HomeMy WebLinkAbout0252 ARROWHEAD DRIVE ` 1
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_Engineering Dept.(3rd floor) Map 47,0 Parcel 6y� "j—Permit#
_ - House# " �Z, Gc Date Issued
Board of of Health•(3rd floor)(8:15=9:30/1:00-4:30) -• Fee-
Conservation Office(4th floor)(00- 9:30/1:00:2:00)
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Planning Dept.(1st floor/School Admin. Bldg.) SINE
D miti a Ian Approved by Planning Board 19
_ BARNTrABLE.
TOWN OF�BARNSTABLElE° `'��
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Building Permit Application
Project Street Address ,) s- Gl ,e��P
Village S
+ P � .
Owner Address
~Telephone
Permit Request
First Floor square feet Second Floor square feet
or
Construction Type
Xr
Estimated Project Cost $ 'j
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House' ❑Yes ❑No On Old King's Highway ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No. of Bedrooms: Existing New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review# -
Current Use Proposed Use
Builder Information
Name 401Ga/V1 Telephone Number
Address ]/ _,���fJ-/J�e0- 1 �//J License# -�
ab6a: ' 4u Home Improvement Contractor#
Worker's Compensation#Gl.It-7/S/' v� j�j d/e4
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
BUILDING�PERMIT DENIED THF,�; LLOWING R ASON(S)
1
6
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED'
MAP/PARCEL NO. 1 �.
ADDRESS "; VILLAGE
OWNER
DATE OF INSPECTION: a I
FOUNDATION-
FRAME � •� .� 1 .: _ • _ J •. ',
INSULATION -
FIREPLACE
ELECTRICAL: ROUGH FINAL -
PLUMBING: ROUGH ' FINAL ' -
GAS: r ROUGH FINAL - #
FINAL BUILDING
DATE CLOSED OUTr 1
ASSOCIATION PLAN NO.
. . °: The Town of Barnstable
HAMM""AM Department of Health Safety and Environmental Services
1679-67� Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissions
i
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstructfon, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existfng
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: s Est.Cost c3 3e?)
Ad
dress of Work: �
s
Owner's Name n
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WrM 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 app y for a permit as the agent of the owner:
to Contractor Name Registration No.
OR
The ComnioniveU1th ojlArssuchuseliv
--- 1: Dt.pftrtnrcttt njlndrtrtrialAccidcnts
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. , �i 1. ;;� � Ofliceo//nvestlgatlons
•���';`: ::i `'` 600 (l<'ashingtoir Street
Bustoa.Mass. 02111
Workers' Compensation Insurance Affidavit
(iP10*iit informatiiin: Please PR(NT lebi ily �•y'—� ��-- ~- -
name, 1 >Ptar -)
location• l RI/G�
cin. �6 4 /y y & nhone#
I am a homeowner performing all wort:myself.
I_am a sole proprietor and have no one working in any capacity
:....,.�, ..ew..' _..•-...-..»..__�,..�_�•+e....s++a�cs�.w�wr+�n�� �.��w.�.�...�y..+.._••.�.w+r...w•`»•..�....__.-.__...
t I am an emplover providing workers' compensation for my employees working on this job.
enntnanv name:
aticlress•
city ahnne#• /
insurnoce co. MACV
M I am a sole proprietor. general contractor, or homeowner(circle otte) and have hired the contractors listed below who have
the following workers' compensation polices:
emmmanv nnmc:
adrlresr.
cin•: Phone#-
inscirnncc rn. linnet•a
�- ., .,_+, _.. `l.'^..-'- _ .��T. -_ __ fir_-•�����lt iS"t 1.w•y. .�Tr..._ ..•e.•�.....�._i_... -
emmnnn.• nnmc:
addresc-
rite nhnne#-
insurance co policy#
Attach additional sheet if necessary i + --+�- '•'• __"�"�r ''�' ' "�_'..�--'�' '~"' -�
Failure to secure coverage as required under section 23A of NIGL in can lead to the imposition of criminal penalties of a line up to SI.500.00 andior
une sears' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that n
Copy of this.statement mac be forn•arded to the Olrice of Investigations of the DIA for coverage verification.
1 rlo herehr rril• tiller th• at and t'l cs ojperjun•that the information provided above is true and correct.
Sianature Date '<7/a
Print name t)c' hone#,
' otriciai use unh• du not write in this area to be completed by city or town official •
city or town: permittlicense# nBuilding Department
Licensing hoard [:
check if immediate response is required C3Scicetmen's Office 1'
C31lc2lth Department
contact person:
phone#• rnOthcr
i.
information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all emplovers to provide workers'-�t�rvipensation for
employees. As quoted loom the "1a��'" all emplut•ec is dcfincd as every person in the service o( :uu�ilir under any
contract of hire, express or implied. oral or written.
An enrplurer is defined as an individual, partnership. association, corporation or other legal entity. or any two or me
the foregoing enLaged in a joint enterprise, and including the le-al representatives of a deceased employer.or the
receiver or trustee of an individual . partnership. association or other legal entity, employing employees. However ;
owner of a dwelling house ha%,ing not more than three apartments and who resides therein, or the occupant of the
dwclIin-, house of another who employs persons to do maintenance , construction or repair work on such dwelling,
or oil the `,rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio%
MGL chapter I�'_ section =5 also states that every state or local licensing agency shall withhold the issuance or
renewal ofa license or permit to operate a business or to construct buildints in the commomi•calth Car any
applicant v ho ltas 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
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation anc
supplying, company narnes. address and phone numbers as all affidavits may be submitted to the Department of
Industrial Accidents for confirm 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 requir:
to obtain a workers* compensation policy. please call the Department at the number listed below.
City or rowns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returner
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 an. quest',
please do not hesitate to _=ive us a =11.
The Department-s address. telephone and fax number:
The Commonwealth Of Massachusetts "4
Department of Industrial Accidents
office of investigations
600 Washington Street
Boston,Ma. 02111
fax R: (6I7) 727-7 749
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