HomeMy WebLinkAbout2135 MEETINGHOUSE WAY/RTE 149 (2) p
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f Town of Barnstable
Regulatory Services
Richard V. Scali,Director
= ,sz,�tt� ; Building Division BARNSTABLE
"t"MPaul Roma
9 IU51g6IF:t5-OS'iCA'ALLF•ftTl4YlalUtE
1639. 1679-2014
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
TENT PERMIT
APPLICATION#
MAP/PAR
r ISSUED ON BY
ADDRESS S IN VILLAGE �� ��,✓i-� ,S �
CHECK ONE Residential Commercial NUMBER OF TENTS
.'9
PURPOSE OF TENT -ell � 15 ETZ
-�
IF THIS IS A NON-PROFIT EVENT CHECK HERE " (if not leave blank) .
l� UO O
DRVMNSIONS OF EACH TENT `Z� ( x yO 1 co
�
DATE TENT(s)UP /0p - ZO 16 TAKEN DOWN ON — Z ?d Jr-, Ln
- w �
ARE THERE SIDES ON THE TENT(S)? CHECK ONE YES NO
ry
If you checked yes you must attach a floor plan of the layout to insure proper egress for emergency
purposes per the Building Code requirements.
ATTACH THE FOLLOWING DOCUMENTS:
FLAME SPREAD SHEET FOR EACH TENT
FLOOR PLAN OF INSIDE OF EACH TENT THAT HAS ASSEMBLY USE
PROPERTY OWNER'S AUTHORIZATION IF THE APPLICANT IS NOT THE
HOMEOWNER
WORKMAN'S COMP.AFFIDAVIT(AND CERTIFICATE IF REQUIRED BY THE t
DEPARTMENT OF INDUSTRIAL ACCIDENTS, INCLUDE POLICY INFORMATION PER FORM
INSTRUCTIONS).
LOCATION OF TENT ON SITE(PLOT PLAN OR G.I.S.MAP SHOWING LOCATION)
PROPERTY OWNER NAME
APPLICANT
PRINT Af l
/ ,p �I �(/
'SIGNATURE_/�_ DATE O f_ 6
RETURN WITH A COMPLETED APPLICATION BETWEEN THE HOURS OF 8-9:30 A.M OR 3:304:30
PM.M TO OBTAIN A HEALTH DEPARTMENT APPROVAL AFTER OBTAINING AN APPLICATION#
FROM THE BUILDING DIVISION.
If.this is Town of Barnstable property,you must provide the property owner's authorization completed by the
.Town Manager.Using the Town Green?Call our Survey dept. at 790-6400 x 4939 to ensure water lines are
preserved for staking purpofes, If you are utilizing Aselton Park call Structures and Grounds 790-6320
EMAIL ADDRESS: Q:forms\tentpermit Rev.06/20/16
i
27m Commomvealih qf Mai adinsa&
Department afladustyid Accidmi&
Ojjwe of rations.
' 600 Washurglon meet
Boston,MA 02HI
tv�v��m�gov�dia
Workers' CompensafsenInsurmceAffidavit:Bnil-derslCnfrachwsMectricians(Phmbers
Applican#Infm-m.aiian Please Print Le: Y
Na= .
Address
Citgf tat ne — 3I —Z-317 G
Are YOU an employer?Checkthe appropriate ba= Type of project(required)—:
I.❑ I am a employer v&h. 4. ❑I am a general contractor and I .
* bave hired suit-co�a�s ❑New eonsi ios
• employees(:Call au�for part-time.
2.❑ I am a sale proprietor or partner- listed on the attsched sheet 7- ❑Remodeling
s*and have no employees . These sub-contractom have g ❑Demolition
waddng far me in any capacity employees and have wodzers'
[No waders'comp.iilmrmn a comp-L„SIXE ^*p I - . 9. ❑]3uildmg addition
reTlired-] 5. DT'�e are a cmrparaticn and its to-❑Electrical repairs or addifions
3_❑ I am a homeoumeer doing all work officers have exExdsed their 1 L❑Plnmbingrepaiss or adchtioms
myself o vwarkers'comp tight of exemption per MO- L R repairs
in n�" d-j T c.152,§1(4k and we"have no _�� oaf
employees:.[No workers' 13_L3'flther
comp_insurance mgdamd_j
easy app&aatthat cheer box in mast also Moot the easatioapaycy infi=tWUML
#l eoara�, snb�dris afsdas�r i g 8ney axe dais ail wort sad beep aatsidQ rn„tTsre.+.e mast sob=a new 2Mdxek iadicsli"sIIClL
tCoatmdosf=cbecYtbi ban musta118rix assddidaaals8ee2sl�ammgthen of the subcamdxachaasadstate�rLdh��natfhuseeolitiesLave
employees.Tfthesuh-toatxaMMhace employees,9heymustpmrddetlteu wadlxess'gyp•poacy m—k-
I am era erriplsr fJtnt is prcuidirrg yvorItets'caarperrsation irtsrtraRce for ury eaupF Belon=isTJte paiicy arld job site
Fafarrrsrrfrnn .
Insurance Company Mine:
Poficy 4 or;Pelf-ms-Zic-;k lixpifatiou Date
Job Site Address: cily/stafe/zip:
Attach a copy of the workers'compensationpolicf declaration page(showing the poficy number and expiration date).
Failure to serum coverage as required under Section 25A of MCA.m 157 can lead to the imposition of criminal penalties of a
fine up to SUM 00 andfor one-yearimpfisonment,as wag as civil penalties in the fans of a STOP WORK ORDERand a fine
of up to$250M a day a, aiust the violatmr- Be adxdsed mat a copy of this statement maybe forwarded to the Office of
Irrvestgations oftfie DIA for insu ance coverage verification_
T do hereby cirri under the pairs and penalties afpedW7 thatthe infotutationpmmW abmv is true and carrect
Irate.
Phone rk
t7jyWal use anly. Do oat Ewrity in dds areq,to be canlpLged by city artown ojjiidaL
City or Toga: Permifflcense;g
Issuing An arity(cacleone):
L Board of Health g De mtment 3.Cfty,!Tawn Clerk 4 Electrical Fuspector S.Plumbing Inspector
6.Other
Contact Person: PhonE :
i
Information and lnstruc ions
Mztccar}rtrceffs C,==alLaws chaca 152 ryes �0y= T ewot 'eon�easatloIl then employees.
iParsa,,int-to this statute,an EVlayW is deed as.¢.every personm$ie smavice of anodicrunder aay confr ct ofhirr., i
empress or hnpliact oral or wntte."
ore
An enp&7m,is defined as`pan mdrvi par ,asso��,�P° On or other Legal e�iiy,or any two or c
of the fizreg tag in.a joint ,and incmdmg the legal re j¢ese�tves of a deceased=3p 11 v rt
the
reivra or irastee of as individual,pazhip,
associalion or offi=Iegal entity,e=Ploymg mnPIDyem �°weer
owner of a.dwelling horse having not more than tbree apadmen is mad who resides ffimmiE6 cr the occupant of the -
dweIIing house of anoffier who employs p=sans to do make,coInsEruction or repair work on such dwelling house
or on.the grounds or building apP ant tjheaeto shallnotbecanse of mxh emplaymeutbe deemed to be an eaaployet"
MC IL chapter 152,§25C(6)also stems that'every state or local I•u:ensing agency shall withhold the issuance or
renewal of a Iicen a or permit to operate m business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable uddeum of cdmpH=ce with ffie hm ra ce.coverage requke&"
Additionally.M ff_chapter 152,§25C(7)states-Neithw the cammumweahh.nor my ofits political subdivisions shall
em into any contract for the perfimz=ce ofpublic wm3c u�1 acceptable evidcam of complignee vYiffi the ins'[nnnce.
regtm-em eats of this chapter bave been presented to the contracting anchor iy."
PHc
Please fll out the wo&=,compensation affidavit completL-Iy,by checlg the boxes that apply to your situation and,if
necessary,supply sub-contradnr(s)name(s), address(es)andphonenomber(s)alongwiththen-c rtficaie(s)of
mmm nce Limited Liability Companies(LLC)or =tedI abffity?mtac=bigs.(LU)xrffno maPloyees ofi'es ffim the
membeas or paatneas,are not rued to cry vtorke& eampensatiaa insarmoe. If an LLC or LLP does have
e3ployee:s,apolicy is regnued. Be advised that this affdaYit may be snbraittcd to the Department of Industrial
Accidents for comEnnation ofmsurance coverage_ Also be sure to sign and datethe affidavit The affidaVitshould
be ret=e d to ffie city or town that the application for ffie permit or license is being requested,not the Department of ;
raj A cc lentsL Shouldyou have any question regarding the law or if you are required to obtam a w033c='
compensafic policy,please call fficDepmtneE±attbenmIIbea listed below. Self-inscnedco=panies shouldentertheir
se
lf-insormce license number on fhe appropriate Line.
City or Town Officials
t
Please be sore that the affidavit is complete and printed legibly. The Departmeuthas provided a space at the bottom
of the.affidavit for you fo fill out in.the event the Office ofIuvestigations has to contact you regarding the applicant-
Please be sue to f ll is the peunrt/licrose mxmbe r which will be used as a reference ntanber. In addition,an applicant
that must submit mvbipIe pemi�l1cease aPplitatinns in any give:a year,need only submit one affidavit indicating current
a olicy information(if necessary)and under"lob STr 1��ess"the applicant should write:"all locations m (may O_
town)-"A copy of the-affidavit that has been officially stamped or marked by the city or town may be pmvided to the
applicant as#roof that a valid affidavit is on file for f3hu permits or vcCoses. Anew affidavit must be filled oil each
j yea,-.,Where a home owner or citizen is obtaining a license or pe=3 t not related fro any business or commercial vtat e
(ie.a dog lcc=se or permit to burn leaves etc.)said person is NOT rIT3ir d to complete this affidavit
The Office of rnvesEigations would lie to thank you in advance for your coopexaii�and sboIIld you have any questions,
please do not bcsziatr.to give us a call.
tel cure andfaxzmber.
The Deparime�s address, egh , - ', - •
CDMMMV=Ift of Masach ,
Deparfmwtc&lut al Accident%
offi=of jnVe&#gkti0=
t�4 T�ashin.�ban�
Bin.MA Oil 11
Tel.. 617' -4 cut 406 or 1-M MA qRAFE
Fax 617 727 7M
Revised 4-24-07 p m .gngt
Town of Barnstable
Regulatory Services.
Richard V.Seali,DhwWr
►�� Building Division.
Paul Roma,Building Commissioner
200 Main Street,Hysmis,MA 02601
www.town.barnstable-ma.us
Office: 508-862-4038 Fax: 50&790-6230
Property Owner Must .
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf
in all matters relative to work authorized by this building pertnit application for:
(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 Signature of Applicant
Print Narne Print Name
Date
i
Q:R0RNLS:0WIqERPERMIS40NPOOLS
Town of Barnstable
Regulatory Services
pIF Richard V.Scab,Director
Building Division
AMR-
AMZ. Paul Roma,Building Commissioner
t&659. ��� 200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 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:
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
i
procedures and requirements and that he/she will comply with said procedures and requirements.
i
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 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.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
I permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in
your community.
Q:\WPFILES\FORMS\buildmg permit forms\EXPRESS.doc
06/20/16
i
}
MAIL IN APPLICATIONS ARE NO LONGER ACCEPTED
2-5.1 Tents
$25 A) A tent may be put in place on a lot used for residential purposes, for no more
than 10 days,in connection with special family occasions or events; but not to be
j used for any commercial purposes.-
` $25 B) A tent may be put in place for not more than 10 days, nor more than twice in
any calendar year, in connection with a fund raising or special event by a public
institution or non-profit agency.
,$100 C) Subject to annual approval by the Building Commissioner, a tent maybe
erected and used as a temporary accessory structure to an existing permanent
ps..J.
business only during the period beginning May until October 31. The tent shall
conform to all the parldng requirements and Bulk or Dimensional requirements of
this Ordinance.
$50 D) Maintenance and occupancy of tents in an organized and supervised
recreational camp subject to compliance with the rules of the Barnstable Board
of Health. Provided; however, a Special Permit is first obtained from the Zoning
Board of Appeals..
(A-D added and changed by Town Council vote on 2/22/96 as item#95-194 - by a
9 Yes 2 No roll call vote.)
I 07/15/2010 12: 08 812-867-0547 ANCHOR IND PAGE 02/04
NJ E uj IMPORTANT DOCUMENT
;< Certificate o�f dame TSAstance
ISSUED BY Date of Shipment
lJ••i' 1-0(r 0 07/07/10
Registration Number CHOW
F140.1 INDUSTRIES INC.c� Tent Identification
14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to: .z
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
OF CALF
' _ 12 E'�P►
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108985(1)
Description of item certified:
CENTURY MATE EXPANDABLE END
40WX20 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By '
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG Nf W PHILADELPHIA.OH'
.Name of Applicator of Flame Resistant Finish
Signed;
ANCHOR INDUSTRIES INC
`�- •- -• .� MEETINGHOUSE .
1 �
FARM
12
r www.meetinghousefarm.org
North
DOM
2.
11. 6 A o
.: 8
4
1. 3
S. L Greenhouse&Barn
2. Herb Garden
{ 4. 7. 3. Display Gardens
4. Rock Garden
5. Floral
-Quilt
ouilt
WA 6. Sash House
7. Paine Black House
& Bird&Butterfly Garden
For additional ir#onnadon contact Judy at 9. Meadow
desrochersira?.comcast.net Or write us at 10. Community Gardens
P.O.Boat 33o, West Barnstable MA 026M ILRhododendrons
12. Trail
f
''• �FTTHE Tp�
The Town of Barnstable Barnstable
�i yam` dos
Office of the Town Manager KE 367 Main Street, Hyannis MA 02601 A&ftWft8CftV
1AMSrABLE, : www.town.barnstable.ma.us Office: 508-$62-4610 Fax: 508-790-6226 I I.
MAW. APPLICATION FORM 2007
USE OF PROPERTY,PARADES,MARATHONS,TRIATHLONS,ROAD RACES-.
The approved application must be on file in the Town Manager's Office at least thirty-(M)days oi�to event.
Parade/Road Race applicpti9A must be received nine 90 days prior to scheduled date.
Date of application: 6 l
Fee amount: $43.00 per request*:Total paid: YES(ck!/ OR cas
*Each request means each event such as a parade,followed by an event on the Town Green,for ex le.
This application must be complete/all signatures prior to submitting to the Town Manager for final approval.
You may be required to leave application at various Departments'.to wait for appropriate signature.
1. CALL TOWN MANAGER'S OFFICE TO TENTATIVELY RESERVE DATE OF EVENT-CHECK AVAILABILITY
Request for: Hyannis Village Green Aselton Park Parade
�. e
Benefit Run/Walk Marathon/Triathlon ► Other(please specify): lj• 6� AV,4,(
Certain facilities may require additional fees for services by DPW depending on location,use of staff&size of
event. The fees will be determined by DPW and paid directly to that department.
2. Name of Event:w 9_S 1s 0.,L 1s r rn b i e. i I+C Q k. re S�-4 cj
Day/Date of Event: I. b `/ Rain date:
y
3. Name of Sponsoring Organization: YV ' ' C'� U n►� 11n1 C-
Mailing-and physical address: - IC;X b 6 3 �✓e�� �Ja�rJ�T�d�b�Q (�'I� d zi—L
�9g W��ols�`��. 2►� I+�es�- �.�,�s-�a,bte �a o z66�
4. Contact person: �- S I�q ll� Phone: 4-2- 7 S�
5. Person in charge DAY OF EVENT: Cell phone:
g- 7�o 7
6. Setup time:-] M Actual event start and end time: 4 —Cleanup time: V t\f` I (03 6 em
7. Estimated number of volunteers/participants:
Estimated number of spectators: y o 15 G a
>>POLICE DEPT will determine if extra detail necessary.
8. Admission fee/registration charged to participants? V No If yes': Amount:
Will there be food or craft vendors at event? Yes No
>>If yes, indicate the number of vendors and type(food/merchandise/etc):
Wh'e ,k,,,.j L;�"21 �� etis r/Ja s G�. 1 . R, S
»Will there be merchandise available for sale? Y Yes No N/A
Vendors need to complete application for special licenses at the Licensing Division-200 Main Street,Hyannis.
9. Map attached(REQVired:
)for road race/parade event.
>>Are street closures r Yes No
>>Detail of.roufee an rest stops ttached/indicated on.map.
10. Food prepared/served at event? J Yes _No
>>If yes;will there be cooking/heating involved? Yes No
t
y TENTS.STRUCTURES.ENTERTAINMENT.DEVICES*Attach map for layout of event including structure placement
TENTS REQUIRE ADDITIONAL PERMITYROM BLDG DEPT.
Structures&Grounds have designated tent friendly zones.
Should you require tent elsewhere other than these zones,location needs to first be cleared with Structures&Grounds.
>>No open flames in tents or propane storage use without a fire permit. /
11. Are you installing or constructing any structures,including buildings,climbing structures,etc? _Yes V No
12. Are you installing any tents or canopies? ✓/Yes No
,� ao k 140
Quantity and size: X lq Own or rent? Rental company: Tel#
13. Do you plan to have any sound amplification? /Yes No Music _Other(please describe)
14. Is electrical power required? ✓ Yes No
(for sound amplification(PA system),lighting,popcorn machine,etc)
>>If yes,circle: will you provide portable generator? OR will you requir TOB t porary service?
>>List maximum wattage required and location for hook-up: R G.c•k o (?Cj co/h UN � 1 Q �d 6
If more than'usual'hookups,please note there will be overtime costs if Town Electrician setting up and removing
"A-frame"or dropping service before/after event outside of business hours. `-
CONES.BARRIERS. 3 p_ c f 6 cG,j Q - 3 0
15.Do you have need for barricades/cones? Yes No
>>If yes,describe for what use: O ac)k, a n-kg,S P a Nk```y
DEPOSITS: $5.00 each cone. $50.00 eachlbarricades(quantities/deposits arranged throLigh DPW).
16.Will you require access to the town building? J Yes No
>>If yes,describe for what use: f=l G w e-, .c-11 Gv✓
VEHICLES N 6
17.Do you plan to drive vehicles onto property? If yes,provide details:
Specific loading zones to be reviewed with DPW/Structures&Grounds.
Organization will be liable for any damages vehicles may cause the ground.
COMFORT STATIONS. PORTABLE TOILETS AND HAND WASHING SINKS
18. Do you plan to provide portable toilets and/or hand washing sinks at your event? _Yes No
>>If yes: )�- #of regular toilets I #of handicap accessible toilets c�, #of hand washing sinks
Public Comfort Stations located at Town Hall Parking Lot,North Street and Barnstable Village Fire Station are
open from 9AM to 9PM,daily. If event absolutely requires early open, it must be reviewed with DPW.
GARBAGE AND RECYCLING SERVICES
19. Trash pick up is the responsibility of the organization requesting this permit. Please provide your.plan_for
the cleanup and removal of garbage d recyclables during and after your event: �v M p S �ti �+� S P
0.� G O rn/hvnlIV ��I' •
Number of recycling containers: I 14umber of garbage receptacles: 15
A one time disposal fee for use of Town containers may be assessed. Any fee will be determined and collected by DPW.
The cost is based on size of event.
SECURITY/SAFETY
20.Will there be demos,displays,materials that are potentially hazardous/impact public safety?_Yes No
>>If yes,describe:
21.Have you made any provision for on-site security? _Yes-41f4o
22.Have you made any provision for on-site medical services? VYes No
PARKING
23.Please provide description of your parking plans(w re event attendees will park): Ku
>>Plans for disabled parking: &`r 6 rv�`M I t
>>Plan for emergency vehicle acce— d: ns, 1.�kI 1 a r/ S Z _
>>Please describe your plans to notify residents,businesses impacted by this event: r Ila pus r.- c)
SIGNS/ADVERTISING
24.Will the event be advertised? If yes,where: 16 w Ot e`"ems
>>Do you plan to distribute flyers or ads before or during this event? Yes No
>>Do you plan to place any signs or banners or other advertisement at the event site? _Yes No
>>If yes,please indicate where: 8 +j g:,/Lu-)V 6 4' eG c19 '
>>Provide sign/banner detail and dimensions and method of attachment or support:
�X 10 vJ! %1v,k 11,�,
1 .
(Signage may require additional permits).
I have read, understand and agree to abide by each numbered item on the attached "Rules
and Regulations for Use of Village Green and other Town Property" H "Rules and
Regulations for Parades, Walkathons, Road Races" and as the agent for the sponsoring
organization, agree to abide by said rules and any o especial co rtions letter may be
attached) established for this particular event. � A 1��/ 6 Q (o
Signature of sponsoring agent/Date
I I
Printed Name: 1,3 �",i"`e' �, C
APPROVED I V
CHIEF OF POLICE ATE:
(Barnstable Police D ent, 20(TPh' ey's Lane,Hyannis 508-778-3805)
6 Al
CHIEF OF FIRE DEPT(S) [/) DATE:
(Village Fire Department,Add see s ary� " ��
RECREATION DATE:
(Hyannis Youth&Commun r, 41 B set Lane,Hyannis 508-790-6345)
PUBLIC WORKS I , DATE:
(382 Falmouth Rd.Hyannis At 90 0)
REGULATORY SERVICES DATE..
(200 Main Street,Hyannis 508-862-46 4
BOARD OF HEALTH DATE: �(7
(N/A for Parade/Race permits)MI69s serving food 62-4644) /
" BUILDING DEPT DATE: `
(N/A for Parade/Race permits unless erectin n .9508-8662-4038)
TOWN MANAGER DATE:
(Town Hall,367 Main Street,floor,H annis 508 62-4610)
SPECIAL CONDITIONS and ANY FEES(As determined by Department's above)
DETAILED AS FOLLOWS:
s
. ( G
Additional Rules Governing Amplified Noise
on the Town Green and Aselton Park
1. The maximum amount of time amplification of any kind can take place on the Town Green or Aeselton Park is
two(2) hours in any given day,and such amplification must conclude by 8:00 p.m. and begin no earlier than
9:00 a.m.on Saturdays, Sundays and holidays,and no earlier than 5:00 p.m.Monday-Friday.
2. For the Town Green, all amplification must originate from the bandstand;unless special permission is granted by
the Town Manager to erect a stage*in front of the Town Hall. Speakers on the bandstand must face diagonally
toward the School Administration Building, not toward Main Street.
3. -Amplified sound must appropriately conform to the Town's noise ordinance(see attached).
4. Any use of the Town Green or Aselton Park that involves amplified music for the benefit of residents or visitors
of the Town,whether a free event or one that charges admission,must have a minimum of one special Police .
Detail paid for by the applicant. Additional Police Details will be at the discretion of the Chief of Police based
upon the type of activity and the number of participants/spectators.
5. . The event contact person listed on the permit shall be present during the entire duration of the event,and must be'
at least 18 years of age. Such contact person shall comply with all lawful requests by the Barnstable Police
Officer assigned to the event,or any Barnstable Police Command Officer. Such Officer shall be empowered.by
the Town to shut off the Town's electricity to the stage area if he/she deems such action necessary.
6. No bullhorns or other similar portable amplification devices are permitted. .
7. Vulgar and offensive language is not permitted under any circumstances. '
8. The Town Manager reserves the right to modify the above requirements for special events that obtain an
Entertainment License through the Town's Licensing Authority,or where such events are sponsored or co-
sponsored by the Town. The Town Manager also reserves the right to impose additional requirements on the
applicant based upon the size and nature of the event..
r
TOWN OF BARNSTABLE
MARATHON,TRIATHALON AND WALK-A-THON
RULES®ULATIONS
SPONSOR'S RESPONSIBILITIES:
All sponsors of the above events will submit a detailed request to the Town Manager ninety(90)days prior
to the scheduled events. Such request will consist of the following:
1. Organization sponsoring event
2. Name,address and phone number of Race Director as well as Board&Committee members.
3. Date(s)and time(s)of event
4. Number of participants expected.
5. Map designated race route as well as narrative describing route of race from start to finish.
6. Support systems to be.set up for duration of race such as water location,first aid locations,police control.
These positions shall be noted on map. Sponsor must also provide number of volunteers to assist during the race.
TOWN RULES®ULATIONS
L.Application must be received ninety(90)days prior to scheduled date.
2. Sponsor(Director)will review race route with the Chief of Police and provide Police Patrol for
•public and participant protection as outlined by Chief of Police at sponsor's expense.
3. Sponsor(Director)will review race route with the Fire Chief of the-District in which the race
will be run and at the direction of the Fire Chief will engage necessary personnel and
equipment to ensure water safety;emergency medical facilities'and such other support
requirements as made by the Fire Chief at the sponsor's request
4. Sponsor(Director)will review race with Director of Recreation to ensure that Recreation controlled
sites are available and that water safety personnel(lifeguards)are available in the numbers required as
well as any other beach personnel that may be deemed necessary by the Director of Recreation.
Expenses incurred by the Recreation Department in support of the event will be paid by.the Sponsor.
5. Participants: Full Triathlon can have up to 400 maximum entrants' each shall be over 18 years of age.
Partial Triathlon can have up to 700 maximum entrants,each over age 18.
6. Sponsor will review race route with'the Superintendent of Public Works for any special requirements
deemed necessary by that Department Unusual expenses incurred will be borne by the sponsor.
7. The sponsoring activity shall provide litter pickup crews during and after each event along the entire
race course including initial assembly area. Litter pickup shall pertain not only to roads and sidewalks
but also to grassed and wooded areas abutting the roadway.
8. No markings of any kind shall be applied to road or sidewalk surfaces to delineate the road course.
DAY MARKERS ONLY.
9. Any signage attached to telephone or electric company poles shall be removed immediately following
completion of the event
10.A limited number of road cones will be provided upon request of the Supervisor of the Highway
Division. The cones.may be signed out Friday afternoon,between 1:00PM and 3`00PM,prior to the
race and must be returned no later than 8:30AM on Monday morning. A deposit for$5.00 per cone
shall be required prior to issuance. The deposit shall be in the form of a check and made payable to
Town of Barnstable.
11. Major events,marathons and triathlons will be restricted to one(1)event per month during the months
of May through September.
12. Events will be postponed if temperatures are above 90 degrees at starting time of event.
13. Any races to be held on a Sunday which require the route to pass a church must have the approval of
the Pastor and also the applicant will pay for any additional police protection to ensure the safety of
the churchgoers.
Notwithstanding the above ANY ATHLETIC EVENT utilizing Town ways within-the Town of Barnstable
requires the'approval of the Town Manager thirty(30)days in advance of the event,as well as the Chief of
Police and other department heads deemed necessary or advisable.
/ k Oogjbr con ledn9 yow Special Event Per It A Ucation.
/Before you submit your application to the Town Manager's office,
please make sure the following steps have been completed:
Have you:
'O Tentatively reserved date/checked. availability for event?
i O SL@ned and dated your application?
O check or cash when you turn in application fee of$43.00
for each request?
O Attached your event site .plan? l
O A ached parade/race route?
.O Provided samples of communications that will be
distributed to impacted residents, businesses, schools,
places of worship and other entities?
0Applied.for a tent permit �f applicable?
0Appli,edju.r afood, permit if applicable?
O Arranged for police detail f applicable?. .
O Made arrangements for restrooms/cones/barricades, etc
if applicable (through DPW)?
O Read all the rules and regulations?
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION.,
4;
Map Parcel :., ' l v 'Ap ica on#
Health'Division y`;Date Issued
Conservation Division - s Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address a-�.�� 44
Village V
Owner ddress
Telephone 7
Permit Request 0 6
Square feet: 1 st floor: existing oposed :2nd floor- existi g proposed Total new
Zoning District Flood Plain Groundwater;Overlay
Project Valuation Construction Type
Lot'Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family .:0 Two Family ❑ Multi-Family(# units)
•t
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing ew
Number of Bedrooms: existing _new
Total Room.Count (not including baths): existing new First Floo oom Coynt
j Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wo d/coal sctove: Yes ❑ No
cxr
Detached garage: ❑ existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: existin3 ❑ .eat, size_
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#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name `"`^-� (�C ~/�--� Telephone Number ✓ -7
Address 5-c ' °ill License #
y• �'�—�-- �" �► Home Improvement Contractor#
6L5( Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE O `�'
i
1' S
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
` ADDRESS VILLAGE
OWNER
J
s DATE OF INSPECTION:
FOUNDATION
i FRAME
INSULATION
r
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL K
FINAL BUILDING
DATE CLOSED OUT .
ASSOCIATION PLAN NO.
i
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Naive(Business/Organization/Individual): A"
• Address:
City/State/Zip: S Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
. employees(full 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 T.❑Remodeling
ship and have no employees These sub-contractors have g• ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• t 9. ❑ Building addition
[No workers' comp.-insurance . insurance. 10. Electrical repairs or additions
required.] 5. We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work officers have exercised their I LR Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.pthcT�r_
pairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.
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.
tha
t sat 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 employ=,they must pravidb their workers'comp.policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 lip to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the p ains-and penalties ofperjury that the information provided ahoyeis t ue and correct:
Si ature: Date:
Phone#: 2-3
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: Phone#:
I E
Information and. Ins' tructi®ns
Massachusetts General Laws chapter 152 requires all employees 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 hue,
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 representative's of a deceased employer, or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §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 v�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 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 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
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 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 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 each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn 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 C6mmonvreaM of Massachusetts
Department of ladustrkal Accidents
Office of Investigations
6.00 Washington Street
Boston, MA 02111
TO. #617-727-49GO ext 4.06 ar 1-M-MASSAFB
Fax# 617-727-7749
Revised 11-22-06
www.mass..gov/dia
BARNSTABLE COUNTY
The Commmweait of Nk%achusetls
n
M� 6000 Sheriff's Place,Bourne,MA 02532
508563.4300 Fax.508.563.4574
BcSO@bshcriffmct
� ACCBEDITE Storm
I = August S, 2014
FOUNDED 1070
Aoaeocau Thomas Perry, Building Commissioner
Correctional TOWN OF BARNSTABLE
Association 200 Main:Street
Hyannis, MA 02601
� t Dear Mr. Perry:
I have been asked to provide a letter regarding workers compensation coverage for
inmates iri the custody of the Barnstable County Sheriffs Office who are erecting
coxamdsS,,m&tatio or, and dismantlingtents for the Town of Barnstable.
Acccediradon of
>Zehabiki�eos�
Facilities These,inmates are not paid wages for the services that they perform. They are
providing a community service. They are not employees as a matter of
Massachusetts law. They are not.covered by worker's compensation insurance nor
are they eligible to receive such.
The Barnstable County Sheriff's Office itself is self-insured for its employees, the
Community Service Officers, for worker's compensation purposes. Therefore, the
Sheriffs Office does not maintain a worker's compensation policy. As an entity of
the Commonwealth of Massachusetts, the Sheriffs Office is self-insured for all
purposes.
Please feel free to contact me if you have any questions in this regard.
Very truly yours,
Matthew Murphy, Esquire
Assistant Superintendent
General Counsel
/sdr
Enclosures
BARNSTABLE-BOURNE-BREWSTER-CHATHAM-DENNIS -EASTHAM-FALMOUTH-HARWICH-
MASHPEE-ORLEANS.-PROVINCETOWN-S,A_NAWTCH-TRURO-WELLFLEET-YA.RMOUTH
AUG-04-2014 23:26 From:5085634574 Pa9e:2,5
IMPORTANT DOCUMENT
Certificate of Flame desistance
Date of Shipment
ISSUED BY 07/07/10
nCHOR'Agistration Number NDUSTRIES INC. Tent Identification
40.1 14877530
EVANSVILLE. INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable)and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
T
N
CCertification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code.-All fabric has been tested and passes NFPA 701, CPAI 84,
Serial 0
8106985(1)
Description of item certified:
CENTURY MATE EXPANDABLE END
40WX20 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG N!�/PHILADE�PHI�4.OH
j Name of Applicator of Flame Resistant Finish
Signed:
AN HOR INDUSTRIES INC
AUG-04-2014 23:26 From:5085634574 Paee:315
IMPORTANT DOCUMENT
Certificate of Flame lZgsistance Date of Shipment
ISSUED BY 07/07/10
CHOR 8
� Igistration Number � .: INDUSTRIES INC. Tent Identification
40.1 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
�$T
cac���o
h. 9,
y
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108890C(1)
Description of item certified:
CENT MATE EXP END 40X20 SNYDER��� �� 7t
WHITE WITH"BARNSTABLE" LOGO
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADEI,PHIP�OH
Name of Applicator of Flame Resistant Finish ,/
Signed: �y
AN HOR INDUSTRIES INC
r
AUG-04-2014 23:26 From:5085634574 Pa9e:4/5
IMPORTANT DOCUMENT
Certificate of Flame �Rfsistance
Date of Shipment
ISSUED BY 07/07/10
CHOR
gistrstion Number INDUSTRIES INC. Tent Identification
12110 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
G�S r
CaL� �Q
h� y
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108402(8)
Description of item certified: TENT WALL L&S2 8'10X22 WITH
2 CATHEDRAL WINDOW WALLS
Flame Retardant Process Used Will Not Be Removed By
Washing And is Effective For The Life Of The Fabric
TRIVANTAG STAT SVILL NC Al
Name of Applicator of Flame Resistant Finish Signed:
AN HOR INDUSTRIES INC
IMPORTANT DOCUMENT
�LrLr3�rns�Ln�I-�n�Ln� a
Certificate of f arne Resista"ce 5
I ISSUED BY Date of Shipment
v REGISTRATION CH IN a 5
NUMBER IS WDUBTRIE ii,�.. 0412310$F14U.01 EVAfi1SVtLLE, INDIANA 47725 Teni IdentificationMANUFACTURERS OF THE FIN SHED 04620438TENT PRODUCTS DESCRIBED HEREIN S
This Is to certify that the materials described have been flame-retardant treated
5 (or are inherently noninflammable) and were supplled to:
5 80923 S
8 Royal Health Group Charitable Foundation
Lewis Point Rd
Buzzards Say MA 02532
oc _
a
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California
M
m 5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI84, ULC 109. `
5
N
CD 00 Serial# efossa3 t2) 5
Descrfptlon of Item certlffed: CentuFy Mate Expandable End, 40WxW yoCD 5
m
Snyder White Vinyl
Cll '�
S Flame Retardant Process Used Will Not Be Removed By 5
N + 5 Washing And Is Effective For The Life Of The Fabric
�., Snyaer Mfg-..ReW Pnlladalptfia OHSigned:
- =� �
cu N Name of AppFfcetor of Flame Resistant Fintsh ANCHOR INDUSTRIES INC.
mm p LI�'ffrj1�ffrJfrJc.JcPIE r1 Jt�J�rJ�rJ�rJ�tJ�zPtPrJ�rJ�tPrJ��P�F0 ry, WE,l51f[!d1 1[30 PrdP1_RPRPLLffl M LTE3j r s.f rJ�tJ�r l'�c,nrJ� CP7
0
1
Q
ti
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map b Parcel l J 0 Application
Health Division Date Issued
Conservation Division Application Fee a
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Add ss -
Village 2�L4 o
Owner // Address
Telephone (o
Permit Request `
Al
z�r
o � Y
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
j Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq j '_
-�_z .�
Number of Baths: Full: existing new Half: existing ""' nev3=
c:7
Number of Bedrooms: existing —new �' Za
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other ` ?
o ,
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove:c0 Yes ❑ No
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 ❑ No If yes, site plan review#
Current Use Proposed Use 7
t.
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Telephone Number �(� —7 7�
Address "/o �lL� 4 �-fil License #
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
I'
Y /g/ 2_d /
SIGNATURE DATE (/ '
i
f
` FOR OFFICIAL USE ONLY
APPLICATION#
to
(Y DATE ISSUED
MAP/PARCEL NO.
,2
k ADDRESS VILLAGE
OWNER
{ DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
� FIREPLACE
I
ELECTRICAL: ROUGH FINAL
f
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
� C
DATE CLOSED OUT a
s
ASSOCIATION PLAN NO. �
w .
1
F!
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): V?
Address:
City/State/Zip: l� Phone.#: ✓�8 'J 2,3
Are you an employer? Check the appropriate bog: Type of project(required):
1.❑ I am a employer with . • 4. ❑ I am a general contractor and I
employees(full and/or part-tim.e).
* have hired the sub-contractors 6. ❑New construction
..2.❑ I am a'sole proprietor or partner- listed on the attached sheet. T. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers'
f 9. ❑Building addition
[No workers'-comp.-insurance nip. msurance' ' '10. Electrical repairs or additions
required.] 5. We are a corporation and its ❑ P
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Ro f'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.
*Contractors 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.
lam' an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 tip to$1,560.00 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: A .�
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 1.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
I
A
Information and Instructions
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 ffi stee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §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 1.52, §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 vzth 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-contiactor(s)riame(s),-addresses)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 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
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 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 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 each
year.Where a home owner or citizen is obtaining a license or permit not related io 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 should you have`any questions,
please do not hesitate to give us a call. o
The Department's address, telephone-and fax number:
The•Commonwealth of Massachusetts
Department of Iadustr'al Accidents
Qffice of Iavestigationrs••
600 Washington Street
Boston, MA 02111
Tel. #617-727-49-00 ext 406 ar 1-877-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www.mass.gov/dia
HUU-e9-cfW14 d,3:eb F-rom:tO85634574 Pa9e:2,5
IMPORTANT DOCUMENT
Certificate of Flame desistance
ISSUED BY Date of Shipment
07/07/10
- CHOW
Agistration Number �.. Tent Identification
,40.1 � � INDUSTRlES CHOW
14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame.-retardant treated (or are inherently noninflammable)and
were supplied to;
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE -- -
BOURNE, MA 02532
1 T
N
rt
R E'C
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
810$985(1)
Description of item certified:
CENTURY MATE EXPANDABLE END 0"— �P
40WX20 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The. Fabric
SNYDER MFG NEW PHILADELPH16,0H
Name of Applicator of Flame Resistant Finish Signed;
AN HOR INDUSTRIES INC
Hula-e4-dW14 d.3:Sb r r om:5b85634574 Page:3"5
IMPORTANT DOCUMENT
Certificate of Flame li�gSistance
Date of Shipment
ISSUED BY 07/07/10
istration Number CHOW Tent Identification
9 INDUSTRIES INC.
40.1 ��y► 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE - - -
BOURNE, MA 02532
ISTCAL
E�
L.� qy
�-RE0
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108890C (1)
Description of item certified; ! �q
p CENT MATE EXP END 40X20 SNYDER
WHITE WITH'BARNSTABLE" LOGO `
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILAQELPHIA,OH /J
Name of Applicator of Flame Resistant Finish ;( � '
Signed: �'f
( � AN HOR INDUSTRIES INC
HUU-04-2014 23:26 From:5085634574 Page:4,15
IMPORTANT DOCUMENT
Certificate of Flame 1f sistance
Date of Shipment
ISSUED BY 07/07/10
��
' gistration NumbertNDUS7RIES INC. Tent Identification
12110 .�,�,,,y 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable)and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
G�Sr
N
�` R E't P►
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8106402.(B)
Description of item certified:
TENT WALL L&S2 610X22 WITH
2 CATHEDRAL WINDOW WALLS
Flame Retardant.Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
TRIVANTAGE STAT SVILL�NC
Name of Applicator of Flame Resistant Finish Signed:
AN HOR INDUSTRIES INC
`'7
� 'IMPORTANT DOCUMENT L.rrJ�cPr�rrJ�iPrlr�r�rr��J�P�r �n�ncJ�rJ�t1�r.Pr�cn�nrJ�r�r�P�.nrlLn o
m
Cortifleaw, of Plan psis ce 5
C� ISSUED BY _
5 Date of Shipment
REGISTRATION CH c
S NUMBER INou:TRIE�II,�•. 04/23/08
IL
c�5 F149.01 EVANSVILLE, INDIANA 47725 rent Identification 5
MANUFACTURERS OF TIDE:FINISHED 04620438 S
5 e TENT PRODUCTS DESCRIBED HEREIN S
This Is to certify that the materials described have been flame-retardant treated
5 (or are Inherently noninflammable) and were supplied to:.
5 80923 5
Royal Health Group Charitable Foundation
8 Lewis Point Rd
Buzzards Say MA 02532
oc
Q
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California
m .
5 Fire Marshal Code. All fabric has been tested and.passes NFPA 701-99, CPAI84, UL*C 109.
(D CoSerial°° efassas tzy
m N _ 5
Description of Item certified: Centuiy Mate Expandable End, 40Wx= �Io S L
`L m - Snyder White Vinyl
5
m �
v 5 Flame Retardant Process Used Will Not Be Removed By S
v CDN
Washing And Is Effective For The Life Of The Fabric 5
g.,New PtillarSiphia Signed:
u ` Name of AppFicator of Flame Resistant Flrsish ANCHOR INDUSTRIES INC.
9 m a L�r C�r�r�LnLnr�Ln1.rr�f`nnCPr�r��nf�C�L Ftnr�r�C�LPLI�r�E��nr�r�r�rrL�r��nub{�Lnr�r tPr�C f�LnL�[�r�L�C�r�Ln�PE��P�n�rC�C���nuC�Cn�nCr7r�t� o
t � t � ■
I r ,
OF THE Tp� The Town of Barnstable Barnstable
P� ~
Office of the Town Manager F.. 367 Main Street, Hyannis MA 02601
lARNSPABLE, ; www.town.barnstable.ma.us Office: 508-862-4610 Fax: 508-790-6226 I '•
' APPLICATION FORM
lED � USE OF PROPERTY,PARADES,MARATHONS,TRIATHLONS,ROAD RACES 2007
The approved application must be on file in the Town Manager's Office at least thirty(30)days prior to event.
Parade/Road Race a is do s must be received nine 90 days prior to scheduled date.
Date of application:
Fee amount: $43.00 per f equ s *:Total paid: YES(ck# OR cash) NO
*Each request means each event such as a parade,followed by an event on the Town Green,for example.
This application must be complete/all signatures prior to submitting to the Town Manager for final approval.
You may be required to leave application at various Departments'to wait for appropriate signature.
1. CALL TOWN MANAGER'S OFFICE TO TENTATIVELY RESERVE DATE OF EVENT-CHECK AVAILABILITY
Request for: Hyannis Village Green Aselton Park Parade 1 d 1 nq
J
Benefit Run/Walk Marathon/Triathlon . Other(please specify): •lL
Certain facilities may require additional fees for services by DPW depending on location, use of staff&size of
event. The fees will be determined by"DPW and paid directly to that department.
2. Name of Event: T24,V_ kk, V -e' �✓
Day/Date of Event: L Rain date: /7 / / / _ �ij/1 C..
3. Name of Sponsoring Or anization: L� 1 �V 1I
Mailing and physical address: 0 . d i�W
66
4. Contact person: Phone:
5. Person in charge DAY OF EVENT: Cell phone: I f
6. Set up time: /= Actual event start and end time: / Clean up time:
7. Estimated number of volunteers/participants: JV U
Estimated number of spectators: zo o
>>POLICE DEPT will determine if extra detail necessary.
8. Admission fee/registration charged to participants? V/No If yes: Amount:
Will there be food or craft vendors at event? y Yes No
>>If yes,indicate the number of vendors and type(food/merchandise/etc):
>>Will there be merchandise available for sale? Yes No N/A
Vendors need to complete application for special licenses at the Licensing Division-200 Main Street,Hyannis.
9. Map attached(REQUIRED)for road race/parade everit
>>Are street closures required: Yes 7 No
>>Detail of route and rest stops attached/indicated on map./
10. Food prepared/served at event? _Yes _No
1 /
>>If yes,will there be cooking/heating involved? " Yes No
TENTS. STRUCTURES. ENTERTAINMENT DEVICES*Attach map for layout of event including structure placement
TENTS REQUIRE ADDITIONAL PERMIT FROM BLDG DEPT.
Structures&Grounds have designated tent friendly zones.
Should you require tent elsewhere other than these zones, location needs to first be cleared with Structures&Grounds.
—No open flames in tents or propane storage use without a fire permit.
11. Are you installing or constructing any structurr s,including buildings,climbing structures,etc? _Yes ✓No .
12. Are you installing any tents or canopies? f/ Yes _No
I
Quantity and size:2 / I Own r rent? Rental company: Tel#
13. Do you plan to have any sound amplification? _Yes No_Music _Other(please describe)
14. Is electrical power required? _Yes No
(for sound amplification(PA system),lighting,popcorn�il,y;,ou
>>If yes,circle: will you provide portable generator? equire TOB temporary service? n /
>>List maximum wattage required and location for hook-up: V
Y
If more than'usual'hookups,please note there will be overtime costs if Town Electrician setting up and removing
"A-frame"or dropping service before/after event outside of business hours.
CONES.BARRIERS.
15. Do you have need for barricades/cones? Yes No
>>If yes,describe for what use: '�J o �V l� �M. G� 1�."Gl.S
DEPOSITS: $5.00 each cone. $50.00 each/b icadess qu ies/deposits arranged through DPW).
16. Will you require access to the tow building?- V Yes No
>>If yes,describe for what use: Ct c, .
VEHICLES
17. Do you plan to drive vehicles onto property? yes, ovide details:
Specific loading zones to be reviewed with DPW/Structures&Grounds.
Organization will be liable for any damages vehicles may cause the ground.
COMFORT STATIONS. PORTABLE TOILETS AND HAND WASHING SINKS
18. Do you plan to provide portable toilets and/or hand washing sinks at your event? Yes No
>>If yes: #of regular toilets #of handicap accessible toilets #of hand washing sinks
Public Comfort Stations located at Town Hall Parking Lot, North Street and Barnstable Village Fire Station are
open from 9AM to.9PM,daily. If event absolutely requires early open,it must be reviewed with DPW.
GARBAGE AND RECYCLING SERVICES
19. Trash pickup is the responsibility of the organization requesting this permit. Please provide your plan for
the cle andre al o age and recycla les during EWd after your event:
Number of recycling containers: Number of garbage receptacles:-71-0
A one time disposal fee for use of Town containers may be assessed. Any fee will be determined and collected by DPW.
The cost is based on size of event
SECURITY/SAFETY
20. Will there be demos,displays,materials that are potentially hazardous/impact public safety?_Yes INO
>>If yes,describe:
21.Have you made any provision for on-site security? _Yes_ L
22.Have you made an provision for on-site medical services? es No t7 7 e,rk,
PARKING
23.Please provide description of your Yarking plan (where event attpndees will park): OA 4 0 S Aw
>>Plans for disabled parkin 60V D fv✓ ✓
>>Plan for emergency vehicle access:
>>Please describe your plans to notify residents,businesses impacted by this event:
SIGNS/ADVERTISING
24.Will the event be advertised? yes here: &
>>Do you plan to distribute flyers s before or hiring this event'.? es
>>Do you plan to place any signs or banneT advert''s/� ent e eve site? Yes . N "
>>If yes,please indicate where: rs o o e vv
>>Provide sign/banner detail and dimensions and method of attachment or support:
(Signage may require additional permits).
I have read, understand and agree to abide by each numbered item on the attached "Rules
and Regulations for Use of Village Green and other Town Property" // "Rules and
Regulations for Parades, Walkathons, Road Races" and as the agent for the sponsoring
organization, agree to abide by said rules and any o r special conditi left s may be
attached) established for this particular event.
S g ture of sponsoring agent/Date /f
Printed Name: _, �G5�l h—e-1
APPROVED BY:
CHIEF OF POLICE DATE:
(Barnstable Police Department, 1200 Phinney's Lane,Hyannis 508-778-3805)
CHIEF OF FIRE DEPT(S) v V` DATE: �OC
(Village Fire Department,Addre e )
RECREATION �C DATE: l
(Hyannis Youth&Communit et L Center, 141 Bassane,Hyannis 508-790-6345)
PUBLIC WORKS 0-& �� � DATE:
(382 Falmouth Rd.Hyannis 508-79 0)
REGULATORY SERVICES DATE: 6 L7
(200 Main Street,Hyannis)508- -4 4)
4\L—
BOARD OF HEALTH Lf ' 1 V 1 DATE: b I`"'
(N/A for Parade/Race ermits unless serving food.508-862-4644)
BUILDING DEPT DATE: caoZ
(N/A for Parade/Race permits unless erecting tents. 5 - 62-4038)
TOWN MANAGER DATE: I /�
(Town Hall,367 Main Street,2" floor,Hyanni -862-4610)
SPECIAL CONDITIONS and ANY FEES(As determined by Department's above)
DETAILED AS FOLLOWS:
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application # :90 d�
Health Division Date Issued V
Conservation Division Application Fe
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address
Village //�/Q S /
Owner 0'v vi Address
Telephone
Permit Request -74
f 0
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: 0 existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) `/ p
Name Telephone Number Lo " O
Address �a �� �5�� License #
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE `���/� DATE X /Z"o
FOR OFFICIAL USE ONLY
APPLICATION#
'ft _DATE ISSUED
.MAP/PARCEL N0.
ADDRESS VILLAGE
OWNER
E
f
r.
DATE OF INSPECTION:
Sr
uAFO-UNDATIO.N;lj+ki:SLl ` ?iknt'!' siJAflL"t "
` FRAME —
r. INSULATIONi n !,Afii:tJ lj H1;::
s#
t.
{` FIREPLACE
' ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS- ROUGH FINAL -
FINAL BUILDING;;;
�a
DATE CLOSED OUT
ASSOCIATION,PLAN NO. _
s The Commonwealth of Massachusetts
i w 1 Department of Industrial Accidents
Office of Investigations
ti i;;is'' 600 Washington Street
�
Boston,MA 02111
c www.massg ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name(B iness/0rganization/Individual): 1 S I G
Address 2 r' 3
v2468
City/State/Zip:' Phone #: — 3�
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2 91-I-am-a-sole-proprietor or_partner- listed on the attached sheet. t 7• ❑ Remodeling
`ship%and=have=no:employe,e�.�'' These sub-contractors have S. ❑ Demolition
working4or me in.an-y, capacity.. rkers' comp. insurance.
✓ 9. ❑ Building addition
[No,workers' c_omp insurance S. We are a corporation and its
required:]'` officers have exercised their 10. Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t. employees. [No workers'
comp. insurance required.] 3t0-.Other..___ _� Y __-�
'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.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penaltiiesof perjury that the information provided above is true and correct
Si afore- ' .�.�. "A bj CA"4,4 Da�e- "" , ZO/
Ph one#: a SDI — 3� 2 - Z 3 f 4
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
Contact Person: Phone#:
A
Information and Instructions
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
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §2SC(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'1S2, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter inio 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 u
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)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 insurance. [f 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 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 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 thai a valid affidavit is on file for future permits 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 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 should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number: !I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-8,77-MASSAFE
Fax # 617-727-7749
Revised S-26-05
wwvv.mass..gov/dia
r
07/15/2010 12:08 812-867-0547 ANCHOR IND PAGE 03/04
IMPORTANT DOCUMENT
Certificate of Flame 1ssistance
ISSUED BY Date of Shipment
07/07/10
Registration Number nJOMU5T SIR Tent IdentlficetionF140.1 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to: �s
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
% T
i Certification is hereby made that:
The articles described on this Certificate. have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108890C (1)
I
Description of item certified:
CENT MATE EXP END 40X20 SNYDER
WHITE WITH"BARNSTABLE"LOGO
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADELPHIA.OH
Name of Applicator of Flame Resistant Finish
Signed:
AN NOR INDUSTRIES INC
I
i
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �,�� Parcel .3 2_ Application # 0�6
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address sYJ30 j#tt16Jf9 Atine. 14"
Village &&Sf Akrad'al/c.
Owner T" of A rnsfab/e Address S4�t-
Telephone J406OW' it. ` l
Permit Request T ta/' i• ap•6. U/ %t C 'red .4-1Aii*/ T sy G
kD4PWI IYo�H Q/
en
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family .❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
i
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No . Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
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 ❑ No If yes, site plan review #
--__:Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) p �[
Name � � Telephone Number J y0 ( Z�` �S
Address J7 W M� kw License #
6' OIL—Home Improvement Contractor#
7-6 k Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
I FOR OFFCIAL USE ONLY
f
t
APPLICATION#
DATE ISSUED ���
=MAP/PARCEL NO. s
ADDRESS '� VILLAGE
OWNER
DATE OF INSPECTION:
r' FOUNDATION
FRAME
5 INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT v
,e
ASSOCIATION PLAN NO.
• The Commonwealth of Massachusetts
Department of Industrial Accidents
=. Office of Invas#gations
600.Washington Street
Boston, M,4 02111
UV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Budders/Contractors/EIectricians/Piumbers
Applicant Information Please Prinl'Lepsibly
Name(Business/Orgmization/IndMdual): �7
•Address: �Z/ S ,�t.�/h9JMaJG aLdy S,6,r jocrZ
City/State/Zip: a)-S, No. . OA 4(,r Phone.#:
Are you an employer? Check the appropriate boxy
4. I am a general Type of project(required):
1.❑ I am a employer with ❑ g ral contractor and I
employees(frill and/or part time).* have hired the stib-contractors 6• ❑New construction
2.❑ I am a.sole proprietor or'partft=-` listed on the'attached sheet T. ❑Remodeling
ship and have no employers These sub-contractors have g.'❑Demolition
working for one in any capacity, r,=ployees and have workers'
[NO workers'•eornp.-in.surance mp.m iranceJ 9. ❑Building addition
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 I LEI plumbing repairs or additions•
myself [No workers' comp. right of exemption per MGL I2.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.9Other
comp.insurance required
*Any applicant.that checks box#1 Est also fM out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arm doing aH work and then hire outside contractors must submit a new a$davit indicating such
$Contractors that check this box must aSfaehed an additional sheet showing the name of the sub-ontactors and state whcthcr or not those entities have
employees. If the sub-contractnrs have anpIoyar,they must providt:their workers'comp.policy number.
ram.an employer that is providing workers'compensation insurance for my employees. Below is the poficy and job site
information.
Insurance Company Name:
Policy#or Self ins.Lic. #: Expiration Date:
Job Site Address: City/Stata/Zip:
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 tip to S 1,500A0 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 statern maybe forwarded to the Office of
_Investigations of theDIA format rance coyerELZC verification.
I rlo hereby under the palms.-and penalties of perjury that the information provided above is'true and correct
Si e: Date:
Phone#. 'SA�"3ti z 070,3 9 6
Official use.only, Do not write in this areg to be cornpleled by crf},or town offzciaL
City or Town: Permit/License#
[6.
sstg Authority(circle one);
.Board of Health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
Otherontact Person: Phone#:
Information and Instructions
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 rwo 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,"const=action or repair work on such dwelling house
of on the grounds or bu lding appurtenant thereto shall not because of such employment be deemed to be an employer."
MCr`L chapter 152, §25C(6)also states that"every stafe 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 prodaced•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 perforrnamc.of public work until acceptable evidence of compliznce 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-contractor(s)name(s),•address(cs)andphone numbers) 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 insmance coverage. Also be sure to sign and date the affidavit.' The affidavit should
be retnmed to the city or town that the application for the permit or license is being requested,not the Deparhnmt.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 enter their
Self insrnan,license m er 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 permittlimnse number which will be used as a reference number. In addition,an applicant
that most submit multiple pmmit(license applications in any given year,need only submit one affidavit indicating current
policy info=ation(if necessary) and under"Tab Site Address"the applica.t 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 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 btim 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 C6mTnmw-Wth dMassachus s
D(,Paz#m=t Qf Indust*Accidents
of Me of IszVest g' -ati Yrs••
600 Washington St Qet
Boston,MA 02111
Te. #61-7-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-J70 i
:vLmd 11-22-06 t
www.m=.gQv/dia
oFErati Town of Barnstable
Regulatory
gvI Cory. Services
�* Thomas F. Geiler,Director
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
as Owner of the subject property
hereby authorize _ �
to act on my behalf,
in all matters relative.to work authorized bythis building permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:F0R MS:0 WNERPERIMISSION
r
Town of Barnstable --
o„ Regulatory Services
• { f
sAxtvsrAsrs. : Thomas F. Geiler,Director
NAM
-Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable ma us
Office: 508-8624038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE
JOB LOCATION:
number street village
"HOMEOWNER'". -
name home phone# work phone#
CURRENT MAIL NG ADDRESS:
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.
DEFINMON 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 B arnstable 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 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 pmon(s)for him 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 Super isors,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.-'ne homeowner acting as Supervisor is ultimately 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 helshe 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 ammd and adopt such a fnrm/certification for use in your community.
Q:\WPFIL.ES\FORMS\homeexemptDOC
O'/15/2010 12:08 812-867-0547 ANCHOR IND PAGE. 02/04
r �� IMPORTANT DOCUMENT
N"Eui
.y0 INC 1/0 Certiflcate of q7lame Wfsistance
W I J—D(,0 ISSUED BY Date of Shipment.
07/07/10
cKenRegistration Number
F140.1 INDUSTRIES INC. Tent Identification
�j•> 14877530
EVANSVILLE,INDIANA 47725 .
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inhe-ently noninflammable) and
were supplied to:
13ARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
H q
-
kE'rp'
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code_ All fabric has been tested and passes NFPA 701, CPAI 84.
i
Serial#
8108985(1)
Description of item certified:
CENTURY MATE EXPANDABLE END
40WX20-SNYDER WHITE VINYL
Flame Retardant.Process Used Will Not Be Removed By
Washing And Is Effective For'The Life Of The Fabric
SNYDER MFG 14 PHILADELPHIA OH
Name of Applicator of Flame Resistant Finish
Signed: �l / !
ANCHOR INDUSTRIES INC
r
tt, 07/15/2010 12:08 812-867-0547 ANCHOR IND PAGE 04/04
IMPORTANT DOCUMENT
Certificate of Flame 1&sistance
ISSUED BY Date of Shipment
07107l10
Registration Number
F-12110 DINDUSTRIE INC. Tent Identification
14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
5000 SHERIFF'S PLACE
BOURNE, MA 02532
%ST
N �
9�Fj� �►QQ`
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8105402(8)
Description of item certified:
TENT WALL L&S2 8"1 OX22 WITH
2 CATHEDRAL WINDOW WALLS
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
TRIVANTAGE STATESVILLE NC
Name of Applicator of Flame Resistant Finish ,/
Signed; �
AN HOR INDUSTRIES INC
r
07/15/2010 12:08 812-867-0547 ANCHOR IND PAGE 03/04
A ,
' IMPORTANT DOCUMENT
Certificate of T&me Wsistance
ISSUED BY Date of Shipment
07/07/10
Registration Number nAftINDUSTRIESNC. Tent Identification
F140.1 14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to:
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
SST
2
• Certification is hereby made that:
The articles described on this Certificate. have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84,
Serial#
8108890C (1)
Description of item certified:
CENT MATE EXP END 40X20 SNYDER
WHITE WITH"BARNSTABLE"LOGO
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADEI_PHIA,OH
Name of Applicator of Flame Resistant Finish
Signed: -
• AN HOR INDUSTRIES INC
Bares
The Town of Barnstable
Office of the Town Manager Iff 367 Main Street, Hyannis MA 02601 All- merleaclly
la"NSMLE, : www.town.barnstable.ma.us Office: 508-862-4610 Fax:508-790-6226
MASS
E13�A,. APPLICATION FORM '� `- ` zoos '
USE OF PROPERTY,PARADES,MARATHONS,TRIATHLONS,ROAD RACES
The approved application must.be on file in the Town Manager's Office at least thirty(30)days proor t ent.
Parade/Road Race a licat'ons must be.received nine 90 days prior to scheduled date.
��.
Date of application: 7— - ?i '!Q i
Fee amount: $43.00 per request*:Total paid: YES(ck#_ OR cash) O V
*Each request means each event such as a parade,followed by an event on the Town Green,for example.
This application must be complete/all signatures prior to submitting to the Town Manager for final approval.
You may be required to leave application at various Departments'to wait for appropriate signature.
1. CALL TOWN MANAGER'S OFFICE TO TENTATIVELY RESERVE DATE OF EVENT-CHECK AVAILABILITY
Request for: Hyannis Village Green Aselton Park Parade
BenefitRun/Walk Marathon/Iriathlon Other lease sP ecify):W�17 %�✓hy���-�-
(P
Certain facilities may require additional fees for services by DPW depending on location, use of staff&size of.
event The fees will be determined by DPW and paid directly to that department.
2. Name of Event: WL5�: tL5A VA, 1ACZ'16k1& � `ih
Day/Date of Event: Z6 1 Rain date:
3. Name of Sponsoring Org nation: (7 r�'
Mailing and physical address: 66 Y X b 014, SC �� • �l 04,(1
04 o �6
4. Contact person: Ky L V f� Phone: •75-Z Z-
5. Person in charge DAY OF EVENT: Y^/5 U&;-k— Cell phone:
6. Setup time: Actual event start and end time: 1(4v" 'y/)"-flean up time: 7 �,✓r
7. Estimated number of volunteers/participants:
Estimated number of spectators: ZD C-0
>>POLICE DEPT will determine if extra detail necessary.
8. Admission fee/registration charged to participants9 ZNo If yes: Amount:
Will there be food or craft vendors at event? V Yes No
>>If yes,indicate the number of vendors and type(food/merchandise/etc):
>>Will there be merchandise available for sale? Yes No • N/A
Vendors need to complete application for special licenses at the Licensing Division-200 Main Street,-Hyannis.
9. Map attached(REQUIRED)for road race/parade evert.
>>Are street closures required: Yes ✓ No
>>Detail of route and rest stops attached/indicated on map..
10. Food prepared/served at event?v Yes No
>>If yes,will there be cooking/heating involved? Yes No
TENTS REQUIRE ADDITIONAL PERMIT FROM BLDG DEPT.
Structures&Grounds have designated tent friendly zones.
Should you require tent elsewhere other than these zones,location needs to first be cleared with Structures&Grounds.
>>No open flames in tents or propane storage use without a fire permit. /
11. Are you installing or constructing any structures, including buildings,climbing structures,etc? _Yes v No
12. Are you installing any tents or c es? vYes No
r
Quantity and-size: Ow r rent? Rental company: Tel#
13. Do you plan to have any sound Zes
fication? _Yes No_Music _Other(please describe)
14. Is electrical power required, No
(for sound amplification(PA system),lighting,popcorn machin ,etc)
>>If yes,circle: will you provide portable generator? O will you require TOB temporary seyvice? �5
>>List maximum wattage required and location for hook-up: —�
If more than'usual'hookups,please note there will be overtime costs if Town Electrician setting up and removing
"A-frame"or drODDinq service before/after event outside of business hours.
15.Do you have need for barricades/cones? Yes No
>>If yes,describe for what use:
DEPOSITS: $5.00 each cone. $50.00 each/barricad1ess((quantities/deposits arranged through DPW).
16.Will you require access to the to building? ✓ .Yes No
>>If yes,describe for what use:
17.Do you plan to drive vehicles onto property? If yes,provide details:
Specific loading zones to be reviewed with DPW/Structures&Grounds.
Organization will be liable for any damages vehicles may cause the ground.
CONIFORT STATIONS.. • cTOILETS
18. Do you plan to provide portable toilets and/or hand washing sinks at your event? Yes No .
>>If yes: #of regular toilets #of handicap accessible toilets #of hand washing sinks
Public Comfort Stations located at Town Hall Parking Lot, North Street and Barnstable Village Fire Station are
open from 9AM to 9PM,daily. If event absolutely re uires early open,it must be reviewed with DPW.
GARBAGE
19. Trash pick up is the responsibility of the organization requesting this permit. Please provide your plan for
the cle p and r o al of azb and recyclab)es during and after your event:
Number of recycling con ers: D
' 0 Number of garbage.receptacles:
A one time disposal fee for use of Town containers may be assessed. Any fee will be determined and collected by DPW.
The cost is based on size of event.
20.Will there be demos,displays,materials that are potentially hazardous/impact public safety?_Yes VNo
>>If yes,describe:
21.Have you made any provision for on-'site security? _Yes_ o
22.Have you made an provision for on-site medical services? es No " .
23.Please provide description of your parking plans(where event attendees will park): 5 r
>>Plans for disabled parking: v V ✓ -Z.
>>Plan for emergency vehicle access:
>>Please describe your plans to notify residents,businesses impacted by this event: 5-t 5
•
24.Will the event be advertised? If yes,where: We S• T
>>Do you plan to distribute flyers or ads before or durinj this ent? V Yes No
>>Do you plan to place any signs or banners or other adverti�ment at the event si ? f,/Yes No
>>If yes,please indicate where: L
>>Provide sign/banner detail and dimensions and method of attachment or suppo
(Signage may require additional permits).
I have read, understand and agree to abide by each numbered item on the attached "Rules
and Regulations for Use of Village Green and other,Town Property" H "Rules and
Regulations for Parades, Walkathons, Road Races" and as the agent for the sponsoring
organization, agree to abide by said rules and any o ' r special n itiorys (letters may be
attached)established for this particular event.
Ig ture of sponsoring agent/Date
Printed Name: �j 1rlS �t` Kam'
APPROVED BY: .
DATE:CHIEF OF POLICE -Ll&
�C
hz
(Barnstable Police Department, 1200 P inney's Lane,Hyannis 508-778-3805)
CHIEF OF FIRE DEPT(S) DATE:
(Village Fire Department,Addr ss ary)
RECREATIO DATE: / z—
(Hyannis Youth&Com uni ent Lane, 8-790-6345)
PUBLIC WORK DATE:
(382 Falmouth Rd.H nis 508-790-6400)
REGULATORY SERVICES DATE:
(200 Main Street,Hyannis 508� 62-4674)
BOARD OF HEALTH Pi ` ATE:
(N/A for Parade/Race permits unless serving food.508- 62-4
D 6 4)
BUILDING DEPT DATE: /c�• —
(N/A for Parade/Race permits unless erecting tents. 508 862-4038)
TOWN MANAGER '�iL DATE:
(Town Hall,367 Main Street,2" floor,Hy ands'508-862-4610)
SPECIAL CONDITIONS and ANY FEES(As determined by Department's above)
DETAILED AS FOLLOWS
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel-' Application
6 6C '
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
Project Street Address
Village ✓� _
Owner V`vl Address
Telephone I
Permit Request l s14'
✓
D 2l 3 &
41JBF C/
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
J �S
Total Room Count (not including baths): existing new First Flop Room Count coy
<_ _
Heat Type and Fuel: 0 Gas ❑ Oil ❑ Electric ❑ Other
O
Central Air: ❑Yes ❑ No Fireplaces:.Existing New Existing wood/coal-stove:�7 Yes ❑ No
Detached garage: ❑ existing Ellnew size—Pool: ❑ existing ❑ new size _ Barn! 0 existing ❑-anew size_
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 #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �,.5 Ti.e epfione Number T ��—a 7✓�
Address j �IS I/U(�Q` License #
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE- ^_DATE�-" L
i
F
c FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP./PARCEL N0._..
{ i
i
t4
'a ADDRESS_ VILLAGE
OWNER
6
i r
f
i-
'4 DATE OF INSPECTION:
FOUNDATIOW.
FRAME
E INSULATION']
FIREPLACE
r
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
fr
3 ` GAS-:;� . < -iROUGH ;i' ire FINAL
S
r FINAL" BUILDING:,
j.i.
'T DATE_ CLOSED-OU_T :
2 ASSOCIATION:PLAN:NO. -
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
UqF 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: 36
6
City/State/Zip: "v ' /5� Phone #:
Are you an employer?Check the appropriate b916, Type of project(required):
1.❑ I am a employer with 4. • I am a general contractor and I
employees(full 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. insurance.1
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 I LE]Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
=Contractors 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify r nder the pains and penalties of perjury that the information provided ab ve is tru and correct
Si ature: 7 Date: za l
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: Phone#:
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
�,�._,t• , Office of Investigations
600 Washington Street
I.:""/" Boston, MA 02111
cv '" www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
=amp{Business/Organization/Individual):
Address:
r i y/State/Zip: ..�j QVh„f7(A.6��, 1W ad!!;'Phone #: Sd� ` 4 A-,;7—
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.ff TTx -a ssole-proprietor-or-par-tner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity., ,vGorkers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance S. We are a corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no 12.E] Re6ofrepairs
insurance required.] t. employees. [No workers' 13`[�Jd 0tFier'
comp. insurance required.] — - - -
'Any applicant that checks box#I 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy.#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
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 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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ldo hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Cignafore--_' _ 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 S. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
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
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house'
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §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-contractor(s)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 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
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 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 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 each
year. Where a home owner or citizen is obtaining a license 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 should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The.Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
]3o.ston,MA 02111
Tel. # 617-727-490.0 ext 406 or 1-8'77-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
w«!w.mass..gov/din
07/15/2010 12:08 812-867-0547 ANCHOR IND PAGE 02/04
N, )Eu IMPORTANT DOCUMENT
jvo Certificate of T&me TSAa4nce
Date of Shipment
ISSUED BY
Registration Number
F140.1 IND CKGRUSTRIES INC. . Tent Identification
14877530
EVANSVILLE, INDIANA 47725
MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN
This is to certify that the materials described have been flame-retardant treated (or are inherently noninflammable) and
were supplied to: ,s
BARNSTABLE COUNTY CORRECTIONAL FACILITY
6000 SHERIFF'S PLACE
BOURNE, MA 02532
�S
of CALF
r
RE'rp
Certification is hereby made that:
The articles described on this Certificate have been treated with a flame-retardant approved
chemical and that the application of said chemical was done in conformance with California Fire
Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84.
Serial#
8108985(1)
Description of item certified:
CENTURY MATE EXPANDABLE END
40WX20 SNYDER WHITE VINYL
Flame Retardant Process Used Will Not Be Removed By
Washing And Is Effective For The Life Of The Fabric
SNYDER MFG NEW PHILADELPHIA.OH
Name of Applicator of Flame Resistant Finish
Signed: ��'l�
ANCHOR INDUSTRIES INC
��•t �tt SZ' a
`yyf•`A. l.i,
,'
7
offis
W. arning
KEEP ,ALL. FLAME AND HEAT SOURCES AWAY
FROM THIS TOP FABRIC
is top is made with flame resistant fabric which meets CPAI-B4
cifications. it is not fire proof. The fabric will burn it left in
tinuous contact with any flame source.
e application of any foreign substance to the top fabric may
der the flame resistant properties ineffective. Importantl
refully read and follow the instructions provided with this
uct. k.
f 00%a Polyester o Made in USA
INTERNATIONAL E-Z UP, INC.
1601 Iowa Avenue Riverside, California 92507 USA
DICE (909) 781-0843 FAX (909) 781-0588 • www.ezup.eom
THE l The Town of Barnstable Barnstable
o„ Office of the Town Manager F 367 Main Street,Hyannis MA 02601
sARNSTARM = www.town.bamstable.ma.us Office: 508-862-4610 Fax: 508-790-6226 11111.1
�••� APPLICATION FORM
USE OF PROPERTY,PARADES,MARATHONS,TRIATHLONS,ROAD RACES 2007
The approved application must be on file in the Town Manager's Office at least thirty(30)days prior to event.
Parade/Road Race applications must be received nine 90 days prior to scheduled date.
Date of application: •' _
Fee amount: $43.00 Pe request*:To ppaid. YES(ck# OR cash) NO
*Each request means each event such as a parade,followed by an event on the Town Green,for example.
This application must be complete/all signatures prior to submitting to the Town Manager for final approval.
You may be required to leave application at various Departments'to wait for appropriate signature.
1. CALL TOWN MANAGER'S OFFICE TO TENTATIVELY RESERVE DATE OF EVENT-CHECK AVAILABILITY
Request for: Hyannis Village Green Aselton Park/. Parade -
Benefit Run/Walk Marathon/I'riathlon Oth�r as
Certain facilities may require additional fees for services by DPW depending on location,
event The fees will be determined by DPW and paid directly to that department
2: Name of Event: �I b� y1•l�l 1, /t� [i i�l� ►% fe �' l[ tr
Day/Date of Event: I Rain date: . r il' Z
3. Name of Sponsoring Organization: Ai J:t
� � n
Mailing and physical address: /,� L4 2c, W it n
r l
La) o /Z.. he9 ,F
4. Contact person: !/1.` �(� ;/K— - . �' C7 Q I f— Phone: G t ' -7 74, — 1-7S2-
�
,
5. Person in charge DAY OF EVENT: .��i S C b-! L- Cell phone:
6. Setup time: I OM Actual event start and end time: 10611119 :,Clean up time:
7. Estimated number of volunteers/participants:
Estimated number of spectators:
>>POLICE DEPT will determine if extra detail necessary.
8. Admission fee/registration charged to participants? /No If yes: Amount:
Will there be food or craft vendors at event? Yes No
>>If�yes,indicate the
�nu'mbbeer of vendors and type(food/merchandise/etc):
>>Will there be merchandise available for sale? v1 Yes No N/A
Vendors need to complete application for special licenses at the Licensing Division-200 Main Street,Hyannis.
9. Map attached(REQUIRED)for road race/parade eve
>>Are street closures required: Yes No
>>Detail of route and rest stops attached/indicated on map.
10. Food prepared/served at event? Vly�es _No>>If yes,will there be cooking/heating involved? t//Yes No
TENTS. STRUCTURES.ENTERTAINMENTIDEV ICES*Allach inap Jbi-hiyoul ofe%'ent inchidin2 struclure placement,
'TENTS REQUIRE ADDITIONAL PERMIT FROM BLDG DEPT.
Structures&Grounds have designated tent friendly zones.
Should you require tent elsewhere other than these zones,location needs to first be cleared with Structures&Grounds.
>>No open flames in tents or propane storage use without a fire permit
11. Are you installing or constructing any structures,including buildings,climbing structures,etc? Yes L"I'No
12. Are you installing any tents or canopies? Yes No
Quantity and size: �L Own orient? Z Rental company: Tel#
13. Do you plan to have any sound amplification? I.Yes No_Music Other(please describe)
14. Is electrical power required? Yes No pDYli' ,4 n���,,u,. �Z2✓���
(for sound amplification(PA system),lighting,popcorn machine,etc)
>>If yes,circle: will you provide portable generator? OR will you require TOB temporary service?
>>List maximum wattage required and location for hook-up:
If more than'usual'hookups,please note there will be overtime costs if Town Electrician setting up and removing
'A-frame'or dropping service before/after event outside of business hours.
BARRIERS.
15.Do you have need for barricadestcones?_ Yes No/
>>If yes,describe for what use: L*-k t a),J,14
DEPOSITS: $5.00 each cone. $50.00 ea h/barricadless((qu�nt ies/deposits arranged through DPW).
16.Will you require access to the to��jbuildm 7 LI Yes No J
>>If yes,describe for what use: _ TLI t � 5 � M-Z !t C Slt d�nJ ��lZ/1? ( P `VEHICLES
�
:,
17.Do you plan to drive vehicles onto property? If yes,provide details: / (� / it 55 f C_ (�.'a Y
Specific loading zones to be reviewed with DPW/Structures&Grounds.
Organization will be liable for any damages vehicles may cause the ground.
• Ac
18. Do you plan to provide portable toilets and/or hand washing sinks at your event? Yes_No
>>If yes: #of regular toilets' #of handicap accessible toilets #of hand washing sinks
Public Comfort Stations located at Town Hall Parking Lot,North Street and Barnstable Village Fire Station are
open from 9AM to 9PM,daily. If event absolutely re uires early open, it must be reviewed with DPW.
GARBAGE
19. Trash pick up is the responsibility of the organization requesting this permits Please provide your plan for
the cleanup and removal of garbage and recyclables during and after your event: ��i uf.-4,y?o 5 �/
' -Number of recycling containers: I r Number of garbage receptacles:_a� Kr c (•l S
V i✓ A one-time-Aispo ,for u es of Town containers may be assessed. Any fee will be determined and collected by DPW.
The cost is based on size of event
20.Will there be demos,displays,materials that are potentially han, doushmpact public safety?_Yes L/No
1 >>If yes,describe:
21.Have you made any provision for on-site security? I/Yes—1 to
22.Have you made any provision for on-site medical services? 1/Yes No
23.Please provide description of your parking plans(where event attendees will park): .-r, Y'i^,1/,62. ky X e. 5 ��
»Plan for disabled parking: t��' V
>>Plan for emergency vehicle acce s:
>>Please describe your plans to notify resid nts,budmesses impacted by this event /�!>:G'- G✓G5�
24.Will the event be advertised? If yes,where: /f, ('r
>>Do you plan to distribute flyers or ads before or during this dent? V Yes .,No
>>Do you plan to place any signs or banners or other advertisement at the event site? V Yes No
>>If yes,please indicate where:
>>Provide sign/ba er detail and dimensions and
d method of attachment or support �.
„i-O till,
(Signage may require additional permits). ,�
I have read, understand and agree to abide by each numbered item on the attached 'Rules
and Regulations for Use of Village Green and other Town Property" // "Rules and
Regulations for Parades, Walkathons, Road Races" and as the agent for the sponsoring
organization, agree to abide by said rules and any they special conditions (1 ers may be
attached) established for this particular event. t/J ( C,/_ / �� , z 1 2 l�
'Signature of sponsoring agent/Date/
Printed Name: ►'(S L'16-t r
APPROVED BY: 2
/
CHIEF OF POLICE DATE: L�
(Barnstable Police Department, 1 tOO Phi ney's Lane,Hyannis 508-778-3805)
CHIEF OF FIRE DEPT(S DATE:
(Village Fire Department,Addresses way)
RECREATION DATE: 7 c ( '
(Hyannis Youth&Communi Ce Bass t e,Hyannis 508-790-6345) 7,
PUBLIC WORKS DATE: !/
(School Admin.Bldg,230 South Street,4 1 r 08-862-40 0) 1
REGULATORY SERVICES DATE:
(200 Main Street,Hyannis 508- -4674)
BOARD OF HEALTH ry I✓1 - !'I j 03 DATE:
(N/A for Parade/Race permits unless se g food. 508-862 6 )
j�
BUILDING DEPT 4ATE:
(N/A for Parade/Race permit(!!�M
08-8 -4038)
TOWN MANAGER DATE: 1711,5
(Town Hall,367 Main Street,2"d floor,PI annis 508-862-4610)
SPECIAL CONDMONS and ANY FEES(As determined by Department's above)
DETAILED AS FOLLOWS: