HomeMy WebLinkAbout1912 MAIN ST./RTE 6A(W.BARN.) o
F
UPC 12543 A•
Now
HASTINGS. UN
RF �� ��)
(laic -� 3 `�
I
� J
i(�
/
`ST�97-`c -
�''avTrr
I certify that this property is
. located in Flood Hazard Zone C (out-
side the 500 year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
Date -9E/94� CERTIFIED PLOT PLAN
cP�� kc.k....�i ,
LOCATION ' ..
SCALE .���: �. .... DATE • 9 4Ff4
Reg.
PLAN REFERENCE
• b b .�.,4`V _<',;"�; ay . . �2Gs"Cy2DG�1} /w Bil! /a3/. . . . .
I certify to its title insurance company THE LOCATION OF THE ORIGINAL DWELLING
that there are no visible encroachments SHOWN HEREON , EITHER WAS IN COMPLIANCE
Or easements except as shown and that this WITH THE LOCAL APPLICABLE ZONING BYLAWS
IN EFFECT WHEN CONSTRUCTED (WITH
plan was prepared under my immediate ; RESPECT TO HORIZONTAL DIMENSIONAL .
supervision. REQUIREMENTS ONLY) ,OR EXEMPT FROM
VIOLATION ENFORCEMENT ACTION UNDER M.G.L.
TITLE VI , CHAPTER 40A, SECTION 7, UNLESS
el.NN/.uGJ,/A�J— J: OTHERWISE NOTED OR SHOWN HEREON.
Town of Barnstable Building
� • : Post This Card So That�it�is 1/isibl'e�Fromhe Street R=Approved�Plans Musi,be°Retained on Job and tFiis�Card�Must�be Kept '� ,
. PostediUntil Final Inspection Has,Been Made. a �!
Permit
;.. �'` ._ : Where a�Certificate•ofOccupancy=is Required;such°Building�shall�Not-be Occupieduntil a'Final Inspectionhas�been made: ' ,���
Permit NO. B-17-1419° Applicant Name: Craig Bishop Approvals '
Date Issued:: 05/16/2017 Current Use: Structure
Foundation:
Permit Type: Building-Insulation-.-Residential Expiration Date: 11/16/2017
,Location: 1912 MAIN ST./RTE<6A(W.BARN.),WEST Ma Lot: 216 034 Zoning District: RF Sheathing:
Owner on Record: TRACY THOMAS a Contractor Name Craig Bishop Framing: 1
Address: PO BOX 721 icense CS-109777 2 -
HYANNISPORT,MA 0264T.. Project Cost:= $.3,035.00 Chimney:
Description: Weatherizationand air sealing Permit Fee:. $85.00
Insulation:
Project'Review Req:-Weatherization and air sealing Paid: $85.00
} Final:
Date 5/16/2017
P
n
Plumbing/Gas
'Roughu
Plumbing:
Building Official Final Plumbing:
This permit shall.be deemed abandoned and invalid unless the work authorized Wb this permit is.commenced within six monthsfaffer:issuance.
All work authorized by this permit shall conform to the approved applicat onnn� e�approved construction documents10 which�th s permit has been granted. Rough Gas:
f�*� fix;.�a"* � -
.All construction,alterations and changes of use of any building and structures shall be in compliance with the local zornng•by laws,and codes. Final Gas:
Yam -
This permit shall be displayed in a location clearly visible fromaccess street or'roa&° nd shall be maintained open for public inspection for the entire duration of the
work until the completion of the same.
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures bythe Building and;Fire Officials are provided omthis permit. Service:
Minimum of Five Call Inspections Required for All Construction Work:.;
1.Foundation or Footing v Rough:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed priorto-Frame Inspection
5.Prior to Covering StructuraLMembers(Frame Inspection) - Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy tow Voltage Final:
Where applicable,-separate permits are required for Electrical,Plumbing,and Mechanical Installations Health
Work shall not.proceed until the Inspector-has approved the various stages of construction. Final:
"Persons contracting-with unregistered contractors do not have access to the guaranty fund°.(as set forth in MGL c.142A). Fire Department
Building plans are to be available on site Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
` Town of Barnstable RECEPi-A.
" raxsr 200 Main Street Hyannis M.A. 02601 508-862-4038
A ` lication for Building Permit
PP g
Application No: TB-17-1419 Date Recieved: 5/8/2017
Job Location: 1912 MAIN ST./RTE 6A(W.BARN.),WEST BARNSTABLE
Permit For: Building-Insulation-Residential .
Contractor's Name: Craig Bishop State Lic. No: CS-109777
Address: Sandwich, MA 02563 Applicant Phone: (774) 205-2001
(Home)Owner's Name: TRACY,THOMAS' Phone: (508)280-8321
(Home)Owner's Address: PO BOX 721 , HYANNISPORT,MA 62647
Work Description: Weatherization and air sealing
c.> :Z�
Total Value Of Work To Be Performed: $3,035.00
C
Structure Size: 0.00 0.00 000 °—
v� rn
Width Depth Total Area
I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before
he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568).
I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by
filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to
accept coverage.
I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have..
been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the
Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and
specifications. All information contained within is true and accurate to the best of my knowledge-arid belief.
All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24
hours in advance.
Signed: Craig Bishop 5/8/2017 (774)205-2001
Applicant Date Telephone No.
Estimated Construction Costs/Permit Fees
Total Project Cost': $3,035.00 Date Paid Amount Paid Check N or CCii Pay Type'
Total Permit Fee: $85.00 5/8/2017 $85.00 })M-X)M-XXXX- Credit Card
j 3464
Total Permit Fee Paid: $85.00
i, _
A,�P�E�$:
State Lic. , , Fed Lic.
GUNSAUTHING
Corey Sibbio,Owner 108-111-4101
o
Custom Rifles
S_'c_ope 1Vrountng
Custo_m.Pi"s_tols - , B'e_acf Was
ming
'lhggerr Work Re_co_il!cad's;
B_arre_li LiniingJ Compen_s_ta___tors;
Re$arr•.eling, C 'e_aning
Stock Work General!S_'mith ngJ
�� uj.( (�
S�' �\�
(Sl,n
Inil,
Liu
Cape Save Inc.
7-D Huntington Avenue TOWN OF RARTSTASL
South Yarmouth, MA 02664
Tel: 508-398-0398 Fax: 508-398-0344 CCT `6 41N' 10. 06
10/02/14
Town of Barnstable
Thomas Perry CBO
Building Commissioner
200 Main St. Hyannis,MA 02601
RE: Building Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed for 1912 Main St,West Barnstable has been
inspected by a certified Building Performance Institute (BPI) Inspector.
Ceiling: R-42 cellulose; R-21 cellulose under decking
Kneewall: R-7 FSK; R-13 fiberglass
Basement: R-19 fiberglass blanket on box sill
Crawlspace: R-10 on foundation walls
All work performed meets or exceeds Federal and State Requirements.
Sincerely,
William McCluskey
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map / Parcel O Application #1�el3 d
Health Division ' Date Issued
Conservation Division Application Fee 116
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/ Hyannis
Project Street Address I i� ,41 /1 d
Village LAAs+ `
Owner An'► —To ki 43c) Address 4m e a�bdr-e
Telephone r) 6of
/ o
Permit Request i✓� ui /�C 6�'�I S� 4se4lell S / k/ °X 4-�t �,f
R-(3 Cef el ��� ,`ate �� a ,� ' A &,Lrrf1
i wf
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Q ' Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new ,d
Number of Bedrooms: existing —new ZE
Total Room Count (not including baths): existing new First Floor Room Gount ` o
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: 3 YeE � No
a
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new sRe_
C rn
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial_ ❑ Yes ❑ No If yes, site plan review# -
Current Use Proposed Use
APPLICANT INFORMATION
i J M401(e'l
(BUILDER OR HOMEOWNER) C Name �" I MI l(We <SaV Telephone Number J �o � �' � � 0� ` V
Address J 1� u`z�� �✓ License # V J
S �a� l/ 6� Home Improvement Contractor# �� y
Worker's Compensation if WC 3 1_�3 96 6
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE ��
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
F MAP/PARCEL NO.
ADDRESS VILLAGE
f r OWNER —
DATE OF INSPECTION:
FOUNDATION —
.n -
FRAME
INSULATION
x
'FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL M
GAS: ROUGH FINAE--
1
FINAL BUILDING
l�
DATE CLOSED OUT ,
y ASSOCIATION PLAN NO. ' ' ,
Building Permit Authorization
I, Julie Johnson , as owner
hereby give my permission to
Cape Save, Inc.
7-D Huntington Avenue
South Yarmouth, MA 02664
Office: 508-398-0398
to take all necessary steps to obtain a building permit to
perform work at my property located at
1912 Main St
West Barnstable, MA 02668
Signed
Date p
I nnt-form
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Legibly
Applicant Information
Name (Business/OrganizationMdividual):
Cape Save,Inc.
Address: 7D Huntington Avenue
City/State/Zip:
South Yarmouth, MA 02664 Phone#: 508-398-0398
Are you an employer?Check the appropriate box: Type of project(required):
I. ✓❑ I am a employer with 17 4. ❑ I am a general contractor and I 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.El I am a sole proprietor or partner- These sub-contractors have g, ❑ Demolition
ship and have no employees
working for me in any capacity.
employees and have workers' 9 ❑ Building addition
insurance.t
[No workers' comp. insurance comp. 10.❑Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ 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 13 ❑✓ Other Insulation
employees. [No workers'
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 sub-contractors 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: Technology Insurance Company
TWC 3353968 Expiration Date: 04/09/2014
Policy#or Self-ins. Lic.#: W a 6, � /-V
Job Site Address: l q, I' ' t'T( � 9 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the airs and penalties of perju tat the information provided above i true and correct
Signature: - -- - - -- - ---- - -- -
_ - - - - - -- __ _ Date - -- �tC' - - - - —---- -- -
Phone#: 508-398-0398
Official use only. Do not write in this area,to be completed by city or town o�ciaL
City or Town- Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
AC�® DATE(MMIDD)YYYY)CERTIFICATE OF LIABILITY INSURANCE 4/9/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAMECT Colleen Crowley
Risk Strategies Company (,o"o . (781)986-4400 FAQ No:{7ai)963-4420
15 Pacella Park Drive EdAAIL
Ss-
Suite 240 INS S AFFORDING COVERAGE NAIL#
Randolph MA 02368 INSURERA Selective Insurance
INSURED INSuRr:Ra:Safety Insurance Ummany 33618
Cape Save, Inc imuRERc:Technolo Insurance an
7 D Huntington Ave INSURERD:
INSURERE:
South Yarmouth MA 02644 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL134960509 REVISION NUMBER:
THIS IS TO CERTIFY THAT THEI POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W[TH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
INSR TYPE OF INSURANCE OOL POLICY NUMBER MMIOD CY EFF POMI Or EXP LIMITS
ICY
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL L41BiLITY PREMISES(Ea occurrenMI $ 100,000
A CLAIMSCAADE �X OCCUR S199448001 0/16/2012 0/16/2013 MED EXP(Any one person) $ 10,000
PERSONAL 3 ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-CONIPIOP AGG S 2,000,000
rxi POLICY P LOC $
AUTOMOBILE LIABILITY [EEaa¢idert)ED SINGLE LNAIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
B AUTOS AUTOS
SCHEDULED 208200 1/6/2012 1/6/2013
BODILY INJURY(Per acddent) $
X HIRED AUTOS N
NON-OWNED
S�� (Perramd.=.YrsDAMAGE $
X Undennsured motonst BI split $ 100,000
A X uh1BRELLA LIAB X OCCUR 199448001 O/16/2012 O/16/2013 EACH OCCURRENCE $ 1,000,000
EXCESSLIAB CIAIIAS-MADE AGGREGATE $ 1,000,000
DED I I RETENTION$ $
C WORKERS COMPENSATION Dfficers Excluded from X TACST4ITUS OTH-
AND EMPLOYERS'LIABILITY
ER
ANY PROPRIETORIPARTNERIE�CUTIVE YIN overage EL EACH ACCIDENT $ 500,000
OFFICERIMEMBFR DCCLUDED7 a NIA 353968 19/2013 /9/2014
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
I(yes.describeunder
DESC�2IPTION OF OPERATIONS Delow EL.DISEASE-POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES(Attach ACORD iO1,Additional Remarks Schedule,if more space is required)
Issued as evidence of insurance. Issued as evidence of insurance. National Grid Corporate Services LLC
d/b/a/ National Grid, Action Inc., Colonial Gas Company and NStar Electric are listed as additional
insureds as respects General Liability as required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Cape Light Compact
PO Box 427/SCH AUTHORIZED REPRESENTATIVE
319S Main Street
Barnstable, HA 02630
chael Christian/CLC ��
ACORD 25(2010105) O 1988-2010 ACORD CORPORATION. All rights reserved.
INS025(201(305).01 The ACORD name and logo are registered marks of ACORD
u
1� massacnuse-s -7eoarment of Public Safety
4��J1 Board of Building Regulations and Standards
Construction Super-kor•Specialtn
License: CSSL-102776
WILLIAM J Me CLUSKEY
37 NAUSET ROAD
West Yarmouth rAA 02673`';
at
Cortxrissioner 06/28/2015
001 M.
Office of Consumer Affairs and eusness Regulation
1 10 Park Plaza - Suite 5170
-- Boston, Massachusetts 02116
Home Improvement C6.ntractor Registration'
-_ - — _- Registration: 171380
--- _ = Type: Corporation
--- Expiration: 3/14/2014 Trt# 222184
CAPE SAVE INC.
WILLIAM McCLUSKEY
7-D HUNTINGTON AVENUE
SOUTH YARMOUTH, MA 02664 -
Update Address and return card.Mark reason for change.
IS-CAl`c± SONI-04104G701216 Address 1.7 Renewal ❑ Employment i Lost Card
✓le �a�wnraiauiealt/ c�� a�aaw.cluvelt _. -- -- - - _-- _-- -- -.
' \ Office of Consumer Affairs&Bdsiness Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
'f Registration: .117t380 Type: Office of Consumer Affairs and Business Regulation
T� Expiration: 3/14/2014 Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
CAPS SAVE INC.--.,,
WILLIAM McCLUSKEY E-.::_._
7-0 HUNTINGTON AVENUE: g \
SOUTH YARMOUTH;-MA;02684 Undersecretary Not valid wit signa
r
1
Town of Barnstable *Permit# k
Expires ti months from issue date
Regulatory Services °bo
Thomas F.Geiler,Director X-PRESS PERMIT
Building Division
Tom Perry,CBO, Building Commissioner NOV 17 2005 j�iB
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us TOWN OF BARNSTABLE
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
L
Map/parcel Number I. 03 YylaI }'i
Property Address C
Residential Value of W ork � D d�� Minimum fed of$25.00 for work under$6000.00
Owner's Name&Address I
� 1 (n y
�-q59
Contractor's Name rizlTelephone Number�' '�
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑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)
�Re-roof(stripping old shingles) All construction debris will be taken
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum.44)
•Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner t sign Property Owner Letter of Permission.
Home r v n ntractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise071405
r
• e
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
, z.63 Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma-us
Office: 508-862-403 8
- Fax: 508-790-6230 "
Property Ommer Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
�0hereby authorize to act on my behalf
in all matters relative to work authorized by this building permit application for:
U�es
r has rab�
(Address Job) ,
iga of ate
T)h n3on
Print Name
Q:FORMS:OWDMRPER1M SION
Department of Industrial Accidents
_ Office.of Investigations' ' .
600 Washington Street
s` Boston,MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information Please Print Legiblv
Name (Business/organization/In&vidual): A/11 SD
Address: a 1 h(:tn
City/State/Zip: bo bQ r h Phone #: �' &C7
Are you an employer? Check the appropriate box:. Type of project(required):•
1.❑ I am a employer with , . . 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full'and/or part-time).* have hired iffie sub-contractors 7. Remodelin
2.❑ I am a sole proprietor or partner- listed on the attached sheet I g
ship and have no employees These sub-contractors have 8. ❑ Demolition
wonting for me in any capacity. workers' comp. insurance. g. ❑ Building addition
[No workers' comp.insurance 5• ❑ We are a corporation and its
required-] officers have exercised their 10.❑ Electrical repairs or.additions
3.&rI am a homeowner doing all work right of exemption per MGL J 1.1.❑ Plumbing repairs or additions
myself.'[No workers' comp., c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t 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 anew affidavit indicating such. "
;Contractors that check this box roust attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
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.Lie.#: 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 UP to$.1,500..OQ.and/or one-year imprisonment, as well as civil penalties in the form of a STOPVORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statementmay'be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby a dpenale ofpejury that the information provided above is rue and correct
i ature: Date:
1z UV
Phone#:
Official use only. Do Wot write in this area,to be completed by city or town official
City or Town: PermitUcense#
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 anci instructions
Massachusetts General Laws chapter 152 requires`all employers to provide workers' compensation for their employees. " A
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."
d association, Forporation or other legal entity,or any two or more
An employer is defined as."@4 iD ,t�a1,,Part�mers ip;:
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 Atbe
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 woiknn 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 numbers)along with their certificates) 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' ;
at the number listed below. Self-insured. Self-ined companies should enter their
compensation policy,please call the Department
self-insurance license number on the appropriate lime.
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
ense number which will be used as a reference number. In addition, an applicant
Please be sure to fill in the permit/hc
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 ihe.-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 to 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
s Office gf,Investiga#ons
,. 600•Washingfcn�Street. .
Boston, MA 02111.
Tel.#617-727-4900 ext 406 or•1-877-MASSAFE
Fax#617-727-7749
Revised 5-26705 www.mass.gov/dia
Application toy
tJ�"" q P 0,5 t ocP s
Odd King s Highway Regional Hisor is District Committee
in the Town of Barnstable for a
CERTIFICATION.OF EXEMPTION
Application is hereby made, in triplicate,for the issuance of a certificate of exemption under Section 6 and 7 of Chapter 470,
Acts and Resolves of Massachusetts, 1973, as amended for proposed work as described below and on plans,drawings, or photo-
graphs accompanying this application. 9
TYPE OR PRINT LEGIBLY to , Bevlgs4k_/ DATE
ADDRESS OF PROPOSED WORK bCJ - T ASSESSORS MAP NO.
OWNER ► I "'y Vi S .ASSESSORS LOT NO.
D �I/1'CVr' NJl lw /C)0® TEL. NO.
HOME ADDRESS L90C11(e.
AGENT OR COON,cT�RACT/iO -5 R Q`0 19 ,,e �a
ADDRESS D C/ c4 � o e� K ytr > y A !��'IZ QCtE` . (�O. �L� S 3-3 -7S a—
U
This application is for exemption of proposed exterior construction on the ground that:
°V❑ (1) It will not be visible from any way or public place.
2) It is within a category declared entitled to exemption by Old King's Highway Regional Historic District Commission.
(Check applicable box)
PROPOSED WORK: Describe and furnish plan of proposed work, showing location on lot,and, if an addition Is involved,show-
ing location of existing building.
-Uv
new
SIGNED
Owner-Contractor-Agent
Space below line for Committee use.
Received by H.D.C. The Certificate is hereby
Date ,
Time
By Date - -
Approved ❑ The categories of work entitled to exemption are listed on
Disapproved ❑ . the back of this form.
z ,
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
;S f
Map 2A(O Parcel 034
Permit# "7®I 2 5
health Division 1 L� �� 5—� Date Issued V1 13 03
Conservation Division 6 )), 103 Application Fee
1 .Tax Collector&�74 Yh' 0 3 Permit Feel
Treasurers
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 1 l l2 �C ,T\ 5d .
Village W.
Owner liUvv� �� Address
Telephone �5U`iS )62- - C)z
Permit Request W�� br,rd"S o-� %
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District � Flood Plain Groundwater Overlay
—Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family if Two Family ❑ Multi-Family(#units)
Age of Existing Structure 14 36' Historic House: ❑Yes O<O On Old King's Highway: O"Ies ❑No
Basement Type: ❑Full O Crawl ❑Walkout Lf'Other C,4a- C-.P- b4zowvc "
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) t� a
Number of Baths: Full: existing new Half:existing o new
Number of Bedrooms: existing Z new o� m ?;'
Total Room Count(not including baths): existing new First Floor Room Count'
N co
Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other '—
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:2'existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes 3�o If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name w°��� .• C_J ANN ,\_� Telephone Number 60
! � o
Address 1 q\-I-. License# c
AA S2bW Home Improvement Contractor# FC — >
Worker's Compensation#
"°
coALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO r n r-
cn m
SIGNATURE DATE ���e7
FOR OFFICIAL USE ONLY r f
f _
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO. "
y
ADDRESS. VILLAGE
OWNER
T
ny. DATE OF INSPECTION:
FOUNDATION ax
FRAME
INSULATION
' FIREPLACE
' ELECTRICAL: ROUGH - FINAL
R PLUMBING: ROUGH FINAL "
GAS: ROUGH FINAL '
FINAL BUILDING
DATE CLOSED OUT
' ASSOCIATION PLAN NO. '
•
s
°FZHE�° Town of Barnstable
Regulatory Services
ST''BL Thomas F.Geiler,Director
Mess.
�`bArE16 9.�A Building Division .
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
Date 1 31
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.
r! !L!
Type.of Work: 5h4'S� � '~ Estimated Cost
Address of Work: 1112
Owner's Name: -Q,a C�)nnPn62
Date of Application: / 13 k I 0 3
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
RJob Under$1,000
Building not owner-occupied
❑Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
OR
Dat Owner' ame
I
— _ The Commonwealth of Massachusetts
: ,
Department of Industrial Accidents .
=_ -- office 0/InsesM9890ns
600 Washington Street
-._ Boston,Mass. 02111 .
Workers' Compensation Insnrance Affidavit
i
name: `(� �1 a l'&P V W,n P,\^—&--,
v
. location. k 4 11 M F�& S�
ci W • (�C+rn IWO L4 hone# 5�1 3-6 2-0Zl$
19
I am a homeowner performing all work myself. .
❑ 1 am a sole rietor and have no one worku in ca *city
%%%%//G/%%%%% %%%%%%%/%%/%/%%%/%%%%/%%���%%%%%%%%/ %/O/%%%%/%/%%/%%%/%%%%%/O/O�/%%%/%%/%%%/%/G%%%%/G%/G%%%�%/%//%%%%/////%///%///%%/
❑ I am an employer providing workers' compensation for my employees working on this job.: :::::: :::::::::::::::
::.::::::.:...................................................,.::...::::._.:.:::..:.::.: ::.:-..::::.:::::::::::::.:::.:._::::::::::::::::.:::::.::::::.:::..;:.::;:-:{{{......>._::::>...................
N.
� ....-2811? ZISQ C''�'' ? > 2<::: � :: :: ' '; " ':s; ?% 2:::::::: i:;:: :::::::':::::::::: :<:'•:::::,>.: ::::?::::::::::::: ' :;:t::;:;::;:;:;:::>;::::::::?::::: ?::;:::;':;:;::
'Amp Y
:_:....
mim
'itililre
_..
::•::::::::::::{......:::.::..................................... :::.:.:..................................::::::..........
................................... ...............:::•::..............:..........................................................................
N.
h
''<Oli`»
%/
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have .
the following workers' compensation polices:
., ........ .,.. : : '.... M�
cotmpauy�n
........................................ .�...
................
>.......
............... ::::::..............................:........:..................:......................................................
T:O:":•:i::i>......}:•>x6»:;{{jJ iiiii::::'::iIN.i..{'.....ijY iiY: :::;:�.. :'}:;:i2i:.... ;:i:....YJ::;{i:i::Y:;j{i}:;:?;'ri:::{^jj}ii;^i:?iiiii;>J:::i:`:i:Ti::iiiii:::ii;y:<;:: ?is3::;:};:jiiiiiiii::iiijj;:r>:>:ii:{•>:::::.:y`•::{.
;`:`y::::::
$} ,
,':k:y:':i::i::ij;:}<;:j::L{ 2:;{:;>.::<2v:;:;:::;i)<:;i:i.`•j.
....:.:.....:::.....::v:.....:.......:::........;.................:::" ....:....... ..... ........ ..... .. .. .....
:::n.:»+"•••.i•.v:..:..:ii'::•:.}-:{.v...::-i>iyvn;:•:{::::::::ny:...::.}:{:;:•:i>::4>iii:{{v:i:4»>i>i:i>ii?»:{?{i>i:•:{{•}:"ii>iii:4:•i}>:?•::->}}i;J{;ti i:hi:{;>?»>:•:•f,.;:!{-;ti•i. .{;..
...:....:::n:..::..........:n.:n.-{:•t::::::.v::•.v::::::::::::.w::.:v:w::::::;^i:v:{W.�::w:-:.v:•:::::::::.v::.v::::::::::•.v::::>'4:•i::::::::::::.v:.v::n:
......4.......... .........................:.........................:.............. :::v:n r
.......... ...{........................ ..............................................................:............w::::::::•.v.v:.v::::.:::.v.v::::::::::::::::.v::::::::::::v:::v:: :....
{i{:4>>>ii}:•:{i»ii%:>::>»:{2::i::::;T:;:;:;::ii>»iii: 'r:3::::ii':::i�ii:•>i:•>i::iii C:i•isiiY>:':':i:•:::is i:::;i:::•:�ii:i is is2"::ii l?":::'"'':i::i:+:ii:>f i::iiiiiiiir::::::Yi:i:...... i;ii:ii:}'iiiiii::3:+::isri}i?::$i?:jrYivvi:ii0}::{iS::S:::•:µ2:iiiiiiii
.........::.v.:v::::::.v::.v:•. .. ........:.::......
....... .......... ..........:...........::::.::v.�::...::::..........:......:w:.v ............................... ..
.......................t.... ................:................ ................................ {v:v};>:•..:;........................:...:::::>>i»:4:.:•.{v:i{.;{.....:.•.... {{ :y\••>•:?�;'::i?::
..:.........................:..:.::....::..:::.......................:...:::....:..:...:.....::....:....... ............nhnne#.
%
h.
';.ipv°:..
................
:::::::::::..::::::::....::.....:: .::::.t•::.�:�.
e i:i�::::•:::::::•::._.{.:>:o::» :.......... .. ..t... ::..... :::+t2<?•>:{{•:•>:•>:{{;;•i>i:i:::r. .... .....t•:::::::.::.:.. �...t{.::<':'•�'::::'.:..{:;
�..;:.;
n...............
..... .....................................t.... ....... '::::.v:.v::..:....:....... ..:.:..t.
.......:....t.............. .. ................:..........................................:............. ..::::::::{:.'.{•i>i>:4>:•:{{v:•:{•>:%:{Ci:;;v{:.;{:<:.t.:.:v:\v +r.J>:J'
.:.. ........._................... ......t.......t........... '.-... .. ...
....,...........................................................::............ ::::::::::.v::.................................. -:•..:.:..:............. ^.h}+:!iiji
ofnrance.,.co.:-:.:.i:{:.:......:.....:.:.:.......:..::::.:::::.. :.:.:::.::..:::::::....::::::......,.:::...:................. . .. ...
//l///�/%%i
::::..:::.:.......:.
::.. ...
sa n ra
- -
<'ditr a
:'tih..
D
»':
tW ::i�•:?•»
:.....
:.:t•::.
:.....
> :.„
:; :#
::.......:::::::..":..............................
.......................................................................................
:•::::.::::::::::::::.:.::::.::::::::::.:::::.::.::.:•::::::::•:::::::::::•:::::::...:::::::•::::::::::::::::::::.::::.:•:.:..........................................
::......
>.;;s:>:::>.s:
::::•.:.;•::•.:,.. :::.:.::::::.: oil' #>;`;':.:'::":::`:'::>>::::.: <- Y:<:>:>::;:»:<>><:: :>::::::•<.
n7Uranl`e:CQ:•i:i:-;;:•.:::::::•:i:-:- •;:i;:{•:;-:;:-i:{•;:{{•::i::-......•.....•::::{.:: : i:-:;>:-i:{•.;•.:•:.::;:;:•>:{.:i:-i:•i:.:.... .....
Fwkwe to secure coverage as required under Section 25A of MGL 152 can lead to the imposition o[criminal penalties of a fine up to S1,500.00 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. I underdand fiat a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and ppee'nalties of perjury that the information provided above is tru<and correct
Signature � e £ `7 �r� D 1 3 f L -
Print name p e - Phone# l�K .3.4 2 �Z"19-
official use only do not write in this area to be completed by city or town official
city or town permit/license# ❑Building Department
❑Licensing Board
❑checkif immediate response is required ❑Selectmen's Office
(]Health Department
contact person: phone#; -- ❑Other��
Umsed 9/95 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers io 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 epntact
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.
Applicants
:? Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names,'address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retmchR'io
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 Depaztment's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
OMce of InvesUgWons
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
}
oF�I+E ram, Town of Barnstable
Regulatory Services
snaxsznBM Thomas F.Geiler,Director
��b .•� Building Division
�FDMA�s
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
/ Please Print
DATE: I I �n
JOB LOCATION:. l�1 t Z 4 . (,,t . ,r n b _ 1,9
number n street village
"HOMEOWNER �nY
': \U Ntky (�n h�M �-� 6N G&—c)-Z 7?6,— ?/f5 CPII l;t
name home phone# work phone#
CURRENT MAILING ADDRESS:
Ll
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwelling 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
requireme
Signs 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.
Q:forms:homeexempt
i
Application to
®Y itt�'� i� t? i 0�ta i�toriC Miotrict Committee
BIn the Town of Barnstable ® ! ' CLERK '
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:
CHECK CATEGORIES THAT APPLY:
1. Exterior building construction: ❑ New ❑ Addition ErAlteration
Indicate type of building: ❑ House ❑ Garage ❑ Commercial Other S�<
2. Exterior Painting: L�
3. Signs or Billboards: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other
TYPE OR PRINT LEGIBLY: DATE Il- ZJ
ADDRESS OF PROPOSED WORK 1'12- W ',,wji�o ASSESSOR'S MAP NO. Zi
OWNER Q�,,, ti,a '� P� �. M ^^ ��^^ ASSESSOR'S LOT NO.�_
HOME ADDRESS TELEPHONE NO. �Sb�
FULL NAMES AND ADDRESSES OF ABUTTING OWNERS, including those of adjacent property owners across any
public street or way. (Attach additional sheet if necessary.)
harms �l►v �-c� '� � '�`�� ,Mc,an 5
dr iAA.c:v, .�-.
�.�MSC i�o8� J:�`• cr,� �rsrc� �AtT'��
AGENT OR CONTRACTOR S tiLJ n TELEPHONE NO. Sq,Ae
ADDRESS
DESCRIPTION OF PROPOSED WORK: Give particulars of work to be done, including materials to be used. Please
include locations of proposed signs. 2)c9
� S W�L�S WC* P 1 �
are, �,1��sP 1Y��2� e. lv�� lv+t. 1n1�1�"-
f1 y�11rJi
Signed r � __--
1Z Owner-Co tr ctor-Agent
For Committee Use Only
This Certificate is hereby Date
Approved/D nied
Committee Members' Signatures: —01
Town of Barnstable
W' Old King's Highway Historic District Committee
SPEC SHEET
FOUNDATION t Q rn^a 4-
SIDING TYPE ,D,;, , ('cG�1,� COLOR
CHIMNEY TYPE COLOR
ROOF MATERIAL_ 4V� COLOR
i3 4
PITCH 13
u
WINDOWS 1 COLOR W`A SIZE S j
TRIM COLOR w'
I
DOORS COLORS
SHUTTERS 6`A �' COLORS
GUTTERS 1� COLORS
DECKS t MATERIALS
I
GARAGE DOORS -COLORS
SKYLIGHTS SIZE COLORS
SIGNS 'IV001 COLORS
FENCE (`p/�'t COLOR
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.
li SPECSHT
Revised 11/98
g
z
. N
r �
d
i
3
I
i
r
cn
rK
7
i
J
�l
i"
j , 3
�.-----------------
v s
i
� 1 tD
sr �
f'
CP
4.:
! i
ti -
t7-
oevi
-
{
I ! PN
• 1� r ,; tr �
IMPORTANT MESSAGE .
For
A.M.
Day Time P.M.
Of
Phone � �d L� �✓ T�d
FAX Area Code Number Extension
MOBILE
Area Code Number Extension
Telephoned Returned your call RUSH
Came to see you Please call Special attention
Wants to see you Will call again Caller on hold
Message
nia 1°,r/1 m ` r o e-lo, /T,- s
Signed
V48023 LITHO IN U.S.A.
• - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map c9 t-6 Parcel a 3 y Permit# 37F 2 3
Health Division715r lJ w Date Issued
Conservation Division Fee o
Tax Collect SEPTIC
Treasurer ` I INSTALLED IN COMPLIANCE
Planning Dept. VIA H TITLE 5
ENVIROWMENTAL CD,-1E
Date Definitive Plan Approved by Planning Board TO Et f;4 UIr :w:
Historic-OKH Preservation/Hyannis
Project Street Address Au. C A ca2nN M
Village l")
Owner 41,11�o4-`�4N_Ckl aP,ror, Address SCMQ
Telephone `6 -'bb 2 _ 2.\cd-
Permit Request 4-r1 !n 6 ' I a v
Square feet: 1st floor: existing ao proposed 2nd floor: e ' o a new
Estimated Project Cost aftmewJ900 Zoning District Flood Plain Zohe. C Groundwater Overlay
Construction Type
Lot Size °�6 AC • 1%randfathered: ❑Yes 0 No If yes, attach supporting documentation.
Dwelling Type: Single Family C Two Family 0 Multi-Family(#units)
Age of Existing Structure , 5 ti Historic House: 0 Yes Imo On Old King's Highway: 6/Yes ❑No
Basement Type: ❑Full O Crawl ❑Walkout 2(Other Qp-e r-oda-
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing n H w
Number of Bedrooms: existing
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas p--ciiI ❑ Electric ❑Other
Central Air: 0 Yes Qr No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 2 Flo
Detached garage:0 existing El new size Pool:0 existing 0 new size Barn:0 existing ❑new size
Attached garage:2 existing ❑new size Shed:Coexisting-0 new size Other:
Zoning Board of Appeals Authorization 0 Appeal# Recorded O
Commercial O Yes 2 o If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION r�
/J
Name � ► G ti ' ' Telephone Number 715SV,82
Address ' .Egg /` �rS� 1 / License# 4 mock A-. '�meuwnor
/, 6 Home Improvement Contractor#
l
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO f da�ji Loa.6�
SIGNATURE / DATE _ (�
FOR OFFICIAL,USE ONLY _
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO. t`
ADDRESS VILLAGE ,
OWNER_
DATE OF INSPECTION' ' +
FOUNDATION
FRAME
INSULATION
F
FIREPLACE
ELECTRICAL: ROUGH. FINAL - +.
PLUMBING: ROUGH +_ - FINAL
_ lw r r . • s • • I '
GAS: ROUGH! FINAL
.-
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. r
a
f
Application to 4 2
Old King 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 CATEGORI.ES THAT APPLY:
1. Exterior Building Construction- ❑ New Building ❑ Addition WAlteration
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 �ther 1 ' l+'!
(Please read other side for explanation and requirements .
TYPE OR PRINT LEGIBLY DATE
ADDRESS OF PROPOSED WORK Ein S7 W, j36V65 lSSESSORS MAP NO.
OWNER ASSESSORS LOT NO.
HOME ADDRESS TEL. N0.
FULL NAMES AND ADDRESSES,OF ABUTTING OWNERS. Include.name of adjacent property owners across any public•
street or way. (Attach additional sheet if necessary).
Math (AJ Ir <n e.✓I M 'a 0 J.
f}o
L Li
AGENT OR CONTRACTOR oein TEL. NO.
f✓
ADDRESS
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).
V ( U/ c:�o o J-/
nov
S7
1
Signed
O er-Contractor-Agent
Space below line for Committee use.
318'ViSNlItVB o WAQL a6 ^ Q
ate T e Ce ' icate is hereby Date
i m
g � Qit�
Q
Approved ❑ I ORTANT: If Certificate is approved, approval is subject to.the 10 day appeal period
provided in the Act.
r
Town of Barnstable
Old King's Highway Historic District Committee
SPEC SHEET
FOUNDATION
SIDING TYPE WWI CWQO`r COLOR
CHIMNEY TYPE COLOR -
ROOF MATERIAL COLOR
PITCH
WINDOWS SIZE
TRIM COLOR
DOORS COLORS
SHUTTERS COLORS
GUTTERS COLORS
bjo MATERIALS �&re,
DECKS `��'•L `�- {'aP�h�„ ,� " P
GARAGE .DOORS COLORS
o COLORS
SIGNS
i
FENCE' . COLOR
NOTES:. . Fill out completely, including measurements and materials/colors to be used. Three copies of this
form 'are required for submittal of an application, along 'with three copies of the plot plan,
landscape plan and elevation plans, when applicable.
SPECSKT "
3
doe-? -,P-P ,e 4L�C't
Al n4 6i 15 X I'S 5 a- S'c,
// tj�-It5
1'w� c�c�i[�e � �� G► eat �!1��, . a ��, . �—�. �,-z, .
EX 5' `1ru4
C, C, J�/S L e/ <r� 0 7/� �p rP vcO
rt LJa S . re c r�d e c.� 6r o � U a 4O y c r c c
r64)ecj av�� uPtS f-L . C. -C. sb
a -e vl
. - ��iI/lvt L./�OVI QUlcX1Sq ,
J► G r
V�
Bo 6o.vp_ 9/•/S'
I -�\ /------ G
PG• �3
3 o
\J i
3
0-574cee,- r
IrN
-� do
STATE.
I certify that this property is
— located- in Flood Hazard Zone C (out-
side the 500 year flood) as identified
by the Department of Housing and . Urban
Development (HUD) .
Date CERTI F1 ED PLOT PLAN
LOCATION In/E37 ai9/?�t/.STAffLF H
}: -
:' SCALE . . '�.. .... DATE
"` ` i PLAN REFERENCE
Reg. ,IAnd,.Su ve�yo'
o.I
�Z
I certify to its title insurance company THE LOCATION OF THE ORIGINAL DWELLING
that there are no visible encroachments SHOWN HEREON,EITHER WAS IN COMPLIANCE
Or easements except as shown and that thisWITH THE LOCAL APPLICABLE ZONING BYLAWS: .
plan was prepared under my immediate IN EFFECT WHEN CONSTRUCTED (WITH
RESPECT TO HORIZONTAL DIMENSIONAL .
supervision. ; REQUIREMENTS ONLY),OR EXEMPT FROM
j VIOLATION ENFORCEMENT ACTION UNDER M.G.L._
TITLE VII ,CHAPTER 40A, SECTION 7,UNLESS
NN/M- IAfJ—A 77 OTHERWISE NOTED OR SHOWN HEREON.
Bo�Na 9rx
100,
I r/ � t A o DG.B�• y'3
` 1
STATE.
I certify that. this property is
located in Flood Hazard Zone C (out-
side the 500 year flood) as identified
by the Department of Housing and Urban
Development (HUD) .
Date Dot•915W CERTI FI ED PLOT PLAN
LOCATION An/657 .di9/Z!t/STAl,3GH
SCALE .���: �. .... DATE .
Reg,.,-.-:hand'r;Suveyo PLAN REFERENCE
. . . . . ... D
I certify to its title insurance company THE LOCATION OF THE ORIGINAL DWELLING
that there are no visible encroachments SHOWN HEREON ,EITHER WAS IN COMPLIANCE
or easements except as shown and that this WITH THE LOCAL APPLICABLE ZONING BYLAWS
plan was prepared under my immediate IN EFFECT WHEN CONSTRUCTED (WITH
RESPECT TO HORIZONTAL DIMENSIONAL
supervision. REQUIREMENTS ONLY) ,OR EXEMPT FROM
VIOLATION ENFORCEMI_NT ACTION UNDER M.G.L.
TITLE VI I ,CHAPTER 40A, SECTION 7,UNLESS
Ce -V1V1v61119Af Per. OTHERWISE NOTED OR SHOWN HEREON.
i
P r •
2 i
} t
• i 44, F k -
a•.of t.{ �'�. l�C.
.-�' r 4', yy�• .. �V! y
� � 6
I
! I
�I
l
i
•
1 I
, � I
I
,
I I
l
711
,
loc—
..... .....
• I -
I
I ! y
I I I
I � _
:
I
v93� �
d
CID
cw
t �
IdX J S+
Fo7 1 �
k
9 �
i,
i
a 1_
? —'�i � -- —
i I I I_� ' q � �r—�— —5 --t +— � � ¢— r1 i—j— 4—d '—�—I �— —{--� � r—'—�—•I ` � � I
Tn
1.1
I � ! a
!
_ I — _ _�� i N 1 6 } a 1 ' I-'
T ggiI I
.] 0__I _
J_t17
177.
'9 ! I jIl 11
j
I
,
7 � i
' � t
'
1
' — ��� + ? L.i , d__• '_ d _> ; s t 9 I + t + t i � I I'-�— $�
q _
I
t
i
+.{ _
—�——I a ! 1 1 a a + T a
-
!
i
t
ii f1 _
VII] _TTTI
�._1.�_! � i 1 i ! A I , ! i_I_I � '—Y— — —0-�.7� —I—• — —-�i
r F T I ! 7 _
A I
Y
—— 1-1-1-1—,_. t r _�_I 11_C t '
a' l`
n
��
a
�,
d
s
y
0
_ s
_ � � . � �
. - �
-� .
S
a
- J
l
i S
r
i
� _�� � w
�—_ � � ,
i �� s� -
a
- . .�
*.;
,�
.,
---
I
C ..._—t--�----F t 1 ) 1 t_.i-.f 1_ I �1— I 1 --`—�--�--j �--•• ` i—'—�--�——'—t-- � � -- --
—
i s E (
—
�— ---. _
—
f.
ittt--I .ifE {—t—t
i 1 ➢_ - r E f 1 1
_f t s
_i_�
f— r 7 t
s h e ; ! r ! s t —! _..__ E F r k t f t ! !
r_+ — Ek'�"� f_ _i s f ` k {t t S ' {
j - F�_•{ L� —�
t
S t
—r
—
_t.._. r � + a ► � 9 c � i { c [ k + t R ' _, _` . !.F i. �._ � --� h — �—
!.� .. _ - E '—�-- `- —1-•'=—k ' r s � k...- r { ... �. .i { t � 4 r i..i._ —
�
_ r.
4 .—rk_L.s 21,
r' lL �— -S -- —
—
iJ1.t,
• --- 1—'r-t—_S r C .. �. ._; .. _. t. s r � @ t t_i r_ y _I d— — —
k + p d
i
r
V �
I � a _I x� " u ' p I�! t I�
—
kC, k --I——LS--r—I' r1._, -
G L �._L L_� r �_i r.._��r,_;_.L_s• �._�—i._ ' 4 C p_ K r _°. i r _ �—`— —--�— — —— I I
L 6 L_ r
i. C ! C 4 I I k L n i __' { —_J_�__.____% r b II i X Ii '•
i'
a
j_ao
L7
ram " ♦ : �_�_ E
1 _
. _ .; _ _
�-
..j� .. �,
___,...
Y: ,,�...
'. - r
' � .,�ti� .. ..
. � .. f
�._. r .. ....a.... ... e � `
4 �
-. f _�
" 7
S � � �
u. � ....
i L �} t� i:x ..�cx� .i
.. � -f,, ,� :x } '�r� S of� �% �; � -Q
..._ o � t �.� _ 1 �. bi�� <-.
_ '
a S .. � � ( 7
��
l- ... �.. .....{. y... _ t�. _
_ veparrmen o
• office VIIAYCSI917t/oos
• _ — 600 Washington Street
Boston,Mass. 02111
— Workers' Com ensation Insurance Affidavit
name ����
location•
city W hone#
I am a homeowner pefforming all work myself»
❑ I am a sole proprietor and have no one working in any capicity
❑ I am an employer providing workers"c'ompensation for my employees.working on this job.::.:::::::::::::::::::.:::::::::t.:.ttt.::.::.-::n......:}}}},,....
::::::..:.:.:................................................:......:..........::..::.:.:.:.::.:::.:.:.........................................................................:.....................:.....................:>.::.:::.:.........
XX
coaoanv n = - - -
?l.:ti:}ti i$ii}:ii:i}::$':.v r:is is{v i iii:::J:}is:i i::?iiii'ii:iii:;i{::ism$i.....j;:;i:;{:;{iti4$ ti;i:;:j}::j....
%<{•i:
is'f:`{.i:;±:i{iiii}:�i:>.ti iii:?{:t{r�i:i}:i i;i:; i>i�:i:}:�iiii$ii?'r$$$}:ii$$f i}$:;i:}:i�i::>:;�:;�:;:;:;:;:,>.;:;:;:;:;:yi:
,i:h:i':!'{hii•::�}:?4i}}:•I,..}:.v:•:::::::::::::.v.v:::::::w:v::::.v.v:::::::•i:{}}:}}}}Y::•}}:..
........::.:i:••:4}:{{•;{v:4:4:{:4:::vv::::::.v:.:.v::::;.v.v i}}:?::•:•}}}:iTi;??{???:{•i?:-}
X.
8 teas.:::..:i:.,+{+•}:;:{;•}:i'::ii$:>. ;Y.:�i`i:iiii�;n}�:.i'-::::L:::^T'-}iY.i�i'-:-i'.. ... .........:... ....... .:. ........ ...... ... ....:.. .: .... ...:..:........................
..:...:......::::............................::............................�..................:.:::.r:}:}i:::..::::::..................::::....
............................................... ...................,.:.......::::-}i:•iii:4:4:^:{4::.}}:•}}:•}}Y}}} ,}.-......v':w::??{:.:}vnyi•}}i:4}:•}:•}i}:•}i:::::.:;.. ..
:•..........................n.n...................................................•:4.......... ...... ............ .....
..................:::.....................r...............................,.:..............:::.,............. ..••:::.,...tv.......................................................................:?F•T:{{.}v:::::::::.v:::::nv:Rv:•:4Y.ti-}}i}:?:•::tx-.vn......{....:'-i::.
:•::b.::.:::'`.':4i:iiii;•}}:•}}}};:!f v.•::::v:4::.. '.y.'..'''�"'•••i:i;:;'::iii:+:4}};>:;:j;:tY:}ii:?•i}:•}:4}i:•:vi:•}}}}i:{i•ii}:•}}:•}:•}}:4f':{v{•';•'+:{:•::i::4F'}:•:•:•::4:'::i.''.
.:::::::':':"'i:'::•:i}}::::!;}}ii:i::•:•}:<:}}iii:?4T}}: T}::?•}}::v.}}T:::::::•:v:::::::{:?:ii:4}i:•i::{^'
':: '::...:::T;::}iiifi:ii:iii:i:}:i}i::;iii}::ii;iii;::......iii:iiiir}ii:4;ii:Ji i}::::ii:S:•::ii:{a i::>::
... . .. ..........................................................................................:•-.�::::::::::::•:::::::.v:::::::::: ::•v.�.�::•:::•:::.v::::::: ::::v:: ::w:._.v::::•::}:::::J..n}...::}:{0:4}T}:}}:::-:
Ci6 .
:,,:;:.;:.:.::.:.:::::::.:.;:.::;.;;T::?.:{:.;::,.}:,.T•:.;:' ::::.:.{:,,.;:;:::::::.;:.;:::•?.}:'..... . .......::....,..::::..:..:........ahone#:..::.:::.:................: ..:. .:..... .:.- : :::.._:i;:.ii:.ii:;?{{::::;;.:
insura
li
i
❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
....................................................................................................r:r v��
............................................................................................
.... ............................................................................. ...............:............ ................................................................:.rf....rir:... .t.......
Co' n
:..:...................:...:.:::.:::::.:::::::::.:::.:.:r....:........:::::::r.::::..:::....:........................::::........................................... :.........:.............:......}..r...............
SadrelS' {? > « ' `"<` ; :: ::::::±:<:: :%<::>::;:>:?:: ;:;;: ::;::......:::::::::::::?:::::;::::;::::;::ii•}:;:q:.;2;:;:;:<:;<:{::::;:::;::T:::: is<:;.........: :;'
............::::: ........:.:.:..:..........:::.::.........
..................... ............r...v...................:.................rrt...................... .::•.......:::::::.v:::::•::•:::::•::::::•:::::::r:::r::r:::::::::::::•r:.:v:::•:•rR•::.trntr rv.{vw+• R M•:1.:4:�:�i:4•TP.r}:�:{.}}>:•
:..:..................::::::::::..........:.........r............:........:...:..:...:..........Y.......:............s....... ............................:..................................R.t.......................a................ ...
:..:.:::::•:::::::..............................::::•::•..:::: :::•.::•.::.:::.::::.::::::•:•:::.:::.::. :•::::::::::..t•.:::::•::::::::::::::•:•:::::.:::........::•::..:.,.,....................................
....:......::•::::............................................................................... ::.r......-..
..:j::..::•v::••.............................v:::::::.....:.� �:r{n}}y:{4}TT}:v:$$$$$j$$$ii:>.:i$$ii:4:^:^'ii$r::4:•i':+'i......:n?v.:.•:•{:: :.v:v:
............................:....::::.v.v:::::::n...................................................................... .......m::v::::.:v:::::nv:::::r::::::.v::::::::::R:•::v:::::::.v::::::::::::::::::::w:::w:::w:x::$:-i':•ti•}:•TT:4:ti4:h::{v}:?4}:4i:
.............................................................................................................................. . -.
�::::::•:::�::......................:..t-:.�..::•:�::.}:•:4i:�:->is�r:;•}:::i:•}:•r:�:.>:»T:->:Ti:;•}i:.}riTis�:{.}iT:.i:-:{:?•:•:;{.;:-••.-•-.�:::::: ::.:.....:.;{••r,.
........ ...: .r..:........................:..n......................w..... :w.{4:+4}}}..v:•• f r. (.:.{�+{n
:..:::v:.............:....:::.+.•::w::. ..0.......n.................r.........:..,.....r......;,........::::r..}:r:v: trr.v:::::::::::::{•.}}v;{: ..........x....rf.....:;ti?v:r;}:.yr... RA.
.........::.�::..•-::.::•.............:$... ...v:•:•:.•:vw;.;........... r....r... ....... Rt.r.v:x:}.•................... :.. x..... :.h:v'•
:......................... .... 4.:v{::?:v:............:......,, ...... {?•Yi}::..{:":'• : i('.�:}::{S••:N•:r+.'R.•,r fir .. ..:
lnsnrance•co. .. . :r.:::.::.?::.�
.........................................................................................r:R-:.:v::............ :y.{.f•
....
::.::............................::..:::::.::.....:. ....... :t•:::::•:-
}
::::::.::................................. v.....
..... ......... ...........t-.v:::•;::•::::.:}•:...:::•:...::•.v:....:.:':•...:...........::.......................rr.....r.... ....:.....IvvX{•A ?•
}.. --
. •.
dd- 3: ::::::.::::::::::............::.. ... ..:..'i.:: v 4::w4}..............
:::::.::::::::::::.....................................................................................
<tilienINU
N. r
ii R$$:;i:'iii'r:4i:i::4ii}::}}:i:{ii:;i:+$iii:{rti!:$?$:ii$'rii:4iiiii$:{ii:$}vri?:wi
............
...............::::.:.............................................
....................................................................................................................................
........................:..............................
.............::::::v.:::::::::::::w::.v:::;:w:::::::nv.,-•....•..............e...v:•.v'•:v::}:+4:::v::.4T:??•i}:4:•::4}:•i:vr r{•}::
.. ::•:i::::::.............::.::::r::tvv::::::x...:.v»x:{v}:•}}}}:::::::::r:::::.?:v.v.?::v::::::::::::::env:nv.{-:::v:::w:•i}}:?•
......................................r.f........:x.....r...........................................................:w:..v.v:::::........ ............... ................. .:::rr::•:•.•x:::::::•.�{eat. ...r....n..t:•:rm::.v::::.
...................:.::...:............. ........:•r::r:nv::v:::•v.v.v:::.�:.v.v:::::::::.v:::x::rr.v::-:::m:::. ...........r..:v:::::%•>:::n:::.. +4•{?•v::::.v w.•r•Y.:.....r. }...•.•.w:::r::.vx
.. ::•.v:::•:Y.4::::::::................rr.......................................n.........rv........... :??????{•}:{4%:.: r.......:...}1..4.:::n r..v:>.}:.........>.•.......T%;.x}:{4:i•Y.4}:::v..........
Failure to secure coverage as required under Section 25A of MGL 152 an lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or
one years'Imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a Hue of S100.00 a day against nm I understead ffid a
copy of this statement may be forwarded to the Ounce of Investigations of the DIA for coverage verincatioa
I do hereby certify pains mid penalties ofpclury tha the information provided above is&w and correct
Signature Date L I 1 9
Print name ,, e Phase# 36 L- 2-1
official use only do not write in this area to be completed by city or town official
city or town: permitaicense# (]Building Deparment
❑Licensing Board
❑checkifimmediate response is required ❑Selectmen's Office
_ ❑Health Department
contact person: phone M, ❑o&er•�._
Dented 9/95 PJIU
a
. ra
i111Vi�{iLiVli f{li�i i1i�71111LLiV11D
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==ar:
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 occup=of the dwelling house of
another who employs persons to do maintenance, construction or repair work an 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 mi surance requirements of this chapter have been presented to the contracting
authority.
Applicants
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Invons has to contact you regarding the applicant. Please
be sure to fill in the peiE�rt/liceose number which will be used as a reference number. The affidavits may be returiM in-
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would lice to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a'call.
Y
The Department's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Imlesduadoes
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 eat. 406, 409 or 375
N
MAM �,$ Department of Health Safety and Environmental Services
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 11"ROVEMENT 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 p t-exiting owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: b4A (oibVrX~ Estimated Cost rr,4'
Address of Work: t Wz t-� 0• U�Q PCs W:e Gwen
Owner's Name: Q,�\V�c c C,
• Date of Application: 1�1
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
[dwner pulling own permit #
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME 5WROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Date Contractor Name Registration No.
OR _
Date Owner' ame
q:fb ms:Affidav
The Town of Barnstable
Department of Health Safety and Environmental Services
Building Division
BAWmAJ= ` 367 Main Street,Hyannis MA 02601
Musa.
1659• ♦�
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: I�Z D1�Q l�(.�,�S � ,(� , W. &^5bo C
Qnumber stitet village
HOMEOWNER": �• C+nntn��•tl�. �� ,36L-O�-I�
name home phone# work phone#
CURRENT MAILING ADDRESS: L�l I Z" Ya v� fs --
u NW 626(vP
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
require ts.
Sign 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 frilly 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 to amend and adopt such a form/certification for use in your community.
Q:FORMSIMMIPT