HomeMy WebLinkAbout0210 MAIN ST./RTE 6A(W.BARN.) i
i
oxford NO. 152 1/3 ORA
A,
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel pplication
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
oil
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
L
Project Street Address 2-1CD `� /f �—S�/ &/
Village
Owner 42 B 7 C.- /V / x,C/6JA2 S Address Zoo
Telephone Z
Permit Request /�e � • -���c��s J"''
ate-,
Square feet: 1 st floor: existing proposed 2nd floor: existinproposed otal new
Zoning District Flood Plain Groundwater Overlay
Project Valuation d ocf Construction Type/
Lot Size? .9 Grandfathere : Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family(`O\ Two Family ❑ Multi-Family (# units)
Age of Existing Structure a Historic House: ❑Yes /�(No On Old King's Highway:*s ❑ No
Basement Type: ❑ Full ❑ Crawl Walkout ❑ Other
Basement Finished Area (sq.ft. fo C Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing Z-1 new r--D Half: existing new C
Number of Bedrooms: existin�new _
Total Room Count (not including baths): existing > new C�r First Floor Room Count
Heat Type and Fuel./O�as ❑Oil ❑ Electric ❑ Other
Central Ate( Yes ❑ No Fireplaces: Existing New Existing wood/coal stov,� ❑o to
Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: Cxisting ewize_
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 # c
Current Used Proposed Use �_ C
APPLICANT INFORMATION c-6// �Z�(� vea
(BUILDER OR HOMEOWNER)
}
Name Telephone Number Isle
4
�� �� �
Address / License #
IHome Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN T
SIGNATURE DATE S
> FOR OFFICIAL USE ONLY
APPLICATION#
i P
DATE ISSUED
a A
MAP/PARCEL NO. a
ADDRESS VILLAGE
OWNER `
DATE OF INSPECTION:
FOUNDATION.
FRAME (orl0'7Lofh lPlhi(,(
INSULATIONll� o(c 03
FIREPLACE
r _
ELECTRICAL: ROUGH FINAL_"
`= PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
:
s' FINAL BUILDING Ah
DATE CLOSED OUT A
ASSOCIATION PLAN NO. '
r
= The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations -
600 Washington Street
Baston,MA 02111
wwl<v.mass.gav/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Abplkant Information Please Print Legibly
Name (Business/Organiiation/lndividuel):
Address:
City/State/Zip: Phone
Are you an employer? Check the appropriate box: Type of project(required).-
am a employer with 4 I am a general contractor and I
employees (bL 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 8. ❑Demolition.
working for me in any capacity. employees and have workers' 9.. ❑Building addition
[No workers'comp. insurance comp. kor ance$
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.❑Plumbing repairs or additions
self o workers' co right of exemption per MGL
my comp. 12.❑ Roof repairs
insurance required.]t c. 152, §I(4),and we have no
: . employees. [No workers' 13.❑ Other—.
comp. insurance required]
*Any applicant that checks box P-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.
kaontractors 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 polruy and job site
information.
Insurance Company Name:
.Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/StaWZip:
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 weIl 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 DfA for insurance,coverage verification.
I do hereby_certify under the p and p es of perju that the information provided above is true and correct
i ature: i �� �'" Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5..Plumbing Inspector
6..Other
Contact Person: w. Phone•#:
�Q
Information and .Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. .
Pu suant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or-written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more ..'
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity,employing-employees.' However the'
owner of a dwelling house having not more than three apartments and who resides therein,or•the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on.such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be'an employer."
MCrL chapter.152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance-or,
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority.."
Applicants :
Please fill out the workers' compensation affidavit completely,by checking-the boxes that apply to your situation and,if.
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no-employees other than the'
members or partners,are not required to carry workers' compensation ins=ce. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial' ,
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested.,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please.call the Department at the number listed below. Self-insured companies should entertheir
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to'contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current.
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city.or. '
town)."A copy of the-affidavit that has.been officially stamped or marked by the city or town may be provided to the' . .
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled.out eaclz•.
year. Where a home owner or citizen is obtaining alicense or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would Like to thank you.in advance for your cooperation and i ould you have'any questions;'
please do not hesitate to.give us a call. i
The Departments address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA Q2III
Tel. #617-727-4900 ext 406 or 1-977-MASSAFE
evised 4-24-07 Fax# 617-727-7749
i
www.mass.gov/dia
of Town of Barnstable
Regulatory Services
F m Thomas F.Geiler,Director
Building Division
Tom Perry,Building Commissioner
200 Main Street,IHyannis,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
I, 12C / / litcL- 1.4, Owner of the'subject property
Hereby,authorize r� / ,2,EJ to act on my,behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
#Pool fences and alarms are the responsibility of the applicant. Pools.
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signatar of Applicant
Print Name Print Name
Date
-Q:FORMS:0VINERPERMISSI0NPOOLS 0012
Town of Barnstable
Of SHE Tp�,_
Regulatory Services
R t
t Thomas F. Geller,Director HAM
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Offioe: 508-862-4038 Fax:•508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: '
JOB LOCATION:
number street village
"HOMEOWNER": ..
name home phone# work phone#
CURRENT MAILING ADDRESS:
i
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINTITON OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeoQ;uer"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
;
Note: T)aee-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control
I
HOMEOWNER'S EXEMPTION i
The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homwwner'engages a person(s)'for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fuDy aware of his/her responsibilities,many communities require,as part of the permit application, j
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t.amend and adopt such a fd m/cer ification far use in your community.
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oF� T Town of Barnstable *Permit m;)60 01417 1
Expires 6 months from i date
Regulatory Services Fee
>iatutsrnst,>;, Thomas F. Geiler, Director � �S
1639. ,�� Building Division
PrFO MA't A '
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 5087790-6230
;.,EXPRESS PERMIT APPLICATION - RESIDENTIAL, ONLY
Not Valid with owt Red X-Press Imprint
Map/parcel Number L
ZAZ
Property Address C
s
Residential Value of Work �� (S Minimum fee of$25.00 for work under$6000.00
I / �
Owner's Name&Address �y
Contrac 1.tor's Name rb / C !�( �-/r1 Telephone Number
/� C
Home.Improvem rent Contractor License#(if applicable) / oo q�
❑Workman's Compensation Insurance X-PRESS PERMIT
Check one:
❑ I am a sole proprietor AUG — 1 2008
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance l 1 T WN 7r .
gARNSTABLE
Insurance Company Name ♦ Y C /
P Y ��l i...�' �� ��.5
Workman's Comp. Policy# r^, rl A
Copy of Insurance Compliance Certificate must be on file.
Fermi it Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑.Re-roof(not stripping. Going ov r existing layers of roof)
Re side t�J V
Replacement Windows door liders. U-Value (maximum.44)
* ,gt ation,etc.
Where required: Issuance of this permit does not exempt compliance with other town departrrmT®tr+er ieft," it nc,.G.o.nSeLY-
'Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is$et> eda.rl
b �..
J L u i! b�i �
SIGNATURE: �~
4y7 ,
Q:\WPFILESTORMS\building permit forms\EXPRESS.doc
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Bostam, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance A£6idavit: Builders/Contractors/Electricians/Plumbers
A.ppUcant Information 0,
/ /Please Print Le -bl
Name (Busincss/orkauizaEon/fndividuaI): �. ✓ �J
Address
City/State zip: - -Phone.#:
Are you an employer? Check the appropn Type of pr6jmt(required):
1.❑ I am a employer with am a general contractor and I 6 New constitution
loyees (full and/or part-time).* havo hued the shb-contractors
I am a sole proprietor or partocr-
e
listed on the attached shcct 7. ❑Remodeling
ship and have no employees Thes sub-contractors have g. Demolition
employees and have workers'
working for me in any capacity. 9. ❑Building addition
[NO wOrkerS' .ins nee Comp.in&urancc.t
5. [] We arc a corporation and its 10_[]Electrical repairs or additoor
r&p&cd-] officers have exercised their 11.0 Plumbing repairs or additioi
3.❑ 1 am a homeowner doing all work
m right of exemption per MGL
yself [No workers' comp_ 12 ❑Roof repairs
t c. 152, §1(4), and we have no
rns„ran�rmo d-] employees. [No workers' 13.❑ Other
comp,insurance required-]
`Any applicant that ehmim box#1 roust also fill out the section below showing their wmi=s cornprnmtton policy information
t Homcowncn who eubrait this affidavit indicating d3ey arc doing all work and than hiM outside contraetnrs must submit a new affidavit indicating such
tC.ontraetans that ehmti this box must affichcd an additional sheet showing the name of the sub-cmtractors and st� iha wbe or not thosd entities have
crnployncs. irthe sub-contractors have rmployccs,.they must provide:their avrkcrs'cm-np.policy number.
Iran an employer that is providing workzrs'compensation insurance for my employees: Below is thepolfcy and job site
information.
Insurance Company Nam / '� ,
Policy#or Self-ins.Lic.#: Expiration Date:
rob Sitc Address: Q V /'/ /�:'s� �' ' city/Sbkizip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date;
Failure to secure coverage as requucdlmder Section 25A of MGL c. 152 can lead to the imposition of gal penalties of.
fine up to$1,500.00 and/or one-year umprisonmcnt, as wcU as civil pcnaltics in the form of a STOP WORK ORDER and a f
ofup to$250.00 a day against the violator. Be advised that a copy of this statcmcrit may be forwarded to the Officc of
Investigations of the DLk for i suramc cov e verification.
I do hereby certify un e pa' d pe of perjury that the information provUed above is true correct
Si c: Datc: C -
Phone#
O facial use only. Do not write in this area, to be completed by city or town officiaL
City or Towa: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Blectr-iCA In
S.Plumbing Inspector
6. Other
A
°FmEr�ti Town of Barnstable
Regulatory Services
M.�.ss.
a�xrrsresce' Thomas F. Geiler,Director
o;q ��� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
n
p ��✓�as Owner of the subject pro'
e
J p p rtY
hereby authorize �/` V C to act on my behalf,
in all.matters relative to work authorized by this building permit application for:
2cs �b CA
ZJ , ,
(Address of Job)
Signature of Owner D to
i2 a iA rn
Print Name
If Property Owner is applying for permit please complete the Homeowners License
Exemption Form on the reverse side.
Town of Barnstable
�pF'(HE rp�y
y�� o Regulatory Services
satuvsTAace Thomas T.Geiler,Director
MASS.
i63F9. Building Division.
�pJfD �a Toni Perry,Building Commissioner .
200 Main Street, Hyannis, MA 02601
www.town.barnstable.malus
Office: S08-862-4038 . Fax: 5.08-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state tip code
The current.exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess'a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on'which he/she resides or intends to reside; on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a t� o-year period shall not be considered a homeowner. Such
"homeowner shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permst. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations:
The undersigned"homeowner'certifies that he/she understands the Town of Bainstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be.required to comply-with the
State Building Code Section 127.0 Constriction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 1 o9.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption Rie unaware that they are assuming the responsibilities of supervisor(see Appendix Q.
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often rr-sults in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultirnately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a forrn/certification for use in your community.
Licensee Details Page 1 of 1
The Official Website of the Executive Office of Public Safety and Security (EOPS)
Public Safety
Mass.Gov Home
DPS Home EOPSS Home Mass.Gov Home State Agencies State Online Services
Department of Public Safety Licensee Complaints
License Type Home Improvement Contractor
License# 100496
Restriction
Company Larry Nickulas
Name Larry Nickulas
Address Po Box 507
City, State, Zip W.bar , MA, 02668
Expiration Date ---6/18/2010------,
Status Current
No complaints found for this Licensee.
Back To Search
i
http://db'.state.ma.us/dps/licdetails.asp?txtSearchLN=HIC 100496 7/31/2008
Board of Building Regulations and Standards j,icense o: is tion valid for indivi¢ul we only
i HOME IMPROVEMENT CONTRACTOR I
t,.;b�for�.the expirafitiiri[ate.:If;found;returlt.to:
Registration: 100496 Board of JBuildmg'Regulations and Standards
Expiration::6/18/2010 Tr# 268011 ::Poe Ashbtirtoin"Pa'ce Rm j:'
Type: Individual s Poston;plat dtZlQ8
LARRY NICKOLAS
Larry Nickulas i
20 CEDAR ST.
W. BARNSTABLE,MA..02668 Administrator Wot'valid'withoat signature
' ��ie U�D?�vntovziue� a�..,ll��aaaa�cfucaelta
Board of Building Regulations and Standards l
Construction Supervisor License
�. .3
License CS 2265
Ezptration `-�(18%201,q,_ Tr# 13429
z
.LARRY D NICKULA� t >.iac s�� gal iV' 1
PO BOX 570
c �
W BARNSTABLE,MA02668 : - • Commissioner
! i
oF114E T Town of Barnstable *Permit#
Expires 6 months from issue date
Regulatory Services Fee
00
\ • BABNSrABM
MASS. /y��I" Thomas F.Geiler,Director
Building Division
` Peter F.DiMatteo, Budding Commissioner ��WY49
367 Main Street, Hyannis,MA 02601w
Office: 508-862-4038 TO 9&6'1
Fax: 508-790-6230 O'c 1Q
EXPRESS PERMIT APPLICATION e ��
Not Valid without Red X-Press Imprint �Rit/�t S',)"
Map/parcel Number
Property Address 2 U G
�sidential OR ❑Commercial Value of Work 2 U UG
Owner's Name&Address
Contractor's Name %°' % 1 �/• `c ` Telephone Ntunber ? Z
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
rr Check ne:
[m a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance /
�/`e
Insurance Company Name .10
Workman's Comp.Policy
Permit Request(check box)
❑ Re-roof(stripping old shingles)
❑Re-roof(not stripping. Going over existing layers of roof)
Re-side
❑ Replacement Windows. U-Value (maximum.44)
❑ Other(specify)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic.Conservation.etc..
Signature
Q:Forins:exp mtrg:rev-070601
s
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Permit#
Health Division Date Issued ��
Conservation Division Z61a040t Fee ZV—yo
Tax Collector ry IN/0
} SEPTIC SYSTEM MUST BE
Treasurer INSTALLED IN COMPLIANCE
Planning Dept. WITH TITLE 5
WITH
CODE AND
Date Definitive Plan Approved by Planning Board TOWN RECULATIn?;S
Historic-OKH r/ Preservation/Hyannis
Project StreA d resSJ yl 3 A4
Village
Owner a 4 Gl J Address
Telephone
Permit Request S
l
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost e v Zoning District Flood Plain Groundwater Overlay
71
Construction Type `
_L01ize Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. f
..Qw_elting Type: Single Family)c Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ,4No On Old King's Highway:,k'Yes ❑No
Basement Type: ❑Full ❑Crawl )(&Ikout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing_r� new 41
Total Room Count(not including baths): existing new First Floor Room Count
Heat Type and Fuel:�s ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes KNo Fireplaces: Existing L-' New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
I Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
i
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
I
BUIL ER INFORMATION
Name ✓ C1,1 Telephone Number 7
Address U Q License# Z 2. G
`-✓ o �Q�� �����G Home Improvement Contractor# 00
C: Z �� Worker's Compensation# e t
ALL CONSTRUCTION DEB:;;VULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE ?
FOR OFFICIAL USE ONLY f tt
., _ -.-...mac •
PERMIT NO. ;
DATE ISSUED `
MAP/PARCEL NO.
ADDRESS VILLAGE s ;,
OWNER ,
DATE-OF INSPECTION-:..r
FOUNDATION _
FRAME '
INSULATION
FIREPLACE s
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH '= ' FINAL
FINAL BUILDING
DATE CLOSED OUT
r
ASSOCIATION PLAN NO.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Permit#
Health Division �i Date Issued Z
Conservation Division Lzt;znogt
Tax Collector O� �o7b -
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis e
Project Street Address)
Village 4J OK2
//
Owner /7 a c..D �� �� !� t /I Address
Telephone C
Permit Request Ilea Ll
000,
Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new
Estimated Project Cost 1.�7 z� Zoning District Flood Plain Groundwater Overlay
Construction Type
ize Grandfathered: ❑Yes ❑No "If yes,attach supporting documentation.
.ng Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure / G Historic House: ❑Yes 4 No On Old King's Highway:,IkYes ❑No
Basement Type: ❑Full ❑Crawl °GValkout ❑Other
Basement Finished Area(sq.ft.) r� Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half: existing new '
Number of Bedrooms: existing new Q
i
Total Room Count(not including baths): existing new First Floor Room Count
Heat f Type and Fuel: ®Gas ❑Oil ❑ ectc El Electric r`Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: Cl Yes ❑No
Detached garage:Elexisting ❑new size Pool:❑existing ❑new size Barn:Elexisting ❑new size
--4i
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑/
Commercial ❑Yes ❑No If yes, plan review#
r
Current Use Proposed Use
1
BUILDER INFORMATION
Name Telephone Number
Address D3 4 - License#
_Home Improvement Contractor# 0
(-( Z Worker's Compensation#
ALL CONSTRUCTION DEBRIS R ULTING FROM THIS PROJECT WILL BE TAKEN TO
f
SIGNATURE DATE _ ?
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
r R
INSULATION
FIREPLACE J .
ELECTRICAL: ROUGH FINAL
r
PLUMBING: ROUGH (FINAL
GAS: ROUGH FINAL
FINAL BUILDING F
DATE CLOSED OUT
ASSOCIATION PLAN NO.
Application to
Highway Regional Historic District Committee
Old Kings
in the Town of Barnstable for a n
CERTIFICATE- 8$
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 )g Addition ❑ Alteration
Indicate type of building: House ❑ Garage ❑ Commercial ❑ Other
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑.Other
(Please read other side for explanation and requirements).
TYPE OR PRINT LEGIBLY DATE ':P• L2•�Co
ADDRESS OF PROPOSED` r�
WORK _�� Maln S� w $arrahle ASSESSORS MAP NO. 13�
OWNER Cponald lyltl ASSESSORS LOT NO. -_
HOME ADDRESS —2ZG 1�ain�-. �] �a,m5�abe TEL. NO. �(0 V5
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public
street or way. (Attach additional sheet if necessary).
• k# 8- � fever, Oneu - Z40 M atn 4 �d Lol- 1� John + en r $u rke
� l tl 38l �ul',ker �-1y1� 5k.
'� - EGlWar�l =1lAwe►l - 17 P ion �LQTC�YVtUP �1aYl -cWn� 02129
a
AGENT OR CONTRACTOR - r�hi- TEL. NO. -771-3900
ADDRESS _ 28 Ge�'1�8YVt� d MDt d2loS2
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).
Gam •kyle i�«�e/addi on -b ex`115tin7 1re�.I trat-t�h 9�yle house. Csee Ph�as�
F, �9• hotase -b be re•slded � Ye•sec} vvl rreW rna'f'etrtals � trla�h pr��
A�i�ior. [wee �-�. she•r�.�
#,cW;6 t JM h'lo 1�G Vwatl otlk }�aseme,tn!- w� clerk aboY�
� �0
f7 `t ! ` Signed
r�ac-e.wlow.6ioe.( - U �J Owner-Cont or•Agent
or Eomsn,aoee-use.
ec ve b ,
ate h Cer icate i reb 4 `
S 996 j y1h. y Date 5
Tm, �Y
TOV N OF BARNSTABLE
>I[prc>v, ,1 IMPORTANT If Certificat is approved, approval is subject to the 10 day appeal period
provided in the Act
L _ J
7
,
OLD KING'S HIGHWAY HISTORIC DISTRICT
SF=EC SHEET
FOUNDATION
SIDING TYPE � rya, =�'Img s
COLOR n&jbYaj
CH I MNEY TYPE_ COLOR
ROOF MATERIAL aft sli�rw des COLOR
PITCH IZAZ
W I NDOWS Wood Uou61e �ungs S I ZE
TRIM COLOR l—?Ye�
DOORS S��� �nsu�al-Pa COLOR G. G•G�re
SHUTTERS C •G-. G�YeVA
GUTTERS_
DECK 'PYe•-,� „r. .� ,r ��
GARAGE DOORS_ N
COLOR
Notes : Fill out completely. including measurements and
materials/colors to be used.
Three copies of this form are required for submittal
of an application . along with three copies each of
the plot plan. landscape plan and elevation plans .
when a
ppltcable.
Plot
Plan need not be "Certified" . but shoulr] mcw
all structures on the lot to scale .
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The Commonwealth of Massachusetts
_== ( Department of Industrial Accidents
'_-- Office 01/nrmfgaUoos
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
city
phone
I am a homeowner performing all work myself.
/ I am a sole proprietor and have no one working in any capacity C/2 3o-1, 7
I am an employer providing woikers' compensation for my employees working on this job.
I
company name:
address•::.
City; phone 0:
insarantx>coi policy#�f I am a sole propri r,general contractor homeowner(circle one) and have hired the contractors listed below who r:,_.
the following workers' compensation polices:
::.
C comtranv na �/�i7 c . P /� �
me• C�
C 57
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address:. �� It �T/ /��J ;-2
c:. f �lJ
comnan.v>nstne:
city: .. /,, ZA ��CJ✓ �G phone
- `I c. 'L licy a C) d CGU C�
Failure to secure coverage as required under Section 25A of N1CL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/tv
one years'imprisonment as well as civil penalties in the form of it 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 OfTice of Investigations of the DIA for coverage verification.
do hereby certify under t pains and penalties of perjury that the information provided above is true and correcx f
Signature Date �// Sf/E
ell
Print[tame / r` 0 ` Phone#_ 7c, Z 2 l )
Ccontactperson:
ly do not write in this area to be completed by city or town official
permitAicense q nBuilding Department �
oLiccnsing Board f..
mediate response is required oscicctmcn's Office
OHealth Department
phone#; -Other
vcviwd 3/95 PJA)
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The Town of Barnstable
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&MWSrABLE. •
Department of Health Safety and Environmental Services
'�Enra 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 cA42A 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 ther '
requirements.
Type of Work: �c� timated Cost
Address of Work:
Owner's Name: C3�/!cr ��P / r
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 PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES.OF PERJURY
I hereby apply for a permit as the agent of the owner:
'44i - fC (?.)
D e fact N e Registration No.
OR
Date Owner's Name
g1orms:Affidav
J HONE IMPROVEMENT CONTRACTOR
Registration: 100496
Expiration: 6/18/02
Type: Individual
LARRV NICKULAS
Larry Nickulas
578 HUCKINS NECK RO
ADMINISTRATOR
CENTERVILLE MA 02632
71.
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number. CS 002265
Blrthdate: 01/18/1955
:"pines:01/18/2002 Tr.no: 13357
Restricted To: 00
LARRY D NICKULAS
PO BOX 570
W BARNSTABLE, MA 02668 Administrator
Application to
POM
T ��S`+
Old Kings Highway Regional Historic District Committee
in the Town of Barnstable for a
109 6\
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, iri triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chadter 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 19 Addition ❑ Alteration
Indicate type of building: 5� House ❑ Garage ❑ Commercial ❑ Other
2. Exterior Painting: ❑
3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑.Other
(Please read other side for explanation and requirements).
TYPE OR PRINT LEGIBLY DATE :P- 12.9t'o
ADDRESS OF PROPOSED WORK Ma ASSESSORS MAP NO. 139
OWNER D21121A wc1 - has ASSESSORS LOT NO. 7
HOME ADDRESS 1QC> 1Aai2�- $ Vn5+a1;le TEL. NO. —3&7--CoZ9s
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public
street or way. (Attach additional sheet if necessary).
S6qen Onet_. - Zito M ,yKL2>ayn
Ld- 41 Bohr► i- rtn r Burk,&
31a'1 5unker >r+tll SA-
Lck 4 Z4- EdwarA CalAwell - IZ 6&J,In Cir 621b. lip- rharle�dwn, � 021 9
L,-Jr A� - Te'.rrt J� 5art,4a6IP
AGENT OR CONTRACTOR AtYchi- 1 h A 't1G. TEL. NO. �7�-3900
ADDRESS k5s-2 r-+. 2B� Gjt( r MA: oZloS2
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).
Gam •1441a -}b e�Est+h' 1 red rar,�h��yle house. C P s�
F '9• hotil� -b be re•slded Ye Yb �! wl new rslafeYtals trraizh prc t
AAA;ii ► (wee she•ek.)
Apm;LL o•t -�p h'lo 10C V Io'11k•Co .�"t etne G w� d - abov2
Signed
_ J Owner•Cont or-A nt
9eSLUCe UelOw line for COmm,ttee use.
Rece,ved-by-MfiD-C.
� t l�7
�) Da lei The Certificate ,s hereb /-%
• � �tyy Datc
e
a KING' .t
A()prov,rti IMPORT NT If Cer ficate is approved. approval is subject to the 10 day appeal period
provided ,n the Act
l
OLD KING'S HIGHWAY HISTORIC DISTRICT
SPEC S H E E T
FOUNDATION 8r red =C nortt�A
S I D I NG TYPE h, ('tea,, s��ng 5 COLOR Cla'�L1ra1
CHIMNEY TYPE_ extrlg --�Yi COLOR
ROOF MATERIAL sh,rwles COLOR
PITCH I?,AZ
W I NOOWS Wood Dou6� Ll
t�WA'S S I ZE Z.-(o x
TRIM COLOR G�pG C�oc� �?yetq
DOORS COLOR G• G•G�re
SHUTTERS
GUTTERS_
DECK ,
Ca�t�
GARAGE DOORS COLOR
Notes : Fill Out completely, Including measurements and
materials/colors to be used.
Three copies of this form are required for submittal
of an application. along with three copies each of
the plot plan , landscape plan and elevation plans.
�when applicable.
. ty'P lot plan need not be "Certified" . but snow I r7 :ncw
Pit structures on the lot to s;ca l e .
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