HomeMy WebLinkAbout0094 MEADOW LANE JnNO. 152® A
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Application to 0 9
PHf•G�.,E,,3tN 1 g
Old Kings Highway Regional Historic District Committee
•
in the Town of Barnstable for a
CERTIFICATION OF EXEMPTION
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 b DATE
ADDRESS OF PROPOSED WORK 1� `� �u-L ASSESSORS MAP NO. %PzqA, fe
_ -•Q: : l33
OWNER - y CV+113 EL. ( ASSESSORS LOT NO. 7 ID 23
HOME ADDRESS V'� 1�) C-N• u3 "/�8 -' 1.� TEL. NO. 'XZ_(Q
AG EN OR CONTRACTOR
ADDRESS 'PO �� i�.�o J"Uk TEL. NO.
This application is for exemption of - 1
p proposed exterior construction on the ground that:' e.
(1) It will not be visible from any way or public place.,
❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
( ` ' (Check applicable box) :. ... ,;f
`._ PROPOSED WORK: Describe and furnish plan of proposed work,showing location on lot,and if an addition Is involved show•
ing location of existing building.
1k_)5r*U_ FeA5,-T ,e&t4 AILL%Mr141 L -
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- SIGNED
Space below line for Committee use. 3
wner•Contra Or-Agent -�
Receive The Certificate is hereby
a. UlnjTe
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+gy .. _.,R,�>... at y `�
pproved The categories of work entitled to exemption are listed on
Disapproved ❑ the back of this form.
MORTGAGE INSPECTION PLOT PLAN 8a- ► 8�0
NORTHERN�ASSOCIATES, INC. - --
11 BALLARD WAY,LAWRENCE,MA 01843 - Tel.617-975-7117
3220 MAIN ST.,FITE.6A,P.O.BOX 253,BARNSTABLE,MA 02630 - TEL 617-362-8839
MORTGAGOR A M LS M- 2 I 1 { DEED REF_�E zT. TI:TL� s s c; R Ott
ADDRESS OF PRINCIPLE BUILDING PLAN REF. e-Ic7 I co
DATE OF INSPECTION:_ J"_
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180.00
M EAR .NV
I FURTHER STATE THAT IN My PROFESSIONAL
ea' Thisti� nspecton was presrad p OPINION be prMeipw sauc%Aws and accessory
bcally for mortpape Purposes and is not io be r•- - �� outbuadings
on as a survey. Northam Associaws, Ina aooapts no Ws[6y,t�
sponsibifity for damap•s rva +lo« + �'y with caw setback mqus•rnants of tw local zorunq
yon•oa,« than to .cab nar>an9d ft .. °L A �c`
nrwction with la proposed mortpap• a ho tab /a r-orarhanoa:.,nd that than•are no erh«oacM.+enhs of major
^w,r z imorovements either vnly rmce
y Application to 9�C
g g Z 0
Old Kings.Highway Regional Historic District Committee _
in the Town of Barnstable for a
-CERTIFICATION OF EXEMPTION
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 u/ZShl
ADDRESS OF PROPOSED WORK 1�, ��-� _,__ ASSESSORS MAP NO. 2
OWNER - y B� E, ��1l�y3 133
'.ASSESSORS LOT NO,
HOME ADDRESS . Vj TEL. N0. '36Z�QO�
AGEN OR CONTRACTOR
ADDRESS PO Q iZO.�o T : w_�... TEL. NO. (o Z :y017
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 a category declared entitled to exemption by Old King's Highway Regional Historic DistrictCommission.
(Check applicable box)
PROPOSED WORK: Describe and furnish plan of proposed work,showing location onlot,and, if an addition is involved,show,
ing location of existing'building. _
f=1�oNT .•A�A .e-Evt4 bob -S - A'u-�i L_. 41A�
� LdjQS� �i0 r'•vA°I'C.Nir
CIST/�Cr
7.
SIGNED
Space below Iine for Committee use. wne►•Contre or-Agent
Receive The Certif ispwls hereby yQ jZ 4
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pproved �~ The categories of work.entitled to exemption are listed on
Disapproved 0 ' the back of this form.
I� MORTGAGE INSPECTION PLOT .PLAN 8a= ago
NORTHERN ASSOCIATES, INC. - _-
11 BALLARD WAY,LAWRENCE,MA 01843 - Tel.617-975-7117
3220 MAIN ST.,RTE.6A,P.O.BOX 253,BARNSTABLE,MA 02630 - TEL 617-362-8839
MORTGAGO DEED REF_ �E2T- Tl�ru= t� 5 r«Ft
" ADDRESS OF PRINCIPLE BUILDING PLAN REF. U-1co t
DATE OF INSPECTION:
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180.00'
)TE: This morbapa ina I FURTHER STATE THAT IN MY PROFESSIONAL
was paotiat
905=DY br mwVmP PWom and is not to to OPINION iM DtlndDla attac>utals and aooessory
on as a sway. Nanhwn Assodatss. Inc aooapts ao M Ws
;PanatbiitY far damapas ftm acid moor" Q C n—j 9, t�
y0n.0111af Otan Ow acid n a� Md ib atalOfli Y�1 1'jr� Cy Mllitl dfa W1baCk IagtAlangflb Of tl1a IOCaI ZOfWfO
nnecdon wfih Its prOpoaad mortpapa R b said /?e � w*w1Oaa,and that from am no W aoact~ts Of major
'n^�v / z. /�•'7J1 - immvements either wny nnrn"nm nn r.-,,.—._. ..
Engineering Dept.(3rd floor) Map Parcel Oc23 7O'"Permit# 2 V
r House# qT ate Issued _ ' 2-3
Board of Health(3rd floor)(8:15 - 9:30/1:00-4:30) _�/7 P.t `L -/Fee 3 -P'7 . J
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) blaol�-l�p�
Planning Dept.(1st floor/School Admin. Bldg.) SEPTIC Sy T SE
Definitive Plan Approved by Planning Board 19 INSTALLED NCE
WIT
eeet
1� TOWN OF BARN5TABI�aNru°E E AND
�GSTOWN REGULATIONS
Building Permit ApplicationProject Str Address �'4 Mew(ow I-eA- t _ �V- LF1 T ,1 �4►-
Village tU• -1 ZV'k T2 Jam►
Owner -3Z Ll Address 94 � e1 l oc.; I. Z4
Telephone -- 3 ,(,J 3
_ - (9Q /
Permit Request _I EAL->Kf S4ECOk (RU�D+(r MZ�f6- /ZO (1'4e4
�Un,,
First Floor C9-10 square feet Second Floor [�`C square feet
Construction Type 1Vco� W2n.�Q
Estimated Project Cost $ Ow
Zoning District Flood Plain no Water Protection
Lot Size Grandfathered aYes ❑No
Dwelling Type: Single Family f Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes f"No On Old King's Highway YY/es ❑No
Basement Type: Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) _d" Basement Unfinished Area(sq.ft) too
Number of Baths: Full: Existing New_�� Half: Existing New —0 "
No. of Bedrooms: Existing_3 New ' 0 _
Total Room Count(not including baths): Existing — New First Floor Room Count - '-
Heat Type and Fuel: ❑Gas GAI ❑Electric ❑Other
Central Air ❑Yes Uor<o Fireplaces: Existing INew '-0^ Existing wood/coal stove ❑Yes f To
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appealiro
rization ❑ Appeal# Recorded❑
Commercial ❑Yes If yes, site plan review# -
Current Use @is,"C64 Proposed Use 54
Builder Information
Name Telephone Number ®
Address License#
�—ir(A4 c N2- Home Improvement Contractor# /0 4 s/y
i
Worker's Compensation#6M 6 Q 69(a3(S -Q�b
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE B.VILDING P IT DENIED 6THE F L OWING REASON(S)
� � `a.
FOR OFFICIAL USE ONLY
PERMIT NO.
�x-
DATE ISSUED j
MAP/PARCEL NO. —
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: Y
FOUNDATION / I
FRAME
INSULATION 6 _ ( , C� �L2
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROXUGI-E-' I—• FINAL
GAS: �'RO, JGEI FINAL •
FINAL BUILDING' aA P
' $a.-- .
DATE CLOSED OUT) R 3 1
ASSOCIATION PLAN:N,O. YVY
�tME The Town of Barnstable
BAR Department of Health Safety and Environmental Services
t619- `0g
i
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 l ,J
Location 1A&eAA- aw LIC.1�1a2. Permit Number TO
Owner Builder T
One notice to remain on jobsite, one notice on file in Building Department.
4
The following items need correcting:
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v • Y
6� t S e 1 iL1L ktUe—
Pw A 6 CL � Z�
P i s a v 46 `eye
V
Please call: 508-790-6222.7for re-inspection.
Inspected by V'-
Date
I
MORTGAGE INSPECTION PLOT .PLAN
NORTHERN ASSOCIATES, INC.- --
11 BALLARD WAY,LAWRENCE,MA 01843 - Tel.617-975-7117
' 3220 MAIN ST.,RTE.6A,P.O.BOX 253i BARNSTABLE,MA 02630 - TEL 617-362-8839
MORTGAGOR_IJ ArnE-, M- 2 t c--,-k DEED REF_--E m-r- -rj Ln L is t t o A-�,R
ADDRESS OF PRINCIPLE BUILDING ? ,' PLAN REF. 4-1c , t (.o
94 DATE OF INSPECTION:
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)TE: This aW in,Pecdon was prepared
I FURTHER STATE THAT IN MY PROFESSIONAL
eOfi for gage Purposes and it not Io be rakedoutbuudrlps'
&` D tttat>urWt and aoeestory
on as a survey. NoMam Assoaates, Utc aooepts no NIFLy
an
;Pcnstbilty for damages mvA*g ban said retienw by �E ., ��� Cd�,�o2rrt
yone otfw than me said mortgagee and " 6, �y , rrtM the satback requirements of the local zonirq
nrectton wits+ its Proposed mortgage 6rwreing said Zia .r/fr.ordnanoes.and that there are no erwoachrnents of major
Imomyements either wqv nr.mtt
8' 10, 12'
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OOPJCA
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KILROY RESIDENCE
94 Meadow Lane
West Barnstable, MA
Proposed Addition
U
UP HALL
UP
V DINING ROOM
LIVING ROOM
it Existing
P I W. MUDROOM/
` wallexterior PANTRY
wall
Existing KITCHEN DEN
S. GARAGE
exterior 1/2 BATH DECK
t wall
DECK
Kilroy Residence
Second Floor
UP
Computer/Playroom
� Bedroom .
i
t
{
Hall
iLF
O Bedroom
Master Bedroom
� Study °
Bath
Master Bath I �
1
! ¢ i
- 1
71)zv"4e-��
82'6
26'10 10'2 13'10 8111 13'8 10'3—�j
7• 11'1 T 17 6'1 3 3'10 6'4 3'8T3'9 U 5'2 2'2T-6'---y.-5'4 4'9-T5'6
I]rT7r
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— — 26 — — UP ❑
U„
DINI G LIVING
a
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37�-45 —
Y iii
P$ 8'4
OQ �\ rsli
ILI L3
_ _ I � ❑ L-U
6'3
DECK
30'
�9'4 1118— 3'2 3'1 10'3 T11 3'10 7-11 6'1
LIVINu AREA
30' -� 6'3 -Sq-ft-18'2 -� 1T10
74 2
UP
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Applicatlon to g
�c��p NiS�EP,R•0`. .-7:::�.yr";;"s,.:c•?,�S:•i9L: , ���•:+ .-.. � ;a.:^ •
Old Kings.Highway Regcimal tii o _ =LL st ric DLstrict Committee
1.ice` N
S
'in`tha Townof Barnstable for a
' j1: aypgy:�-'•a1:,n. :fir ::sir" i .kit`ot,J.`..!},-. 'iSr�jlk,,•'. ,., ::i•.;ri'•:[�•-,`J'Fa.-•
t,��.,� 5• :.f�t� . "•-'lk:.•.i
.. ..C„•,,tt�•te�'•.�'•h'•S+:y S. = .•��`.:'4'r:�'=}'� q.�.y�y�i:.±,�,�f:�':�:Z-I�::,:ia,,, s`S�:e'
:. AT OF EXEMPT-ION
�.CERTIFIC ION .� r •r --
�, -
- d 1 {t � t7`:-'ts es.S•w1.-•Yr'r'^,srn Y,...} •5/:�.-:..1-.'.:.. . ' ,:. ..' .: t.i ''':�. .'u`.. -.}-i)Ij .w .:'3 w...l..»'.''..:•>,.i:`..-'..:t.4gfi�.l,J �� 5i+��. l.'.:;' Yam:•.
Application is hereby made, in triplicate,for the issuance of a*certificate*of exemption_under'Section 6 and 7 of Chaptar 470, :' ~
Acts and Resolves of Massachusetts, 1973, as amended for proposed work ai described below and on a lens,`drawings,or'photo•
.... .. :1"- .:i.;;�•%k+"' i t,. 2�"q ,La:J3• .^x:it::a<t?::Fs:.y,• - ..).�::. .Y: •.�c.. ,.
graphs accompanying this application. x•� ': r i's� ? r 3i
.... _ _ •). t '3 fi,-,.Xe!,:.."Wit� �;.�F�yy`„-�`tYi"�,vj P.Y, a.�_.d§ ..��,A'7s'>a+.i� .�
':,,:R.•i.�_..:'w) a% nss -, -d�-c + i � nfikp y, 'te1A.y+:. �a•.'i3�y$]f ti } 6� wL. � �i
�{
TYPE OR PRINT LEGIBLY4 n '` 1 � R � it't+�� � < It y �•�^;t �' ��1r E
�
' ..; - i y :...'. .:.:...n-, a: �t >£5 �. ec". `T3- i, •rw,,•v.f ti Y Nf' v.", ,�>,•. -�
" �:,t-. 'u •s �, � Fv c f R �rs ,33wf 2 � �+l�j� .4�'.� o�!( •a.��33. -
ADDRESS OF PROPOSED WORK, 1� ^•i21- , ~{} 3 ;
v ,x• � `' "'> 3t�'-.�ASSESSORS MAP NO. ' `� F
cow
- - 'hi% �:!'i:G'Ki. t y:,lR`F �,. 1- J•.�:'�t :.^3 tiW .' r�,� ,4 V �i !r' •!
y' -}+J ��"t i 1 r. " ..
OWNER '"` ">� Y'`ASSESSORS LOT NO .
�' tr .. t...'• l ^� y,^t..:: f ✓ i �� ..-Gd.;..� T5 j7 •. ,K:
HOME ADDRESS y 1� W �). .. .. TEL NO.•�r Z
..�:;•.`�'; :�,s. ;� �1 � `'has,�I ..:):.•-5 .T.1T.:.,ow'!": .�:'u5:t:4: ��.+ry
:,(:..{.,..:,.. :-t•;;Yi__..; �.>,;.fiM1�F,:i:..;�i:•:�Kr,_..ra.Y._-?+,a¢�-,t.�!c�-�.';efE:..,U;..:
AGEN OR CONTRACTOR
.V't:.:r,•,;.' +:,,... 'fr^-c:�, `:�•r�.. .r.�:^),n;t�.�(/:: .�h:il•in:-,y-v5�:•*:+-.,. .� ,;,9.: ;<ic., •:r:C.:CA.�ti.,.:.`:`aw-":::'r' �•
ADDRESSEL NO.
1•:
.... ::;/.:: ^f;::�'t°i, -a.d .iti.�=� i:•.r ai`i..i.`':.: .na`y",:'A'yrr' r1�.�•^'t' ,^'�,•N' •4+:;..��i:. ',.
;.. _ .. ..
This application is-for exemption of proposed exterior construction on the 46urid that: � x' ,tL2ati4 r t'�Z1 :
- - _ tiv."''0�•i1 fin;{+ d :.y. ..,,2...,..L.�,t :as,).gn -
{l)yfwi)I not be visible from any way or public place.'
❑ (2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission �)
.d:.• ..f: .j:• .fit-. �•J J�:+,:' - it�
•a li box r: ;';:-.=r .i:• -�����-;•,.4. ��;- ( PPvable
f\/ '1:., `�.ti �.,.,�.:.r;i,t .:i:yxy..:� .,'..:,•,:�++,'-:a . -• ,'VS[it.. -y.Zr,-;...
PROPOSED WORK:.Describe and furnish plan of proposed work showing location on lot,and, if an addition is involved,show-
in location-of exi
gexisting building.
..-�...
9 9• •�
• `.^.' .t: -F�' >.•4: + i•'•?a!Y :1, -5 VS••.:' •iP•,�.r:J19$:r- .^'1�:4:}N!<s:Ati''Y::.�h�
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.` Y '. .ly ..�.� 1.. a I t.i *.:+.T.1 S �,•{M ,.a��._. y J �:a -1 :�.Y�i
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SIGNED
•.. .. ..:ice'.
- .. .+.
Space below-line for Committee use. -=' - _ ---- caner-Contra Or-Agent
r
Receiv /
The Certificate is hereby J�.r( ee tl4'
n
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T
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lu':sl;i yr u.,.::..}•,•. . _ -
Ap oved." Z] -
?r :. � The categories of work entitled to exemption are listed on
Disapproved ' ❑ the back of this form.
310CMR10.90 -
Form � n�w� \ �°-�'v~�
-~~~` THE
Barnstable
cxv'rv°"
Commonwealth � --�
' Kilroy
= of Massachusetts ' Applicant
kJ
t639-
t" � Date novv*mFi/ov May
Determination of Applicability
Massachusetts Wetlands Protection Act, G.L. c, 1 31 , §40
' . 'TOWN OF BARNSTA13LE OR.
From Barnstable Conservation Commi5si n Issuing Authority
To John Kilroy same
(Name of person making request) (Name of property owner)
94 Meadow Lane
West Barnstable
Address
Address
This determination is issued and delivered asfollows: �^
/ (date)
byhandde|ivarytoperoonmaWngne�ueo�on �
-1 bymskudmail, on --'- 20, 19 —(date)
.
Pursuant to the authority cdG.Lo. 131 §40 the
has considered your request for a Determination o/appnc ability and its supporting documentation. and
has
made the following deter ninohnn(check whichever isappicabe):
Location: Street Address .94-Mead lo,�i Lane, W- Barnstable
133
Map Number:
` The described be�w wh which includes�all/part area described in your requasz, is an
1 [] aaneo ' / n�v' Area S' bie��\oPrctecdon Under the AcL.TUere� removing,/ng fillin
g,. dredging or
altering cd that area requires the filing ?falNodoaofIntent.
'
� .
�
�
| r- TheworkUesohbedbo�w.wh�h�dud ~a8¢�rcd the work daschbedhn your request. iswthn
' ^. -- ' 0 mova �0 dr�dgeoraKarMh�darea There-
unAroaSubinct\opro\echonUndertheAn!andw ne . .
fore. said~orkrequiroothe0ingofallodcaof|ntenL |
~�
Eff»chve11t1O8]9 '.
,
_ _
All
=j 3. 01 The work described below,which includes aWpart of the work described in your request.is within
the Buffer Zone as defined in the regulations.and will alter an Area Subject to Protection Under
the Act.Therefore,said work requires the filing of a Notice of Intent.
This Determination is negative:
1. O The area described in your request is not an Area Subject to Protection Under the Act.
2. 0 The work described in your request is within an Area Subject to Protection Under the Act.but will
not remove, fill, dredge, or alter that area.`Therefore.said work does not require the filing of a
Notice of Intent.
3. The work described in your request is within ttiz Buffer Zone,as defined in the regulations. but wilt
not alter an Area Subject to Protection Under the Act.Therefore, said work does not require the
filino of a Notice of Intent. i.
4. CG The area described in your request is Subject to Protection Under the Act, but since the work
described therein meets the requirements for the following exemption.as specified in the Act and
the regulations, no Notice of Intent is required:
Issued by Barnstable Conservation Commission
Si nature(s)
00,
C�v
This Determination must be signed by a majority of',fhe Conservation Commission.
19t1i June 1 a 97 before me
On this day of -
personally appeared Audrey Olmstead F, to me known to be the
person described in,and who executed, the foregoing instrument, and acknowledged that he!she executed
the same Ini s/her free ct and deed.
MY COMMISSIM EXPIRES SEPI 21,200
Notary Public �my commission expires
This Determination noes not relieve ine aooticant from comolying,wrth all otner applicable federal,state or local statutes.ordinances.
by-taws or regulations.This Determination small be valid for three years form the Gate of issuance.
The applicant.the owner•any person aggrieved by this Determination.any owner of land abutting the land upon which the proposed work
is to be done,or any ten residents of the city or town to whicn sucn land is located.are hereby notified of tneir right to request the Deoartmerr.
of Environmental Protection to issue a Superseding Determinattdn of�Applicability,providing the request is made by certified mail or nanc
delivery to the Department.with the appropriate filing fee and Fee,Transmmal Form as provided in 310 CMR 10.03M within ten nays from
the date of issuance of this Determination.A copy of the request snail at the same time be bent by certified mail or band delivery to the
Conservation Commission and the applicant.
12-2A
dprne
The Town of Barnstable
Department of Health Safety and Environmental Services
� ► Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissione:
1
For office use only
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: Q,0-(%-0U Est.Cost
Address of Work: (iq Ne,-4cx,, LLI
Owner's Name X",
Date of Permit Application: ,?-,9A- '-2
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
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 G 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the o T 7
Date Contractor Name Registration No.
OR
Tile CUllllt101111'Calill of-1 tuscuchusctts
12 Deptlrilllcllt of Indusiriai.4CC1rlL'AlS
1 li-1.
oflccollmrMV92lloas
600 !iushirr,�turt
" i; Strcrt
#Z111 m
_ Workers' Compensation Insurance Afrid:t�•it.Al '
i li •tn in rnt i6i - — Pl — -v
name-
cit%
❑ I 4m a homeowner performing all work myself
a sole proprietor and have no one working_ in any capacity
.. .. .. �..i.`�✓ram-�A-. -_-__. _ 1.__ _ __ .-,.1.
t am an emplover nrovidinc workers' compensation for my employees working on this job.
ennrnanv nnmr:
arlrlrccr '
cif___ __ nhnnc#!
I am solee neral contractor, or homeowner(circle olre} and have hired theMonctors listed beio�+'
the following workers' compensation polices:
cmmn:tnc• Warne• \ �t
trlrlrrcc �� . '�� Doi •'i
0,2636 nhnne O-o& 'SW-?(2-q4 79
incrrr:tnrr rn nnlirc•!l
cmmn tn� narnr
adtlrrcc- '
-in nhnnc#!
ncurnnee cr) nniin•
lttach additional sheet if necessat w +•r' - •r .+Ii' L N '.s• +•�+.• .�....7+5 - _••-+
rilurc ttr secure cm-cracc as requrred un er Section•25A of AIGL in ca��E to,the imposition of enmtnal penalties of a lineup to SISOU.UU and/or
ne years'imprisonment a. well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a
OP) of thin statentcot mat- be furn•arded to the Office of lavestications of the DIA for coverage verification.
t!v herebr crrriAtint : cria cs of perjum drat the lnforotation provided above is true and 6ff v L
=nature Date r !Lc
'rint name Phone t±
n(Ticial use unlr du not write in this area to be completed by city or town official
city or tnw•n: permitAicense d r'tlluilding Department
❑Ucensinr Huard C.
a check if immediate response is required C3Seleetmen's Office
�1leallh Department
conracr Person: phoneft• r-101 ter_
i.
Information an4' Instructions
Massachusetts General La++•s chapter IS'_section _'S requires all employers to provide workers' ct�mpcnsatio:
m to ecs
+ • c noted from the "ta+v~• an entpinree is defined as every person in tite scr+•icc at :another undr
e . As 1
P .
contract ofhire. express or implied. oral or+vritten. ,
An cnrph rer is defined as an individual. partnership. association. corporation cur other legal entit}, or any tw(
the foregoing em,agcd in a joint enterprise,and including the legal representatives of a deceased employer. or
' rccciver or trustee of an individual , partnership. association or other legs entity. employing employees. Ho+l
owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of
d++.-cllin, house of another who employs persons to do maintenance, construction or repair work on such dwc!
or out the ;,,rounds or buildingappurtenant thereto shall-not because of such employment be deemed to be an e:
MGL chapter i�? section =5 also states that ei-cr-% state or local licensing agency shall ++•itlthulJ the issunnc
rene++•al of a license or hermit to operate a business or to construct buildings it, the Commonwealth for s
ble evidence of compliance with the insurance coverage requires
applicant who has not Produced acet_Pta
Additiotiall+, ncitlter the comunonwealtlt nor am• of its political subdivisions shall enter into any contract for tl-
performance of public work until acceptable evidence'of compliance with tlae insurance requirements of this cl
heen presented to the contracting authority. '
Applicants
Please fill in,the workers* compensation affidavit completely, by checking the box that applies to your situatio
hone numbers as all affidavits may be submitted to the Department of
Supplying company na:ncs. address and p
Industrial Accidents for confirmation of insurance co+erase. Also be sure to sibs and date rile affidavit. Ti
affidavit should be returned to the cit}• or town that the application for the permit or license is being reques.ed.
not the Department of I ndustrial.Accidents. Should you have any questions regarding the "law"or if you are re
to obtain a workers* compensation policy. please call the: Department at the number listed below.
City or Towns
Ple��e be a that tfie afffda�•it is complete and printed legibly. The Department has provided a space at the bo
sure
the affidavit for you to fill out in the event the Office of Investigations has to contact you regardina flue app tear.
be sure to fill in the perm itilicense number which will be used as a reference number. Tile affidavits may be rct
tiie Department by mail or FAX unless other arrangements have been made.
Tlie Office of Investi=ations would like to thank You in advance for you cooperation and should you have any q�
please do not hesitate to _,ive us a wll•
The Department's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents _..
Office:111nVestlgatinns
600 «'as)dngton Street
Boston,Ma. 02111
fax 727-7749
.... .r. ..• .nnn //lam fna
. 't` �'J4'yt�o 3.•f L}r�� � 7aw +� F 4A� r [ '.A/�irvw.r
• k�tt't �'' Xw'Dt.'•��,�`'`4"'%r•�i'�'�,�t� Tr".'N�"�d '�in.F�fY„ '{'p �.Fa.A�1s .. x -
�'���':.'4�.�arri r13 JYF�� Y s�n �a�w�r ���° •"'�Y;p ... � �.�i' �w a t��;=.///}� r.r,�� t.,#,��>,1,�,+1='o�S��k
,1 � ..y.�L �•i.Y H ;�• k y`k.•,�x,s�2 r�Y' 1 r4r a�,TV1�C ]"��y. �,•-""��p�� �� ` }
r �'t,.trr�L• �3.{j .•Y t�. �ss�ki.!,,s�`�.�,�t•y," ta`iirt' kP�'�v.i r ,_0�4 y"8� ���� t6e�=!
' �'"7Y'..,�' �'xc.�`"' a,•�`s `�J'."1'''+, r,,� g� '�"`: zr •! z�; �•r.���7'��'tfi•'"M't�•,J'+� �j.. ti ._ e
R gC �:.;"2 ra war' xt 4 HOME;IMPROVEMENT`CONTR{iCTO- 7 lK..•i '�,r �K.'Y s"#';w'i�kwa^'f" -1 '"x 'si' ''!`'+rt.�f8'I . _ ,� ° -
Licen` v egistratioi'*F164 14 T�i
seoitiegistrationjvalid',+for Fndyvidual.+
foulliefore`expiranon,date If,.found � tgpe, ,INDIVIDUAIsz'
use Y �.�, Rm�1301 , ;
$EzplraEon'' "O7/14/98 }�
l return-to One Ashburton ace, _ v j.
�,Bostori Ma 02108'' f "` t L k yam,y '�•y 4� _����
.�3rF�" r 'y, + t..�
BLAKELYt
13FRedwing Ln/P 0.Boz
" 20 =
'"`O afi3`£able MA 02630
"ADMINISTRATOR l
AZT
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AUPHRADR036 (Rev.2/94)
TRAVELERS INS - PREMIUM AUDIT
1000 LEGION PLACE
ORLANDO FL 32801-9817 00182
BLAKELY, GEORGE W
P 0 BOX 206
BARNSTABLE MA 02630
i
Show these actual gross payrolls opposite the`appropriate cias-1—�l�L •� ---
"AMOUNT."
For insurance purposes, payroll includes total gross wages, bonuses and commissions (before deduct-
ions). Do not include your company's contribution to group insurance or pension plans. Also, the
additional pay for overtime(the amount over regular pay)is deductible,as follows:
For Deduct
Time-and-a-half 1/3 of total overtime paid
Double Time 1/2 of total overtime paid
Exception-, Exclusion of overtime pay does nct apply to payroll assigned to'any"Stevedoring" classifi-
cations with a class code number followed by the letter
3. Please sign your name, give your company title, telephone number, and the date the form is completed.
P y
Thank you for your cooperation.
I"14PORTANT
In addition to completing the Report, please provide us with a copy of the last four 941 Forms or State
Reports for the state(s) covered on your policy, and Form 1096 if applicable. If you are a sole proprietor,
please provide us with a copy of the last four 941 Forms,if filed,or a copy of your 1040 Schedule C pages 1
and 2.We will not be able to complete your audit wsthout this information.
AUPHINSA001 (Rev.4/96)
TravelersInsurance.�w
A Member of TravelersGroupJ
WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
The Travelers Insurance Companies
(Each A Stock Insurance Company)
Hartford, CT 06183-4040
TYPE AR ''.I'NFORMATION PAGE WC 00' 00 01 ( A)
POLICY NUMBER (6N-UB-696G630-8-96)
RENEWAL OF 6N-UB-696G630-8-95)
INSURER: THE PHOENIX INSURANCE COMPANY
NCCI CO CODE: 12610
1 . INSURED: PRODUCER:
BLAKELY, GEORGE W RIDER RISK SPECIALISTS
P 0 BOX 206 2 SHORE ROAD
BARNSTABLE MA 02630 BOURNE
MA 02532
Insured is AN INDIVIDUAL
Other work places and identification numbers are shown on the
schedule (s) attached.
2. The policy period is from 12-12-96 to 12-12-97 12:01 A.M.
at the Insured' s mailing address. *
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies
to the Workers Compensation Law,"of the state (s) listed here:
. i
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies
to work in each state listed in-,item 3.A. The limits of our
liability under Part Two are:
Bodily Injury by Accident: 100,000 Each Accident
Bodily Injury by Disease: f 5100,000 Policy Limit
Bodily Injury by Disease: 100,000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the Policy applies to the
-states', if any, listed here: SEE ENDORSEMENT WC 20 03 06
D. This policy includes these endo.r.sements and schedules:
�= SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
4. The premium for this policy will beldetermined by our Manuals of
I Rules, Classifications, Rates and Rating Plans. All required
information is subject to verification and change by audit to be
made ANNUALLY
is
DATE OF ISSUE: 12-19-96 EO ST ASSIGN: MA
OFFICE: ORIND 161 DISTRICT: 'C-09
PRODUCER: RIDER RISK SPECIALISTS 28XXD