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TOWN OF BARNSTABLE BUILDING PERMITAPPLCA I TXON
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A
Application
Map 067
Parcel"
Date Issued
'bivisi:h Health on
Conservation Division
Ap.Ofidatioh Fee
Planning'Dept. `Permit Fee,
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation Hyannis
Project Street Address j?16A)l5f
Village Wef,:f &12A
Owner PJ5Q5R!4 4- S�F, J3 A)p Address M I-
Telephone3 4
Permit Request IA)S7AZ-1-
M TuA
4?�ZU 541 M011-AL77-! 7Z L4-7hl 76k).A16: A,92.0
Square feet: 1 st floor: existing proposed 2nd floor: existing
g proposed Total new
Zoning District Flood Plain Groundwater Overlay
0iect Valuation 00 0 Construction Type
-*'
L&Size Grandfathered: Q Yes C3 No If yes, attach supporting documentation.
Dwelling Type: Single Family :Q Two Family Q Multi-Family (# units)
C)
Age of Existing Structure Historic House: Q Yes Q No On Old King'sr i hway: 1,2 Yeses No
Basement Type: LJ Full Q Crawl EJ Walkout Q Other -n
N)
LQ
Basement Finished Area(sq.ft.)- Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing nevqj2 :r-
L."
Number of Bedrooms: existing —new *_0 M
Total Room Count not including baths): existing new First Floor Room Count
Heat Type and Fuel: El Gas 'L3 Oil Q Electric Ll Other
Central Air: Q Yes Ll No ' Fireplaces: Existing New Existing wood/coal stove: Ll Yes Ll No
Detached garage: Ell existing Ll new size—Pool: Q existing U new size Barn: L3 existing U new size
Attached garage: U existing q new size —Shed: Q existing Q new size Other:
Zoning Board of Appeals Authorization L1 Appeal # Recorded Q
Commercial- Ll Yes U No _If yes, site plan review
,2 Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name -: ro -r5; Telephone Number 5eg'2371 3'99�
Address License # 9
.1,02 93
Home Improvement Contractor# 160360
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE Z;O— DATE
0 -
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
S
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL j
FINAL BUILDING ?Z/��0f# 4 CA-- (�i j 9/•�0Y,41* 9s
DATE CLOSED OUT "
ASSOCIATION PLAN NO.
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The Comtnonwealth of Massachusetts
,Depatfinent 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 Legibly
Name(Business/Organization/Individual): 2
Address: 120
City/State/Zip: 14111544MI15, Phone.# �D 2 3-7` �7
Vean employer? Check the appropriate box: Type of project(required):
1m a employer with 4. [] I am a general contractor and I 6. ❑New construction
• � employees (full and/or part:tim.e).* have hired the sub-contractors
listed on the'attached sheet. T. 0 Remodeling
.2.0 I am a soleproprietor or'partr]er-' These sub-contractors have
ship and have no employees 8.'0 Demolition
ees and Have workers'
working for me in any capacity. employ 9 ❑Building addition
[No workers'.comp.-insurance . comp. insurance.
5 2/We are a corporation and its 10.❑ Electrical repairs or additions
required] � '
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.[]Roof repairs
insurance required.] t c. 152, §1(4), and we have no kzW_0 moo,
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.
XContractors that cbeck 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.
Iam an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 crimiri4l 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce ify under t e ins•and penalties ofperjury that the information provided above is true and correct.
Si afore:
Date: —
Phone
Official use only. Do not write in this area, tb be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health '2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6. Other
Phone#:
information and. Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation'for their employees.
Pursuant to this statute, an employee is defined as ,..:every person in the service of another under any contract of hire,
express or implied, oral or written.,$
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 tiustee 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
Ot on the grounds or building appurtenant thereto shall not because of such ernployment 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 unto 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-con6actor(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 confinna.tio .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 perniit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permiWicense 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 maybe 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 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Iayestigatious•
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-72777749
Revised 11-22-06 www.mass.gov/dia
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POWER RAIL INSTALLATION GUIDELINES
JIRE VIEW-FOR POWER R&LENGTH UP j0144,
NO CANTILEVER NO SPAN BETWEEN =NOCAOTILEVER L
GREATER THAN 32- SUPPORTS GREATER THAN SCr GREATER THAN 32-
20%.n%OF I 8M%480%OF ( 20%,22%OF L
OVERALL LENGTH OVERALL LENGTH OVERALL LENGTH
SIDE VIEW-FOR POWER RAIL LENGTH OVER 1440 AND UP TO 224":
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0 NO SPAN BETWEEN NO SPAN BETWEEN 2 E E
SUPPORTS GREATER THAN SW SUPPORTS GREATER THAN 80- 0 T 3
1 S%-22%OF 36%-8%OF I 36%-26%OF 1 M%-22%OF
OVERALL LENGTH OVERALL LENGTH OVERALL LENGTH OVERALL LENGTH
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OVERALL LENGTH OVERALL LENGTH OVERALL LENGTH OVERALL LENGTH OVERALL LO
POWER RAIL IS DESIGNED AND WARRANTED ENOVIEW PHOTOVOLTAIC
FOR LOADS UP TO SO LBS/SQ. FT. APPROX. 325-bdPH-WINDMI
POWER CLAMP MODULE
WHEN INSTALLED AS SHOWN. FOR INSTALLATIONS IN AREAS MOUNTING
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PDF Documents
Tech Data Part No.:
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Adobe Acrobat&0 or higher is
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instructions.
This product works best for these apPficatim-
Materials
• Atumhtura
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34-0 PROPOSED AC
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BASEMENT) PLANS &
ELEVATIONS
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EXISTING VENT STACKS
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Residential Solar Contract
This agreement is between
Jason Stoots, DBA
E2Solar Inc.
120 Chase Street
Hyannis, MA 02601
(508)237-3892
CS license#CS090293
E2SolarPV(a)gmail.com
Hereinafter called the"Service Provider"
And
Steve and Debra Binder
55 Pioneer Path West
Barnstable MA 02668
(508)428-5136
sabinder(a)comcast.net
Hereinafter called the"Buyer/owner"
Whereas,the Buyer/Owner seeks to have a 4kW grid tie solar photovoltaic(PV)system,
hereinafter called"the system"professionally designed and installed at 55 Pioneer Path West
Barnstable MA 02668.
Whereas, the Service Provider agrees to install the system in accordance with all local code
requirements and in accordance with current National Electric Code.
Whereas, the Service Provider agrees to install the system in a professional and courteous
manner, leaving the job site secure and clean at all times.
1.) System Specifications:
The PV system will consist of twenty (20) Evergreen Solar ES-A 200 photovoltaic modules
installed on the south facing section of roof using DPW Solar photovoltaic system racking
components. In addition the system will consist of one (1) UL listed Solectria PM 4000 power
inverter to be installed adjacent to the main panel in the basement. The AC disconnect will be
located at the northeast comer of the garage, with all appropriate signage posted as required by
the utility. This system will connect to the electrical grid via the grid tie inverter. This system will
not include a battery back up system, meaning the system will not produce power in the event of
a power outage.
9.) System Orientation:
The Service Provider agrees to provide the customer with an Operations and Maintenance(O&M)
manual at the completion of the installation. The O&M manual will include all the specifications
on the primary components in the installation along with their warranties. It will also include the
electrical oneline diagram,and information on troubleshooting in the event of a malfunction. At
the time of issuing the O&M manual the Service Provider agrees to review the manual and the
system installation so as to orient the Homeowner/Buyer with their new system.
10.) Dispute Resolution:
Both the Service Provider and Homeowner/Buyer agree that in the event of a dispute both parties
will use all efforts to resolve the dispute in a fashion that is agreeable to both parties. In the event
that the dispute cannot be resolved between both parties the parties agree to contact a mediator
through the American Arbitration Association to initiate a mediation process to resolve the issues.
The cost of this mediation will b bome equally by both parties.
US
Steve Binder/Debra Binder (date)
Jason toots, E2 Solar Inc, president (date)
I
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Assessor's office(1st Floor): 00A,-?7— 7Al
Assessors map and lot number /,q k 01 7 40 �i /� o%TM f_To`o
Board of Health(3rd floor): D� 0/?D
f Sewage Permit number �C.
1i aeaasrsnr,Z
Engineering Department(3rd floor):
l rius
House number
Definitive Plan Approved by Planning Board 3 — 30 1921 d
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABLE _y
BUILDING INSPECTOR .
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a-permit according to the following information: '
G 0-�TT
Location
Proposed Use
Zoning District _ Fire District
Name of Owner Address �� sl s�U
Name of Builder t/ Address
Name of Architect Address
Number of Rooms Foundation
Exterior 4/ L� Roofing S
Floors �� -��� �� ('� Interior S
Heating 7r— > Plumbing
Fireplace A f Approximate Cost `7 �i if 6 C�
Area
Diagram of Lot and Building with Dimensions Fee
7 C(
I
i
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above constr ction.
Name
Construction Supervisor's License
v
r- -
GREENBRIER CORP.
A=128-017. 002
1 afs=o 17,00�
No 318 5 3 Permit For 1 Y S i-n ry —
.qi nql P F�pi 1 y dia !ink
'Location Lot #20, +; Pion -Pr P�Lh
r
West Barnstable
Owner Greenbrier C'nrp
Type_of Construction Frame
Plot Lot
Y 10, 19 90
'Jul
Permit Granted ,
Date of Inspection 19
Date Completed 19
PERM.1T COMPLETED 1,1dL
*THE TOWN OF BARNSTABLE 3853
Permit No. . 3
BUILDING DEPARTMENT
TOWN OFFICE BUILDING Cash
7 Nl
6T9•
ouT HYANNIS,MASS.02601 Bond ..........�.
CERTIFICATE OF USE AND OCCUPANCY
Issued to Greenbrier Corp.
Address Lot #20, 15 Pioneer Path
Best Barnstable, Mass.
USE GROUP FIRE GRADING OCCUPANCY-LOAD
THIS PERMIT WILL NOT BE.VALID; AND THE BUILDING SHALL.NOT BE .00CUPIED UNTIL_
SIGNED ,BY'ThE BUILDING,,INSPECTOR, UPON SATISFACTORY .COMPLIANCE WITH••TOWN
REQUIREIvIENTS-AND.IN.ACCORDANCE'WITH SECTION I19.0,OF THE''MASSACHUSETTS STATE
BUILDING CODE.
November
................ 30.'..... .19. 9.. ..
Building Inspector
1
tB*RNSTABLE, MASSACHUSETTS B V I,LERW07P
28
.-M7.002 July 10 90
Ovmer DATE 19 PERMIT NO.
PLICANT ADDRESS vuli_
(NO.) (STREET) LICE
(CONTR'S IICENSEI• '-,'•,_;�
PERMIT TO Build dwelling ( i3 I STORY Single family. dwelling NUMBOWELERNG UNITS 1 '
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE) ,
of #20 -1&-Pioneer Path West Barnstable
AT. (LOCATION)' ZONING
RF
" (NO.) S !STREET) DISTRICT_
:BETWEEN, AND IM.:
(CROSS STREET) ,(CROSS STREET)
SUBDIVISION LOT.
LOT BLOCK SIZE
BUILDING•,IS TO.BE' FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN C0NST.RU.CTIOM":,
L5 TO TYPE. USE GROUP BASEMENT WALLS OR FOUNDATION
p (TYPE)
REMARKS: .Sewage #90-307
T .BOND -
'VOLUME , S66 SQ. fC. 4S,000 FPER EEMIT,. 69.'2S
ESTIMATED COST
(CUBIC/SQUARE FEET) - ;
OWNER Greenbrier" Corp.
Box
Centervi
ADDRESS, �'' x1e! BU.ILDING DEPT..".
BY
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. HtS E NMI T DOES NOT�RELEASE THE APPLICANT FROM THE CONDITIONS F
MINIMUM of THREE CALL INSPECTIONS REQUIRED •APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
ALL CONSTRUCTION R WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
ELECTRICAL, PLUMBING AND_,- _
1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MINAL IN PE TI TO LATH!. FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION) BEFORE `
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
1
1 -R d�a�. �1� • 1 -
2 2 TiA,4 6' 2
Gti
3 C :S HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
1 (f Sv�3j` 7"t� Gva-��.efrti.
2
BO F YOF HEALTH
All
OTHER SITE PLAN REVIEW APPROVAL
�-?"t"
0291(oV
WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT W!LL BECOME NULL AND VOID IF CONSTRUCTION
TOR HAS APPROVED THE VARIOD ARRANGED FOR BY TELEPUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE INSPECTIONS INDICATED EP THIS CARD CAN N
CONSTRUCTION. THIS
OR WRITTEN
PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION.
�(D
00
o.
LOT 20
43,726 sq.ft.t `�2)
O
a
V)
0
co
o
62.8 q°c VTR
72.4
FF Elev =
80.0 Q
ap p
n Q
O
a,
180.00
1 09/901 INITIAL ISSUE elk
THIS PLAN IS NEITHER INTENDED N0.1 DATE I DESCRIPTION BY
FOR, NOR SHALL IT BE USED FOR AS—BUILT FOUNDATION PLAN—LOT 20
MORTGAGE LOAN PURPOSES. PIONEER PATH
BARNSTABLE, MASSACHUSETTS
Fm
tREENBRIER DEVELOPMENT COMPANY
I CERTIFY THAT THE FOUNDATION o��4a SCALE: 1" = 50' JOB NO. 1120 LOT20
PAUL 0 50 100
SHOWN ON THIS PLAN IS LOCATED a LEVY
ON THE GROU INDICATED Nc� uCIs17 )
mm-
LEVY, EUREDGE & WAGNER MCIATFS INC.
�;
STF�
A T R E G I E R D l A D S U R v E 1'0 R EXCHO Isco AR HM i�Lu= im s1il:Y� is
889 WEST MAIN STREET CENTERVII T.F MA 02632
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APPROVED
NOTE C ANGES
/. / ! �� /R= � ICJ�L�L .NgmR 1't/�'�.133YJ. �'•-YR Jim• I
TO OF BARNSTABLE ""- .. .;Z 32!.2
Building Inspection Deper
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' 7J ALLED IN CO
�EE
Assessor's office(1st Floor): O 7�4�9� ���I
Assessor's map and lot number d1 ��
Board of Health(3rd floor):
w
Sewage Permit number o OrJr`-� ' f �EGV
ITAXE i
Engineering Department(3rd floor): �o clue
' House number ' ° i6}0'
�0
Definitive Plan Approved by Planning Board .-3 — :O 19
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF -BARNSTABLE
BUILDING : INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION �+
�G 19 0
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a,permit according to a following information:
Location G o7 of O 1 o A---e'f
Proposed Use J t•mot S "� 'L' ' ��
Zoning District
Fire District �' ���N S ^
Name of Owner ��-S i � Cal?�� Address V
Name of Builder ll Address
Name of Architect Address �1
Number of Rooms Foundation
Exterior �✓G° �* C'�^' �lr -T—� oofing
Floors Interiorta
Heating �` Plumbing
Fireplace /�rf7 Approximate Cost
Area
Diagram of Lot and Building with Dimensions Fee
7C� � zy ��
alb
i .
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the ab v onstr cti n.
Name
F
Construction Supervisor's License b D I U
f
i
GREENBRIER .CORP.
t
R
No 33853 Permit For 1 i Story
y
Single F
1 _b� `
Location Lot 420, Pioneer Path
West Barnstable
Owner Greenbrier Corp-
Type-of Construction Frame
Plot Lot
Permit Granted July 10 , .19 90
Date of Inspection c� 19
alteX,q let d �c7 19
C)
OWA
t�a1 �
Town of Barnstable *Permit# A 9�
0• P � Expires 6 month rom issue date
S Regulatory Services Fee
:QanMSTABM : a""� omas F.Geiler,DirectorMASS.
.
1 qPR � wilding Division
Eo W/V of Z� m Perry,CBO, Building Commissioner
egR�S' 200 Main Street,Hyannis,MA 02601
Tq&4Fwww.town bamstable.ma.us
Office: 508-862-4038 Fax:_ 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTUL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
oG
(Residential Value of Work �J�60- Minimum fee/off�$25.00 for work under$6000.00
j Owner's Name&Address S`��v -�- ��h h. I3 /`/'1 40_l_
Contractor's Name _ J~U t�t�h� Telephone Number
Home Improvement Contractor License#(if applicable) ISO t
❑Workman's Compensation Insurance
Check one:
® I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
V -Re-roof(stripping old shingles) All construction debris will be taken to I a rVa 0 VYk 1 Q:,A i
❑Re-roof(not stripping. Going over existing layers of roof)
4 ❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)
*Where required: Issuance.of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required.
j SIGNATURE: n A A.
QAWPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� � Please Print Legibly
J Name(Business/Organization/Individual): (DS P�n �T" f'w
Address: -3(,, CAe,k P r-6Pr t'u 1-,wi
City/State/Zip: re P►vt o v'1Gt O� Phone.#: 7
Are you an employer? Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
:.2: Lam a sole proprietor or:partner-' listed on the attached sheet. T. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp.-insurance comp. insurance.$
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 L F1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof 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 subcontractors have employees,they must provide their workers'comp.policy number.
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 tip 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.
Ido hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signattire: r Date:
Phone#: q -7
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#:
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 defiied 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 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-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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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.
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
i
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 1 i-22-06
www.mass.gov/dia
r
Town of Barnstable
• snxxsrasi.E. •
� Regulatory Services
ABED MP'�p Thomas F.Geiler,Director
Building Division
Thomas Perry,CBO
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 i e n to act on my behalf,
in all matters relative to work authorized by this building permit application for:
UD C� \ o(-\f-Q PCN c vim► . (i —
(Address of Job)
Signature of Owner Date
Print Name
Q:\WPHLESTORMS\building permit forms\EXPRESS.doe
Revise020108
�IK Town of Barnstable ,
Regulatory Services
BAMsr.,BM t 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
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 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 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 of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
T Q:\WPFU-ES\FORMS\homeexempt.DOC
,...Board pf_Building Regulations anI.d Standards
License or regist
HOME IMPROVEMENT ration valid fo'r individul use only
.CONTRACTOR before the expiration date.' If found return to:
'Registrations: 150889 Board of Building Regulations and Standards
Eiipiratiori ;5%5%2008 One Ashburton Place Rm 1301
Types Individual Boston,Ma.02108 •
JOSEPH E. KING` ,
JOSEPH KING i
36 CHECKERBERRY LN:`..-.:: -
WEST YARMOUTH,MA 02673
De u Administrator ;10�aoafld hout signature ..-
s .
O
19
o:
LOT 20
43,726 sq.ft.t �)
O
�t a
o
6 2.8
72.4
FF Elev =
80.0 Q
00
Q
O
00
rn .
180.00
1 0J ��• INITIAL ISSUE elk
THIS PLAN IS NEITHER INTENDED No. oA DESCRIPTION elk
MORTGAGE LOAN PURPOSES.
FOR, NOR SHALL 1T BE USED FOR AS—gt_� FOUNDATION PLAN—LOT 20
PIONEER PATH
V B;=—\_-,TABLE, MASSACHUSETTS
FM
gip.,jH oc�,� tRF= DEVELOPMENT COMPANY
SCALE 50'1 Joe NO. 11 20 LOT20
I CERTIFY THAT THE FOUNDATION �o cy
SHOWN ON THIS PLAN IS LOCATED A PAUL a 50 100
ON .THE _.GROU INDICATED " roQ. EW IAT
A
ac WAONKR AMOCIATM INCFa
� .-7� �+•Q�'![h-VL11F�11A t12RD2
r
n+>*k�'. ",:.:�'C:'�:.'aT= R? _ ..-.,--rr--f;�'?.c-x.,,. ,.�'-s�:^�-i.*3»....;2r:c..+w—c.:::-,!i^+.---•s.-->�'7
Asses LMoZ S Parcel Z Permit# A 3
Conservation Office(4th floor)(8:30- 9:30/1:00- 2:00) 3 2 9(0�}� Date_Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) 9!� ��4� Fee .5Z
Engineering Dept. (3rd floor) House# �S �JS• � �
4Eo,,
SEPTIT �r�
oor ) INSTALANCE
' a
19
ENVIRO A^. D
TOWN OF BARNSTABLETOWN REGULAT!C
3* treet
Building Permit Application
P Address S 5 R 0 n-e e,(:Z—, _ P")); - a.O�_
Village A - Q a(.0(C't
Owner &u Address
Telephone Rs s -S 1 (a•
Permit Request70 PJ t k� �,A b Ave 2 Z e W A-t4 / Cf P-4a 42-, - '
/C a2(o
First Floor square feet
Second Floor square feet
Estimated Project Cost $ a.c� Q OO
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 (y ectAa. Basement Type: Finished
i
Historic House No Unfinished X
Old King's Highway t,1 p
Number of Baths . No. of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel CAS Central Air N/fl Fireplaces
Garage: Detached Other Detached Structures: Pool /A
Attached X Barn W/A
None Sheds CD-
Other N
Builder Information
a;k � �' � �+�bAeA Telephone Number Name 6
Address .�)Cj Pi pylp License# —
ILI . bmasi", � ,���; Home Improvement Contractor# '-
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 1 ,a��A :fDkr-� DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
r I.
t
FOR OFFICIAL USE ONLY
PEA MIT NO.
D TE ISSUED ,
M P/PARCEL NO
YDRESS VILLAGE
OWNER
DATE OF INSPECTION:
/ 1
FOUNDATION , 'I�
FRAME 1� " ` ✓ �— V;� �'vv `�' '�',
INSULATION
FIREPLACE4L
ELECTRICAL: ROUGH FINAL
PLUMBING: ;,RO.UGH�p . FINAL
cr
6 GAS: C—RZ4J� FINAL '
co ITI
FINAL BUILDING,.
DATE CLOSED OUT r` i
ASSOCIATION PLAN'NO. `
`OF WE Tp The Town of Barnstable
Y SARNSTABLE.� Department of Health Safety and Environmental Services
MASS.
0
��FDMPy°' 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 , �vy
Location S� qw,eu PK6f- Permit Number
Owner J Builder t YkQ J
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
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Please call: 508-790-6227 for reeinspection. c
Inspected by
Date
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`OptHE ipW The Town of Barnstable
BARNSTABU. Department of Health Safety and Environmental Services
MASS g
i639. �0
Building Division ,
367 Main Street,Hyannis, MA 02601
Office: 508-790-6227 t Ralph Crossen
Fax: 508-790-6230 ' Building Commissioner
Inspection Correction Notice
Type of Inspection
Location � { �� Permit Number
3
4
Owner �'� ,;J Builder
One notice to remain on jobsite, one notice on file in Building Department.
The following items need correcting:
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Please call: 508-790-6227 for reeinspection.
Inspected by �,, ✓ .-�a v�,v
Date
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TE(RY LU FF AR-UH ITECT
i 032 Main Street • Suite 0 • Osterville,MA 02655 •. (500)420-9119
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TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB- LOCATION__
Number Street address Section of town
"HOMEOWNER" � e `�e��� Z" 5A) qa 6 S1-5(o CS 67) 7-7��a�•
Name Home phone Work phone--
PRESENT
MAILING ADDRESS �J S o ,�\,e 2 -
U�
City town State Zip code
The current exemption for "homeowners" was extended to include owner-occupie
dwellings of six units or less and to allow such homeowners to engage an in-
dividual-for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person(sj who owns a parcel of land on which he/she resides or intends to re
side, on which there is, or is intended to be;-a one to six 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 Offic
on a form acceptable to the Building Official, that he/she shall be responsi:
for all such work performed under the building permit. (Section 109.1.1)
The undersigned "homeowner" assumes **responsibility for compliance with the S,
Building Code and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requirement:
and that he/she will comply with said procedures and requirements.
HOMEOWNER'S SIGNATIIRE +�
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35,000 cubic feet, or larger, will be required
to comply with State Building Code Section 127. 0, Construction Control.
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for which,.,.ta .building
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that. ij
Home Owner engages a person (s) for hire to do such work, that such Home Owr.
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the responsibilities of a supervisor (see .Appendix-. Q, Rules and Regulations
for .licensing Construction' Supervisors, Section 2. 15) . This lack of awaren.
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home "Owner act
as supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities,. m.
communities require, as part of the permit application, that the Home 'Owner
certify that he/she understands the responsibilities of a supervisor. On t
last page of 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.
The Town of Barnstable .
�P Department of Health Safety and Environmental Seances
1 Building Division
367 Main Strut,Hyannis MA 0201
Ralph Crosses
Office: 508MO-62 7 Commt:
F= 508 775 33"
For office use only ,
Permit rw.
,
Date
t
AFFIDAVIT
HOME n ROVEmENTCONTRACTORLAW
fP
SUppLLTAENT TO PERWr APPLICATION
MGL a 147A requires that the"reconstruction,altc=o maovadon,rtq�boa COMMON
impruvemeat,.remo%-4 demolition.
o on of an addition " ant P'm'� °� 00�ed
building cantaiaiag at least one but not more than four dwdUng units or to which are th
to such zt sideace or building be done by registered oonnactors.with=taia ooQptions,along with other
tequir=FgM.
Type of Work: C Est. Cost 13IS WD,W .
—
Address of Work:
Osrner.Name: e. `�e. _A
Date of Permit Applicttion:
I her ebt certify that:
Registration is not required for the following rrason(s):
Work cmduded by law
Job under SLOOD
Building not oana-0=00ed.
Owner pdling own p=ait
Notice is hereby gi`'ea that:
OWNERS PULLING THEIR OWN PERMIT OR D WORK EALING W N NCO THEFOR APPLICABLE HONE IMPROVEMENT
ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A
SIG,MD UNDER PENALTIES OF PERSURY
I hereby apply for a permit as the agent of the owner:
?j" • e�C6 R � No.
Date Contractor wane
OR
I Department of Industrial Accidents
6111111 ashin;ton Street
Boston.At= 02111
�- Workers' Compensation Insurance.AlTidavit
�T
,ewfien—n nformationi Pleaee PRiN'i'le y -
name, !A pw 2.(1
location- c�C� o nQ Q Q\ P
Cih, W Cam) Ql�r7 P���' 9 �� b��e nhone
4 1 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.
nflMe,*N\ NIX
inattrnnce cn_
q-1 so 1
L
1 am a sole proprietor,general contractor,o omeowner a one)and have hired the contractors listed below who have
the following workers' compensation polices;.—
comnnnv nnme:
nddress:
eih^ �l'�1�1U ���1� ��l . nhone/h L� �
insurnnee to, Ll�� CAD El_:' nelict�ll ( 2: ( k
L�:i �= :_«.<:-r.�_•- - ._ .snrr.r..•a..•ac�..-n�srr?'- !!s; _ rw• �ra•„r+-•
city: I I�I�N'�C��n`1 �\ LI Dko�H phone 1h.
insurnnr+•.•n��� L (1�3.�SS CP. �' nolieya V� C �0�� 530^ 00
Atinch additional'sheet If tieeessarr-:�.r -•i -�-,t' +r'� **+r- �'�hi'�+- •rr..& +�. `�•'�
failure to secure coverage as required under Section SSA of MGL 152 an lad to the imposition of criminal penalties of n flue up to SIS00.00 and/or
one 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
coin•of this statement may be forwarded to the Ogee of Investigations of the DIA for coverage verification. '
I do berebrcerryy under the painsand penalties of pedurr that the information pm ded above is true and conuL
cc
Signature- b X 1�_ �-Ao. - Date 'C� b
Print name e h b )i n . Phone7�
oMciai use only do not write in this area to be completed by city or town official
ein•or town: permit/license p nfiuilding Department
OLlcensing itosrd
D cheek if immediate response is required pselectmen's Office
z plialtb Department
contact person: phone ft. rlOtber
Immed)M P)A)
II
O�
20' MINIMUM OR AS INDICATED ON PLAN C,
NOTES:
s�
10' MIN.
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E. OSTERVILLE - WEST BARNSTABLE WHITE BIRCH WAY
MASONRY EXTENSION TO 12' 79.5 TITLE 5 ; THE TOWN OF BARNSTABLE RULES AND PIONEER PATH
TOP OF FOUNDAT�3, 78,5 79.0 BACK` S oTH REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE;
79. MASONRY EXTENSION TO 12' AND THE REQUIREMENTS OF THIS PLAN. LOCUS JENKINS LN.
BELOW GRADE
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
X WITHIN 12" OF FINISHED GRADE. WOOp ROAD A
4' SCH. 40 PVC PIPE 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE ODE oRlV
MIN. PITCH 1/8' PER FT. it
OF SHALL BE MORTARED IN PLACE.
P FLow LINE %a--11/2 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
tIN TEE 1000 WASHED STONE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR '
76.5 s MIN. 76.0 21 MIN IEvGALLON < WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING
76.2 4'-0- 75.6 PIT SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR 10
MIN. 75.8 3/4- - 1 1/2-
uoUiD F WASHED STONE PARKING. GE RO•
LEVEL DISTRIBUTION 74.0
Box 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED O� sTP
68.0 RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL
1000 OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP
GALLON SEPTIC TANK z_ 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE
L2'1_ 6' J_2'J ASSESSORS MAP 128 PARCEL 4W6
: & WAGNER FIELD NOTEBOOK # 272 _
LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW UNE I_ 10' J
4 FEET 14 INCHES BOTTOM OF TEST HOLE 1 59.9
5 FEET 19 INCHES OR USGS PROBABLE HIGH WATER LEVEL
6 FEET 24 INCHES
82 SEWAGE DISPOSAL SYSTEM PROFILE CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS
Tel.
80 NOT TO SCALE MIN. FRONT SETBACK 30 FEET NUMBER OF BEDROOMS 3
Elec. Elec. 4, MIN. SIDE SETBACK 15 FEET GARBAGE DISPOSAL UNIT none
TOTAL ESTIMATED FLOW
CATV MIN. REAR SETBACK 15 FEET ( 110 GAL./BR./DAY X 3 BR.) 330 GAL. /DAY
84 78 REQUIRED SEPTIC TANK CAPACITY 495 GAL.
` Basin ACTUAL SIZE OF SEPTIC TANK 1000 GAL.
PERCOLATION SOIL TEST P.T.AP-7610 LEACHING AREA REQUIREMENTS
`� . #
ti SIDEWALL AREA�-GPD./S.F. BOTTOM AREA 1.0 GPD./S.F.
Q DATE OF SOIL TEST 6 12/90 SIDEWALL 27r(J.0 /2)( 6 )SF x 2.5 GPD/SF = 471 GAL/DAY
PROP. TEST BY Steve Wilson (LEW) BOTTOM 7T (-LO-i SF x 1.0 GPD/SF = 79 GAL/DAY
WELL % �'C� Paul Landers
� WITNESSED BY
i o, PERCOLATION RATE < 2 MIN./INCH
R6_ 267 SF 550 GAL/DAY
Well 0
84 TEST PIT #1 TEST PIT #2 BREAKOUT CALCULATION:
ELEV.= 78.1 -0.00 ELEV.= 71.9 -
� -0.00 SLOPE x 150 = 4/27 x 150 =
,, 82� Top & Top & 0.15 x 150 = 22.2 < 113 OK
Subsoil 36" Subsoil 40P
®80 Well
Sandy till Sandy till
� �
w/ stones to w/ stones to LEGEND:
24" dia. & 18" dia. &
Cq�r 78 med sand med. sand EXISTING SPOT ELEVATION OOXO
w/ pebbles mixed EXISTING CONTOUR-------00-----
` 76 Basin 1
-144" -144" FINAL SPOT ELEVATION 00.0
NO WATER NO WATER FINAL CONTOUR
80 1 eo MH Tel 1' ASPHALT BERM BOTTOM OF TEST HOLE BOTTOM OF TEST HOLE SOIL TEST PIT LOCATION
LOT 19 76 I \ CATV OR WATER ELEV. 66.1 OR WATER ELEV. 59.9 TOWN WATER W W
o ' SEPTIC TANK
78 78 82% DISTRIBUTION BOX 0
1 80 WATER LEVEL ADJUSTMENT: N/A PRIMARY LEACHING PIT 0
VACANT ; `�� ` RESERVE LEACHING PIT
1 76,\ \
82 Y 62.8 ` 1 TEST DATE WATER LEVEL
72.3 INDEX WELL 2 6 19 90 ADDED NOTES ELK
WATER LEVEL RANGE ZONE 1 6/15/90 INITIAL ISSUE ELK
84 DEPTH TO WATER LEVEL FOR INDEX WELL NO. DATE DESCRIPTION BY
T12 Q FOR MONTH OF:
TP#1 ` ��, a SITE PLAN AND SEPTIC DESIGN FOR LOT 20
� ` ti� �, p WATER LEVEL ADJUSTMENT
86 \ `� [if DEPTHTO HIGH WATER PIONEER PATH
\ 74 fi ,I IN
88 I�,� BARNSTABLE, MASSACHUSETTS
LOT 20 74 ®Well
4{ FOR
` 1 43,726 s .ft.f �`
1 q I , APPROVED: BOARD OF HEALTH " �P��N MAssq GREENBRIER DEVELOPMENT CORP.
PAL,
>; Breakout contour /' A.0
L E V Y SCALE: 1" = 40' JOB NO. 1120 / LOT20
78 -:� N0.10 a ra
` t VACANT
1 ` DATE AGENT It .`l 4�;
76 w pL�EVY,,� EL�D�RRE/D��GpE &&}�p'WAGNE�R��ApS��SOC�IAATEEpSppIIN�QC.
FV I1I�SCAPB diWflJlLlilJ CLlI11111a1L7 I,ANII $(IRVEYOR3
88 86 84 -82 $� SITE PLAN 74 72 PERMIT #
889 WEST MAIN STREET CENTERV= MA 02632