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HomeMy WebLinkAbout0881 MAIN ST./RTE 6A(W.BARN.) �l s 0 (III/I__l__�fO =J�,0.ECYClE0�o2m IIII s UPC 12543 ILO. 3®R `bsnco HASTINGS,MN +�i+..^_.. R.._.�.� '^.;ix"- .r—+--• - .• -ti. .+.-c...-...�.,.n.�r,.,.�., -i.- r.��...�.-,=r".ar �. "" .++,.Pt..-.A-.r.�..nR� •r.�.a;..u-.:...uc-yn,.L .-._"'" �s��,�:..e.�� ....:_.o:,��:t`......�cir;.C�eiiah....a.1.�. _ env. - _ _-f _ _ �.O O V—L+ p Byrd u r r; i 1� ypt[± 1, d S, r: i t �.5 C' f I i 6 . 1 s \V 1 - •' ............... :_ai:6YdYrl1br •-""'' �atlmiYlS`r�`�` i'"sca'�:;�• .,.e.:.:enf.4:idr�.._^-•- - Ao[ia,.[.b.:a�£F..,.•--� �r..avaCi`an: v..c.,e..,.i .m.a - �...•.:.. OFIMZ Town of Barnstable *Permit# Expires 6 months front issue dal tuvSrAB ; Regulatory Services Fee 4-1 MA pa Thomas F. Geiler, Director 7 PIFo �� wilding Division Tom Perry, CBO, Building Commissioner (OK, 200 Main Street, Hyannis, MA 02601 www.town.barnstab le.ma.U.S Office: 508-862-4038 ' Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RE,SIAENTIAL ONLY Not Valid without Red X-Press/ntprint Map/parcel Number Property Address '291 MQ 1 6L U), 84e��'14,dk9- residential Value of Work Caa CD. Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address 4Ue- ENE oa-�,i1 /V Contractor's Name J pSE,�j J�� Telephone Number (,�(� �� ,2�t 7d Home Improvement Contractor License #(if applicable) 1-3 g5-j!7p Construction Supervisor's License#(if applicable) !q! %`3 ❑Workman's Compensation Insurance � .° Check one: P ESS PER ❑ I am a sole proprietor AUG 3 1 2009 ❑�,,Lam the Homeowner L7 I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 1—iAi5 6_T��qf _ Workman's Comp. Policy# 9 7 q 064 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 �,�e0 t7ENi�/� ,vl/f ❑ Mro(o):fftnottripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance orthis permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Ho e proveme t Contractors License& Construct Supervisors License is required. RE SIGNATU : nAurocn rc%cn0n:fQ1r 0P,YPRFCCPPRMfT nn(, ot Y The Cotnmompealth of Massachusetts Department oflndustrial Accidents Office of Investigations d 600 Washington Street Boston, MA 02111 ��•� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print Leeibly Name (Business/Organization/Individual): Jj7<ap Address:3 & Ea)00.e W- City/State/Zip: /A9A)t CA A14 Da(�`�S Phone.#: 50k q3 a 4414, Are yot}an employer? Check the appropriate box: Type of project(required): a with employer 4. I am a general contractor and I �— 6. ❑New construction employees(full and/or part-tiin.e).* have hired the stab-contractors Remodelin 2.El I am a sole proprietor or partner-' listed on the attached sheet. T. 0, g ship and have no employees These sub-contractors have g. 'Q Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'.comp.-insurance comp. insurance.$ required.] 5. �] We are a corporation and its '10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑Other comp.insurance required.] ''Any applicant_that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.- xContractors 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. .l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: laEe4� /vo/1 qG Policy#or Self-ins.Lie. #: G(�G �,3�5.3 yo7 9 Expiration Date: qlZtm l a o t o Job Site Address:lief l N\A]l M 6k City/State/Zip: W. dfie4[fjA" A AeL. A 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 crimirial penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for,insurance coverage verification. r do her by c rtify un e pa�stand penalties of perjury that the�inforin�Datc�.- �s�true �cod ect Si afore: — Phone 6/.30? 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 S.Plumbing Inspector 6. Other w . Infor � ion and. Instructi®lis Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is.defined as "..:every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the lli dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house of on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal 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«zth 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 certificates) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should sted, not the Department of be returned to the city or town that the application for the permit or license is being reque Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitflicense number which will be used as a reference number. In addition, an applicant that must submit multiple permitflicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address" fhe.applicant should write"all locations in - (city or town),".A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future pcmiits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to btirn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone-and fax number: The Commonwealth of Massachusetts Departmcmt of lndustri,al Accidents Office of Iuvestigati.ons• 600 Washington Stre(, , Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-877-MASSAFE Fax 4 617427-7749 Revised 11-22-06 , www.niass..gov/dia �e .;. NOTICE .- ___: _ .___ ____ NOTICE TO' w yTO tl ' - EMPLOYEES EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass. ov/dia As required by Massachusetts General Law,Chapter 152,Sections 21,22& 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: LIBERTY MUTUAL INSURANCE CO NAME OF INSURANCE COMPANY PO Box 9102 Weston, MA 02493-9102 1-800-762-5026 ADDRESS OF INSURANCE COMPAN"Y i WC1-31S-342974-039 04-26-2009 04-26-2010 POLICY NUMBER EFFECTIVE DATES MARK T VOKEY INSURANCE AGENCY (508) 945-3535 NAME OF INSURANCE AGENT PHONE # PO BOX 1247 WEST CHATHAM MA02669 ADDRESS OF INSURANCE AGENT JOSEPH JACINTO DBA SEASIDE 3 LAKEWOOD DRIVE EMPLOYER ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'Compensation Act.A copy of the First Report of Injury must be given to the injured employee.The employee may select his or her own physician.The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is I x necessary and reasonably connected to the work related injury.In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER Insured Copy I i i�'l,tssachusetts- De Board of p m .irrtent of Public B Safeh�> uildin�t,Re rulations and• Construction Su Pervisor S Standar`tls sl License: CS SL 99163, Pecialty License=:= Restricted.to: RF,WS r EPH JACINT0,, 4 .3 LAKEWOODtDRIVE F HARWICHr:: MA 02645 ; Expiration: • , (.ummissiuoer;`' 10/7/201 •" "';: 7r#: 99163 1 of �auaelld a; Board Buldi R gulations and Standards ' HOME IMPROVEMENT;CONTRACTOR 3v, Registration:,138539 jf e Expiration =47-11.I2011 Tr# 282017 ; .f — SEASIDE ROOFINGANDSID—IN . r- J.. SEPH JACINTO' �4,t r f 3 IAKEWOOD DR •:; HARWICH MA 02ti45 Admm�strator k r • y vtali if found return to: 'e. License or registration before the expiratioRuedulations and Standards i. Board of Building g One Ashburton Place Rm 1301 Boston,Ma.02108 • l• •:'�.. 'cif L ✓D Not valid without signature i Aug 31 09 10: 48a HARTWICK COLLEGE INST. ADV 607-431 -4024 P. 1 BB/31/2009 10:33 035084325443 JOSEPHJACINTO PAGE 01/01 i r• Town of Barnstable Regulatory Services r was X'6om2s F.Geile.r,T)irr.rtnr Building Division Tom Perry,Building Commissioner 200 Main Strcet,Ryeunis,MA 02601 wwov,town.barnstgble.ma_us Office; 508-862-4039 Fax: SOV. Property Owner Mint Complete and Sign. This Section If Using A Builder r,S�7ti f ,as O voer of the su6ject pmp,rty hereby authorize �p 6 LC;,��o to act on my behalf, .in alI mutters relative to work authorized by this building permit application for` sS L JAPttA ._6 I�J))Wll AAA1144J4& (Addmss of job) 5ignaaue o Omer Dzre SC TN T. NA16HT Print Name If Property Owneris applying forpenxnit please complete the Harneo• ifners Licen e Exemption Foxtn on the reverse side- t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel [Ill Permit# 4q T44 Health Division � �� �I�Z/u ��� Date Issued ' Conservation Division 11h1oo rw Fee -looTax Collec Treasurer � `rIC SYSTE Planning Dept. U,13TALLED IN COMPLIANCE WITH TITLE 5 Date Definitive Plan•Approved by Planning Board ENVIRONMENTAL CODE t pin Historic-OKH Ezw/i a*� Preservation/Hyannis TOWN REGULATIONS Project Street Address -Village Owner � a I�U �'--r2s6'� AddressM'� ` Telephone Permit Request 04,114 � b�elc G�e�e-�• � I Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size �� `� Grandfatliered: O Yes O'No If yes, attach supporting documentation. Dwelling Type: Single Family O-"'�Two Family O Multi-Family(#units) Age of Existing Structure S� yQ s Historic House: ❑Yes CJ- o On Old King's Highway: Cis O No Basement Type: O Full ❑Crawl O Walkout ❑Other Basement Finished Area(sq.ft.) ��f`�"' Basement Unfinished Area(sq.ft) r�A Number of Baths: Full: existing new Half:existing /U'✓ new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new P First Floor Room Count Heat Type and Fuel: 3ea's 0 Oil O Electric O Other Central Air: ❑Yes @-No-- Fireplaces: Existing , New Existing wood/coal stove: ❑Yes CLAIo- Detached garage:testing ❑new size Pool:O existing ❑new size Barn:O existing O new size j Attached garage:O existing ❑new size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded O Commercial O Yes O No If yes,site plan review# Current Use Proposed Use --- BUILDER INFORMATION Name �1�1�p'{� Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO IGNATUR DATE Al �1/ OV FOR OFFICIAL USE ONLY .OA� _EEi�MIT NO. �•' DATE ISSUED.-_ MAP/PARCEL-NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION. FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH '' - a FINAL GAS: ROUGH ~ e= = FINAL FINAL BUILDING 5 DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Miff Va7yesaaaalffs 600 =c Washington Street Boston,Mass. 02111 workers' Compensation insurance Affidavit .nniic^ui�iitfa ��. 3E �4`� ����������������������// /�„//� r;= name locaticn $`bl 1M ST city phone# I am a homeowner performing all work myseiE r `I am a sole ArWrietOr and`have no one worlQng In any capacity %i%i%; :%%/%'/'%/%%%/%%%O///i �/// % %���/l///////////l//l///l%//ll/O��//%//u� /O.e��/�'ti ��e'�i,� �/ei.��i. '��.////M//'0////%/%%%/%/%%/%/%%%/%%%/%/�,i.,;;;,;...:: f-1 I am an employer providing workers' compensation for my employees working on this job. i comonnv name: ....:: address: one. ,......• insnrnnce co. I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below have the fbllo«ing workers' compensation polices: :.:•:::>•.::.:.:....: -..:. ;::.:..:.. ...; ... comvanv name. - address: .... ............. .......... .:.;.}::::jii::;`{•:qi:�::::F{::�is�.A-xr;.:nw::.;;.:.,.;..;:•... ..,... ....::::... ..OOI���i1 .....�::i.v.;,,.v:.}:Y�!{i•::'::�:;.';:tr•:{i':''•i:is•::�::;•:;i:;:::•i?:;::.;fir:,.;..... insnrnnce co. .... ....... camnanv name: .........:. ............ :.:::...:.::::•.-.:..•: v•.:..... . addi ess: .. ......... one. insnrnnce co. I *A WA 7,1111110111111112 / Failure to secure coverage as required trader Section 25A of MGL 152 can lead to the imposition of criminal penalties ota fine up to SI�00.00 and/or one. ears'imprisonment as well civil to the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy o f this statement may be forwarded to the Office of Investigations of theDIA for coverage verification. I do herenv cerrif under and penalties o ttry that the information provided above is trw and correct Simatui Date — - print name 1� Phone# 3&"3 33 �„tDcial use only do not write in this area to be completed by city or town official permit/license# Mudding Department city or town: ❑L,icensing Board ❑Sdectnten's Orrice citecKlf immediate response is required ❑Health Department phone#; ❑Other_ :s contact person: _ ' ,ys Information and Instructions P, all employers to provide workers' compensation for thei.T Massachusetts General Laws chapter 152 section 25 requires emp Ye lovees is defined as every person m the service of another under any coin- emp - . As quoted fi�the -law",an emPIOY" of hire, express or implied, oral or written- oration or other legal entity, or any two or more c: An employer is defined as an individual,partnership, associaxion,,corP a ed in a oint enterprise,and including the legal representatives of a deceased employer, or the re.,... ' the foregoing engag 7 Io However the owner of a u'um--of an individual,parbnershiP,association or other legal==Y, cmP10Ymg emp yes• not more than three apattineats and who resides therein' or the occupant of the dwelling house of dwelling house having mP work on such dwelling house or on the�d another who employs persons to do mainteaance building appurtenant thereto shall not because of such employment be deemed to be an employer. state or local licensing agency shall withhold the issuance or renef MGL chapter 152 section 25 also stases that every the commonwealth for any applicant who h: of a license or permit to operate a business or to construct buildings the fiance with the insurance coverage required. Additionally,neither not produced acceptable evidence of comp contract for the performance of public work uasi commonwealth nor any of its political subdivisions shail'enter into any . acceptable evidence of compliance the ID � with s of this chapter have been presented to the contr...c'�:= authority. Jill w- Applicants ' by checking the box that applies to your situation and Please fill in the workers' compensation affidavit completely,ers along with a c of insurance as all affidavits maybe 4" supplying company names, on office coverage. Also be sure to sign �d `r yi4i to of He=s-- �C submitted the Department �town that tmrfirmntihe application for permit or date the afidaviL The affidavit should be returned to the�y ��"law"o.i Yc • A,ccidents.' Should you have any ens big requested,not the Department afbid steal atthesamber lister'below. required to obtain a workers' co®P °1n policy,please call the Department ~ are �. : City or Towns The Department has Provided a space at the b ottmn of`. • Please be sure that the affidavit is complete and printed legibly. � u�• Please f. affidavit for you to fiIl out lathe event Office of has to contact 3'�� ap plicant number. The affidavits may be ren=EEd t^ be sure to fill inthe peke member which will be used the Department by mail or FAX unless odlr cooperation and should you have any Questions. The Office of Investigations would like to thank you is advan:e for you please do not hesitate to give us a ceall. The Department's address,telephone and fax number The Commonwealth Of Massachusetts Department of Industrial Accidents Office of 101estl020003 600 Washington street Boston;Ma. 02111 far-#: (617) 727-7749 phone#: (617) 7274900 exL-406, 409 or 375 • ��p 1ME Tp� The Town-of Barnstable asaivsraei.s. = - _ _ 9 '1 Regulatory Services '�Eo�u►+° Thomas F. Geiler, Director . Building Division Ralph Crossen, 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: D1ILA - IV� X�7 __Estimated Cost J �� Address of Work: �1 /3 S—T �� Owner's Name: — Date of Application: I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 ❑Building not owner-occupied. �I caner pullingng own permil't 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. Date Contractor Name Registration No. OR Pate— Ow`ner's Name �, q:forms:Affidav °FINME r The Town of Barnstable EIMMsrnB14 • M^M Regulatory Services 'OrEo319. ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please-Print'' DATE: JOB LOCATION: a Tr N S-T number `n n street village "HOMEOWNER": KQ Yt `V�kkVV&4,j 56'?,�?33� name home phone# work phone# CURRENT MAILING ADDRESS: to S V t < . TVW OZ Ste' city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Sign ture of Homeowner Zy ""r,Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. j 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 fomi/certification for use in your community. Q:FORMS:EXEMPTN Application to O O 0f! V`W`�Pp�NS�•P,NCO, ,7��.��, - i � a -}�cf.:'�.a i ,.' .:!�`' y f..i — � _ O f 188 t1' Old Kings Highway Regional Historic•District Committee . in the Town of Barnstable for a `CERTIFICATION OF EXEMPTION ��,�, 1 - Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section_6,and 7 of Chapter 470, Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings,or photo- graphs accompanying this application. TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK ''`�� I 1, ASSESSORS MAP NO. S� OWNER �ari M�v�r��t ..... 3;; .. ,•._. ;:,;9:►r• ._. ,>.:*_.�.s. .. . ..�-,..�,;:�•.: �t�: OZ� ASSESSORS LOT NO, HOME ADDRESS 991 Mda++\ TEL.`NO.' �•'?� o� LE) AGENT OR CONTRACTOR S�F• /�(�'�^� 1, " _s r .Ys.:a ;c ADDRESS , �' �' . . .. . .. . TEL.NO,_ ��.. This application is for exemption of proposed exterior construction on the ground that: (1) It will not be visible from any way or public place. ❑ (2) It is within ' category declared entitled to exemption by Old King's Highway Regional Historic District Commission. ;. (Check applicable box) PROPOSED WORK: Describe and furnish planof proposed vrork,.ihowing location on lot,and, if,an addition is involved,show• ing location of existing building. � �-L� l�Pni►� I�e�+�s� Ste.• ���:¢+�&-��t�.�.. �''���1r /�`UN' . r. .. .•. �Sr i..f±:•'Y}1i rd,aA`! 'ti .Y'. 3t ?4Y1..� ,.L'L�.t.' :�: ' ) XF41 �,. o N , SIGNED _ Own er-Contractor-Agent Space below line for Committee use. i ,. aggjyed(by H.D.C. The Certificate is hereb By ate ,0VV OF BARN.STAsLE d ' 1:•.v K IG'S wIG:4%;:AY I Approved �" The categories of work entitled to exemption are listed on Disapproved 0 the back of this form. I FILE # NIP 16630 t n ' KIrrine, L.L.P. CENSUS TRACT 122 OWN Ja No on — - 90�2 AG 310 i ra 30 17 J 5 0 8 N0RTGAG £ INSPECTION p LAN OF LAND LOCATED AT 881 MAIN STREET SCALE : 1 "a loop W. BARNSTABLE, MASSACHUSETTS JULY 14, 1999 U DO W ry O N r{ o �. G, r OD 1+ a. is rNK L L P THE COMMUNITY BANK, A MASS. CO-OP. FY TO DUNNING KIRRANE,NU ITS TITLE INSURANCE COMPANY, TTHSTP�ANRWASRPREPAREDIUNDERNMROIMMEDIIA MENTS EXCEPT ASSHOWN AND THAT HIISION ,CATION OF TH£ DWELLING AS SHOWN HEREONCt)MPLIANCE WITHTHE LOCAL APPLICABLEO`iiY-LAWS WIN RESPECT TO HORIZONTALIONAL REQUIREMENTS ,F� ► t NG SHOWN HERE DOES�NOT�FALL eWcnHnN ".R�,,,.�•,...', .f (1) MAL* ' S CALE-2 2 caH CA pp LE- -- -- 2"8 CCA JIDice` �L~ C. - GAW STD SILL,Tien,kxL---- _ I /G L C l�Ravn,p TR�� EAST L 1!� � � View 'ew P aA Cot- z9 N ` The Town of Barnstable 9AN?757ABLE.MASS. Department of Health Safety and Environmental Services 9 0 039• �0 MAC Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-862-4038 - Ralph Crossen s Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection CC Location Permit Number, Owner Builder One notice to remain on job site, one notice on file in Building Department. The following items need correcting: ��—�� ' Is -3 O� .0 2 rt 46(z.� 14e- WkR 4&- 0t— g u-AV,D A L� n3G 3 G, Tav . S� lk�t�.� . ;IBC� �a2:c�-� •��P�( .�'� d - i �l c � �e 'mac a R K1 ''C�� Please call: 508-862'4038 for re-inspection. Inspected by5� J Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map IS-6 Parcel Permit# /®DO � a Health Division�JG�s l�Q% �i� ,p� Date Issued %OnFee Tax Collector C � �� `�E®0�C Treasurer w�T�i CCC,AND Date Definoto Q-Boar -- Al Historic-OKH Preservation/Hyannis Project Street Address Ca/ ' Village w .S jj Owner e r r Address Telephone Z- 5 (P 3 72T—1071 Permit Request Square feet: 1st floor: existing o proposed QD 2nd floor:existing �� proposed /M� Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size �e r e g Grandfathered: ❑Yes Cl No If yes, attach supporting documentation. } Dwelling Type: Single Family )RI Two Family ❑ Multi-Family(#units) -Age of Existing Structure �� r Historic House: ❑Yes KNo On Old King's Highway: Yes ❑No Basement Type: ❑Full )4 Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) �"— Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 44- new Half: existing new — I Number of Bedrooms: existing_ rim- 0-Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas '`Oil ❑Electric ❑Other Central Air: ❑Yes ANo Fireplaces: Existing I New Existing wood/coal stove: ❑Yes 'ANo Detached garage:existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes )4No If yes,site plan review# Current Use C! Proposed Use J� ��o[e v� C'c" BUILDER INFORMATION Name qS- _C_te_a_v-y Telephone Number 477-50 52— Addrresss/de_r-e_d;Tk d. License# C5 69(7 Tov-!f51' _a � Home Improvement Contractor# f/y 2.�7) Worker's Compensation#.�La g. --1 ye) FW AIDV S ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (�b�7Zc lr— SIGNATURE A DATE FOR OFFICIAL USE ONLY PIRMIT NO. t DATE ISSUED MAP/PARCEL NO. 9 ADDRESS VILLAGE y OWNER DATE OF INSPECTION:" FOUNDATION ' y d FRAME t INSULATION FIREPLACE ELECTRICAL:' ROUGH FINAL . v PLUMBING: ROUGH 'FINAL GAS: ROUGH FINAL FINAL BUILDING S DATE CLOSED OUT ' • :b ASSOCIATION PLAN NO. e * Mach, . R Rm 6 - 1 The Commonwealth of Massachusetts ' -1 . . Department of Industrial Accidents --_ -= ' = exce ofloYesd shoos - 600 Washington Street • - -. v Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit . i 1 name: c1 h vL e location: /,57 M E re 4 i /- LC) . city © it te-S /�La f". . Aa. iv 2�q y Rhone#LvO_T - ->— I am a homeowner performing all work myself. . . I am a sole rietor and have no one worlds in ici /////////////////////////////////// , ❑ I am an employer providing workers' compensation for my employees_working on this job.:::::::::::::.::::::.::::.::.::.:::::::::::::::.::.:: cfaaanv :< < ::< ::.: .. .... :: . ill�3E es QtY:::... ....................... :::..:::::::.::::::::::.:::.::::::::::.::::..::::::::::::::::::::::::.::::::::::::::::::•::::::.:::::::.::.: atisutaRt eao... . _. _...... so ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have . the following workers' compensation polices:..:..:.:::..::::::.:::::::::...:::.::.::::::::::::::.::.::::::::::::.:::.:::..:::.:::::::.::.::::::::.:..::::.::::::::.::.......... :::.::.,..::.::::::.::. :comoanv<name:-;;:> :>::><..>::»::>::::»;...>:<>::::::>:<:>::<>:<......><::::;::.1.'.<:::>:::>% . ........ ......... ........ ::o:>;::>:„ ::::<:>;>:> , - ....... mm'.i.:: ?... ..................................................................._. .,:::.:.::...:.............. ...............::•:......................................................:..:............... 3.............. ... .tFt• i:.::::: ...................................... .... ............................:............................................................................................. ::.;;:.:............................. ::::.:::::::::::::.::::::.::.::::::::::::::::.::::::.:::.:::.:::..:::.::::::::.:::.::::......:.:::::.:::::::::;:;.:;:;: :::::::n :Hffv ::::::::.:::::::.::::::::::::::.:: ....>•::. :....... ::::.::.. .: ::.�:.;r::.,.x .......,,:.:..::::......................................................:.. ...............,•.............. ....................,.,........... .....:.....................,::•::::::•:::::::::::::::•:::::::.:... ... .. .......................................1.:.... .:....:::::::::•.:..............::-.:::.:,.................................. .. .uu:..:.:::::>::r:•.;;.;.:•:.,:•...:.............<.......................::I..,wu�..�.,..ar a.�,k..;X-.-.::::::: .. �i. :::......:::...:..................................... ..... . .... erJnrRany :....... ......... ..... :� — . - „r:., :.. ...............:::............................................................................... ::::•::::::..::..:....................:::::::::::::::.::.:::::::::-..,::: atlttr tv' Ieti :.:111..:::.::�:.-.: ..........................................................,..:... ::> ::>: n;': : ::awe;;>:;:>:;:: ::::::.::..............:......:......:.... .. :......:::.:.:.:..........................::::.:....,... :........::....:.......:.:...." :.""'::.::.:..:............::.:::::....:..........:.:..:...:... ...... ...................... . ::::::: ::::::: ................................ ..................................:�Y....:....:............:::::.vi:y:::n:::n�::.:::::•::.?:>.---.:.: ./. .,::.:{:{:•1-'1 :ii:•:??C4 ii:•i:•i?:'v?iii J:{?Li:ii:j;4iiiiii:>isisisiL:i!?............... i{vti:i'::i:•.�::::v: ::v: ::::. �ll .: ::::•::............... ...... Rsnlaaee.co. ......... ...::....:.._. . Fame to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a nne up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verincatlon. I do hereby c ' the p ' penalties erjury that the information provided above is&w and correct `� Date 9'/io l 9 Si - Print name2N Phone# z 7 - SD. official we only do not write in this area to be completed by city or town official city or town* permit2cense# ❑Building Department . ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office _ Health Department contact person: phoned, ❑Other Omsed 9/95 PJA) 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. t°� MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or'renewal of a license or permitto 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. - iFEWIRAF Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided'a space at the bottoms of Elie 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 p jermit/license number-which will be used as a reference ninmber. The affidavits may be refit med-fo the Department by mail or FAX unless other arrangements have been madee The Office of Investigations would like to thank you in advance for you cooperation and should you have nay 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 Oftice of invealwadoo: 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 . °F ZPIE Yq� . 'Y The Town of Barnstable • anaNsrrnBr.e. • `+� Department of Health Safety and Environmental Services '�Ea Mop" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: a k LC�- Estimated Cost Q ®0-�, O p Address of Work: a Owner's Name: Date of Application: l� 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 IlVIPROVEMENT 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 gent of the owner. 44 Q C 0,,, ,, L 41 Z to Contractor ame Registration No. OR Date Owner's Name g1brms:Affidav i _�_ .�.e�ia�xvwonuiaalGts o�r✓�,omadjua�Q2 I HOME IMPROVEMENT CONTRACTOR , 'Registration •114127 ?;Type :INDIVIDUAL ",..Expiration 08/06/01 T.. r J.OHN 'R'.`MCCREARY 'Z-7 ig *.-a. 15 MEREDITH RD G� docjt�RfSTDALE MA 02644 rX ADMINISTRATOR DEPARTMENT OF PUBLIC SAFETY tea. CONSTRUCTION;SUPERVISOR LICENSE E ' Expires: ct'ed-To _- 1G JOHN R=`ACCREARY: vrot., LS NEREDITH RD FORESTOAI E, HA 02644 w k