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HomeMy WebLinkAbout0075 BARNSTABLE ROAD i �� �i � �� , ' ,� �� �O*THE T TOWN OF BARNSTABLE 2AHH9TAFILB, i 16 9 BUILDING INSPECTOR ,e0 m M• APPLICATION FOR PERMIT TO .. d�f�/T/�� 4 C7A /�'/ �% ..... .........X.. ........................................... ............... TYPE OF CONSTRUCTION C'.... �: (.��. ........................................................................ ................................... ........19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following inform�ati�o Location .................. ProposedUse ...� � ........ � .....�...... .............................. '... ........... ................................ Zoning District ...,. t �� � ................Fire District ............. �... x,ralvCTli ja 3 Nameof Owner ......................................................................Address .................................:............................ ......Y�.C��� Nameof Builder ....................................................................Address .........................................../..................................... Nameof Architect ......� C- .................................Address .................................................................................... Number of Rooms � � �`� Foundation ........... .............................................................................. Exterior ®.��.�Cj�G�� ..... �/%� �O/ .// .............. ............ ........ ....................Roofing ....... ... .............. ....................................................... Floors ............... ....... ...............................................Interior ......�Y....��.................................................................... Heating �,� `S � . ..�....Plumbing ....... Fireplace ................-......--................................................Approximate Cost ..........1✓..`... .................................. Difinitive Plan Approved by Planning Board ________________________________19 rig Diagram of Lot and Building with Dimensions �Pe. N d 5Row© 4s C � V.o 0 Uj r Oyu L3 � (n _, t hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. ZQ= .................. Atsalis, Konstanos ` DEC 3 1970_ �• , No 129d..... Permit for .....add••to commercial " t building .................... ....................................................... Location p .arnstable Road i ...........�xannis....................................... Owner ............gonstanos Atsalis ...................................................... I Type of Construction ........!?$:Son "y••••••••••••••••••• + ................................................................................ 'I Plot ........................ Lot ................................ Permit Granted ..................................19 70 9 I Date of Inspection 19 Date Completed ... ......1 ....19 � 1 `i PERMIT REFUSED .......................................................... 19 ............................................................................... ► .................................................. .. ............................................................................... s nP! e � I Approved ....................................... 19 } + ............................................................................... TOWN OF BARNSTABLE BUILDING.PERMIT APPLICATION Map 3 ;. 7 o 1 Parcel Lo-7 s 19=3 Application# 9DU7� � Health Division Date Issued, Conservation Division I.Application Fee - Tax Collector Permit Fee Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis n� Project Street Address — b.A it k1 5 7�M A6 f, i2 n Village jsl 7 IQ L4 a l S Owner Q 12 W U r1Lj) Address 7i �:a� ����.t. 2j�f YbaP,� Telephone .Sow / 9 76 Permit Request ITS c7,��r=��� 6 C Square feet: 1 st floor:existing ro sed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation o 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 F � 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 r V Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count i Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other 2 Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal--stove: O=Yes -2:❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑dew size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: CFI = TA� Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ -- Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION me !��ILA/ YAnn/ / �Nc Co Telephone Number A6'dress /� 3�Ct7Z9,y �T License# 02 Home Improvement Contractor# / C/ 0 d.g zatfdJ1l Ilya/6 I Co Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 6 A4 51 r SIGNATURE DATE ' ZO b q LO 7 / \ \ , ` FOR OFFICIAL USE ONLY \ APPLICATION# } DATE ISSUED MAP/P RCELNO . � . . \ ADDRESS VILLAGE ¥ OWNER � DATE OF INSPECTION: ! FOUNDATION � ' FRAME } INSULATION FIREPLACE . ƒ ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL \ � . .GAS: . ROUGH FINAL 5 . . t FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r ( 107f0/2007 01:34 5087781869 CLOTHESLINE LAUNDRYB PAGE 01/01 Oct 09 07 10:52a Kevin Lyman 5082793372 p.1 KEWN LYMAN ROOFING CO 123 Green Street Bridgewater, Ma. 02324 50M97-8244 PROPOSAL FAX#508-27"372 Date: 10-9-07 Proposal submitted to: NAME: The Clothesline Laundry, Inc. c/o Karen Clark ADDRESS: 71 Barnstable Rd: CITY: Hyannis, Ma. 02601 PHONE: 508 778-1976 FAX# 508 778-1869 Description of work: 1. Rip off and dispose of wet insulation and rubber in 40' x 30'area at bottom middle section of roof. 2. Screw down 3"fiberboard insulation over.area to bring back up to height. (any bad wood will be replaced at extra-cost) 3. Screw down W isopolysanurate insulation over entire middle roof. (approx. 2760 sq. ft.) 4. Fully adhere 1 ply.U6U rubber roof membrane. 5. Flash stacks,wails, and soil pipes with rubber. S. Inetall aluminum termination bars at outside edges of roof. 7. Caulk seams with rubber caulk. . 10 year guarantee All material is guaranteed to be specified, and the above work to be performed in accordance with the drawings and specifications submitted for_above work and con letedworkmanlike manner for the e sum of . DOLLARS $ 15,530.00 with payments to be made as follows: 1/2($7765.00)down,balance upon completion.` Re*pectftir)ly submitted _4 .ACCEPTANCE OF PROPOSAL The above prices, specifications,and conditioons are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above, If acc noted,please sign. below and send 3xtra. py back to Kevin Lyman Roofing Co. DATE Id 0 SIGNATU It The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' w}vw.mass.gov/dia Workers Compensation Insursince Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information J n Please Print Legibly Name(Business/Orgmization&dividual): 12'1 L•VM it Al Address: 3a City/State/Zip: oa Phone.#: 0 611 7 � Li-� Are you an employer?Check the appropriate bog: .Type of project(required):, 1.❑ I am a employer 4. [] I am a general contractor and-I with� 6. ❑New construction employees(full and/or part time).* have hired the sub-contractors 2.El am a'sole proprietor or partner- listed on the•attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have . g, ❑Demolition workin for me in an capacity. employees and have workers' g Y P tY• t• 9. ❑Building addition [No workers' comp,insurance comp.insurance. 5. 0 We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11. Plumbing repairs or additions ' '3.❑ I ant a homeowner doing ill-work . ❑ g P myself.[No workers'comp. right of exemption per MGL 12.O Roof repairs insurance.required.]f c. 152, §1(4),and we have no employees.[Na workers' 13.❑ Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees, If the sub-contractors have employees,theymust provide their workers'comp.polic)r number. lam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site' information. Insurance Company Name: /13 Xlf. Nut rr,4 i �d f(0 -- Policy#or Self-ins.Lic. ,zo !7/1-06r, Expiration Date: Job Site Address: / 13fiA L rd 812L Rn City/State/Zip: A/!;�A UAD /411 O),&O 00, Attach a copy of the workers' compensation policy declaration page'(showing the policy number and a itation date). P P Y P b ( g P Y gP ) Fafiure,to secure coverage as required ender 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 thq violator. Be advised that a copy of this statement maybe forwarded to the Office of' Investigations of the DIA for insurance coverage verification, I do hereby certify undeohe pains atsd nalHes of perjuty that the information provided above is true andcorrect. Si afore Date: O �. Phone#: -ce � 7 a Official use only. Do not write in this area, to be completed by.city or town:officiat City or Town:' Permit/Liceme# 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#: Liberty Mutual Group Liberty P.O. Box 7202 Mutual® Portsmouth,NH 03802-7202 Telephone (800)653-7893 Fax(603)-431-5693 k October 31,2007 TOWN OF BARNSTABLE,REGULATORY SERVICES BUILDING DIVISION 200 MAIN ST HYANNIS, MA 02601- - RE: Certificate of Workers Compensation Insurance Insured: KEVIN LYMAN DBA KEVIN LYMAN ROOFING CO v-123'GREEN STREET. ...... ,,... . a., n...._.. BRIDGEWATER, MA 02324 Policy Number: WC2-31S-430911-067 Effective: -3 /31/2007 Expiration_ 3/31/2008 Coverage afforded under Workers Compensation Law of the following state(s): MA Employers Liability imits� Sole Proprietor/Partner Coverage Election: Bodily Injury By Accident: $ 100,000 Each Accident. The workers'compensation - _ policy does not provide Bodily Injury by Disease: $ 100,000 Each Person coverage for: Bodily Injury by Disease: $ 500,000 Policy Limits KEVIN LYIMAN As of this date,the above-referenced policyholder is insured by'Liberty Mutual Fire Insurance Co under the policy listed above. - c� c The insurance afforded by the listed policy is subject to all the terms exclusions and conditions 'ands not altered by any requirement, term or condition of any or other documents with respect to which this - certificate may be issued. ; is 1 This certificate is issued as a matter of information only and confers no right upon you, theertificate.,�. i holder. This certificate is not°an insurance policy and does not amend,extend,or alter the coverage _ afforded by the policy listed above. cxr � If this policy is cancelled before the stated expiration date,Liberty Mutual will endeavor to n tify you of such cancellation. AU-1 HORIZED REPRESENTATIVE LIF3ERTY MUTUAL INSURANCE GROUP -fhis Ceiii5cate is exectited_by LIBERTY,-N4U I'UAI_INSUR.ANCE.GROUP as respects such insurance as is afforded.by_those cmnpaiiies. _ a cc: Insured: Producer of Record: KI VIN LYMAN A I,C1JST ' \N &SON INC DBA KEVIN LYIvIAN ROOF 1NG CO P O BOX3009 123 GREEN STREET BRIDGEWATER, IvLA 02324 BROChTON, NIA 02304 Louis St. .i:' .`+l:i.+ir ice•SEE J? .J. '•'J:':�:::t:::�}i::i�i.}i:i::.+•::/i.}t:ii:ii:' J J?Ir is J•"�'+'! .:t.. < •t: c a W Q ?pia`? N 6 O O •'a\,.�\->�. ':+.;ice'>'`o'''• aw how -jj +\ Y .... ...... ,,,.t.. ,,.,:: .. MINIM ....................................._..... . .,............\..:..... ...._.:..:..:....,................................. .u...,....._.....o...»:..\z..n. ..._..............,..,.,.,L..:...<,........v..,�\..,._ ....n._ .:,, .at... Y::... .. . �\ » :: .. .. ...,. g� g:g .. \\mo\ MEN » k\. .ate\ \ >at+ .Ya, i r' N _( r FL 111 ca ,Gr I F: y ,[ L• , t 4 . r. r' -J t y �9' r: c• � a F f� ^+ •r � :1 1 1� '1 w 'I f. cm '1Rol ------------------- aa 't E% �F C r C 6 ar o d s SENT BY: ;11-26-90 : 12:58PM 5067786448-� 5087753344,# 1 I- YANNI FIDE DEPAR 711"IE T FIRE PREVENTION DIVISION 95 HIGH SCHOOL ROAD EXTENSION HYANNIS MA 02501 BUSINESS (505) 775-- 1300 FAX (508)'7 8-5445 a-;YANNIS — k i u m rz . TELECOPI R TRANSMISSION GOFER LEI TER SENT TO; L-1 %SSA SENT FROM : �c:� + �, rs(1y�i SUBJECT — NUMBER OF PAGES, INCl.0 1YER LETTER, BEING TtANSMITTEi r �. � ,L 1 ErR.,,kMnrtdtf':�'Nr.Uw Assessor's office(1st Floor): a �7 g ;lAssessor's map and lot number Twt ro` Board of Health(3rd floor): �' Sewage Permit number � Di/� �� � yc�a Pb -wrU' I-11CONNEC I )o IVIN DARISTADL6 i Engineering Department(3rd floor): �_ UU& House number S °o 039• 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 TYPE OF CONSTRUCTION Gad/7/j7CJ,F'G'/A�. 19 TO THE INSPECTOR OF BUILDINGS: The underlsi�ned hereby applies for a permit according to t`h�e following information: Locatio�" Proposed Use /9lei j Zoning District Fire District ' Name of OwnerGld�l��S �it S TiT ��',B�V&4 Address WA157W271 4 Ailu I s Name of Builder 11 e��' .0 Cow&Co - Address,--?/���/e��r l/Y(KjV /�������4P Name of Architect s /Cf: S Address DEC .9�99 �4NN1S. /144. 02-638 Number of Rooms / VQ X US Foundation 4fD4C�e,--7C &zj s?cCG Exterior �D/�C,��%� 4711X`d AVO S0i6/C4 Roofing eeW1I een14,4 %,412 Amp (5;Mlel— Floors n111Czee%e /1�0 Interior U0001*4We CL*1A fX e(f /—Xe� Heating C"39S Plumbing e-01 1nenc11'11- Fireplace �/G���% 3�00t M/A 460t /o/T S Approximate Cost Area Diagram of Lot and Building with Dimensions Fee i r 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 construction. Name /�Qiiav'/�771 /V, Construction"Supervisor's Licens 5 J WILLX,'S TEXAS PIT BARBAQUE s No 34118 permit For Remodel Restaurzt t commercial Location: 75 Ba-rnstabie Road Hyannis Owner Willy' s -Texas P'it BarbaZue , Type of Construction Frame - Plot Lot - _ Permit Granted December .2 6 , 19 90 Date of it spection 19 p Date C'o pleted 19 . - - 3' 2-1/2" ---► - i r r r t e 3' Section j T Sign r BARNSTABLE PermitBARNSTABLE. TOWN OF MASS. i6 9��FC 39..�A� Permit Number: Application Ref: 200901815 20070292 Issue Date: 04/29/09 Applicant: Proposed Use: RETAIL & SERVICE STORE SMALL Permit Type: SIGN PERMIT Permit Fee $ 50.00 Location 75 BARNSTABLE ROAD Map Parcel 327019 Town HYANNIS Zoning District HVB Contractor PROPERTY OWNER Remarks REFACE EXISTING SIGN CLOTHESLINE LAUNDRY Owner: CLOTHESLINE LAUNDRY INC Address: 71 BARNSTABLE RD HYANNIS, MA 02601 Issued By: P Cc POST THIS CARD SO THAT IS VISIBLE FROM THE STREET 1 ti. 4. }"^` 1 Town of Barnstable P�oFYHE To,�ti Regulatory Services ,x, o y � Thomas F. Geiler,Director 9'"R' "B'�' Mwss. Building Division i639 `� Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 . www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit# Application for Sign Permit Applicant: Map &.Parcel # ,q6 lal Doing Business As: 6" 1/n'6 1'4V,'J2_x/!�jalephoneNo. , h�-77k-m 76 Sign Location Street/Road: A Zoning District: Old Kings Highway? Yes/No Hyannis Historic District? Yes/No Property Owner G"( i Name: /r Telephone: ,3 0' 714'/f�b Address: Lk Villacre: ~ Sign Contractor Name: Telephone:' Mailing Address: . Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new sign. This should be drawn on the reverse side of this application. n l Is the sign to be electrified? Yes (Note:Ifyes, a wiring permit is required) (� CO)v Width of building face ft.x 10= x .10= Sq.Ft. of proposed sign' c�� I hereby certify that I am the owner or that I have the authority of the owner to make this application,that the information is correct and that the use and construction shall conform to the provisions of§24M9 through §240-89- of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized Age Date: �� Permit Fee: Sign Permit was approved:: Disapproved: Signature of Building Official: Date: In order to process application without delays all sections must.be completed. 0:I FYPFILESISIGNSISIGNAPP.DOC Rev.9/12/06 v. - Icy ..R �4 h^ t �� /3` i h,` •�� �+ �� 1 t �� � � r � .i�• T �� at �� ,�' .. ��: �. �� ,- ,�; , � ; �Z �_ � � rf �� � �� . �. �� _� = _ a _. N' � ll ill � ,� 1 M :;0 6t, �J ir l� R.i'),,,�+rz '�'"c .:,r._ ,C . —2' ,..4 ,. .�. .4i-. ,....t-r...• .�,r.'7s'�{r ,,." 'p. ,° q. ... �: aY.x:.... ._. ..,, • ..,.. -... .. .. i Assessoors office(1st Floor): Assessor's map and lot numbed J poi TwE To` Board of Health(3rd floor): "Sewage_"Permit number ' �"� E Engi,nee frig Department(3rd floor): _ -�^ House number s 039 �O �6}p. Definitive Plan Approved by;Planning'`Board 1 19 0 MAI ' z APPLICATIONNS,PROCESSED 8:30- 9:30 A.M.and 1:00-2:00 P.M.only (TOWN .jOF 'BARNSTABLE t BUILRIINI INSPECTOR APPLICATION FOR PERMIT TO • TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The,undersi%ned hereby applies for a permit according to the following information: Locatio� Proposed Use�`G'. 1 a�- i & Zoning District Fire District /!5 . Name of Owner 6E/! Y I'� X�i S Ti7" ,t:: Address �,g�l.P/1/.STf�f1�'�G 8J. IIYAAJA)i 5 -' Name of Builder /I l��epT �C"�i� -60�� CO Addressdf (Ee� f �tl� ,4llh' . Name of Architect Address 96y'C 9 �4 N/1//5 /44. 0 2-638 Number of Rooms / Ve A-'US AiN,Qa +R21: M&A Foundation <feWflee7cr &W S7TeC� Exterior �D/!/C.��%C � .� W/7 Roofing emlllj9Me-l�,4 72A AQiy 6,ewle Floors C'L lynee7_� /UDD/d o�`�.9 C. Interior AJ00A 11;W e fI7�T�DGL F i Heating Fireplace7 S 4'I Approximate Cost I � 1•� Area L�l C� �4wC'b_ " biagram,of Lot and Building with Dimensions " Fee t` OCCUPANCY PERMITS RE'OUIRED FOR NEW DWELLINGS I. I hereby agree to conform to all the Rulesand Regulations of the Town of Barnstable regarding the above construction. Name,:� ,c �7-' t ,1 moo- al � Construction Supervisor's.License � ti WILLY' S TEXAS PIT BARBAQUE A=327-019 c3o)7-0Jq No 34118 Permit For Remodel Restaurant Commercial Location 75 Barnstable Road Hyannis Owner Willy' s Texas Pit Barbaque Type of Construction Frame Plot Lot Permit Granted December 2 6, 19 90 Date of Inspection 19 Date Completed 19 Nl- fnt'lir- r makI, Only [Alec n ©at ©f�NSI�G y 9a l PE MIT COMPLETED TOWN OF AARNSTABLE SIGN PERMIT PARCEL ID 327 019 GEOBASE ID 24131 ADDRESS 75 BARNSTABLE ROAD PHONE (508)778-19761 HYANNIS ZIP - 1 LOT A 2 & BLOCK LOT-,SIZE DBA DEVELOPMENT ' DISTRICT HY MET MINNr,pT �,i E �..�'"'� I P RMITT TYPE SI �Y+ E§IPTION SIGNH�J MYT LAUNDRY I CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: $25.00 ME BOND $.00 pxt 'CON'STRUC,TI'ON-I;OSTS-- - -'---- - -$.OI 753 MISC_ NOT CODED ELSEWHERE * + I * BARNSfABLE, + I MASS. I 1639. A� .FDMAr r BUILDING DIVISION DATE ISSUED 01/06/1998 EXPIRATION DATE S The Town of Barnstable ent of Health Safe and Environmental Services • � Department Safety KAM * Building Division 059. 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Application for Sign Permit / Apphcan Assessors No. Doing Business As: r E �� "l.�u(`LI Telephone \o. 77�'-LGt7 P —� Sign Location Street/Road: �l( b � fll f Zoning District: --- Old Kings Highway? I es/.To Property Owner n n Name: onner U!/ (o -0 -u t i�. Telephone: 7 7 V 1`176- -q.�O-W;�--0-- Address: `7� F1/n � " . iMP�`� N"��'village ar�n� A , .reign, CCiuu`a%t'- Name: )o r^ eell'tcp, Telephone: Address: 10 1 Villager_ i Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Yes/No (Vote:If j es, a ivi ing permit is required) I hereby certify that I am the owner or that I have the authority of the owner to make this application, that the information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authoriz d ar Size: Permit Fee• Sign Permit was approved: Disapproved: Signature of Building Offrci 91' :a I ov w. ..2z,a- W Ll J�wqu+` OgA ¢%L x°3 AcTTIEU V lJ!/-11U V IJ OIJ.U 1 D\:./if U _ i Engineering Dept. (3rd floor) Map 3 a7 Parcel <<} J�J� .Permit# House# ��5. Date Issued 9 �� D P w s��2 P< r— t io. cry Be�-e�eal 3fd-Beer)-(&:3-�-9:30/1:00-4:30) 0 0 q�, o Fee j�� Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) d THE 19 1 MRNSTASM MASS TOWN OF BARNSTABLE Building Permit Application Project S ddress swr n C U Q_ IDe A E�3 Village A�/C_\N,NJ I S // Owner t>oNN A IV1 onf TF I kA2rN CIA M k Address 193 98A�J S h U2E AJ AA11V I S Telephone - to n Permit Request �C •r ..Q �u iV First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ Ovv 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 WApis Authorization ❑ Appeal# Recorded❑Commercial ❑No If yes, site plan review# Current Use .LDL ci VJ.�tl Proposed Use - Builder Information Name Telephone Number s 8 34 oL �/ Z Address �/2= License# OG y� 7G -� / .(. ,� � Home Improvement Contractor# /Gi Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS. PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) .. _ . _ , .,a _ . . = - - - • :,, _ _ . . - . - . , r .. _ _ `2- - - . .-. - _ � I , 'l . ., - ,-�I.,.,--,�*;�-,..I..,i....-..-,�..1,�,....�,.,.,�.I.���,,.I I.—�-I,,...�,.�..�.,:,,-�-...-;..---,,,-�I.I�.--.�,1.-.-.�.�-.,-...�--,..".!.�,:...�1,.- - . . .;, - - �--��-.�I,,I.%-I.�..'-....�...-,....-,..,.I1�-�,:,1.,-�.�-�.I",:-1-,.�....I I 1.,'....-..I--,,,--...,...I,.,..�"..".----.-�--.-,.I-.,�"-.,.I�"I.-......-,�.-.....`.;,--.,..-.:I-�:.:,..�..-:,.�.-.,,r 5�-I,,II.I,�-I-...-�..I-.,...,-.I.���,I,_.'-�-,-I....1..,.,:---..�-.-.".--,�-I:.--,-�,,,I,-.�.I..I',,--1,:�..I l....-I,�--,.,�,�",�.'�--"-...,,�,-.,-I�.*.,�.--�-,.,��s��;,,,':.--:'0,�-,-�.I-�!.;,,.�;,,-�-i-.-�..:,;,��.;-��j,�,:,,.��-o-�.��-,-�.,—:$..�',�.l,—'�!,-.,.��-'.-­-�-�l-,1.- 0!.�-.,,I,��;. .I�.I---,T'.-�Ii.I 1—&-,1�6 or..'G.,t1.1.�..,V..��—...",-".,.,.o,,.,.-1�;:�.-,,.�...--�.I�...:�.I.i r..3*--.I--1..�-.I I,��,I.,'.,-Ii,.,,.I�,.�... 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The CU/tt/1t0/1H'ealth gr?Itassacliusetty •i:i� '' :-�i Department of Industrial Accidents ' Olrceff"MOS119211otrs 600 Ti a+hi/t.ton Street -; Bosto/t.Mays. (12111 ' Workers' Compensation Insurance AlMdayit �pnlica�n nformation�- Please 01I.W le:ibly name:A—y— D 6 4 d�r— location. Gam!C C G/^ / C /r /( ailL. �jv/i9 nhone0 JAG �G �C // 72 1 am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity L..+.b...l�..�..f+�ra.....�.a....w__�.,..y err. --��__ •..:..:.-:...'--.-.c ._..._ .-. I am an emplover providing workers' compensation for my employees working on this job. cflmpomfl•imc /'f(" / /�GLGGf�' � Z � address• city. nhone#. :1 4 // 7 a insurance co. lieu tt W ffl O G I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who havL the following workers' compensation polices: compnnv name: address: city phone 0: insurance co policy# �-- ., .. _. _. �csf!= _ TY�sT.:�r'...:'Tt1'!«c'•+��.._�.�^sae•+•+`��-1;'t7!7!��^;�,.�r._�.�.....;e.�!v-:`..n••.:...�w;�..'„r,'�---T cnmiiinv name• addre s- city nhone#- insurance co policy# - f . .:.. :• a .. .. F'E.. ...�' .Attac_h additional sheet if necessa_ ram;;; i '�+ `�"'' `f�"r sp±ei x:.�.. ....•,.rr.•`�. +�•"+�� yy�., y��;��,A Fuilurc to secure coverage as required under Section 25A of 1%IGL 153 can lead to the imposition of criminal penalties of a fine up 10 SI.500.00 andiur one rears'imprisonment as well as civil Penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 understand that n copy of this statement may be forwarded to the Olficc of Investigations of the D1A for coverage verification. ' 1 do herebt•cerrify uutlrr the mitts and penalties of perjurt•that the information provided above is true and correct. i_nature Date T 91 Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permitAicense# Building Department C3Ucensing Board check if immediate response is required Selectmen's Office (311e2lih Department contact person: phone N.- riOther f . (n,,.td,:os rrAa Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employces. As quoted from the "law", an enrphtme is defined as every person in the service of another under anv contract of hire, express or implied, oral or written. . An emplorer is defined as an individual, partnership, association. corporation or other legal entity. or anv two or nor the foregoing enLa`tied 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 ill owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the dwclliut'�; house of another who employs persons to do maintenance, construction or repair work on such dwelling lie or out the :rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe 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 fins 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 full in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested. not the Department of Industrial Accidents. Should y6tt have any questions regarding the "law' or if you are requires to obtain a workers' compensation policy, please call the Department at the number listed below. Cin• or Towns Pleasebe sure that t he affidavit is complete and printed legibly. The Department has provided a space at the bottom o the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pie. be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned 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 question please do not hesitate to _ive us a call. The Departments 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 a . nhone.#: (617) 717-•4900 ext. 406. 409 or�75 lI r' 1 c � � n r E � ... ............................ 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