application is not
required when repainting existing colors, changing to white, or using colors approved by the Town Historic District Committee.
3. SIGNS OR BILLBOARDS: An application is required for any sign or billboard to be erected within the District, with the
following exceptions:
a. Existing signs or billboards on November 27, 1974 shall have until November 27, 1977 to secure an approved Certificate
of Appropriateness.
b. Temporary signs for use in connection with any official celebration or parade or any charitable drive as long as they are
removed within three days of the event. Certain other temporary signs that the Committee feels does not detract from
the Act may be allowed with the prior permission of the Committee.
c. Real Estate signs of not more than 3 square feet in area advertising the sale or rental of the premises on which they are
erected or displayed.
d. A single sign of not more than 1 square foot in area showing the name, occupation or address of the occupant of the
premises on which they are erected or displayed in a residential zone.
4. STRUCTURE: An application is required to build or alter any structure within the District which is defined by the Act as a
combination of materials other than a building, sign or billboard, but including stone walls, flagpoles, hedges, gates, fences, etc.
GENERAL RECIUfREMENTS
5. Work on projects requiring approval shall not be started until the Certificate of Appropriateness has been filed with the Town
Clerk by the Committee. Approval is subject to the 10 day appeal period provided in the Act.
6. No changes shall be made from the original approved specifications without advance approval of the Commission on an
amended application filed with the Committee.
7. A separate application must be filed with each project requiring a Certificate of Appropriateness.
8. Under heading of "Detailed Description of Proposed Work" give detailed data on such architectural features as: foundation,
chimney, siding, roofing, roof pitch, sash and doors, window and door frames, trim, gutters —leaders, roofing and paint color.
9. Unless application is complete and legible and all material required is supplied, application will not be accepted or acted upon.
Copies of the Act establishing the Regional Historic District may be obtained at the Town Hall.
REVISED".-(1 a
DATE
ire E�-s k 1 T�Zc_/
OLD KING'S, HIGHWAY HISTORIC DISTRICT
_ SPEC SHEET
FOUNDATION PYE
gLUY-44 o4 c� r>i c_
SIDING TYPtCi+y-t -{ y�►�h�� l. � �' a
(rtD(COLOR
CHIMNEY TYPE oblJ -Stli COLOR o,L-
Ct
ROOF MATERIAL Sg743 prL-r Ski t�(� �s COLOR_ Q"4ty< Oc
i
PITCH -7
WINDOWS V I G1 ub-LkJiyv, 1 SIZE 2
15
TRIM COLOR t+
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e
SHUTTERS r - (^,4e,
GUTTERS_ L 4 W I ti�t nA_ _ Lv T7-6-
DECK
GARAGE DOORS_ 4q��NC,c. t) —COLOR Ei
Notes : Fill out completely. including measurements and
materials/colors to be used.
Three copies of this form are required for submittal
11 of an application. along with three copies each of P
the Plot. p.l an. landscape plan and elevation
*Plot
when applicable.
•P 1 of plan need not be "Certified" . tut.__.shou.l h Shcw
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ASSESSORS MAP: 110
TEST T HOLE LOGS NOTES:
PARCEL: 4-11
1. VERTICAL DATUM. ASSUMED FROM QUAD (NGVD +/
b[cLELLAN P E.
`'. CURRENT ZONING: RF ENGINEER: TX OMAS 2. MUNICAPAL WATER IS„NOT
AVAILABLE.
BUILDING SETBACKS: WITNESS; JERRY DUNNING 3. SCHEDULE 40 - 4" PVC PIPE TO BE USED THROUGHOUT SEPTIC SYS
:- . TEM.
r DATE _, -93 - UNITS TO CONFORM WITH AASHTO X-10 & H-20
fcd, F.� S. 15 R. 15' 4. ALL PRECAST
'aT PERCOLATION RATE: < 2 MIN/IN
LOADING SPECIFICATIONS.
LOCUS FLOOD ELEC. MANHOLE
OD ZONE: C TH-1 TH-2 5. PIPE PITCH 4" PER FOOT, (UNLESS NOTED OTHERWISE).
-- \
7so 6. FIRST 2' OF PIPE:OUT OF D-BOX TO BE LAID LEVEL.
UTILITY CLUSTER Top &{, ELEV. 7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE
SUBSOIL 0$ \ 24" 740 USE OF A GARBAGE DISPOSAL.
i INE; 8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE
94 SAND
`` s8.5 STATE OF MASS. ENVIRONMENTAL CODE.(TITLE FIVE) AND LOCAL
LOCATION MAP PROPOSED WELL Gl g,_ . HEALTH REGULATIONS.
(LOT 8) d l� 94 '9Z ya M 9. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR
LOT 10 �► a FINE
-
30,375 ± S.F. SO %0' ❑� � � 190 SAND TO CONSTRUCTION.
(0.70 ± AC) y1+ • 10. DESIGN ENGINEER TO INSPECT AND CERTIFY SUITABLE SOIL CONDITIONS
• �� az`s • 88 44" 64.o TO A DEPTH OF 4' BELOW LEACH PIT AT TIME OF CONSTRUCTION.
, ` / - 11. D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW.
{yd ;0�115
12. SEPTIC SYSTEM AND WELL LOCATIONS :HAVE BEEN MODIFIED FROM
84 MASTER PLAN REVISED 5-2-93) ON FILE WITH BARNSTABLE HEALTH
PROPOSED �raLL . - (G OUNDWAT R O LOT 5 AT ELE DEPT. ALL PREVIOUSLY APPROVED SETBACKS REQUIREMENTS REMAIN
(LOT 7) 82 (GROUNDWATER ON LOT 5 AT ELEV.;= 48J)
so �� ' 80
IN EFFECT.
0 - , . , ' ' ' , ,76
88 , 76 ,,� SEPTIC SYSTEM DESIGN
74 ,
OA
q, 86 , - ' - - , , ' , . , 70 68 FLOW ESTIMATE:
85. s I '� ' 110- AY BEDROOM -Oa GAL DAY
v � �„ ,,-.. �......� , , - , � � � , � BEDROOMS AT GAL/D / /
� � 9 ,.. •. •..•r• � � � , � ' � � i r i ✓ i WALK-OUT
l / r i i ' ' , i 66 DECK
�+ ` 84 6►� - ' ' ' ' SEPTIC_TANK: so'
G ,
f....................Y , ,
� � , � , � � � ,` � 550 GAL/DAY * >.5 DAYS = 825 GAL
/ USE GALLON SEPTIC TANK 5Aq
BEDR O
yd �, , i i i 'S00 26' S BEDROOM e 2 P
?G 82 / DWELLING
�`` ' i ► QoN�46q LEACH.,"
`64 LEACH N'G AREA:
8s p�v
°0, ' �°, sT: %. ,' ,' � ' � ' ' USE 2 LEACH PITS (6' x 4') WITH 3' OF STONE ss' 14'
80/ 9. 12 t,FFECTIVE DIAMETER x 4 DEEP)
� � � •• _. � �t►�' / � � � � � � , � YI To L� _ = GAL' DAY PROPOSED DWELLING
:� SID. AREA 12 x 4 x PI 151 SF (2.5) 377
e.19 ' , ' ' �� BOT,"'OM AREA: 6 x 6 x PI = 113 SF (1.0) = 113 GAL/DAY
TOTAL CANACITY.._ 0-GAL/DAY
x 2 PITS = 980 GAL/DAY _
62 SEPTIC SYSTEM SECTION 2„ PEASTONE
LP-2 RES ,� � ��' � i � »
�4 > , i
REs i ? 86.0 COVERS WITHIN 12" WASHED STONE
o TOP OF FOUNDATION OF FINISHED GRADE
TH-5
DRAINAGE EAs NT-'
EXISTING LEACH PIT 76.55 4" o
76.8 1500 GAL ELEV. D-BOX ELEV. LP-1: 64.0
5. 3 64 ELEV. 75.49 LP-2: 60.0
i 1 p \ SEPTIC TANK
ey \ \ss ELEV. LP 60 .--• 4-3-,*ELEV;
.
BENCHMARK CENTS `_ _ 0• 68 TEE SIZES: 3
CATCH BASIN ELEV=75 2' 76 .70 77.0 ELEV. ----- 12' -�
\ ELEV. INLET: 6" UP, 10 DOWN
76. 5 72 OUTLET: 6 UP, 19 DOWN TWO LEACH PITS (6' x 4) WITH
,74 (UNDER X OF STONE (12' EFF. DIAM. x 4' DEEP) (H-20)
l .a ` .76 BASEMENT) BREAKOUT CALC: (64.5 62)/58 x 150 = 7'
78 8. s f
SITE AND SEWAGE PLAN
BY: APPROVED BY: DATE:
CHING LOCATION
EXISTING CONTOUR. O LEA
S CONTOUR: ... .......................... LL T W PROPOSED 4y�E `ry 18 COV ENTRY AY
EXISTING SPOT ELEVATION: 25.5 I N MIA51). `i�ao�Mks
PROPOSED SPOT ELEVATION: 2s c WEST BARNST ABLE, MA
_,
TEST HOLE:
UTILITY POLE: -0- ' _ -s PREPARED FOR
FENCE LINE:
DM REEF REALTY
RETAINING WALL: DEMAREST-MCLELLAN ENGINEERING 'S - SCALE:
1 = 30' DATE: 3-18-95
24 SCHOOL STREET P.O. BOX 463
REFERENCE: PLAN BOOK 454 PAGE 96 REV: 4-8-96
►j�[ # 93-028 WEST DENNIS, MASSACHUSETTS 02670
iH70MASU McLELLAN, P.E. JOHN Z. DEMAREST JR., P.L.S.