HomeMy WebLinkAbout1679 MAIN ST./RTE 6A(W.BARN.) o
F
�.
f
1�
J
c�
cr-
t
O �z
C\j F
U-) i
ILA
w
c
• f
t
1
e11
1
i
S
.�
"1
•a
,3
r
r
i
l
i
w�
Assessor's office (1st floor):
E
Assessor's map and lot number .................... .j.. Q.;°��NTO�♦
Board of Health (3rd floor):
Sewage Permit number ........................................................
Z B_AHd9T1►DLE,
Engineering Department (3rd floor):
rae
i639. �00�
House number .........................................................................
e rpv a.
Definitive Plan Approved by Planning Board ________________________________19-------- .
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. only t
TOWN OF BARNSTABLE 45
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO
TYPE OF CONSTRUCTION .............W.0 5.a,..........
...................................
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location .. (? .....:n"?..G./.n....S4........... ... a.r: e...............................................'..................................
ProposedUse .....clU..SS.e A..................................................................................................................................................
Zoning District - f .............................Fire District ?^17. '.TCi ?.I e, ..
......
Name of Owner ..DC.?na./c .......: .GJQ.e.r E.............Address ../.G:.7L...... —0.110..L9.1......W.A arl?.....
T Q
Name of Builder ......J—o.h.L7....../.-.l.Q.&./s...............Address .y0.. .�. ...'.:�� !7... .:�.. '!�1.Q<`!'N. s
Nameof Architect ..................................................................Address ...........................^........................................._................
Number of Rooms ....... .........................................................Foundation .. .0.iv.reG .'........�t U.�..�': :7`C�.............
Exterior .......f•.11.h.�: ��......Ceda./.. ......Sh./:n.L�/a.eS..Roofing ....oslo�a j: ..................................................
Floors .............�.<1O.0CJ.....................................................Interior
..........................................
Hearin '?.C?r?..e.............. ........ -
g ....................................Plumbing .........n.�.h. ..... r "
...... .............................
Fireplace ..........hC)./l.er .........Approximate Cost ....... `SOUO
Area
Diagram of Lot and Building with Dimensions Fee
1�3U
i
3
a 2
10
130
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to oil the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ....................::............................................................
Construction Supervisor's License .....�,/...1. (�.
ROGERS, DONALD A=196-009
No Permit for ..Ad!klo..................
Sinctle Family Dwelling
Single ..........!�...........9.......
Location .....1671 Main Street
.. .................................................
West Barnstable
...............................................................................
Owner ....Donald. Roser§.............................
Type of Construction .......Frame........................... .......
........................... ...................................................
Plot ............................ Lot ................................
Permit Granted ... ....1.7.1...................19 90
Date of Inspection ....................................19
Date Completed .......................................19
'PERMIT COMPLETED 1/1/21
V;�
Ada � o � �,
Assessor's offioe (1st floor):- y
Assessor's map and lot number .........//.....
Board of Health (3rd floor): �/
Sewage Permit number t! R� .........0 .'....1..-... T'^ :• ; ' t Bsaas?wLE, S
Engineering Depa"rtment (3rd floor): /,,' (� Vo raea
House numbef 'l'':�:/..... O�f6}9.1W
.....:. .... i 0 WO
APPLICATIONS PROCESSED 8:30-`9:30 A.M. and 1:00.2:00 P.M. only'
TORN. OF BARNSTABLE
BUILDING INSPECTOR
/� /if�Ff17G°a�L
APPLICATION 'FOR PERMIT TO .............:...... �.... ...............................................................................................
Gf/C1cU/� - "
• TYPE OF CONSTRUCTION ............... ............................:.......................................................................................
- "
rr
Te o 17
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ....... ...... /�i//(d.. .....C! .. .:...... ! s.. /!/ /q/ L /1....................................................
.� C� r� s��,ql�.... �Proposed Use ...........t...:...../7�.............. �........... ..... ..... F� 1................... ............................:.........................
Gl/
Fire District r Zoning District /. . ............ ...................`.+.-....�(/l.'... !,...::..................................
Name of Owner .7iv ,c� /(�UG'�PS %6�1� �//l�.
...... . ....... ...................................Address ...................
................'........... . ....... ............L.
Name of Builder `S�yf.�Pl !4�('�k/... V.�..................Address .....10.4(....SC"WrR. A��E !/�/rvll✓6S /��
Name of Architect ...... %thG';/l0 /? , ! iole/............Address ................
....................`...................................
Numberof Rooms ................ ..............................................Foundation ..... 0 .. ..........................................................
Exterior ....... ..J..... //!/�LS..............................Roofing ....... 51� �� r.................
Floors Interior S%.C'F%,�BC,�
.......................`.............................. ............ ........ ..............................................................
Heating ......... .....s?? ...................:..Plumbing ... r...aC'v it)('el:................................................
..�����'kn....T.....C•006 . Approximate $ c'`�
.......... Cost Fireplace ................................... ..............1.......�....... ..............................:....
Definitive Plan Approved by Planning Board --------=-----------------------19-------- . Area ,
Diagram of Lot and Building with, Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
all
(10
V,
t
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 1
construction.
Name .......
d Construction Supervisor's license ...... ........,..::, .
ROGERS, DONALD
30437 -ig
No ................. Permit for ..Remodel.....................Dwe....1.1ii
.Sin4' e Family Dwelliha
..................!............................................. ..........
. 0
Location ... �nf=....Main...Street.......................... .. .... ..
West Barnstable
........................................................:�....... .............
Owner .........Donald...Rogers............................ .. .. . ..
Type of Construction ...Frame..........................
...............................................................................
Plot•........ ................... Lot .................................
Permit Granted ....,February ....19 87j
Date of Inspection ........... .......................19
Date Completed ........ .. . ................19
Assessor's offioe (1st floor):
0*1 V 0
Assessor's map and lot number .............. ...
Board of Health (3rd floor): � /�R�A>IC� �— �r
Sewage Permit number V �^ ' i 21asa9TsncE,
Engineering Department (3rd floor): (� 'oa 1639- \e�°
House number ......................................'..............�.7......�i.. !� '°�o YfPY d-
APPLICATIONS "PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
TOWN p�OT ' BARNSTABLE
BUILDING INSP ECTOR
if?c�f�loa
APPLICATION-;FOR PERMIT +TKO ......../F �L....E �.. ......................................................................................
TYPEOF CONSTRUCTION .............(� .........................................................................................................
+ ..................T.e•!�....... .........19. .7
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location /6 7./.......�llA/rv--..ST....�! ..6 .�........w� J��9�f'/I/STfr1L.E-.e IrIA
Proposed Use .....................�Ei�.�-..... Q�/.IgG�.. Xmq�P...... i /!l.!/
ZoningDistrict ...................... ......................................-Fire District ..................! ........................................
Name of Owner �D/U/�.(Z1.....!UCrCRS............................Address �.../�/�l/ ST'....�
Name of Builder .....5. •%% Qh/...-Trt/5..................Address .....��?!/�...S000IDER,AI�E......IIvVfIzIll/S riM4.-
Name of Architect ......�rEVE,V { �Q�r�in�,�. ...Address ...............s���
..................................................................
Numberof Rooms ................3..............................................Foundation ..... vC ...........................................................
Exlerior ........... ..;!....SiV//Uli5..............................Roofing r
Floors ......Interior ....S/ PT,t'OG,�
Heating .........��~ CCTiP/!...... /SFi^'[7. i(? .....................Plumbing ......s(✓.....CSC iVif2.
.......... ...................................................
Ed�ic?....70.......C'00E— . o °a
Fireplace ............... Approximate Cost ..............d...............T.........................
Definitive Plan Approved by Planning Board --------------------------------19-------- . Area ..C> .C . 0
Diagram of Lot and Building with Dimensions Fee D �d
............ ... ....................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
l
f
_i
OCCUPANCY PERMITS i.REQUIRED FOR NEW DWELLINGS
tea.
I hereby agree to conform to all the Rules and Regulations of the Town of'Barnstable regarding the above
construction.
Name )l�G �fli ''""�
Construction Supervisor's License .....................................
ROGERS, DONALD Are
i9 00
00 4a
30437 Remodel Dwelling
No ................. Permit for ....................................
Single Family Dwelling
..........................................................................
Location ....16 Main Street
West Barnstable
...............................................................................
Owner Dona
...................ld.....................Rogers..........................
Type of Construction Frame
...............................................................................
Plot ............................ Lot ................................
February 1-8 , 87
Permit Granted ........................................19 J
Date of Inspection ....................................19
Date Completed ................-................ .....19
y
)TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map to Parcel 0 Z7 ._ Permit# �l-Z 6 /
TtIt�Ii C' SaPNSTABLEDate Issued J Z
Health Division � 1 U g�'
Conservation Division :5 Z0V t , 20-01 FLAY 20 P
M 4: j Application Fee 00
Tax Collector Permit Fee �7` �2
- SEPTIC SYSTEM MUST BE -
Treasurer �`l� f)iVJISIOP 6 ED 114 COMPLIANCE
Planning Dept. T WITH TITLE 5
Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE XV )
OWN REGULAl I '
Historic-OKH Preservation/Hyannis
Project Street Address I n9 rti 1
Village
v 09 eyl Address � G
Telephone 3( Z 6( �
Permit Request (2k2a1-%,?-T'S QQZ !�J Aq,-./
Square feet: 1st floor: existing t 3 a proposed 160 2nd floor: existing proposed — Total new
Zoning District Flood Plain �I� Groundwater Overlay i'"O
Project Valuation Construction Type -
Lot Size 42_4d0 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family O' Two Family' ❑ Multi-Family(#units)
Age of Existing Structure 4 O Historic House: ❑Yes &No On Old King's Highway: Yes O No
Basement Type: O Crawl ❑Walkout 0 Other
.. Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) �^1 3 y
Number of Baths: Full: existing .2- new Half: existing new
Number of Bedrooms: existing Z new
Total Room Count(not including baths):existing - new First Floor Room Count
Heat Type and Fuel: 0 Gas C_Oil O Electric ❑Other
Central Air: 0 Yes O'No Fireplaces: Existing New Existing wood/coal stove: O Yes t9'To-
Detached garage:0 existing ❑new size Pool:O existing ❑new size Barn:O existing ❑new size
Attached garage:0 existing ❑new size Shed:Ca existing ❑new size Other:
Zoning Board of Appeals Authorization 0 Appeal# Recorded❑
Commercial 0 Yes @46 If yes,site plan review#
Current Us.,l ���Qw.��dkL_ Proposed Use 5
BUILDER INFORMATION
Name S S 1 Telephone Number 3
Address S,r
�• ,A� T License# l
B Home Improvement Contractor# l d 39 a
30 Worker's Compensation#
ALL CONSTRUCTION DEBRIS RE G FRO OJECT WILL BE TAKEN TO 1 C 3
SIGNATURE ;`sP. • ��'� DATEZ—
LA`
FOR OFFICIAL USE ONLY '
PF,RMIT NO.
DATE ISSUED
MAP/PARCEL NO. -
ADDRESS"-- VILLAGE
OWNER
DATE OF INSi ION, .
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGE FINAL
GAS: ROUGH FINAL
FINAL BUILDING
<;r
DATE"CLOSED OUT
ASSOCIATION PLAN NO.
mRESIDENTIAL BUILDING PERNIIT FEES
APPLICATION FEE
New Buildings,Additions $50.00 ,
Alterations/Renovations $25.00
Building Permit Amendment SZ5.00
FEE VALUE WORKSHEET
NEW LIVING•SPACE ? •
square feet x$96/sq.foot=
25 0 x.0031=
plus from below-(if applicable)
ALTERATIONSIRENOVATIONS OF EXISTING SPACE
square feet x$64/sq. foot= x.0031=
plus from below(if applicable)
ACCESSORY STRUCTURE>1Z0 sq.
>120 sf-500 sf $3100 '
>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
STAND ALONE PERMITS
Open Porch _x$30.00=
(number)
Deck x$30.00=
J
(der)
Fireplace/Chimney x$25.00=
(number)
Inground Swimming Pool $60.00
Above Ground Swimming Pool $25.00
Relocation/Moving S150.00
(plus above if applicable)
permit Fee
projcost
f
�OFINE lqt, Town of Barnstable
* Regulatory Services
vBMMUMBIA
HAM. Thomas F.Geiler,Director
019. �0
A 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. n , n
Type of Work: 14 S, Estimated Cost �S
Address of Work: ��1 �'l�r�v.� l�_ 6�2�►J p L.t, L
Owner's Name: -DO a
Date of Application: d) S 1 O"L
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
❑Building not owner-occupied
❑Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDE NA SO Y
I hereby apply for a permit as the agent of er:
Date C for a e Registration No.
OR
Date Owner's Name
Q:fomis:homeaffidav
The Commonwealth of Massachusetts
- Department of Industrial Accidents
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
i
name ST{�✓Y'1 1 S �� .
location: (CP�.� 2
city ?
• 11�N Rim%�`p�L'S G • Pt phone# 3eca-_ 9 i 2�;
❑ 'I am a homeowner performing all wofk myself
I am a sole r ni for and have no one working in ca aclty
%% %% /%%/%%%/%��/%%/%%%/%%%%%%/%%%/G/%%%/%��%%/O%%%%%%%%%%%%%%/G/�%%%%�%////%/
I am an em to er roviding workers' compensation for my employees working•on this job.
❑ P Y P................................:.:::::::::.:::::::::::..:..........:.:::::::::::.:::::::::::::.::::...:.........:::.:.::::::::.::::::.::::::::.::::::..:::...3::....:............................:::::::::::::::::.
:cum an nani
`fire
:C1tY
" anc .
I.am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who...-.
have
r:,::....
the following workers compensation polices: :::::::::::::::::::::::::::::::.:::::::::.::::::::::.}:.}:.}:.;;:;;.;;:?.;:.:.;;:.}:.;:.;;;;;:<.;}}};:.;:.;:;.;:.:;:;.:.};:.}:.}:.}
an n ame
v m +�:CO A
:}!::;:.';:<::4i:%}} :}?:;i:::i��i:;i:;i%i;i:;:jiji;{:?:�v.
...... ?:}:v:::::.v:::.v::•i:::::::;•}.:::i:::•:::i::.: ::::::.::.:::i�::ir•:ii':::
v.I....v
es
.i.';':vii 'i:;>::::$j iii ii i::ii..l%%?i i:ii ii>.ti:>:Y:;?iiiiiii>i:::>.>.:: i:;'}i}iii:•}i:•isoi};•:}}ii}}:^:^:•}:{<•ii:v:4iiii}:v:C:i:•:3::vi}y,??;?•}:;•:^:??.}}}}};v}Y}:;•}}:::::::•
S:•:is S}i:::::::::::.�. :• .....
.....:.............:....:...:...:........:..:.:...:..................................:::...........:.::............:...........................:.......:::
..... ............. .......................................::::::::::r.......................r::.......................^:•.:w:::::w::.v}}':•.}:;•}ii'i}v::G::::....r............:v:}:.;� ....:::::^...........r::.v:.::!'•:::•.. •• 3:X. 2
.......... ...r.............. .................... .. vs:nw:•:v:.v:v.v:::.:v:+;:::::•::::::::::v:::::::..................• v. 'V}:3}}:f:: v:. ,. ♦........ }::;....:1...;.;•
......... ..... .....rr.....r........v.�•.: :...:::::::::N:...: ;w:�.v:.::::::::.. :.vi:3:v Y:4i:i�}}:;3:3:}yii:;•};:.q;}a}}
... ... .r............ .. .. ..... ...;•.:w::::::::::::::.:v:::::::::::::::: .......:.. ....... .. ... .. w. v:^}iiA}}!?.i:•i};;::::n�}::::::iii}:�:+.}•Y;J?:
:•:•iii:•i}}}:3:;3::3}i ......:......:::.::•}}::•}ii:vii:;•i}i....... ..:::::: .:::::.'vi:;'•}:: :;i:: ............;i:;}:ii;::;.
...::.::::::•.::�.i.:; � ....}:^i;{tiff!?.i} ... ...........................::v::::^v::•.................. ii ....: :::., i:•.-'��iijii jiiiiiiiiiiii�+:�.:....
'�► � ....................::::..:...............................phone:#:::.�.�; .. ...:..;:::�::
a j4.y
>:.:...:
�...
2•
dd
..v...S�ie•...
........:.........
::�. •:.�.•. -i:.:;::+.-.,..:_.:�. ........... y±. ;• NX
;'::...::::::::i..;.;i:..r::.:;;::�i:�:;:�::;r;•:.+.i3.3i;:}'�r• :;3i:::tr.?%c•:
:::.:}::.i:.::::i}:.i};:.;i:.;;i;:<.}}:.}:.::.}:. i:..i}}:.i:.:}: :::<:gi
l%1/I///1I//l
.............
:..................::...........
..
ess.. ... .... .,.
addr
aion b y:i•:J
i:Cdiv.^
............
'"(:}.:Ji:Jii::';;iii��ij;:;:<:iii:•}f:}:•}:•}i}i};^}»}i}Y.!i?ri`viiiii i:rii:v�::^iiii?i}:•}}iii}ii:l•i:4iii':i•ii:•.
Fafiure to secure coverage as required ender Section 25A of MGL 152 can lead to the imposition of criminal penalties of a See up to S1,500.00 and/or
one years'imprisonment as well as d9,11Raities in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I miderstmid that a'
copy of this statement may be fo to th e o tions of the DIA for coverage verification
I do hereby.certify u the pains and es of per that the information provided above is true and correct
Date
. Signature �
r
'Tjf✓ 3.. Phone#. :::3 L 3�
Print name � _
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Depa�nent
❑Licensing Board.
❑checkif immediate response is required ❑Selectmen's Office
_❑HealthDeparlment
contact person: phone#; ❑Other
(Devised 9/95 PJIa
i
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is.defined as every person in the service of another under any contract
of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or
trustee of an"individual,partnership, association or other legal entity, employing,.employees. However the owner.of a ...
l:kY
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance orfenewal
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,- Y thec�' box tlat a$ lies to your situation•and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits maybe
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 cull°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 tine
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please..
be:sure,6 fill in the permrtllicense number whrch will be used as a reference numlier..The affidavits may lie'rehuned
the Departmennt b `maiF or FAX unless other arrangements have been made: w
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
Me of Inves"gadons
600 Washington Street r ,
Boston,Ma. 02111
fax#: (617.) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
' Tabls 1S=b(can!&ssd)
posai Fads
PrSteriptNe Pseka;a for Oas"d Tw*'Fgn*R=Wmdal Bs+WIRP rt"a'd
MOM
MAXIMUM Floor Snc+mmt gabgiCmling
Glazing . Glaring B P Fdfid
Ccilin
w
Aim'(•/-) U-vsluc= R-vsJud R-valua� &vd+d � T
Padca?c
. 3701 to 6500 Hesth�Dr�se Dae�+7 6 Nosmri
13i 19 10 Narmsl
Q 1Z!'- 0.40 31 6
03Z 30 19 19 10 is AFM
R I % 6
13 19 10 N�
g 12:4 . 0.50 3t 23 NSA N/t
T 15% 0.36 . 31 13 6 Normal
19. 19 10 !s AFVE
U 1Sy. 0.46 3t WA
3E 13 ?S N/A as AF UE
v tsi. o.a4 14 10 6
w 15% 0.32 30 19 NIA Normal
X la% 032. It 13 ZS WA
Nark
l9 ZT ?UAy I EY. 0.42 3= 690AME
32 13 19 �..NA
30 40 AFZJE
AA lE•/- OSO30 191910
T. ADDRESS OF PROPERTY:
w
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS .2SZ
3, SQUARE FOOTAGE OF ALL GLAZING:
4. %GLAZING AREA(#3 DIVIDID BY 02): t
S:'SELECT PACKAGE(Q—AA-see chart above):
G ENERG
.. Y'REQUMEMENTS
NOTE: OTHER MORE ASK US FO THIS OF DEM UA
ARE AVAILABLE.
BUILDING INSPECTOR APPROVAL:
YES: NO:
q.f0rms-f980303a
Footnote's to Table 15.2.1b:
Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skyliehts, and
basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall
area. expressed as a percentage. Up to 1%of the total glazing area may be excluded.from the U-value requirement.
For example%3 ft= of decorative glass may be excluded from'a building design with.300 ft= of glazing area.
= After January 1, 1999, glazing U-Yalues*must be tested and documented by the manufacturer in accordance with
the Nadonal' Fenestration Rating Council (NFRC) test procedure, or taken'from Table 11.5.3a. U-values are for
whole units: center-of-glass U-values cannot be used.
The ceiling R-values do not assume a raised or'oversized truss coastruction. If the'insulation achieves the full
insulation thickness, over the exterior walls without compression; R-30 insulation may be substituted for R-38
insulation and R-38 insulation may be substituted.for R=49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing (if.used). For.ventilated ceilings,.insulating sbuthing-must be placed between
the conditioned space and-the ventilated portion of the roof.
Wall R-values represent the stun of the wall cavity.iasulation plus insulating sheathing (if used). Do not include
exterior siding, structural Sheathing, and interior drywalL For example,an R-19 requirement.could be met EITHER
by R-19 cavity insulation'OR'R-13'cavity insulation plus F-6 insulating sheathing. Wall requirements apply to
wood-frame or mass(concrete,masonry,log)wall constructions.,but do not apply to metal4rame construction.
'The floor•'requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces, basements,
or garages).Floors over outside air must meet the ceiling requirements- '
TFe entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
mc_t the same R-value requirement.as above-grade`walls. Wiadcws and sliding glass.doors of conditioned
bz.,ements must be included with the other glazing. Basement doors=must meet the door U-value requirement
d_scribed in Note b.
'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs.
' If the building utilizes eleetric resistance heating use compliance approach 3;4, or S. if you plan to install more
than one piece.of heating equipment or-more�than one piece ofeooling equipment, the equipment with the lowest'
efficiency must meet or exceed the efiicienry required by the selected package.
For,Heating Degree Day requirements of the closest city ortown see Table 35.2.1a
NOTES:
a) Glazing areas and U-values are maxim=�aceeptahl .levels.Insulation R values are minimum acceptable levels.
R-value requirements are for insulation only;aad do not include struttaral components.
b) Opaque doors in the building envelope must have a U ter-value no grea than 0.3.5.Door U-values must be tested
and documented by the manufacturer in.accordance with the NFRC test procedure or taken from the door U=value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
ith your windows and use the opaque door U-value to determine compliance of the door.
glass area of the door w
One door may be excluded from this requirement�(Le.,may have a U all co greater than includes
c) if a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels,the.component complies if the area-weighted average R-value is greater than or equal to
the R-value requirement for that component. GIazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value=requirement(0.35 for doors). .
_ 43
Application to
' > ®Yb Rittg'o 30igbbiap 3egional 30iotDric Aliguitt Committee
In the Town of Barnstable
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, with four complete sets, 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: E3 rp
CHECK CATEGORIES THAT APPLY: Z�
1. Exterior building construction: ❑ New Rr Addition ❑ Alteration a
Indicate type of building: ❑ House ElGarage El Commercial
Commercial ❑ Other rnn
2. Exterior Painting: ❑ rm
3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign
4. Structure: ❑ Fence El Wall ❑ Flagpole ❑ Other v)
W
TYPE OR PRINT LEGIBLY: DATE 0 �1 ?i
r1(017,
ADDRESS OF PROPOSED WORK` Vic, C' ASSESSOR'S MAP NO.
OWNER `7c,�p�11� �i `BAgzm� Q,age1<, ASSESSOR'S LOT NO.QU Z77
HOME ADDRESS Z4'�Ag TELEPHONE NO. d j
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any
public street or way. (Attach additional sheet if necessary.)
AGENT OR CONTRACTOR ky- TELEPHONE NO.
ADDRESS 't_3b>G 3 �� �� C>Z6�> C)
DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please
include locations of proposed signs.
tJQ_,t3 t 2-X CSC, Rn Pa-a'�A.
Signed
wne -Contractor-Agent
For Committee Use Only
t ` - 1-1. . F-- APFKUVtU
r i I ; This Certificate is hereby Date `o�'�"oZ---
1 I Approved/ 'vied
' ( `1� APR 0 3 2002 I J Committee Members Signatures: rz
L _f — W
- so--r r� ,E
m�7 r_4AAZ1_ �6�_
n,. ro
i
1 J
Town of Barnstable
' Old Kin 's Highway Historic District Committee .
SPEC SHEET
FOUNDATION
SIDING TYPE `��-aA. � `� COLOR
CHIMNEY TYPE � COLOR
ROOF MATERIAL COLOR "�Apc -pV-C
PITCH
WINDOWS w>,O iI t\� COLOR SIZE
TRIM COLOR ���
DOORS tj COLORS
SHUTTERS COLORS
GUTTERS COLORS
DECKS MATERIALS
I
GARAGE DOORS COLORS
SKYLIGHTS S---IZE COLORS
SIGNS ,73 j�� Rr r�
COLORS
n APR 0 3 2002 ��I RVED
L� AJPO
FENCE r Z C)LA'. — --. -COLOR
_m
NOTES: Fill out completely, including measurements—and materials/colors to be used. Four copies of this
form are required for submittal of an application, along with Four copies of the plot plan, landscape
plan and elevation plans, when applicable.
SPECSHT
Revised 11/98
•s:... .... ..... ..
.... .........
ui ,9
..........
............. ;:::::
:r
•:{:::::: ..... ...................
....... .......::.?:
�•r?¢:d?.?: SP.:J?•:�WKb"''' '>.yL<Y{�.°:.:. :• ° i• .}?' F:... ......'s._.,T
..... .....
...........:.....:...:: • —
............ :. .... ...............ter--.-�:,:.•
:. .......... ..•....
tse�n 3i i ti ke s: av3ti� i...L No s of waa r`
4 's ..?
.:... i W.LF&. .
....:....................
........ 3t: E. ::V1A<.: & :::::
.......
• ...5..
........ ....... ......:........:.......
• ••••::.vv:vnxvnv�v:n:::n::vvi::.' "`
03/03/2002 .15: 50 5083621089 APlYlGDQ_ PAGE 91
RQrjet-s
West fiat-nstabfe
c4-iald S, t A.
LEM4 Court Ceftilkafe Ho. ................. in auk ........
'p Sp'p 27. 1960
. .-wi Beal
............. .........
a;-1)q ta
In ...... .......
MOPLTGAGE INSPECTION Ptd-.-%,N
LAI*No. Donaid S.
.7i
APR 0 3 2002
A 5 1'; �'2- -lk*'
Mi
Cr
,b a
. 0° 3 �
t
pg
b °
t -
L
�y
v
v
ti
Y
v
cJJ
12-
1
1 �
i
CD F- I
l -
1
-I --
DO /Z o
� s
0
0
0
N
c
f
MtURAppamUzJ
TableJ=b(eominuag
Preerip&e PaduLM for One and Two-Fandy Residential Boildingi Sated with road Fuels
MAXIMUM M11gIMUM
ILA�(n11 a . 9 Glazing Cdiing Wall Root BatemmtalWpmc
Heanag/CooLag
'(%) U-value= R valuer R value' 2 . WaU EMdmcy'
Padcaae
3701 to 6500 Hating Degree Dare'
Q 12% 1 0.40 38 13 19 1 10 6 Normal
It Ir/. 1 032 30 19 19 10 6 Normal
S Im. 1 030 38 13 19 10 6 as A a
T 13% 0.36 38 13 23 WA WA Normal
U IVA 0.46 38 19 19 10 6 Normal
V 13-A 0.44 38 13 23 WA WA ES AME
wI i5% 11 'vac 3; 11 19 11 1S Iv 6 gs nnta
X 18°/. 032 3E 13 23 W Normal
Normal
WA No
Y 18•/L 0.42 38 19 23 N/A WA Normal
Z 18% 0.42 3E 13 19 10 6 90 AFUE
AA IE•/. 0.30 30 19 19 10 6 90AFUE
1. ADDRESS OF PROPERTY:
Ltom`16� �',__���6
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS:
3. SQUARE FOOTAGE OF ALL GLAZING: lJJ
4. %GLAZING AREA(#3 DIVIDED BY#2): n
S. SELECT PACKAGE(Q--AA-see chart above):
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPROVAL:
YES: NO:
q-forms-t980303a
780 CMR Appendix J
Footnotes to Table J5.2.1 b:
' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and
basement windows if located in walls that enclose conditioned space, but excluding opaque doors) to the,gross wall
area,expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement.
For example,3 fl of decorative glass may be excluded from a building design with 300 ft of glazing area.
2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with
the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for
whole units:center-of-glass U-values cannot be used. '
' The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full
insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38
insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between
the conditioned space and the ventilated portion of the roof.
'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include
nxtarior sieftig, gl crnral sheathinva, and interior drywall.. For example, an R-19 requirement could be met EITHER
by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to
m wood-frae or mass(concrete,masonry,log)wall constructions, but do not apply to metal-frame construction.
The floor requirements apply to floors over unconditioned spaces (such as unconditioned crawlspaces, basements,
or garages).Floors over outside air must meet the ceiling requirements.
`The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
meet the same R-value requirement as above-grade walls. Windows and sliding glass doors -of conditioned
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
described in Note b.
'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs.
' If the building utilizes electric resistance heating use compliance approach 3, 4, or 5. If you plan to install more
than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a
NOTES:
a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels.
R-value requirements are for insulation only and do not include structural components.
b)Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested
and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.
One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35).
cl If a,ceilinv_ wall floor FIACPN1Pnt.valh Clad-r..rlae;nr r,.rawl cfi��P.vall =n.,,n�nn..♦in��nl�oC fivn^- W
different insulation levels, the component complies if the area-weighted average R-value is greater than or equal.to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
own of Barnstable-Planning Department r
_ Old King's Highway Historic District Committee
+MP
�IO MR I
1
MEMORANDUM
TO: Building Commissioner
FROM: Gwendolyn Brown, OKH Secretary
DATE: Z 21
SUBJ: Modification to Prior Approved Plan
A minor modification has been approved by the OKH Committee
to a prior approved plan for the applicant (s) named below.
The modification is briefly summarized and I have attached
'h
backup material for your records .
Applicant (s) ►�/C� C�/LC.� (�V �'!1!�
Address of proposed Work 7 Ma4- J
Assessor' s Map & Parcel# [ 7 6 d 2, 7
Meeting Date Approved by OKH
Minor Modification
166" m
Chairman
f
Date
If you should have any questions, please do not hesitate to
contact me at ext . 862-4684 .
rEMosc
Parcel Detail Page 1 of 3
Logged In As: Parcel Detail Tuesday, Jui
Planning
Home Application Center Parcel Lookup
Parcel Info
Parcel ID 196-009 Developer Lot LOT 3
Location 11679 MAIN STJRTE 6A(W.BARN.) Frontage
Sec Road I Frontage
Village IWEST BARNSTABLE Fire District W BARNSTABLE
Road Index 0955
Owner Info
Owner I ROGERS, DONALD ET AL TRS Co-owner
Streets 11671 MAIN ST Street2
City JW BARNSTABLE State MA zip 02668 Country US
Land Info
Acres 10.54 Use I Multi Hses MDL zoning RF Nghbd 0105
Topography Level Road Paved
Utilities Gas,Well,Septic I Location
Construction Info
Building 1 of 3
Year 1950 SR�ct Gable/Hip TypeI None
Effect 564 Roof Asph/F GIs/Cm Bed 2 Bedrooms
Area Cover Rooms
style Cottage Bath
wall Drywall Rooms I_
Model Residential Total 3 Rooms
Rooms
Grade Average Minus Floor Bath
Kitchen
Stories 1 Story StyleExt �� !
Heat l Bath
Wall all Wood Shingle
Fuel � Split
TypeNone _. I Found-ation Electric
Building 2 of 3
Year Roof AC
http://issgUintranet/parcelinfo/ParcelDetail.aspx?ID=14184 6/7/2005
Parcel Detail Page 2 of 3
Built 1950 struct Gable/Hip Type I None
Effect 560 Roof Asph/F GIs/Cm Bed 2 Bedrooms
Area Cover Rooms
Bath
Style Cottage Wa1l Drywall Rooms
Total
Model Residential Rooms 4 RoomsInt Bath
Grade jAverage Minus Floor I Style �.
Stories 1 Story Kitchen
Style
Ext Wood Shingle Heat -'--"""—"'"—� Bath
Wall Fuel Split
Heat None Found- None
Type ation
Building 3 of 3
Year
Built 1950 S ruct Roof Gable/Hip TypeI None
Effect 466 Roof Asph/F GIs/Cm Bed 2 Bedrooms
Area Cover Rooms --- 1
_Int Bath
,I
style Cottage Wall Drywall Roomstotal
I '�
Model Residential Rooms 3 Rooms .
I
Grade Minus Int -'--" Bath
Average
Floor Style I
Stories 11 Story r—� Kitchen
Style
Ext Wood Shingle Heat --' Bath
Wall Fuel Split
Heat
Type None Found-
ation None
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
12/1/2000 New Addition 50305 $5,000 9/4/2001 12:00:00 ADDITION IS ON
AM 2OF3
5/1/1990 B33749 $5,000 1/15/1991 WB ADD'N
12:00:00 AM
2/1/1987 IB30437 1$28,000 1 WB REMOD'
- Visit History
Date Who Purpose
9/4/2001 12:00:00 AM Martin Flynn Mea./List Bldg Permit Only
�15/10/2000 12:00:00 AM Paul Talbot Meas/Listed
3/15/1988 12:00:00 AM M
Sales History
Line Sale Date Owner Book/Page Sale P
1 2/3/1997 ROGERS, DONALD ET AL TRS 10594/162
2 ROGERS, DONALD S 1293/241
I
I
http://issql/intranet/parcelinfo/ParcelDetail.aspx?ID=14184 6/7/2005
Parcel Detail Page 3 of 3
I Assessment Histo
Save# Year Building Value XF Value OB Value Land Value Total Parc(
2 2005 $154,100 $7,100 $0 $147,900
3 2004 $123,500 $7,100 $0 $147,900
4 2003 $92,800 $7,100 $0 $46,200
5 2002 $88,500 $6,900 $0 $46,200
6 2001 $88,500 $6,900 $0 $46,200 ;
7 2000 $79,200 $6,600 $0 $34,900
8 1999 $79,200 $6,600 $0 $34,900
9 1998 $79,200 $6,600 $0 $34,900
10 1997 $88,500 $0 $0 $27,000
11 1996 $88,500 $0 $0 $27,000
12 1995 $88,500 $0 $0 $27,000 ;
13 1994 $96,400 $0 $0 $38,200
14 1993 $96,400 $0 $0 $38,200
15 1992 $109,700 $0 $0 $42,500
16 1991 $124,000 $0 $0 $61,800
17 1990 $124,000 $0 $0 $61,800
18 1989 $124,000 $0 $0 $61,800 ;
19 1988 $82,900 $0 $0 $21,900
20 1987 $82,900 $0 $0 $21,900 ;
21 1986 $82,900 $0 $0 $21,900 ;
Photos
I
http://issql/intranet/parcelinfo/ParcelDetail.aspx?ID=14184 6/7/2005
JKAssessdr's office,(1st floor):, Q
—.,-'—Assessor's map and lot number ... .... ..<...tD........v?.��`8S��+SYSTEM EST �pFTNE TO``
ALLEDIN
Board of Health (3rd floor): ��rrT'
Sewage Permit number .... ". . . '3 7..�. 1. WOTH YBT�C' ''
.`..... .. . ................ Z B6Sd9?ADLL.
Engineering ,Department (3rd floor): -JS ENVIRONMENTAL Gs;. �p0 t639.
.l/ � 7
House number ................................. . (D ........ rjWNi REGUL 111 �o
Definitive Plan Approved by Planning Board ________________________________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 ...Qond.T/..v.C-1...../.0'....10.........L�.�R'/...��d n...........................
TYPE OF CONSTRUCTION .........W.O.0.Cl.....T/:.'a.r.7..ley............................................................................
• a
...............................a5.11719.1.�.J...
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location J6..71.....Mow)....4JT)........
............c...G.... .Q�.�..�.............:........................
� LL ..........
ProposedUse .....C1o..tseT..........................................................:.......................................................................................
Zoning District ............................ ............. ..Fire District �� ��r.�.............. � . 9� . ...........
Name of Owner ..�C7ona101......��.9.e�'.�' .. t�n....t�� .......r,�.:..�3ar s�ccl�le
Address ,../....... / rI
i-_ Name of Builder ......��..ohn....../.-'/..e.--1c6S.................Address A0.02a.?.../.e— .n�.It!!...f6C.xrntlk.�k
Nameof Architect ..................................................................Address ......................................................................................
Number of Rooms ....... .........................................................Foundation .. fJC'.'.(. ........ D.�.�./c—:/c.............
Exterior .......whzk......2eda.r.....a[.1:/. Roofing ...aoph /i ...................................................
Floors .a.�CA d................................... Interior ?. e�. .... .Ck..........................................
Heating .........../.l.(J.n.�.........................................:............Plumbing ........n. nt ........................
Od
Fireplace .....noae............................................................Approximate Cost ..........�Doo. .
Area ........../.. ..............
Diagram of Lot and Building with Dimensions Fee o0
• r,3o�
OF
45
IQ
to '/
t �zoo
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
construction.
Name .... .. ..................��...f ����G�l .
Construction Supervisor's License ....1�..7..6.5.....
ROGERS, DONALD
3 Add to
3749
CILN'o ............4.1... Perm'.i't for ....................................
Single Family Dwelling
. .................. .................................................
Location
1-6- } Main Street
................................................................
West Barnstable
.............................I........................................
Owner Dona a..l.d.......Rogers
.....og...e.....rs.............................Type of Construction Frame
..........................................
...............................................................................
Plot ...... ..................... Lot ................................
Permit Granted ......T` EjY...1.7 ................19 90
Date of Inspection .............. .......19'
Date Completed .............. ...............19
Application to
CIA
OPEC PpP�P� ,
Old Kings Highway.Regional Historic District Committee
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: ❑ 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). ! `
67
TYPE OR PRINT LEGIBLY DATE f / •/
ADDRESS OF PROPOSED WORK fA 57' yo• 61 I`ASSESSORS MAP NO.
OWNER ��O-Z/ A Z YD S. e,) ASSESSORS LOT NO.
HOME ADDRESS IVIALN5-7- w " 1V:. 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).
l'14I N S r' LD-) (A)
i;t; �/?IQ/11S/���C o� 6l0� /� � :'� S lN• ��)z� /��ss G,.�.(�(�
Ja
AGENT OR CONTRACTOR O / !� 1 -� TEL. NO. 3-14A ,ego"t
ADDRESS `> d A �7�' 1.P o=s A/ IiV �✓f���!`/
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).
y �US
l Vd fi( j �' Signed 3l'L. �"' �`��•� fl r
Space below line for committee use.
APPROVEt� Owner-Contractor-Agent
Received by H.D.C.
R �ate. s , The C 'ficate is hereby Date
rv � r E /
Tim n01
ANK ) 1
By
Approved_ I PORTANT: If Certificate is approved,approval is subject to the 10 day appeal period
provided in the Act.
Disapproved ❑
f
{ Form
A
OLD KING'S HIGHWAY HISTORIC DISTRICT
Spec Sheet
Foundation Type 7 0
Siding Type lil)f7/ / �farr SIi �r `=
Chimney Type Color
Roof Material Color
.�
Pitch � ! �� / ��. .Al-5- f�,�/,(
i
Windows /� �� G Jt� "J/� l�LSize C'_
i .rN,
Trim Color
Doors
Color
Shutters "
Gutters r d'
Deck
Garage Doors /1 Color
APPROVED
Notes: _,Fill out completely, ®KHRHDC
p y, including measurements and materials/colors to be used.
Threel"copies of this form are required for submittal of an application,
j R E C E I V E ralong with three copies each of the certified plot plan, landscape plan and
elevation plan, when applicable.
APR 3 1990
OLD KItiG'S HIGHWAY
<< Barbara A. , !;
BARNSTABLE Donald S. R ers
Land In ...............................,................... Belong ...°�.................. Deed in Book....1293.... Page 24C
ing to........................
Land Count Certificate No. ... ........... ,,,,;,,,,, .Barnstable, of.Deeds
in Book. Page. In. Registry.:
Land in Barnstable by Nelson Bearse`& Richard Law, Sury ors Sept. 27 f�60
RecordedPlan ................... .. .. .... ............. ............. ... Date of [an .........................................
Barnstable of Deeds, in 185 �23Registry.................................... Book... .......No.. .... Filed Plan No.
MORTGAGE INSPECTION PLAN THE. MORTGAGE COMPANY OF THE CAPE & ISLANDS
Lean No, Donald S. &.Barbara A. Rogers
SToniL {✓AC.L
14
O
_ N \
414 .
f r za Ave
\a
M LOT 3 . LOT 4
2 �27.79)
ONE!y
°T
Z9.6tv)�
s�
Oct. 27,1986
JN 50913
Scale 1'°=40
APPROVED
RECEIVED OKHRHDC
APR 3 1990
GL G KING'S H u" WAY
s
�. Ilk
ou
O r
T4
Q 0
LET
i
i
. i
s
f1 I
I �(
RECEIVED
APR 3 1990
GLD KING'S HIGHWAY
Q
c>
w �
O �
7 �' 40
/If
t I
,y
RECEIVED
APR 3 1990
OLD KING'S HIGHWAY
0 u
W
i
Y
1
i
/ 1 P
i(}1
APR 3 1990
0 K'NG`S HIGHWAY
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map JU ParcelZ Permit# a -
Health Division Date Issued
s 1 2
Conservation Division O'er Feeo2�:x�
Tax Collector
Treasurer -�e—�—�- �1� ?/Z SEPTK"A' SYSTEM MUST BE
Planning Dept. INSTALLED IN COMPLIANCE
_4 WITH TITLE 5
Date Definitive Plan Approved by Planning Board - ENVIRONMENTAL CODE AND
Historic-OKH Preservation/Hyannis
TOWN REGULATIONS
Project Street Address A 7 9 Al Q i*r- Strei_l',
Village 11
Owner &�ftl�v` /IOcers Address
Telephone 3 L b� S
Permit Request X/ ��/'rcts'"�- !�ti-S,D'�-'
Square feet: 1 st floor: existing proposed W 2nd floor: existing proposed Total newAW 216
Valuation �g16o6 Zoning District Flood Plain Groundwater Overlay
Construction Type W60
Lot-Size a3 906 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
I"Dwelling Type: Single Family O'/ Two Family O Multi-Family(#units)
Age of Existing Structure �sm Historic House: ❑Yes W4 On Old King's Highway: as O No
Basement Type: O Full brawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing Z new
Total Room Count(not including baths): existing y new First Floor Room Count
Heat Type and Fuel: ❑Gas O Oil ❑Electric ❑Other V oy?tl
Central Air: ❑Yes CTI o Fireplaces: Existing New Existing wood/coal stove: O Yes O No
Detached garage:O existing ❑new size Pool:O existing O new size Barn:O existing ❑new size
Attached garage:O existing ❑new size Shed:O existing 0 new size Other:
A
Zoning Board of Appeals Authorization O Appeal# Recorded❑
Cc'W'Imercial ❑Yes ❑No If yes,site plan review#
Current Use Z'Week SiArr&M& C2AAe-e/ Proposed Use �r�,r►y'Pi
BUILDER INFORMATION
Name 1A,4c,,1-k 5'�an-/� Telephone Number -7P16
Address / License# t 5 no , Y3�
A . 3 Home Improvement Contractor# ' &,!� _33
Worker's Compensation# !✓�
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE L�f DATE z2qhoo
FOR OFFICIAL USE ONLY
T
AIT NO. s
D`71 E ISSUED c;
MAP/PARCEL NO.
ADDRESS' `o) VILLAGE
OWNER
DATE OF INSPECTION:-,
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL t
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. `
2000f21
Application to
Old Ki H s Regiong Historic District Committee
n$ ' ' co
In the Town of Barnstable for a
NO _ .
CERTIFICATE OF APPROPRIATENESS iv
Appl;=do I is hwsby"wit*jejoillijeeW for the Issuance of a Cwdficm of 1lppropriatahess under sectioWB at 470.
AM and Re IM-of U"sw*wsetts, jM for propar<ed work'as described below and an plam or b
accompany"this appineaaon for: c
CHECK CATEGORIESTHAT APPLY:
i. Exwior Buiiding cwmue w. ❑ Naw Bul&V GAddition ❑ fir' _
Indicate type of 91 House ❑ Garage ❑Gara Corrwrwrclal ❑ Othw O I`1
2. Exterlor Pelot1 Mr
3 Signor Billboards: ❑ New sign Q Existing sign ❑ Repainting exisg sign
4. such ww ❑ Ponca ❑ Well ❑ Flagpole ❑ Other
(Please read oth&side for explanation and requlrarrherrts).DATE �LT j6
TYPE OR PRINT LEGIBLY C /p,
ADDRESS OF PROPOSED WORK 6 9 ��'ti J �� fn r . p�Es9pRS MAP NO• —199.
OWNER J 1 rv.. LJ ASSESSORS LOT NO.
I40ME ADDRESS ` Ashes, �4 _[AL ?2l.r TEL NO_
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS` Include name of adlacent property Owners acmes MY public
street or way. )Attach additional sheet if necessary). .
AGENT OR CONTRACTOR ,v k'r w TEL NO. yd-P- L 910
ADDRESS OkDA-
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done Indudirhg
materials to be used,if specifications do not accompany plans. In the case of signs,*0 locations of ex signs and proposed
locations of new signs. (Attach additional sheet,if necessary). ? i X 1:2 ! ck fe,s i a r, o-- b toltv6'rt., )✓ -
5C.'r+%.m fl, Go ttc6t, O06�- F or- Cem ,t p;v� L to G �Ar Si�e •va�l�
CiJ�k a-rvL 14 roe j'w.r � rn w�� ex;s�;� 3 "X y'y
Gl�inp4`av" G o h, 03 GA
Signed
Ownw4ontranw Asm
space blow tine for Cmn vdtm or,
i
R. o AAA P
0 �,
D e Ce to is hereby
� ate_.OCT
..,.•.
14 T 6=
me
TOWN OF BARNSTABIFvr��a 71Y��
to U KINGS HIGHWAY �}
'['owa of Esr '
OM Ida Ukhway Euork Dishid COMMON
SPEC SH
FUUMATZOA
SIDS
COLOR
IbOOF SAL COLOR
PTTCCB y
wnwiONS-Wook COLOR i SZ88 ,� X LI
Twa CoLolt 4
DOORS COLORS ^•�
g �f�} COLORS
t $A3 J��i7 COLORS
DECKS /' Td MATERIALS. --
t�'
30'6
I 6'11 �5'4 3' i 15'3
3'4 37 2'8 T
2'8- �37 76 4 4'2
i
0 6 5 5L Cios.
LO Batr�
----- --i co g Existin
`. .. ... . �— 149
Proposed
i .._............
_
I �
� I 1
I
N Co CIOs.
I r CIOs. Cios:
--- 12111 --
r�
N N
bpi v `� Room Living _
N I 2nd r�edroom
CD
-.... CN
.
a�I ao
---
rn Screened Porch
10
Proposed Addition For
r-3'3"2 --- 5'6"6-- -- 38-.4----4'3 -- --- 4'6-� Barbara H. Rogers
1'1�--------- -- 12'6------- LIMING AR 8,9a —+-� 1679 main Street
i 64 sq fft �� W. Barnstable , Ma. 02668
-22'4' (508)362-6185
F - - Drawn bytvlark A. Stanle}28-7810
October 24,2000
Scale: 114"=i'
�p
n r
�r
` Q
k d .
rCR R
' ' 4U -fit Y,
-771
3 } 4
S
��! ...ry„�.,:d"s3^e-�"s.:`„i �. ":_2"F"�3.C...-�., .sr.•'.t�' .. ,.+c�-:r
? �� .^--.�...F' .c.:CS.-r"1- �'`'` _ _"' 9� _ J«.2 ♦c. --„r. m' !:.;yl.S � ,a.
'�k"G,i� _4+} ✓'atM�a_. i t �.. � s� �" � Ft.�.a�.' y�i� - �-ply,° �
'.d, ,.""_P�'y.�`i✓ t"�,`-�s ��„Y�� ,t•, '�`.�.c. x. S'.Sti..`�-� r rh �v. d..J.a_- .
�� .y��,r`-e.?^s..3e'r .�"'','�'�,�"-n r_l;.`a<.�>.-e'�a`.,I.C�4 t � ',�� � X.xFr YM'��'�^}� 4-..f���•-
6 Q �lnu{
�U l!
..:---a B..arbara A. 8 1293 '
Donald ogers Deed in Book................Page 24
BARNSTABLEBelonging to.. ••••..••R' " "'" ' of Deeds
Land In................................�................... .. _ 1n.Barnstable.R696", ......................
...............4 page............ -
Land Court Certificate No..............•••in Book S
Land in Barnstable by Nelson Bears fi Richard Law, Surv�y ors Sept. 21 9fi0
• .. Date at Plan ......................................
Recorded Plan .....ip••PlanBook•. .185.......No Filed Plan No. ..... .............».............
Barnstable ofDeeds, .....••••
.Registry....................................
ORT"GE INSPECTION PLAN THE MORTGAGE COMPANY OF THE CAPE ISLANDS
M Donald S. S Barbara A. Rogers
Loss Na
STONE W.4Li-
�'.
�`' S7Z7f�C N
LOT 4
LOB' 3
I®
WAY
40-
A401
�o
Oct. 27,1986
JN 50913
Soak 1"-=40.
VED§�V
Barbara A. & 1293
Donald S. Ro ers ... Deed in Book................Page 24C
Land in ...BARNSTABLE .... ......... Belonging to...................^........�............... of.Deeds... ...
�n• Barnstable.Registry
Land Court Certificate No.... ...........in Bonk................ Page............ .:.
• Sury ors Sept. 27���60
Land in Barnstable by Nelson Bearse > Richard Law, P
Date of Ian .......................................
Recorded Plan..... .... ......planB ...... �185 .......No...123 filed Plan No. ...................................
..
Barnstable of Deeds, in No............
in........................Registry.............................
MORTGAGE INSPECTION PLAN THE MORTGAGE COMPANY OF THE CAPE & ISLANDS
No. Donald S. & Barbara A. Rogers
Loaa '".
STvN[ AIALL
414
OW
/ - LOB' 4
LOT 3 t `� 9i
,'�°•
=� wti a411'�l
•3S), (/29 AY
40.
Oct. 27,1986
JN 50913
Scab 1"=40�
30'6-
.r --611 —64-- -3' -ice--- 193 y
1:--3'4=-�—:�V7 + 218 78—1 .—3'7 T6 i.
-4'2--,I
i
! — -�-T
j Clos. i
KiC..
. ... ... Existing �a t
I i -- -- — 14 9-- --_to -- l
! I Co Proposed L) . N i
I ,
I N I i Glos. i
i °� '•, I Clos. Clos.
i
i 12'11 -- -- j -...�i..
i cD i f
N
i — — i 41
- - v N b
Living Room 2nd L edroomSP
8,5
i f
! m ! I
Screened Porch SP
�_ I
1
i N
i
I i Proposed Addition For
. 3,3„2..4- _. ..5,6„6 .._....... �.. 3�g..... _._...4'3.... --4'6— �i Barbara H. Rogers
1 LIAING AREA ' 1679 Main Street
64 Sq ft 89_ _ --� W. Barnstable , Ma. 02668
(508)362-6185
224 Drawn byMark A. Stanle}28-7810
October 24,2000
Scale: 114"=1'
Y
l�
;t,1.1 b'�a�'l�YinM1,sa.F't.liZ�(V�:'�tt fit. f
�r'�l%'"•�`�};�'f'',ri�'#�a`]-a4`'a':j�lk N'tj��`c+",
r!•iy�3 �� �.:f t�r ip �£ t t ;�
MI
.".fit,.• .t.�`-0'7%�3n>:�f�j
,w,,2�:;Ctrs,:,;
iy .;t;}Zf
:,• 1,�I Y�..:..;
I
l
Q�
Piz-
LA
The Commonwealth of Massachusetts
- Department of Industrial Accidents
&NCOof/tNes9fFROos
_ 600 Washington Street
Boston,Mass 02111
Workers' Com ensation Insurance Affidavit
name:
location: >y Cen-fr' ,w,,^ ^�r,
city L° N.irr y i//`� (/v`Gr• d�� ohm&009,*/Y�
❑ I am a homeowner performing all work-myself.
�Q�I am a sole etor a"nd have no one woridn _in- cavacitV
❑ I am as employer providing workers' compensation for my employees working on this job.:::::::::::::..::..:::::::.:::::.::.. :'
iapeoY tiatIIe
h........:.....
w:::::•.v:::::::::.v::::.�.�.�:.�::::::::::::.v::::::'w::::w::::::::.�::::..�::.:_:::v::::::•:::v:::::::v:�::•::::v:::::::::::::.�::::.v::.v::::::::::::::.v.:v:::::::.�:.�:::::::::::.v:::::.�::.�.............................%::..;...F.
..............::::::::::::.�: :::::. :::::.v::::v::::::::::v::::::::.�::.�.�::.�::::::::::Y::::::::::::::::::...................v........:.....-.............. x::x• v{r.•x:rev:
..........................................w::::•:::::::::::.v:.{4}}}}:4}:?•}:ir-}}Y}:v:4;•}}}ii:4:4•;{4};.y}}}:4}}:is?•Y:v:;;'v{>{?{3:4}}:i3:•}}i:...:..}Y.iiiii..•:'�•...:...
........ .................................v::::::::::.�._::::::•::w:::::::::::v:....:•:...}T:::::::......:::i{:L.v.v..v:.v::'-:4:?:;4 :::::::::::::v.v::::..........;;.....,
art 3 ::.�:.�:::: i'::::::.�:.�::.:�.::.�::::::::.�:•::::.:i;:.�::::;.v.�._:::::::::??^.:^:}:i::i}:'{{sYii}i:ii}}i:•i}}ii:•i;•:•:•:?i;i4:{.:??i•:^:}}}}}}}:•}i:•}yp:•::;L;ii}i}::}:�}}:?i4}:•}}:ti•::3iii:•;?•:•Y::}}}i:;:i3}}:•:•Y}::}}':;
:::::::...::.:::..... ....... ::::.......::... ,
city ..........:::.:..... .....:...:::.::::..:..::..
o' :� <
....... .........
,..
.................................................:......:..:..................:...........:.........:..........:...........................................................................:::::....................................................
::::::::.::.::.:::::.;;:.}:;.;;;:.;:::}>:};:;.}i}:.;:->:;;.....:.: :::.;}::.;:::.:::::.3>}:;4:-};;}};;:;;?.;;;:.i}:.;;};;:.Y:.iii:3:.;:.};};:.:.i;;.} i>i} ::.}}:}:;i;;:.....:.:.....::::> >:::»:<:::
}:;rilict►
'nsurarr
❑ I.am a sole proprietor,general contractor,or homeowner.(circle one)and have hired the contractors listed below who
have
thefollowing workers' p9mPensation polices:............................................:::::..::::::::.:::.::::::.::::.:;:::: :.:.:.:.::::.:::::.:::::::-.::::.::::.::.:::..-•:.:.:.::yw.k,>, :h«>.>.<:>:;
...............:.::.:..........................................................
....................
~cam
} {
T
i?::{:} {'{:; ;:j?:?i>i}ii:i:;isj::}}yiiiiitvi;^iii?i::'tiY,.::}};ii:ii`i:{ii!i•
:::w:::::..:::::r:.v:n:;r3;??.:•}:3:•}}}}}:?;;;•Y:?•}}:•i:3i i}}: }T:::: K?iw:v:4:4:4}}:4Y}Y:3}}}:??{{?x::.�.vv.
........... ........................................ .......v......-................. ........v............: •?4::.v:::r::.?-.v::::•::::::::•::v.::::::::::::::::::.�:: ....::•:.:.v:•.v:::..v
.y�..� v:,{v::.v.�::::::::v::.v::.w:::::•v:L::v:::.:;.+..v v:::.v:•m::::.v...:::::::.......................:::::::•::
::.:......::...:::::::. ..............:..:.......,....: :::::•i2:2::::4:2.;.})}Y:?{:•ii?.:::::i:•::
}'4Y}Y?:::3; :
..........
•::•......................:v::...:....................................................:....:::::::::•.�:::::::::-.�::::::::w:::::::::::::::::::vyw::}•Y}`}}}Y"�Y}}::.y.v iv......n:':4%: :4i:�:rii}-::.;.y!';;{.Y^y����p�
( ,h..v...n...?4Yi}}:?tiff
:....................:::•.:.....................................................:::v.:::::.. ....:. .-....n.. .....:•.v•::r.:.::m:::.vr. .,f..n....4n•.:n. -.v-r.•::•:.?�..:^::x. .......r...:>!^:.{n.... •:}:f'•T.3?: fY�<
. ...............:::v...v..............-..n.................................. n.....n:{w:::.vnY.r•:•. Yv<n.:...., }.. }.t•`••. ••r.�.}
.... .........n...n.................:...........................................v.{.......... .. .::::::rev: .. :..4..:.......-........... ..... ... V:�'•.
.re:,r.r.... ...............f...re.. v.........................::v::.-::., ...v'4:'•Yi;•}•:v:v: ... ...... n,..:::::::: vr.;.
.r.. ........................w:::::•:::................. .............r..xv.-..:v:.......-.. ). �..:.:..::$...... ..................... rev.y;y:•.. ..
., .. .. .......................v....................{..... ..............h...re.r........... .x....:.:vn„-}....r..... rvh�:.3,'{Y.hl?;�`...::.. \:
..r}rr.. ......:....F.....F... ... ............ ........................ ,fir..{.rr::.j4:::.}.:•:•':rev w::;::•.�}:
................ ......-.....r..................... .:...-....-�•..x.v:rev::•::vv::rev..........................................: ..:::rv:.::: .,:::•::::::�:::Y::v:::.v 3"v.3}i:}`::•:• ...........-....
fv:r::':•x.>.v::.::h
.. ...:•...............:.:::::.v::::::re•:re:•.v:::::::::::.vnw::::::x.v:::::::::v:.:{•:4:4:-}:{?v:.:..................v......re....-..}.-rev...........:• .....::}3,Y., .,
'tllr0>tt:- o�2Y.C.:
I
I %vT.4 <
•:::•:ti:;OY:•i}3}v.:vreiY:.v...........................................r..... ..,w.....• m.v:::.vv:-::::^:::w:.v........- .....:::::.-....... ...:
..... ...::.vv.:....:.v:w:::::w::::{:::rew::vv:v:r::::::.:�:::Y:{v:w.........:"'v�•.........rxY.•:re•.3:•::.v:}:•:4nisti"w::uv.vvv:4'F4}:Ji}:v.{:•'F:Y:.•-...;x::}}':•.v::::::::::.......... n,v........
......................... .....v........rn......................................... .........../.-.........-...Tk...........:v::Y:::........r::n,v >>..........................Y:4}'•�:::::•}'•:C4:•}}r{:'4:~'ti'�:<...w'? ...;...:.vn•
r..{r? 4"• ?45;{•.....v:m,v}:}::•::•r• h .::.`.,1. dt4.:::::{•:w::::::v:.vv:::::;:.}{4:::v:v:•::w::::::rev:::::::::re:�::::.vv:::::w:::v.:v.v:::::•i:vi}nv.•:v-:re-:.v:vv.�:.,:::•:::nv:revx......•.;?:::.Y::•:::•... � v:r:::::r.•:x:::
•...,.L...:......re•: ..................4.........................................::::::.v:.:vn.... ....- }. ....`•:^:}:?4i}}}i'{::}}Y:4;{3}}'. .....: ..::: .r:..;-.}•;:.y:v:::v:::::::,.r
.?}................:..................re...... ........................-...... ............... ... ...Cv. ... .. ... -:r:::::.:•:vr:<?•:v}ii}}k::.J.%.rere.v x}.:<:::vw::.:..C4:iri•$}re:,:3�.'F.�:N•)��.' ;>:; .<t?:;
• ......:::.:..::�::::••.....................r...fre.....................,.......,.. ,:....,.......{.h,..fi�S:rv:.�m. 1. ..vrre........r..
3•;4;:.Y;.;;;}:.;.;;.}:•;;Y;>:>:•� >;:�»<:�»>:<:»�:�>;:<�:;»:x:s:<�>:�>:�>:�::>:�>:»:::�>:�>:�»>:�:�s»:Y;:�:�:<�:�»»»�:};::�>::»:;�>�:<::«:»>:�:<�>:z�>:•Y:-}:;.;;:�}>%:�:.>:�>:�»:�:;�»:�;:�>:�»:<�:�>:.>:;�s>;:�:•>:z{<{•YY:•Y:>;.}s>Y:�»'�>:<:;}}:::}:•::•:-::�>:s:<}:;•:;•}:;.:;}:•}.. r... ..y..
... ............v.........................................:..v::::::.v.... ........... ...•...hw:::}.........,yn.....n.....w.-:::..........n......... C^::h•.v:::v.;.;.-
... ..... ........................ ....:.............................................::::::::::::::::::::::..�.�::::::: �:::::::::v:re.:::3:4:•Y..}w:::::x:::{.Yv}:4:4%v}0.v:::<'<'\{??{.:J}:ti4i:?ti^:-
..........................:.. :::::::::...::.....::.............................:...... v.....
......... ....................v::................................ n..... yy..•v
....................................................... .........................:.............:*......-.....'.rev:::::•}......:::::rev......v,.......w::y:w.w..r......4 ..:.:................
................................................................................................:. r.......................-..
..........................rev:.�:............................................................................................:........:.........:..................::w:xny::.v:x::.:•:.v::::..v::::::::::::::.v::::::.v..v:}:}}:{;:{........ 4.'.;{{•Y}:re}:v.v??^:
....... ....
;:.}::.:....:.
addres
`en'`b
< ,
f N
'`��.}:tijii:3}:;':4;:;:;'i,:;i:}:4iii}:4�:i;:;i:?{:jrey`y':''4:0;}:{i3:;:::<;:•Y:?:j::;:;:;:;i:;:;;:;:;:;:i;::ti�:�iiY'j'';'.;ii:;y:i>:}<:?:,>.::;i3,:;:';+:;:;j:OY}:{{':v.�:,::YY}:•i:0:
..........................:::::::.............................................................. .......................4}}:i{{:}}}:4:4}}'-}:•Y3}}:?•isi:.......................-.......................:-.....
{;:i}i:•i:ii?}}iTriY'. 'tip............
................................................:w:::n:v::;;}}}:•}•.4:}:::::::v.v.:''.:•:::::::::: :4):.:<v.�.YY:•Yi}:4i:?•}:•Y}}}}}}}}}}}:vti{:u':•::n;:2,.3.• ,...-
:v.................w::r.:re............................................:.�:::::•. .......................-. ...::::::::::w:::re::••::::.v:.;......r....v....' x:::.v::::::::.v::rev::::::r:.:vre•.v:::.v::::: :,.....vv:{:.r•:vren, .%hYC{ay.•wvnw::
.............. ........................................... ::::::.v:nv.v-:::....:• v:::?:.�:?!OY}}w:rev
Y}}:4:v::::;{.;{SYYY}Y}}:4:4.4:::rev:•.:v:::::::r:xnv::::::nv.v.::::::.v:::::::rev::.......................v...�.p?yv,.x....... .....�?...•.v:::re...:, ..................
....... .............. ............ .v.....:.......... ...... .................re•.wre�•}}}::?:•• r:...v4Y:w:F.x,4}:hvn• ..... rewrew::.4:....
...........:... ..................:.. .............................:::w:::::::.r...........m::: ........A^.ty.:........ ::v:::::.v.:v:.?•:•:.�::::::::wr::>:2�:iih::::::.....:::::re... p•.:.... ?4
.................. .. ......::•:xv:Y:-S:-•:x::.v::::::::::::rev::•:r...:.................n..........re......... {.....:::•:
INN
F n re to seems coverage as required under Section 25A of MGL 152 an lead to the imposition of atnind penalties of a fine rep to S1,500.00 and/or
.one years'hnprisoninent as well as dvil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I undersbud that a
Dopy of tbis statement may be forwarded to the Office of Investigations of the DIA for coverage verifiatlorL
I do hereby certify under the pmna andpenajdes ofpeF�y that the inforntafon provided above is frftp mid coma
Signahire ,, Date
Print name r' C od Phame#
101
Ccdityor
ly do not write in this area to be completed by city or town ofiidal
perudWcen+e# :ealth
ailding Department
censing Board
mnediate response is requireddecdnen's Oda Department
n• phi#; ther
oraud 9195 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",an employee is defined as every person in the.service of another under any contract
of hire, express or implied, oral or written.
An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of
the foregoing engaged in a,joint enterprise, and including the legal representatives of a deceased employer, or the receiver or
trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any.applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
r Applicants
` -
Please fill is the workers compensation affidavit completely,by checidng the box that applies to your situation and
1 • names,address and phone numbers along with a certificate of insurance as all affidavits may be
supplying company Y
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 a odm'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 is the event the Office of Investigations has to contact you regarding the applicant' Please
be sure to fill in the permiUlicense number which will be used as a reference number. The affidavits may be retsirned 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 eat 406, 409 or 375
�F IME A
. '1 The Town of Barnstable
• a srn UL
MASM& �m� Department of Health Safety and Environmental Services
�E1659. p Building.Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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. ,p /
Type of Work: //\>nrn, �L�tPa.S �' Estimated Cost �Ob6
Address of Work:_,�i�7g ��'�'
Owner's Name: /JCnr r1r 46U1�.�
Date of Application: /1 o 06
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
❑Job Under$1,000
rIBuilding rot 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.
S-IGNEDTUNDER PENALTIES OF PERJURY
I hereby--apply for--a-permit-as-the-agent of the
Date Contractor Name Registration No.
OR
Date Owner's Name
s
q:forms:Affidav
' lie i�an>/nwox�ue� a�✓�aaoac/ucP,lla
• BOARD OF BUILDING REGULATIONS
UcerM: CONSTRUCTION SUPERVISOR
Number. CS 005432
j.Birthdate: 03/20/1950
res:03/20/2002 Tr.no: 1910
Restricted To: 00
MARK A STANLEY
14 OXNER RD ( !
CENTERVILLE, MA 02632 Administrator
NONE IMPROVEMENT CONTRACTOR U
Registration: 116533 r
Expiration: 6/23/02
Type: Individual {
MARK A STANLEY BUILDER
MARK STANLEY
G� o-;f f2gVta/ 14 OKNER RD
ADMINISTRATOR CENTERVILLE
MA 02632