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Home My WebLink About0264 PARKER ROAD r' t Oxforcr NO. 1521/3 CM MAW N EM13E �� --� � # .. J Y7 , 1 -. I 1{ � � * r � � � � � �� .V - � �7 ��._.,��+k._�—.,,,__..,,_ — - ... � --—+.ram - � �e � • ■ � `,. .. � - � _ � ! , .. �.k ; � i Town of Barnstable *Permit# � Expires 6 mo hs rom issue date Building Department Services � fee aAtitvsTABIA : Brian Florence,CBO 16 Q. ]Building Commissioner I, 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number / (/ Property Address �6 ❑Residential Value of Wor�k--$-'Z Q - /Minimum�fee of$35.00 for work under$6000.00 Owner's Name&Address t�AV 1 � /V - C�/3l�'IE�QO� � 1� ,eAgk44 S",Vs 44E Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one:' Wam a sole proprietor am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name 'Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ t(check box) [v]Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to e'oy,.A M. .fit 6452g,a L ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. ,SIGNA QAWPFILESTORMS\building permit forms\EXPRESS.doc 08/16/17 r G` Tlie Comn onivealth of Massadliusetts . j Deparhment oflndustrial Accidents - O f ce of Investigations { - 600 Washuigion Street z ti Boston,ALA 02111 *vrvau mass govIdia i Workers' Compensation Insurance Affidavit:Bu ildersiContractarslEIectricians/Plumbers Applicant Information Please Print�b 1V Iv ame(BUSm8ssx)rg Im ionand a): r—� /�y l 1 ) /V Address: 2 K.E e City/StaWZip: S—r Lr Phoneme SCi� �� 07302 Are you an employer?Check the appropriatUTL Type of project(required)- I.El am a employer with 4. a general contractor and I Ioyees(full sirdfor part-time)-* have lured the sub-contractors 6. ❑New consf�iction 2. a sole proprietor or partner- Tasted on the attached sheet 2- [ Remodeling ship and have no.employees These sub-contractors have 8..❑Demolition wodring for me in any capacity. employees and have wodmrs' 9. ❑Building addition [No w-ork=s'comp.insurance comp_inanranmi required_] 5. ❑ We are a corporation and its 100.❑Electrical repairs or additions 3.❑ I am a homeov«er doing all work officers have exercised their 11.❑FZ=f grepairs or additions. myself[No workus'comp_ right of exemption per MGL 12. C. 152, 14 and we have no +�+�+�n�e required-]F § { k employees.[No wo&us' a El other camp.insurance required.] *Any appticmt&at checks has R nmsi also fill out the section below shmmy,then workers'campensation policy informsfion_ i Iinmeawners who sabunt ibis affidaslf-&c-=_9 they are doing aU wank sad then hie outside connsctors mast submit anew affidavit indicating sorb_ Zdanttactots that check this boar must attached as addifiand sheet shovribg the name of the sub-co wncom aDd state whether or not those entities have enrp901jees.Ifthesub-contotetarshaaeemplafb_,%they=nTpmuidetheir worken'romp.policy number- I am au eiunplopr fliatis prmzding itorkers'corWmsaffaii iitsziratce for uty enrpingees BeNv is idle policy and job site informatiom Insurance Company Name: Policy#or Self-ins.I.ic.#: Rkpiration Date: Job Site Address: City/StaW25p: AEtach a copy of the corkers'compensation policydedaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 andlor one-year imprisonment,as well as civil penabies.in the form of a STOP STORK ORDER and a fine of up to$250-00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations ofthe DIAL for insurance coverage verification. I do Hereby cetWfl,rinder thepains m ,ape/nabYes a Fury thatthe informafiart provi&d abm�e is trues avid correct Date: Phone 0 Official use only. Do not write in this area,to be completed by city ortoirn offl at City or Taws: Permitffikense# Issuing Authority(circle one): 1.Board of Health 2.BuRding Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts Geheral Laws chapter 152 requires all employers to provide wolkers'compensation for their employees: . PurSUant-to this sfaftift-,an elrrplayw is defined as."_..every person iu the service of another under any cont-act of hire, axpress or implied oral or wattea" An vnpinyer is defined as"an individual,par[nershi;p,association,corporation or other legal entity,or any two or more of the foregoing engaged inaJomt eat Parse,and iucTn�the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However tho owner of a dweIling 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 ma;,,�ce,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 sues 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 corumonwealth for any applicant who has not produced acceptable evidence of compliancewith.the inssurance.coverage requireth" Additionally,MGL chapter 152, §25C(7)staters"Neither the commonwealth nor auy ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the in srcran ce._ req Tired eats of this chapter have been presented to the contracting aurthodtyf Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sob-contractors)name(s), addr zs(es)and phone number(s)along with their certificates) of insurance. Limited Liability Companies(LLC)or Limited Liabi f-Partnerships(LLP)with no employees other than the members or pmtaeas,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is reguued. Be advised that this affxdaYrt maybe submitted to the Department of Industrial Accidents for conffimatioa of insur�ce coverage. Also be sure to sign and date the affidavit The affidavit should be retained to the city or town that the application fur the permit or license is being requesi:ed,not the Department:of lodn,strialAccidents. Should you have any questions regarding the law or ifyou 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 t Please be sate that the affidavit is complete and pried legibly. The Department has provided a space of the bottom of the affidavit for you to fill out in the event the Office of Investigations has to coact you regarding the applicant Please be sure to fill i a the pen iiVlicense nuunber 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 cureat p olicv infbir ation Cif 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 fartare*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 vent re a dog license or permit to bun leaves etc.)said person is NOT reqdred 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. 'fie Commmwed&of hbtssa.chusetts IIepartnent cf Iuidustzal Accldont% Q��e ref Xu•�P��tio� 604 wasbivau Stcee-t Bastau,MA FI l U . Tt,-L 4 617 727-4900 ext 4-06 car I-M-M&SSA E Fax# 617-727 7749 Revised4-24-07 macsgavldia I WE Town of Barnstable Building Department Services • sesxsrwBis. • Brian Florence, CBO 6.A Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs 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 by this building permit 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 Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 Town of Barnstable Building Department Services ' Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 ' www.town.barnstable.ma.us• Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION p DATE: 7 Please Print � / ^��_ JOB LOCATION:6�4 Z��&1— 6 /N. U A✓1Nf I�(�L�C number street . / village "HOMEOWNER": �rt✓ t 0 C��6eON JP name Q home phone# —7 work phone# CURRENT MAILING ADDRESS: l� Z2. #- 4 3 / 02-aP cit)*own state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellines 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 pro s and require en andt he/she will comply with said procedures and requirements. Sig6at06ofHomeo er 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 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\building permit fornu\EXPRESS.doc 08/16/17 PROJECT NAME ADDRESS: C12(4 �i42.lCss.L w PERMI*r#. I ^1 PERMIT DATE:.- I Z. LARGE. ROLLED PLANS .ARE ilia. BOX `L. . SLOT Data entered m':MAPS program on: G M Assessor's Office(1st floor) Map -1 Parcel 1 Perinil> ��o Conservation Office(4th floor)(8:30-9:30/1:00- 2:0 1� sued Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) 0S 2) Engineering Dept. (3rd floor) House# , p ie -4�57 �E Planning Dept. (1st floor/School Admin. Bldg.) l�S3ALLED 9N . CE Definitive P ppr ed by Planning Board 19 ENVIRONMENTrN AND TOWN OF BARNSTABLTjR°N REGULATIONS Building Permit Application Pr • Stree ress Village I&), *' Owner PAO 6 t LOWC_,9---d CAMF.�-A-) Address Telephone ` Permit Request ! First Floor J pip square feet , Second Floor �3ao square feet Estimated Project Cost $ lotJe��od Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House ND Unfinished Old King's Highway Number of Baths 7 No. of Bedrooms Z_ Total Room Count(not including baths) First Floor 3 Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other l Builder Information Name ,� ��o �L �1t1jV Telephone Number. Z— Address ? 3AA"7L,i kp License# 63 Home Improvement Contractor# h Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE - �� t 9 — BUILDING PERMIT DE D FOR THE FOLLOWING REASON(S) �- FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED - - MAP/PARCEL NO. - ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION a FRAME INSULATION FIREPLACE. ELECTRICAL: ROUGH i FINAL ' PLUMBING: ROUGR I-- FINAL , GAS: • ROI?'1 FINAL _ - L.@ FINAL BUILDINGo `': �; h! 4 '-1 • L _ In DATE CLOSED OUST=s gaA C1 ASSOCIATION PLAN,JIO. t.i v i l • f t � I Application to :¢ Old Kings Highway Regional Historic District Committee in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, iri triplicate,.for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 19.73, for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGOVR S THAT APPLY: 1. Exterior Building Construction: ❑ New Building EZ Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage ❑ Commercial .❑ Other 2. Exterior Painting: ❑ 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall- ' ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). ' Y_2:�174, TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK �'6+ PAR4c�cz, Q .76A" ASSESSORS MAP NO. I7& OWNER 2)A /?1J- -ASSESSORS LOT NO. 01 HOME ADDRESS .40 r FAQ � �� ARNSr�►�31 TEL. NO. FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). 2g Z- PP-rdc6t- 1_ '14ECex) LC.SCAc,�z-t- Gy> ?AR-,\/ AGENT OR CONTRACTOR B4D`&-1 > Ic,— 1441� TEL. N0. ADDRESS ZS_ _L•ll.A/?J'"- W' Bpi DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8, other side), including materials to be used, if specifications.do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). 13 � TJ• � �1" Signed Owner-Contractor-Agent Space below line for Committee use. �eceav ate �he Certificate.is hereby �/,?/I�o� � Date10 I ' : SEP :2.6199� ,�a � ,) _,,A7_6-VTOU.-I --'me CAL T01N^I OF 13RRaVSiABLir Approved ❑ IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal period provided in the Act. Disaooroved ❑ R 7 001 . L 17 HINCKLEYS LANE CTY05 TDS 500 WB KEY 104513 ----MAILING ADDRESS------- PCA9031 PCSO0 YR00 PARENT 0 BARNSTABLE., TOWN OF ( CON ) MAP AREA80AC JV MTG0000 CONSERVATION COMMISSION SP1 SP2 SP3 367 MAIN STREET UT1 UT2 133 .00 SO FT . HYANNIS MA 02.601 AYB EYB OBS CONST 0000 LAND 1336700 IMP OTHER ---'-LEGAL DESCRIPTION---- TRUE MKT 1336700 REA CLASSIFIED #LAND 0 1 ,336 ,760 ASD LND 1336700 ASD IMP ASD OTH #PL HINCKLEYS LANE W BARN DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE #RR 0722 5115 TAX EXEMPT 1336700 1336700 RESIDENT 'L OPEN SPACE COMMERCIAL INDUSTRIAL EXEMPTIONS SALE00/00 'PRICE. ORBC60006 AFD LAST ACTIVITY0.9/11/90 PCRN RCV F Window PCR/l at BARNSTABLE ( 28 ) 1p R177 002 L000000 MAIN STREET W . BAR CTY05 TDS 500 WB KEY 104522 ----MAILING- ADDRESS------- PCA9031 PCS00 YROO PARENT 0 BARNSTABLE , TOWN OF ( MUN ) MAP AREA80AC JV MTG0000 367 MAIN ST SPi SP2 SP3 UT1 UT2 32 .50 SO FT HYANNIS .MA 02601 AYB EYB OBS CONST 0000 LAND 331500 IMP OTHER ---=LEGAL DESCRIPTION---- TRUE MKT 331500 REA CLASSIFIED #LAND 0 331.,500 ASD LND 331500 ASD IMP ASD OTH #PL OFF MAIN STREET W B DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE #RR 0955 TAX EXEMPT 331500 331500 RESIDENT 'L 552500 OPEN SPACE COMMERCIAL INDUSTRIAL EXEMPTIONS SALE09/88 PRICE ORB6454/299 AFD V LAST ACTIVITY08/30/91. PCRY RCV F Window PCR/l at BARNSTABLE ( 28 ) ip Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION (, SIDING TYPE C �=�/t' S��✓1 "' COLOR CHIMNEY TYPE A01-0— COLOR ROOF MATERIAL Ct T COLOR PITCH WINDOW CPQti� SIZE PL-f TRIM COLOR J�l� DOORS J COLOR SHUTTERS COLOR GUTTERS DECK GARAGE DOORS COLOR SIGNS /� COLORS FENCE COLOR c;) rioT 8 p Fill out completely, including measurements and materials/colors to be used. Three copies of this 19 i form are required for submittal of an application, along with three copies each of the plot plan, k i k-,' landscape plan and elevation plans, when applicable. Plot plan need not be "Certified" except for new homes, but should show all structures on the lot to scale. SPECSHT gARNSTABLE. MASSACHUSEtTS ASSESSORS MAPS • 1•so.c • �o . O`er NIB N _ Z lops s •1.17 AC S d'� N JL V C6 ,p ti0 o y 19 • � E 2 ta.70 na Z' 15.60 AC-S I,t - I . _ � �. • � r--- • i � d 1� L_ Y 1 ' o c ,. o u � �� '� w r o, o,G C"• ✓ .+ G ` � O � O ..� � V m� � A b �� S � � O A G • M ;y O p • p N ` ` � G N � A v Y G A O N V O .. .. � a = � O N V . � , f N ( � O � � 11.,� _ = O . � N JjjJaa � o� � P �� Z � i ..�14�. f» C •6 ~ aC d OHL W � O pOG O=L O6D 4�kff {i�tr� 5f tad" y,a :`.. � �' ��' �.� `` '.'m N Y' f _ � 0��: ,� .g ; �;..� e� K �� 1 a� i � "✓� A.K �fi,+ � • � , °FINE r The Town -of:Barnstable BARNSTABM � `� Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: A b D),r `�/`� Est.Cost _610 j ow Address of Work: �# Qv Owner's Name PAJ)6 . CpMC--lL o d Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Massachusetts Department of Industrial Accidents Office o!/nvesMallow 600 Washington Street Boston,•A1uss. 02111 Workers' Compensation Insurance Affidavit Applicant ntormation: ....:_ /_ ) name: � ��-� K-- &JA l�( l location: 2_'!�_ lL L am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity f:,•.,^:'•��+:'MU !�� A'Pt;R'!fr,!s^SIyS.T...l'T_!�.�4iT.V'63['." *e�"?7�T.°�'y^Luw+t {r'a.+FA' .T!!`Y�•M�Tq'IC'�'....ww.tr•.�4C� L.......iie..__ ^L .tvRi _-S{�:xh9i,.WnA�,.�.� � ':l`2Y�'ihJ'�'i�sY. :..��' '` ,"^`�''r-•^_ _ —'�.�lar f+':��r_�.�r.� I am an employer providing workers' compensation for my employees working on this job. company name: add ress' city: phone#• insurance co, policy.# ,.... ...:...._.............:;::,�+..,.s_• :g:...y -..,r- •x1R" '"+^'r{}.-a;..m•.-.+-..ew,..s�...r-;•sw. «.�...•.-�.•.......e I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name- address: city': phone#: insurance co. policy# ._...... ...... ...W e o - t..r - -G:"f;'Y:.:'._ ♦fY4n^e-.p ..1'T.^-I �vr ir:;n -..�IC�r•:^!-'ri. _ ,sy« �?r�•c*+ :--r e.. ,>r': ;+x� :��?�-,�!:r.r.,vfr;!�r;-.5�•:t;-.,...�'c:�:m.�? -T�_'°•..�:,.: ._.._s_..._,.u..- �__-.._'.:.iw:a•_,_ ".::a::1i►s:►� �.�.:.�'=..: _— company name' address• city• phone#: insurance co. policy# :Afiach idditioiisfshct i if'eeiessary� "' � ;rv•L rr r;•�st may; ,r�;�a;'"O c ,�r4 -.' ;�.._;� _"�y�"' �;via: Failure to secure coverage as required under Section 25A of 1%1CL 152 can lead to the imposition of criminal penalties ot's fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine orSloull a day against me. I understand that a copy of this statement may be forwarded to the Offtcc of Investigations of the DIA for coverage verification. t do hereby if•unde tl pain and pet a ies of perjun`that the information provided above is true and correct. Si_nature � Date 'Print name k 'zipz 7QA V<��d Phone# `YoL�� official use only do not write in this area to be completed by city or town official �< city or town: permitAicense# riBuilding Department C3Liccnsing Board U0 check if immediate response is required ❑Selectmen's Office } C]Hcalth Department ' contact person: phone#; rJOther "'_.r,:1"_-:;:a--..-.-rr:.n,i.,ate^. ,�a'-+'ywe':^,�-;try: - :'3:.,-v.�.s.•..-•Q• (revised 3,95 PJA)' . Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers* compensatian.for their employees. As quoted from the "law", an enrpl( tree is del fined as every person in the service of another under any contract of hire, express or implied, oral or written. An enrplt trer is defined as an individual. partnership, association, corporation or other legal entity. or any two or more of the foregoino engaped 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 dwellino 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 charter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or rene'Wal 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 authority. 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 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. Tile Department has provided a space at the bottom of the affidavit for you to fill out in the event tite 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. The affidavits may be returned to the Department 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. r+Yaw:r.-w.•.—.-..,.,...-,...-,�r.r,-o..•.- :.-� .. �:1,e.. -"n•+xA^•lrr.•ego_,s..r•,cawrRw.rtj�ow+.*..�.-r+-m-,.,r. •+.•.s+i►.+vw..s�•� �q-srr.-rr.�,n-.•^•w,.•�n.-r+e,.nw• a The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 g'Dept. (3rd floor) Map —f ParcelEermit# �1 S House# Date Issued Board of Health(3rd floor)(8:15 - 9:30/1:00-4:30) 0-Y 11 Fee-AN, Conservation Office(4th floor)(8:30-9:30/1:00-2:00) , I�(5 ✓� ��; j,. i bard 19 �� dj') ' BARNSTABLE. MA61 SS., p TOWN OF BARNSTABLE Building Permit Application Project Street Address Village (J ?ADWSTAI3(—C., mla Owner Cp�64-16,k) Address Cc-) Jw'A'I Telephone ci . 5 Permit Request ADD/Ti First Floor square feet Second Floor square feet Construction Type IJDzy� CJZpvh-G Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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 dcrawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) � Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing�l/A NeVVP Half: Existing New No. of Bedrooms: Existing n/A New IVA 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) 'Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information �+ Name � �DF p ��VE Telephone Number'36ff Z Address (��1?�ti/�lLLr R'� License#. O0n9-2'� yv,p Home Improvement Contractor# �DJ Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DJNIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY - � DATE ISSUED: MAP/PARCEL;NOi ADDRESS 1 VILLAGE OWNER i k DATE OF INSPECTION: FOUNDATION 7 FRAME INSULATION FIREPLACE 5 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT . ASSOCIATION PLAN NO. 70co,Y=of s7B�E_.- Coi✓s�2vAriow A/Z�A �� CS BA f P2op�iz7ry t/y6s P�2 BK.3oS7 PG. 27/ r cB / ID' i i o Z��s'/ ate WOOD �2H,o , Y v p �� J t D.FI. La FIND. /y072r' PIZOPERlY G IAI rJ 4-5 SN o wN 01V 49977244 4.C. pGR�✓ DD NoT AG2EE �//7'i�/��PGDESUz��u�o� CERTIFIED PLOT PLAN Go�vS. �'/V.S7"�U/�e�✓T S!//Z!/Fy TLE�Dn�s�EnivEl� �Vo�. THE PrzO12E/2T y 00 Es iYcr F.4tL w�Ttf��+/ LOCATION 26 ?' F2T��w�{,?�vs7'!QBhl�}SS q /GH ffAZfl�o �LOD� 20 vE,�zdN�* aC•'��}S SCALE . 3D.� . . DATE . :/3.P Z -S#dAVN q^1 G0InMVNIT y PEEL No. 2-0000l-00/1C PLAN REFERENCE /ngP`2F�rsF o .gvGrrsT i 9, /98.E BY f�./►�. �. ,3,Gy�B�.--sf�P�T3-,�gtio��f��/IHsTko[� $ol�r�E E!�ivE�/zl�G.Co• _S�/1vEya2s . O.£�GEiriBE� 28/!y6s7 sEPIEm/�Fi� !s 14 OF M /96q : �Ci9L E, Sonno "�T TD�sv /�✓� JOH G I CERTIFY THAT THE �, SHOWN ON THIS PLAN IS LOCATED ON THE GROUND . . . c NEWT AS SHOWN HEREON v "' 30 O DA1/io N•.� leY"1f�4 i.✓ NO SUR DATE w o S . PETITIONERS . . �� EsT REG. PROFESSIONAL LAND SURVEYOR suuecr�..; #264 parker Road, West Barnstable, Mass. T6 , Whom It may concern: i I have examined the certified plot plan of property located at #.264 Parker Road, Went Barnstable, pMass. aa prepared � P P by John L: Newton, Registered Land Surveyor, and in my opinion the buildings as shown thereon conform to the zoning setbacks' of the town of Barnstable. Date 'O�� Building Inspector Town of Barnstable I. PM,770i✓ �j�iys'��G�-�Ss� sso.Ls p A,10 / 7eo MASSACHUSETTS-; ;,:. .; kps za . it ry O IL 6 G S y VA. op a PAP �t2'� o L to 2.37 pp o : : ` The Commonwealth of Afassachusetty � «:J Department of Industrial Accidents :tr Ofllee01fivesfiffs0os 600 fl ashinl ton Street Boston,Mass. (12111 Workers' Compensation Insurance Affidavit — - Annlicant information: name: ,;624,DF&Q4D hIAXII location: ZJ 15A&A'JNJi-L. A-0 Q Q Z.—D75 j ❑ am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity ❑ 1 am an employer providing workers' compensation for my employees working on this job. company name' address: city phone#• - inctir•ipolicy# _.r. - a sole propn for g r homeowner(circle one)and have rZhe contractors listed below who have the •ers' compensation polices: citt, phone#• insurn Ice co. policy# t,�:..��ri.. �. -:..T. — wens✓�'..�.•:7t�ssy? ?' !SC:sSg;', COpIDA IV name: d .. City nhonc#• insurance Co. nolicv# ;'Attach additionnal'shcit if cess � •r < .;- •.�:''t"""��.",�.,"�..,".�."" - .-.us.1..,-__w•L"+.�r.;'_f`�'<•,tr`.Y":a rrr �.:.;Syr trt�' .::. ;..w.... 'SLtG.ril.Jw'!�m Failure to secure coverage as required under Section 25A of hIGL 152 Can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a COPY of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certif--under lite gains and pena/ties of pedurt•that the information provided above is true and correct Signature pate � ��i 3/ Is Print name ' k d Loe----" Phone# /+++Z-b Z--gV f- official use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department oUcensing Board check if immediate response is required OSelectmen's Once ONealtb Department ' contact person: phone#; nU I er In„sed 3M5 P)A) . �r _, rye",`r.. ��.=•-�r• ]>>Ai••..'�i�.r t7Ito m. �IDMp�5(R.IROit• t� 1 •� .� M1\t f i ..t O"WON EALTH OF I' DEPARTMENT . _;�, > CHUSEMASSATTS - ONE ASH UBUC SAFE a 1[erito { BOSTON;MA p110a�u .E `d'^" IDossurt� Jf D(PIRATION DATE - "Ills` 4 a, Nj . S !01 TR , RESTRICTIONS 9S Q EFFECTIVE Y -� +, t t '; i' CAUTI HI CTIVE DATE r too 06/30/-19,9' i ,5 :FOR PROTECTI N AGAINS}>- ?I g 3QS.392 I i THEFT PUT RI HT THUM . 25 BARpH11 dkN �� BOX ONLI ENSE WEST Ano w• PHOTO WE OPR ONLY) F y R p s �. AR 0?6 BLASTING O 00 .;; ".,ti:^MUSTINCLU E PHOTO. . I ' • HEIGHT: NOT vAuo uNnl, 54ol JUG 2 r THIS OOCUMEN7 MUST: _ ° -' j r CARRIED ON THEpERSON r �J I OTHERS.RIGHT THUMB PRINT � THE HOIOER WHEN B I ! F - GAGEDIN THIS OCCUP TITi TUBE OF 1SEE f , 4EINF�Tj`- A �J \E SI • - n• :�.�• .. :°ter' y.f' '�+�� yel!�. 'e�•'- 7f:°.�i.,y. .�. .a., r=•• •, •v., .. �•(\':4. .. I' f fl1•,{i ]l�f•�1"': • .,.4•.>.•„Y. ... •�.• I• .:Lr. ,.. .- .� .. .'•M.�a..........,.,. . :v'.�•.� •'J•..i-_'L:•1..Ib;:i'..._�.: '�'`��',•.-..I t.a�Litca:d ev.✓.i.l�r'::S•2�'�r;ilr'::.6'a,'1'•i...:.�•✓� �..(._- _ _r _ l�fce Restricted To: 00 17117 DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE 00 - None Nuaber: Expires: 16 - 1 1 2 Faaily Hones . Restricted To: 00 Failure to possess a current edition of the Massachusetts State Buiilding Code BRADFORD K HAVEN is cause for revocation of tlis license. t " 25 BARNHILL RD NEST BARNSTABLE, MA 02668 • _ , ' -t ; ti ^',� �. ti:1 ram.- isTV .l '. ri QV�MdIT''C'DI#TR�T . `i fi�p►�- I1RO'I9T9U� Expiratla #7114t94N InAfart 1. Nov", �►ea Tip 21 AA#SrAw '