HomeMy WebLinkAbout0018 PARKER ROAD RIX
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-UPC 12543 _-
-- - No, 53LOR
- - -_ - HASIINGS, MN
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map j Parcel Permit#
Health Division Date Issued
Conservation Division CL,5. / 7 G a - Application Fe
Tax Collector .. Permit Fee D
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address ►fie
Village 41,_ i3A--iz,, tj t3 Lur
Owner l3 s o e)iz rA L C iR�.,c rZ —�,- kn Address
Telephone S—t)k— TO I A q)� o v i c �Iess,
Permit Request R,,�5 (k�- o_r ti
Square feet: 1st 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 Er' 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:Cl 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
BUILDER INFORMATION
Name Telephone Number
Address License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE , DATE r r lJ
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
A
MAP/PARCEL-NO.
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ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
's
FOUNDATION
y FRAME
4
INSULATION
5
S
f FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
} FINAL BUILDING
DATE CLOSED OUT
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ASSOCIATION PLAN NO.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
-= Office of/nsestiffa inns .
600 Washington Street
-- . Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
XXX
name
location: �/ q
city phone# -3C of= 3�d Y 1
❑ I am a homeowner performing all_'work myself.
❑ I am a sole r rietor and have no one workin in an capacity
❑ I am an employer providing workers'•compensation for my employees working on this job.
name ...............
:,. _..::.
iOmDaAY .......
D kone
xXX
....................................... .. ........ ... ...... lr .. .....
❑ I am a sole proprietor,general contractor, or homeowner(circle one) and have hired the contractors listed below who
have
the following workers com .:.:.:.::::.......l..l.c...e.s:
...... .... . .. . .... : : :: ..................................:...::.:::::::::.::::::::::..................
`:comma v n
addfi s
mom
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.............. ....................... .:.1ii:;:.;. :.:...........................:................:...:..
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XXX X.
M.
xx
can..name.......................... ..................
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ci ":::::::.::•:.:................................ :............
Q ?E"E ?` 'E`'`3'`isisz? >it?iE `Etz' i '``?ii ````'•:':>AE`` 2
1L11i11'A2rCe:::L'0.:::s::<:::>;:z:::s::>;;;;•:;r::::;:,:>.>::%:::i:;:::;::::;::::::::%;::;::%;:;':;:;::`:::2::?::�;:<:.;:.;:::< ;:':::.......... .... ..
Fafiure to secure coverage as required ender Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine np to 51,500.00 and/or
one years'imprisonment as well as dvfi penalties in the form of a S 1'OP WORK ORDER and a See oP 5100.00 a day against me.'I imderatand that a
copy of this statement msy be forwarded to the Office of Investigations of the DIA for coverage verification
I do hereby certify under the pains and penalties of perjury thatYhe information provided above is true and correct
Signature Date
Print name Phone#
official use only do not write in this area to be completed by city or town official
city or town: perndt/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectrnen's Office
Health Department
contact person: phone#; ❑Other
Oevised 9195 PJA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees-. As quoted from the"law", an employee is defined as every person in the service of another under any contract
of hire, express or implied, oral or written. 4
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 section 25 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,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
authoritq s'
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit.- The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required.to obtain"a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the 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 permrt/license number which will be used as a reference number.. The affidavits may be returned`tn .
the Departrnent by.mail or'FAX unless other arrangements have been made. -
The Office of Investigations would like to thank you in advance for you cooperation and should you have any 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 Investigatlons
600 Washington Street
Boston,Ma. 02111
fax#: (617)727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
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_SUN-07-02 01 :21 PM WEST BARNSTABLE FIRE DEP 5083623683 P. 01
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WEST BARNSTABLE FIRE DISTRICT
a 1601AEETINGHOUSE WAY
WEST BARNSTABLE,MA 02668
(508)362.3241 FAX(508)362.3683
FAX TRAINSWTTAL SHEET
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TO: FAX# &3
ADDRESS: too
FROM:
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Total pages sent—$
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