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HomeMy WebLinkAbout0051 PETER BLOSSOM LANE ®kfCFd(DNO. 152 1/3 ORA E 10% , T SSELTE D i PROJECT NAME: AAJ DT ADDRESS:/ ©.Q rt,,v PERMIT# PERMIT DATE: M/P: © - Oo'7 — 00 LARGE ROLLED PLANS ARE IN: B O �a SLOT_ Data entered in MAPS program. on: � BY: ��^ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map %Parcel 009 ��€' Permit# ' 5TQ / 0 C Health Division _ 7 ab q e Dat&4s%"d- 00 Conservation Division �� �#n p4iUU6 PIS 1: 11 Xfo Tax Collector GI 0�/o Treasurer i&4MTEM MUST BE Planning Dept. INSTALLED IN COMPLIANCE WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REGULATIONS Project Street Address c5 , -o3<�Om Village . OV-bi �nr"n'� Owner f Address Te ehon�e j eP rmit�Re uest al it .11 q Square feet: 1 st floor: existing proposed_ 2nd floor: existing -- proposed Total new, Valuation*—)z Zori ii g District ` Flood Plain Groundwater Overlay Construction Type '�' ` '� COKE DETECTOR REQUIREMENTS� � Lot Size r igh ff o If yes, attach supporting documentation. - AR v TRIGGE I NEW BEDROOM WILL uETECTORS Dwelling Type: 1U%O0 SEJ• Iffbpi y t��Wits:)TT O t� I RAge of Existing�t cti reLgtSt e `es t o�- On Old King s Highway: �Xes ❑ No PLAN w gPPROP f" Basement Type: O ff0TR r"aw1 T aIp ' cn E�. E DErHrc i r T. �� T TAR Basement Finish�'d i�r �. t�. _ Basemert Unfinished Area(sq.ft) �SC� 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: P Gas ❑Oil ❑ Electric ❑Other Central Air: IXYes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes Vo Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:Vexisting ❑new sizdJ Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization Cl Appeal# Recorded❑ Commercial Cl Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name &e,i rd Telephone Number _ Ad ss J License# T�% U Home Improvement Contractor# Worker's Compensation# U2 CA DO5 � ✓�� ALL CON ST CTION DEBRIS R U STING FRO HIS PROJ CT WILL BE TAKEN TO j SIGNATU� DATE v� 1 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED r MAP/PCEL NO. ADDRESS VILLAGE _ {+ OWNER DATE OF INSPECTION-- FOUNDATION ,6 FRAME 07 oft l0�/ /B INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ' ROUGH ,�„ FINAL GAS: ROUGH 0 Y,_ o FINAL ., FINAL BUILDING S S tn o 00 DATE CLOSED OUT tit s s0�n ASSOCIATION PLAN NO.' f17 I RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renoviations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE C9_square feet x$96/sq. foot= o2U (9 �x.0031= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE i square feet x$64/sq.foot= x.0031= plus from below(if applicable) GARAGES(attached&detached) r - square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf '50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq. foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) t Inground Swimming Pool $60.00 Above Ground-Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee .The Commonwealth of Massachusetts f=a Department of Indusrrial Accide= ��� dNIIGT OtlDY�9�oas - 600r Nrtzshin;roa Street Bevan. Mass. 02111 woricars' Campeuafzon lnsur-sncn affidavit I city -hone L, f a hom--cwner per�crmins --if •Nark mvse!f. I rrn a sale propriecor and'nave no one workma in any c=ac:r/ ' f am an emplo - vidinz workers' a ensarian tqt my e:nni vets working an tis job. ,ddrL•-f- v W d' LCI in r..rt _c ��� nli rj• (�l� f am a sole proarecor, gener_1 con=c:ar. or homeowner(c-n-`e one) and have hired the contr=ars lisped beiaw who have the following workers' compersarion polio: corn LtR`,rtame• 3�d city' vhorte ar COR7QAny'RAiTt . add rrr city- iR I ! C9T1 Failure to secu coyerage wire&under' ' bICL M can esd to the imposition of criminal peoaities of a Gne up to S1�00.00 and/or one rears'im risonmcnc 123 civil pestaId a the rm f a STOP% RK ORDER and a fine of S100.00 a day agzittsc me 1 uudcr=nd d=c a ropy of this scat ay be forwarded to Office of 1ny the DU rar coverage verifietion. I do hrreby p the irr ormaden provided above is mw and Corr= Sigffataue Dau Z SITZ 1 Pri n�tne Phone�. � J oflicial use only d not wrtte is rftu ar= be pieced by city r town ofrici2f.. city or town: I �rmitllicrase x r,Building OgDrd C:Uc=ing Bo a check if immediate response is rrquiml asciectmcn's aHcalth Oepa contact person: phone,t: rl0ther I T..w 1011 PIA . °FTME,°,fy Town of Barnstable Regulatory Services I )B3 rABLM& ` Thomas F.Geiler,Director y M,►ss. $ `�AIE6.39-,ta`0 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT' HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, -improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other ) requirements. Type of Work: Estimated Cost Address of Work: Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law 4 Job Under$1,000 []Building not owner-occupied []Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN P T OR D t G WITH GISTERED CONTRACTORS FOR APPLIC HOME OVEMENT WO O NOT HAVE ACCESS TO THE ARBITRAT N PRO G Y FUND ER MGL c.142A. S P ALTIES I hereby appl�ff a permit as th gent o 0 Contractor me a eg tration No. ate . OR I' Date Owner's Name ✓die i�anvma�uaea/� o�✓Gr'aaoaclucaekd Y{" BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 2809 Birth /11/1954 F Expires: 03/11/2d06 Tr.no: 17369 Restricted: 00 EVERE BOYJR PO BOX 186 sw W DENNIS, MA 02670 Acting Cc mis oner ✓!e Vi omnna�u�eal�i o�✓l//,aavac/u�aelta Board of Building Regulations and Standards _ HOMEI ROVEMENT ONTRACTOR Registration: 101380 Expiration: 6/2 //2006 Type: Private Corporation REEF R TY LIMITED Everett Boy,Jr. 24 School St./Box 186 �L--•. "`� West Dennis,MA 02670 Administrator i Town of Barnstable pF•SHE ip�� Regulatory Services y-rAat.E. Thomas F.Geiler,Director SAN W-S& Building DiviSIOU Tom Perry, Building commissioner 200 Main Street, Hyannis,MA 02601 . Www.tayn.b arnstable.ma,us -.. Fax 5508-790-6230 Offiae; 508-862-4038 Property owner Must _ Complete and Sign This Section If Using A Builder CU ,as Qwner of the subject property I, hereby authorize L to act on mybehalf, In all matters relative to work authorized by this building Permit application for. ( ddre s of ob) Si a o er .Date . V � not Name Application.to -� Old Kings Highway•Regional Historic District Committee in the Town of Barnstable for a TOWN Of BARNSTABLE CERTI FICATE OF APPROPRIATENRY"-Z AM 9: 18 Application is hereby made,-in triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below an :on � S tngs or p otographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building $ Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage 9 [] 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). _ TYPE {-PRINT LEGIBLY DATE_ �S• o ADDRESS OF PROPOSED WORK 'U���� �% A SESSORS MAP N �dnp.nry c t-Urge, s 7-b OWNERi* ASSESSORS-LOT NO. ME ADDRESS �j .,� U �`'� � TEL. N0. L �r� 01:)_(9 W-) ALL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). ' n _ n ME}R CONTRACTOR6aad, TEL. NO. es ADDRES ran 0%76 {n f 4 DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done (see No. 8, other side). including <Taterials to be used, if specifications do not accompany-plans. In,the case of signs, give locations of existing signs and proposed 1 orgcations of new signs. (Attach additional sheet, if necessary). b. i •j- Signe ' ra or•Agewat_ Space t)elow line for Committee use. Received by H.D.C. AD r Bu\ k4i Date The Certificate is.hereby Date Time By , apf,roveci i= IMPORTANT If Certificate is approved, approval is subject to.the 10 day appeal period provided In the Act t) is Ilia. , SMOK ECTO S REVIEWED IMPORTANT - UPGRADE REQUIRED a J013#10N JOB#1229 STATE BUILDING'CODE REQUIRES THE UPGRADING OF BARNSTABLE BUILDING DEPT. DATE SMOKE DETECTORS FOR THE ENTIRE DWELLING WHEN ON OR MORE SLEEPING AREAS ARE ADDED OR CREATE©. 1Tw.) 12" FIRE DEPARTMENT . g' NO E: A SEPARATE PERMIT IS REQUIRED FOR THE EOUIRED FO�,R G Ix6cou�R INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL Tk5®4e"o- EMTINGFE 1:!IT DIES NOT SATISFY THIS REQUIREMENT. zx 1?7�ERS 01G,Or-gw. ®16"0.-(TW.) ATTIC m 16"04(TW.) EXISTING BUILDING HOIGE TWAR HgXoE Ex 8 O.G.,rT5. R-39 INSLI WRAPpf.) ��Pp•) 16"OG(M,) IN OG pn 112"CDX i/z"CoxA. }W-T ROOF SFONC�ES RY'/vD.(ryp.) R•131N5U_ R-13 WaL (�•) ') 2 X 4 X 7'4'5TID5 3/4"T&G FIYND. 2 X 4 X 7'-4"5TID5 EXISTING ®16"OL.(TW.) CE&NAL(TW.) a 16.Or-Mr..) ® BUQDING DAW PROOF R-t9PL�U_ DAtYFRODF EX5TING • _ ��GRADE 2 X 10 RR JSTE, ow..) BELOW GRACE BIRDWG - 1 X 5 CCKNFR 8"x 3'-9"CON- 0 12"Of".) CRAWL 5F'ACE FOLPD.WAUS BOARDS(RY.) FOUND.WALLS RED CEDAR OAWARD5 ® 'TO THE WEATHER 16'X F CONC.FTC6. w CON-DUST WAR ROOF OVERVIEW W#"NAYOW.) OVER COWA.CTED 50L NOT TO 5•,ALE FRONT ELEVATION CROSS SECTION Ex5TING BULDING 12" MTY4G 9.. BLILDY r A5PHALT ROOF 5HINCiES . ® ® EX5TPIG• EXST WF4TEODAR SHWCl.E.S ® �TW6 05"TO THE WEATHER i X 5 CORNER Effl BOP,R05 WHITE CEDAR SHWES 1 X 5 CORNER ®5"TO THE WEATHER BOARD`'(f W) IBM RIGHT ELEVATION Lot 9 Feter Blossom,W. Barnstable REAR ELEVATION Scale: 1/4"=V-0" DrA by.FROF05ED te:ADDITION Da 5/5/04 REEF REALTY LTD. GeorgeRuesa REVISED: 5/27/04 ELEVATIONS (Sc SECTION A 1 OF 2 i ADDITION J013#1229 &'X 3'-TCOW-FOLM. WAI15 ON 16'X 9'G(XC BEAD M6.W/KEY WOW TYPE 97E ROUGH OPENING 1 DOUBLE HUNG 24465 2'6 1/8"X 4'-9 1/4" (2)#5 RE-ROD 0 1?-0.'0 FOR ANPER5EN WINDOW5.VERIFY ALL MEAS.IN THE FlElD. Tcrabmcm OR. TYPE 517E ROUGH OPENING A INT.SWING 2'6"X 6'6" 2'-8 1/2"X 6'-8 1/2" E5 INT.f3I-PA% 6-91 X ro'-G" 6-2 1/2"X 6-9 1/2" vw WALL PETAL 5CAE--1/2"=V-0' — — — — — - -- — — 16-C, ............. 61 11 e WAILL5 ON WX 91'CCNC W x 3�-9 ALL5 O CaCONC.N 16'X 9?'CO FOUND.NC- EMTU,* 5PREAD FrC6.(TYP.) I I BREAD"c6-w/"(Tw-) !' 16-0 3/4" @ CUT 36'X 24 I � CRAWL SPACE iv ACCE%TOiv CRAM ePACE 16-4"x 14'-3" I in EXISTING �l KITCHEN EXISTING 3PCONCRETE M.BEDROOM N VU5T COVER N M.BEDROOM 13'-4"x 15'-0" N 15'-7"x 15'-0" EXISTING BASEMENT N AO I'� — — I 2 U N L — 40 Rffi-'�a MTW EMT WA)" HAU 5EE 0-1 cq 0> CLOSET N ILJEN 0 C) DZTNG Ld EMTNG WALK-PI R BATH CLOSET E)SM* LAUNDRY CV 7 FOUNDATION FLAN EXISTING GARAGE EXISTING GARAGE 250 5F.OF ADDITIONAL LIV.AREA Lot 9 Peter 13lo55om,W. barm5taMc FlP,5T FLOOR PLAN Scale: 1/4'.- REEF REALTY LTD. ty. Date: 5/5/04 1 George Pur-ae 250 S.F.OF ADDITIONAL LIV.AREA PEVI501. 5/27/04 15T FLR, & FOUNDATION A2 OF 2 . 00 1e\ LOT AREA 43,6 + -S.F. (1.00 + AC.) PROPOSED ADDITION JOB ##96-126 SKETCH PLAN -' PREPARED FOR r LOCATION : ASES MAP 88 PAR -8 REEF REALTY 51 PETER BLOSSOM LANE WEST BARNSTABLE ��,cr1�,► 0 SCALE : 1' = 50' c3' JOHN yGm Z. a REFERENCE : LAND COURT CASE '#40599 DEMAREST,JR. N 4 No.36859„ D M °FESSx qH�SURVEY EEMAREST—McLELLAN ENGINEERING 24 SCHOOL STREET P.O. BOX 463 MAY 18, 2004 WEST DENNIS, MA. 0260-0463 (508).398-10 DATE PR ESS NAL LAND VEYOR FENESTRATION DATA WORK5HEET Location: Lot 9 Peter Blossom, W. Barnstable Prescriptive Package: (Limited to 1 and 2 family residential buildings heated with fossil fuels only.) TABLE J 1.1.2.5.1 Prescriptive Envelope Component Criteria Additions Existing Low-Rise Residential Buildings Gross wall & clg. = 602 Wall K value = PI-13. Glazing area = 59 Floor R value = R-19 Glazing % = 10.2 Basement wall = R-10 Glazing U value = 0.59 max. Slab perimeter = R-10 4 ft. Ceiling R value = R-37 Heating % AFUE = &0% min. (Ceiling R value may be R-30 if full R-value is achieved over entire ceiling area) ? May use 5unroom alternative if Glazing is greater than 40% of the Gross wall area. Homeowner must sign the "Consumer Information Form" detailed in Section J 1.1.2.3.1. Note: The glazing for this project is 10.2% and does not exceed 40% of the gross wall area so the prescriptive method will be used. N ASSESSORS LAP.W KEY. Ereo NOTES: PARCEL. 7— EXISTING CONTOUR ——-- TEST HOLE LOGS Po • PROPOSED CONTOUR .............. 1.VERTICAL DATUM: ASSUMED FROM OVAD(NCVD a/-) CURRENT ZONINC., RF EXISTING SPOT ELEVATION: 215 ENGINEER THOMAS MCLELL .AN PA. L MUNICAPAL WATER IS NOT AVAILABLE, Laws BUILDING SETBACKS: PROPOSED SPOT ELEVATION: WITNESS: EDWARD BARRY cIDlr A F.r S:�' & M TEST HOLE:* DATE: 9-19-98 3•ALL PRECAST - I PVC PIPL f0 Be USED THROUCHQIf SEPTIC SYSTEM. t ALL PREL^AST UNITS TO CONFORM WITH ALSAfO H-IO d H-IO UTILIfT POLE:-O- PERCOLATION RATE: <2 YIN/IN LOADING SPECIFICATIONS FLOOD ZONE' C PENCE LINE.. S.PIPE P?CH- 1/! PER FOOT.(UNLESS NOTED OFHBRWISEl HYDRANT:b FH-I 9SD TH-2 DAD B.FIRST P OF PIPE OUT OF D-BOX TO Be SET LEVEL .gam t LOCATION YAP eLar o A H0,J itaV T.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE LOT 8(13b7J SP), q q RETAINING WALL D/A � d UA fffjl �UA USE OF A CARBACE DISPOSAL LOAN al °( ` RANDOM SET:• f roIa r 1 9 RoafrDN B.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE D sofil ON SII/LW LOAN STATE OF MASS.ENVIRONMENTAL CODE(TITLE FIVE)AND LOCAL 9v DW �� ,♦ _ SANDLOAN 2" S r To rlmr ADm/xc rRJA u SAT 6/8 C'Ho T ON sre ATE HEALTH REGULATIONS. SAND " .CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR qr �Alr �}[ SC er RDJVSON TO CONSTRUCTION. rr �, LOIN suZrr C�Lo" f0.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO ar 9r' , eF ZJr D/4 EXCEED 30. q C3 HOafrON ?INS SAND 11,D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. ♦ ` ♦ FINE SAN , adf r/4ox ` n<a CA HORlIDx r2.ALL UNSUITABLE SOIL(APPROX.T DEEP Cr RORIroN )f0 86 BELOVED AND REPLACED ,1'� '-___- ♦,`♦,`` , , SANIT LOAN WITH CLEAN MEDIUM SAND WITHIN S OF LEACH TRENCHES. % ,DL' z"D/r an C ♦`` ♦♦,` ` NO CAWNDaOSA SNCEUNTFRSD ISEPTIC SYSTEM DESIGN -- ' FLOW ESTIMATE: VALE•mr 'A9♦ _-- `,` ''♦ L BEDROOMS AT JIO CAL/DAT/BEDROOM-IX CAL/DAY ,e 'oLD rssr HOLE♦ ♦' SEPTIC TANK: bscr /a I Alb `\ ♦''�� , CAL/DAT z 2 DAYS-§0-CAL USE I5 CALLON SEPTIC TANK / p` " \fir ♦`� ♦ ♦p 3APAW LEACHING AREA: a OrOamr f7 OrrLLfMC USE 3 FLOWDIFFUSORS WITH 3'OF STONE ALL T.P.-0!D AROUND AND f UNDER (30 x f0 z S DEEP) 14 a rrd SIDE AREA (30 f f0)2 x 2 160 (7!) f1B CAI,/DAY q CueAef ♦ r ' ' �� ' BOTTOM AREA 30 s 10-300 SF (>!)-222 CAL/DAT zi-r N g f ,,♦ ' ' �, ' y TOTAL CAPACITY-�41Q CAL/OAT PROPOSED D►ELLINC Ak SEPTIC SYSTEM SECTION rPEunNE r cvvzxs Oa♦ w za 99D —I-►Irafx rriw 3/4 rIXISBSD OaADr TOP OF FOUNDATION ��oxr INSPSLT/ogx rovr8 I,ISHED STONE ♦♦, q �l Dr alrefx ov cRAnrJ --_M fR p c ` -- ---.dy 9558 ♦DSCI YIN; 1300 CAL 6LE9. D-BOX 9263 893 ♦ P>mmSrD 6LEV. SEPTIC TANK 83D (8'or EL6V. Y ELEV. ` ♦ a BrnRmr 9eD (9'OF STONE UNDER OR ELEV. STONE ♦ ♦® ,♦ ,DISLLNC MECHANICALLY COMPACTED UNDER 30 ♦si♦♦ ,rr.-99.0 , .� PJWPOSFD NrLL ELEV. ) ) 9f.5 3 FLOIDIFIT ISORS WITH Y OF STONE 1 % (13V FROAf!EACH ARSA) FEE SIZES: Ar av��r9S Ems• ALL AROUND AND f UNDER INLET:9'UP,fY DOWN (39 r roll.E DEEP) (H-20) OUTLET:r'UP.14'DOWN r ' ' ® ♦ UTILIT7 Cmarre Dahl as ,. _ rr,rfrxDarLs SITE AND SEWAGE PLAN a hIa HIK vaoPaatD ♦ _�teACHlxc AflaA) APPROVED BT: DATE: UTILnTCWS79 ' LOCAT70M- CDONCRSrHrr AND or LOT 9 PETER BLOSSOM LANE =� aLS9-mbsr w `a• ``�r 'e r'` rncr of PArr ,crz BEST BARNSTABLE.MA at r r>'O PREPARED JV p'r LANE REEF REALTY PETER BLOSSOM ph( DENARCST-NelELLAN rNOINESAINO SCALE: f-30' DATE: DIf/ 96-1Dr(OtDlRT 24 IDSCOWL Srx DDN a.Sxr Poear a ozaro REFERENCZ: LAND COURT CASE 0 40599B fHOYAS MCLELLAN.Pd. JOHN Z.DZMAREST JR,P.L.S. k TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY PARCEL ID 088 007 008 GEOBASE ID ADDRESS 51 PETER BLOSSOM LANE PHONE (617)582-9541� WEST BARNSTABLE, MA ZIP 02668- LOT 9 BLOCK LOT SIZE j DBA DEVELOPMENT DISTRICT PERMIT 22515 , DESCRIPTION SINGLE FAMILY +•DWEL°LING (PMT_#19543) PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.00 Ox CONSTRUCTION COSTS $.00 756 CERTIFICATE OF OCCUPANCY * 1ARN3TABLE. MASS. OWNER SPELLACY, WILLIAM & ADRIENNE i639' ADDRESS 6 SHORE DRIVE ED MI►� KINGSTON, MA BUILDI DIVISI BY DATE ISSUED 04/22/1997 EXPIRATION DATE rt , TOWN YY N V tf ..J7 BUILDING PERMIT PARCEL ID 088 00`7 008 GEOBASE ID ADDRESS 51 PETER BLOSSOM LNNE PHONE: (617)582-95 WEST BARNSTABLE, MA ZIP U2668— �U'1' 9 BLOCK F,0T S 121"E -- DBA DEVELOPMENT DISTRICT i "r"RNIT 1254 DES'.;RIPTION DINGLE FAMILY DWELLING (SE-'W_ PMT_ it 6—6 2 0 ) `r TYPE BUILD Ti`.CC,E NEW RESIDENTIAL BLDG PM1 14TRA-l'-TORS: 130Y, iEVE ETT W. JR_ Department of Health, Safef RCHI'1'.ECTS: and Environmental Service., �TAL FEES: $434.00 �Im .30CD $_00 CONSTRUCTION CCISTI: $140 ,000 . 00 103. SINGLE F A M HOME: DETACHED 1 PRIVATE P. ABLE, s MA83. 039. G'idER SPIELLAC' , WILLIAt•i & ADRIENNE: FDMA'�A JDRf,?SS 6--SHORE DRIVE BUIL G DIVISI , KItJGSTOtd, MA BY `-)AT .I ISSUED l_1/25/1996 EXPIRATION DATE HIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.E' ;ROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET C kLLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF TH 'ERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION I 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- PERMITS ARE REQUIRED FOR (READY TO LATH). PANCY.IS REOUIRED,..,S�UCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- �. ANICAL INSTALLATIONS. 3.INSULATION. ;OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. ;pill I ' � '' POST'THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION PROVALS ELECTRICAL INSPECTION APPROVALS 110 2 2 � 2 Y /7 IS Ir �..— 3 f I 1 HMTING �INSPECTION APPROVALS ENGINEERING DEPARTMENT -2 BOARDOFHEALTH OTHER:'.n Ll C kj SITE 01AN REVIEW APOROVAL -; _ WORK-Si :E; G l��' a L BECOME NU` �. �, 'E:. THE INF ,F".r,VEG' d WORK IS NC rggrr _ �S"''► )F DATE T- _ .. � . .. .+ n4Vti7Yif g.Oe fL�w�rt.'f^1Ar•-.Fw's v .-s1'.�1rri`.y,,•.d.r. iw r.41"r.II 7< <" .�! ».... -*�i`•slh^'i�' "KR _ �'�� �"` -�• �.•T'Mr�t.A1a"�- r+w�L:Q+S�✓�:L'�,�` w.di3..;"w.� r `OFtNE to,,� - The Town. of Barnstable BARNSf'ABLE. Department of Health Safety and Environmental Services 9 MASS. 059• �0 Building Division 367 Main Street, Hyannis, MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner / Inspection Correction Notice r t Type of Inspection -�n/S u -A T /o V Location6/ 7P7-V2- a S S 0 Permit Number / q �—q Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: -t✓o _771i LA ( A,le GAS 1 o g P e e 1q- O�C S�2 2Ti/LC� cJK f-4LC 7J a CPS 1 i Please call: 508-790-6227 for reeinspection. Inspected by r Date � ` y,.,v;..:,,-yn.;,n,ti,ri.,�.t`tilr„rr'yr;•''.'ir++7-..'t.+7ai' �-,r.,,�+:7+�. . :✓`.. -- ."R.,^�>,.r�...n..... .._s'+r..�.Had•�-i's^..:),.....�'^-�-ti.... - 'R'r'"�.""'s+oi`i:.r.... The Town- of Barnstable BARNSTABLE.MASS. Department of Health Safety and Environmental Services t6}q. �0 �Fo„�•> Building Division 367 Main Street,Hyannis, MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection /� � GI— Location u-1 �T�2. �ss �-3: o�%— Permit;Number 'Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: t'01V, V*)v nl 0-r Q.0,-T' �n ti M.) , J �a , R (0 012 —To t Please call: 508-790-6227 for re-inspection. Inspected by Date Assessor's Office(1st floor) Map Parcel S Permit# Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) Z Date Issued / Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) H 6 -, ;;7 Fee 07) .� Engineering Dept. (3rd floor) House# S-1 �fS �,� Planning Dept. (1st floor/School Admin. Bldg.) SEPTIC S ST BE lProjit n Approved by Planning Board (, 19� aIANCE L J + � e P4s �� 6 / ON E ODE AND TOWN OF ARNSTA�LE OWN 4REGULATIC':3 Building'Permit Application Addres �`� Village W Owner Address Telephone Permit Request \© C' c�y����"�� " �n�.�� `, ko;Q ' � X U u \moo L-­212'M �cwc� l.� �il7o Cs.�� car clak� 2� tic2 d First Floor \ \O square feet Second Floor� square feet Estimated Project Cost $ 1 140 l 000 Zoning District - Flood Plain C Water Protection Lot Size t LQ'1'1 c-L-3r,\--Yk Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use \J o—c _„�,�� \L�� Proposed Use Construction Type W cDco, ,- Commercial Residential x Dwelling Type: Single Family_Y\ Two Family Multi-Family Age of Existing Structure 3 `(\ Basement Type: Finished Historic House Unfinished X Old King's Highway `-t 2--1 Number of Baths Cr4 No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel'i�\�-0 C9c­!�� Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached a Cis Barn None Sheds Other _ Builder Information Namej�4� \��,L�� �v� � �Telephone Number 3°(4{ Address-�,� � \ �� License# O�`01%0 q r V\c c> O Home Improvement Contractor# U I Z%0 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 �/ — 1— 1c►to BUILDING PERMIT DENIED FOR E KLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: AL FOUNDATION 1 L a FRAME. INSULATION FIREPLACE ELECTRICAL:' ROUGH FINAL PLUMBING: ;ROUGH i; FINAL I � � 1 , GAS: PRO$kGHM FINAL FINAL BUILDING t� c j ''/: DATE CLOSED OUT M ? " > J ASSOCIATION PLAN=NO. f i i JAN.02 '97 99:51RI REEF REALTY LTD P.2 i 0 0 I a �j LOT 10 f I LOT 9 I 43,677 + S.F. "a. (1.00 ±Ac.) 4, x' LOT 8 04 v1 JOB # 96 1.26_I f CERTIFIED . PLOT PLAN PREPARED FOR it LOCATION : .USES MAP 88 PAR 7-8 PETER BLOSSOM LANE � II WEST BARNSTABLE REEF REALTY �f SCAU : 1" = 50' 'I RL'FEi'2L'NCE : LAND COURT CASE #40699 � I HEREBY CERTIFY TMT TM STAUCTURE � ZT. SHOWN ON TWS PLAN IS.LOCATED ON THECROUIND AS SIVWN HEREON. JAK it D j{ DEMAROV - McLELLAN ENCINEERI.?fC 24 SCHOOL STREET P. 0. BOX 46:9 DECEMBER 31, 1996 I WEST DENNIS, M 02670 "— (508) 398-7710 DATE �wjpos lOMAL LAND EYOR -57/ �Q � Application to • / Opt �' .t�p7� Old Ding's Highway Regional Historic District Committee, � r •o in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, in triplicate, for the issuance of a Certificate of.Appropriateness under Section 6 of Chapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans,•drawings or,photographs accompanying this application for. CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: �a New Building ❑ 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). TYPE OR PRINT LEGIBLY —� DATE ADDRESS OF PROPOSED WORK ASSESSORS MAP NO. a�� OWNER \\�c,� - Q�C �e—r`VV-- ASSESSORS LOT NO. , HOME ADDRESS � � 1.c�s�— � - `ct�V��s�'V�.Vh`t TEL. N0. FULL NAMES AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach additional sheet if necessary). AGENT OR CONTRACTOR yJ TEL. NO��O&3�4 -1090 ADDRESS P t 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). (�'Q.CJ �drC,.-` I t�t,C� 1 ."�1y��N\p}]qar-•UVT �0.. � ��� ♦�5 �`�`/1� / c�-eL\C� `�`(i a ��������r �Yrlf•71 ��j. l � ./= l//:�/ � 'i Signed -Atgrr Space below line forfCommitze2euse.= `-Cy '6°vnerC tra ceived-by H SC� �Dat� ��lhe Ce 'ficate is h reb Date w n Time SEP 2 41996 a Ij Brrt�Afnl r1F 63tl,RNSTABLE � � � o� Y.a LI]KlNG'8 I;I�:t�v�:�Y Approved ❑ IMPORTANT: If Certificate is approved, approval is subject to the 10 day appeal period provided.in the Act. Disapproved ❑ Town of Barnstable '"-- Old King's Highway Historic District Comm:sso4 SPEC >SHEET FOUNDATION p.� CphLQ �rp.,��'�� C.sL��y C\c.".��ocxta� '�r�S��c'�`a•1 SIDING TYPE �` ' ��.�.�.��� COLOR CHIMNEY TYPE lycx�� �- �RS�, COLOR ROOF MATERIAL �5,"��.�\� ���S COLOR �x�\ C9�c•� PITCH VZ� c, WINDOW SIZE 1 Z l 1 Z TRIM COLOR DOORS SHUTTERS GUTTERS DECK GARAGE DOORS cy\c, NOTES: Fill out completely, including measurements and materials/colors to be used. Three copies of this form are required for submittal of an application,' along with three copies each of the plot plan; landscape plan and elevation plans,<y when .. .applicable. Plot pp plan need not be Certified , . but should show all structures on the lot to �� � scale. TOWN OF BARNSTABLE OLD KING'S HIGHWAY HISTORIC COMMITTEE LOCATION: Lot 9 #51 Peter Blossom Lane West Barnstable OWNER: William and Adrienne Spellacy 6 Shore Drive Kingston, MA 02364 ABUTTERS: John Weir, Jr. 10 Desire's Lane West Barnstable, MA 02668 Laurie P. Snowden 1600 Falmouth Road Centerville, MA 02632 35 Peter Blossom Lane West Barnstable 85 Peter Blossom Lane West Barnstable 11 Desire's Lane West Barnstable .. _•jib. A/�_ .. .�—' > /<.. ♦ ♦♦ y_ ♦ ♦ ♦ ♦ DECJC pi oposeD DWEUJmrp ' ♦ ♦ L Sri.• 99D !, vARON L .:• .. �� DR1YE °� . ` � ' tlrany Cl t1STE , l 1By 9�. p �DOa �. �� r LANE • TER BLOSSOM PE DM y ,.r.,.:::,:t °• :..::' . r ,. "n. >'r: r,y.ti.•'t"�. ..,.. , ..'.adl....��'tali'•'a��h'fis'.&Njt11i4.{YM:Y•s7.ti. COO �� �� r,� �O� •• ,. . .. • CDQCQ�i.c-s'; N ASSESSORS MAP..' 6 =- _- KEY: - TEST HOLE LOGS Pg— - NOTES: PARCEL, 7-B- - _ EXISTING CONTOUR• ——-- PROPOSED CONTOUR .............. _ L VERTICAL DATUM:_ASSUMED FROM QUAD/NCVV a/-1 r CURRENT ZONING:Rom- _ EXISTING SPOT ELEVATION: 254 ENGINEER THOMAS McLELLAN.P.E. _ E.MUNICAPAL RATER.IS NOT AVAILABLE. LOC 18 BUILDING-SETBACKS: - - PROPOSED SPOT ELEVATION:25 WITNESS: EDWARD BARRY J 3.SCHEDULE 00-!PVC PIPS TO BE USED THROUGHOUT SEPTIC SYSTEM. beDypyT' :�y�S:1�R•-1� TEST DATE: a-f9-eB _ 6.,ALL PRECAST UNITS To CONFORM YITX AASXTO N-IO a N-20 UTILITY POLE: PERCOLATION RATE. <2 MIN/IN - - LOADING SPECIFICATIONS FLOOD ZONE: C - - FENCE LINE: - S.PIPE PITCH- 1/4* PER FOOT.(UNLESS NOTED OTHERPISE'k ' LOCATION MAP !HYDRANT:b TH-1 95D TX-2 OlD aFIRST P OF PIPE OUT OF D-BOX TO BE SET LEVEL C - . ELE9 0uzoAr /A HORIZON aLLY 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATB THE RETAINING TALL: LOT 8 43bTJ SF /�\ ( t TREE:i� joeg 2i°eD L OTR 2 j�O esa USE OF A GARBAGE DISPOSAL. I , \ RANDOK STAKE SET:• 6 fOlR P f B.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE B HORIZON S M°Dr!DW ai \ , \ sANm IDAN 3v zaT E e °Ia STATE OF MASS.ENVIRONMENTAL CODE(TITLE FIVE)AND LOCAL f00 FROM ADUfT/NG FELLB/B siN°o EOurr SANG HEALTH REGULATIONS. _ 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR ♦ ` MIX°sir°o sANm es NORIzoN TO CONSTRUCTION. 1� ,\``` `\\ /i/ ��•s!!a'r ctu Ssry B°CEto'toW a f0.CROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO Da 81- , \ GAT E/A EXCEED 3D'. ♦ \ ` \ C3 NOR]EGN ct eoRrroN TIME SAND 11.D-BOX TO BE PATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOP. FINE%AND j Z"7/4 BPS \ ` f8Y a HORIZON fE.ALL UNSUITdBLB SOIL(APPROX.T DEEP)TO BE REMOVED AND REPLACED \. ___-. ♦ \ ` , \ , \ _ WITH CLEAN MEDIUM SAND WITHIN 5.OF LEACH TRENCHES. ` I \ \ . ` \ ` IBM SAVOY IDAN zzr e/3 I % .' - ```♦ �````` ` ` NO GFOGN07QaR dNCQ/NTl%D - --__--_- ' ` SEPTIC SYSTEM DESIGN %\`` \ ' FLOP ESTIMATE: . �BEDROOMSAT-1_CAL/DAY/BEDROOM-Mk GAL DAY IIL6-0Or `0, / fe OLD TEST HOLE`, I i , �♦` SEPTIC TANK: DdCE fH lrgl I , I ` 330 CAL/DAY z 2 DAYS-660 CAL go USE 1500 GALLON SEPTIC TANK PROPOSED ap, I I ♦ LEACHING AREA: S Af GsZLLIJVcuNc I TJ.ti980 USE 3 FLOWOlFFUSORS PITH 3'OF STONE ALL AQ ee. AROUND AND f UNDER (30 z It?z 2 DEEP) 11 e p 74 SIDE AREA: (30+10)E z 2-f60 (7A)- 1f9 CAL/DAY GARAGE BOTTOM AREA: 30 s fO-SOO SF (Jd)-22E CA41DAY si-r :•i - so` °p TOTEM CAPACITY-340 CAL/DAY \ , I I , PROPOSED DWELLING SEPTIC SYSTEM SECTION 2•PEASTONB ; ' a1, , I . COVERS EJrHIII Iff OF 3/!-1 A>`` ♦`�♦ ♦♦ - `♦ _ar 99D FINISHED GRADE IONL INSPECT/N COVER WASHED STONE ``� ` _•, .. sH�'E TOP OF FOUNDATION to BC r/rHIN of CRAGS) ` �`\. _ - Ag ddd ` ® ELEVr•8E0 ♦ % I^7 \ \ ♦ ` `�♦ DdCd ` 7N 10 c \ -- ---^� 9555 e� ` . \ . ` `% , MIN;` ,_ ,. `;�'.:.. - --- - 5 fSQO CAL ELEV. �OF B9S �. % % % ` PRDf+OSED --- ELEV. SEPTIC TANK 93.0 . Y ELEV. t .i `% `\``` ` `E DCDRDDY I' 96D (6-OF STONE UNDER OR ELEV. STONE �_ \ , 37 ` ♦ ` ® \ ,nNaLUNG I MECHANICALLY COMPACTED) UNDER \1�, ♦u ` , ,iJ. > I ,� 03Z F�LEACH�A) ELEV. CAS DAPPLE ) �S 3 FLOWDIFFUSORS WITH Y OF STONB TEE SIZES: AT OUTLET TEE ELE V. ALL AROUND AND f UNDER I \ �1 `, ,\. ,.',,-�. I II INLET:6'UP,f3'DOWN (30 s f0 s E'DEEP) (H-20) •• ` 'GARAGE OUTLET:6'UP,14 DOWN `\ , , 11 1 EB 18�`"momPROPOSZD SITE AND SEWAGE PLAN \ LEACHING A%A) APPROVED BY: DATE: - vrrurr crosrd ft LOCATION.' t CONCRcrE BODSO 01 LOT 9 PETER BLOSSOM(LANE ELEV-WarDD w +b °A °e Ise ` -d°ea of PA��f+e WEST BARNSTABLE,HA -� PREPARED FOR t PETER BLOSSOM LANE DM REEF REALTY D"A%ST-MCLdLLAN ENCINdERING SCALE: f e 30' DATE: i 24 SCHOOL STREET PD.BOz Ass REFERENCE: LAND COURT CASE B 40S99B ' DM B a1-1tE(GEOFnI Edsr DENNIS.YASSACHUSS"S OtO7o TXOYAS McLELLAN,P.E. ✓OX N Z.DEMAREST JR,P1.S. fl�r ,�r -. .The Commonwealth of Massachusetts - _ Department of Industrial Accidents r Of eeofflresaffatfoos 600 Washington Street Boston, Mass. 02111 `~ Workers' Compensation Insurance Affidavit A tnformahon• t ; :;.. ... name: location: cin' phone# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1l am an employer providing workers' compensation for my employees working on this job. company a d d r c��' •n ura!,Ice-cg. policx �^C `a Q�7 1 5.� QJ1POK 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: hone# .. . ..;:: ... insurance co. P cY company name: address: . city: phone#: insurance co.. ; . • ... .:.. ... r Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Otlic nvestigations of the DIA for coverage verification. l do hereby certify under the pains nd pen ti of perjury that the information provided above is true and correct Signature `� ate Print name V e�e- V�7 •� v Phone# 3 el�19 i4-309CC l official use only do not write in this area to be completed by city or town official city or town: k - permit/license# rlBuilding Department Licensing Board check if immediate response is required C)Selectmen's Office oHealth Department contact person: phone#; _ nOther ircvsed 3r)5 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide „porkers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied,oral or'written. An enzpluti!er 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 dwellins 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 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. 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 permitAicense 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. 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 ,•. I '�'...,11. � � � .t� 1�r rl.rr � fir:l..: ,. •dJ'..,':fi'.:1.; z` it It it tk tit It it t ' :1• r 1. , ��� r ..iii.ld'; ' � ,�• ''1�'• , r � , i �I� •'. ;'111 i t:r .1 � �j!'�I'Lil' trl y:1. .. � t .,.' �ir .• 1•.- r 1 �!'r�1 1:�.. , : .. .t'.,,1�• i. ,1' t - ... I�'' , .is _ .' 1 •i is - ..,.. .:r .. .. 1 1:!,ai�i!.;- _�'33'.�:':::• .''A' - - •''�0i'.'.•/:r J cr , j'i. 6ate'• p �� i:r m• ri - ._V:: ....�' .I;Cr.:t.�">;' '•1'�. ':t:tT.. .z� Ca :•1,::!, i .1 .1:, :el .Q r- t•:+:rt:`'''•''• 1�. .i.. as e� ao a j; cp r► .r• .. 'lii'i•i� .. �'d \crL(qy[.'�y!.f.':•-:': o-:^`,' r• u .a a•-i c? .r, .:1! 1 1 • 1 r.;� 0•.aD!•oCN'f'JrV!�'-' . .O•. - !i1.i 1. c'' .. �. ao �. f :••) 1 I . 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