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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Ma J Parcel' 01
"A lication #0 � 6 3
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Health Division Date Issued Li
Conservation Division ` Application Fe
Planning Dept. °Permit Fee '
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
Project Street,Address �3 7 I's h®P5 -7:ze cel
Village n n LC
Owner L/ 56 t& S— Address
Telephone
Permit Re uest ��w�e c�fJS',MirS LJ/�arn 12 7ZA
Square feet: 1 st 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'docu ntation.
Dwelling Type: Single Family, Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King'sHighway.F.,❑Yes ❑ No
t4..l
Basement Type: ®'Full ❑ Crawl ❑Walkout ❑ Other rn
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) x µ
Number of Baths: Full: existingf new / Half: existing new
9
Number of Bedrooms: 3 existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: X Gas ❑ Oil ❑ Electric VNew
her
Central Air: ❑Yes No Fire laces: Existin Existin wood/coal stove: Yes ❑ No
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Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage:Xexisting ❑ 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
(BAR OR HOMEOWNER)
Name �. r P, li'S.660t) UG4- se-
Telephone Number
Address S 74 � /L. �.5� 6OO_ /��c�' License#
�lC�h A l� �a Cx 9 G5 r f Homo Improvement Contractor# N
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 1f
f
ti FOR OFFICIAL USE ONLY
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±jtrt` ,APPLICATION#
DATE ISSUED � • I•.
,MAP/PARCEL NO.,
ADDRESS VILLAGE
OWNER '
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DATE OF INSPECTION:
k fOUNDATION_
9
FRAME
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INSULATION= ' ,,
FIREPLACE
d ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
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CAS _ ROUGH rtr, : - FINAL
itFINAL BUILDING! E RIA;..,€ •
i ;DATE CLOSED.OUT
ASSOCIATION'PLAN NO.
.4
The Commonwealth of Massachusetts
., Department of Industrial Accidents
!n Office of Investigations
600 Washington Street
c Boston, MA 02I11
sy www.rnass.gov/dia
' 'Workers' Compensation Insurance Affidavit: Builders/Contractors%ElectricianslPlumbers
Applicant Information Please Print Le ibI
Name (Business/Organization/Individual): P,2-4,ev-' I & ��[S�C5AA(2auLT1 �r
Address: , 94. �t5 BPS �/'n R
t 717 1 - o$tl
City/State/Zip: G ( Phone #:' QSS-.1 r) -
Are you an employer? e a
Check thppropriate box:" Type of project(required):
1.❑ I am a employer with 4. I am ageneral contractor and 1 6. New construction
employees(full and/or part-tune).* have'hired the sub-contractors
2.❑ I am a sole proprietor.or partner-
listed on the attached sheet. 7: �-Remodeling
.' These sub-contractors,have g,' Demolition
ship and have no employees
working for me in any capacity. employees and have workers' 9 E] Building addition
urance.$
[No workers' comp. insurance comp. ins.]
F 5. We are a corporation and its ' 10.r] Electrical repairs or additions
required
3.T\am a homeowner doing all work .Officers have exercised their 1 1.[ Phirnbing repairs or additions
right of exemption per MGL .
myself. [No workers comp. 12.[] Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' ,13.0:,Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workcrs'compensation policy information. .
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new aff davit'indicating such.
tContractors that check this box must attachcd-an additional shcct showing the name of the sub-contractors and state whether of not those entities have
employecs. If the sub-contractors have employecs,they must provide their workers'comp,policy number,
I am an employer that is providing workers' compensation insuracnce for my employees. Below is the policy and job site
information a
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: _ City/State/Zip:
Attach a copy of the worker's' 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 er and the pains.and penalties perjury that the information provided above lisrue and-correct.
Signature: Date:
Phone#: -
Official use only. Do not write in this area, to be completed by'city or town officiaC
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#�
• - .:M• 01
Information and Mstructxons
Massachusetts General Laws chapter 152 requires all employers to prthe service
workers'ceof another under employees.n for their
nderany contaac ofh fe
Pursuant to this statute, an employee is defined as ".,.every person in
express or implied, oral or written."
her legal entity, or any
o or
An employer is defined as ''an individual, partnership, association,
corporation
livets of a deceased employer,,or the
of the foregoij5g engaged in ajoinl enterprise, and including (he legal Pres
receiver or trustee of an individual, partnership, association or otherlegal 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 coucth iemolooment be deemair Work ed to ben such aaneelmpl yer5e
P y L
or on'.,the grounds or building appurtenant thereto shall not because o ,
MGL chapter 152, §25C(6)also slates that "every state or local licensing agency shall withhold the is or
to operate a business or to construct buildings in the commonwealth for any
renewal of a license or permit
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the conurionwealth nor any of its political subdivisions shall
enter into any contract for the perforrriance of publicWork until acceptable evidence of compliance with the insttrarice
requirements of this chapter have been presented to the contracting authority."
Applicants
Please.fll out.the workers' compensation affidavit completely, by checking beshalooxethhathPpleir cerlifiy to ecate(s)ur iof on and, if
necessary,supply sub-contractor(s)name(s), addresses) and phone nt O g
y Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the
insurance, Limited Liabilit
members or partners;are not required to carry workers.' compensation insurance. if an LLC or LLP does have
employees, a poLcy is required. Be advised that this affidavit may be sba ididatcd e the a the Dffrdavit Department
affidavit of should
Accidents for confirmation of insurance coverage. Also be sure to sign
be returned to the city or town that-the application for the pennit or license is,being requested,not the Department of
u have an questions regarding the law or if you,are required to obtain a workers'
IndustrialAccidonis. Should-you y �
compensation policy,please call the Department at the number listed below.,Self-rnsured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the afdayit 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.penniUlicense number which will be used as a.reference numbone affidavit In nnd.icatpngicurrtent
that must submit multiple permit/license apphca6ons in any given year, need only subm (city or
policy information()'f necessary)and under"Job Site Address" the applicant should write"all locations in
town)."'A copy of the affidavit that has been officially stamped or rriarked'by the city or town may be provided to the
avit is on file for future permits or licenses.. A new affidavit must be filled l each
applicant as proof that a valid affid
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 wotild7ike to thanl�yuu�p �� �for—your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The.Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07 www•lTlass.gov/dia
Town of Barnstable '
Op'rKE rp
Regulatory Services
BARN,-,gym Thomas F. Geiler,Director
' ttwss
Building Division
'°rFn►M't�
Tom Perry,Building Commissioner
200 Main.Stre_-e Hyannis,MA..02601: "
m Rww.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HWD OW ER LICENSE EXEMPTION
e Please Print
DATE: O f7—Dg" 101
JOB LOCATION: 3 /q —' sAo os. aze yQ dI/I S
mbcr street village
"HOMBOWNER": JuLiA {+. " 9c�NNc�Ktuf $T SOS-`I7i=d8ll G�S�`�7 �7g�
name home phone# work phone# .
CURRENT MAILING ADDRESS: 37a"'r-31SAQA
city%tovro 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 constrgcts more than one home in a two-year period shall not be considered a bomeowner• 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 w.ih 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
n7inimtlIn inspection procedures and requirements and that he/she will comply with said procedures and
re eme
Signatiirc 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. y
HOMEOWNER'S EXEMPTION
The Code states that: "Amy 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'(sce 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 ht/she understands the responsibilities of a Supervisor. On she last page of this issue is a,form currently used.by
several towns. You may care t amend and adopt such a for7m/ccrtification for use in your community:
Q:fomis:homcexcmpt
r
THE rp Town of Barnstable
` Regulatory Services
swxxsrasr.E, «
Mass. g Thomas F. Geiler,Director
Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owwr er Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subject.property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
Signature of Owner Date
Print Name
If Property_owner is applying for permit please rnp epside.
Homeowners License Exemption Form on e reverse
Q:FORMS:01ANERPERMISS10N
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THE FOLLOWING
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�ssesor s map and lot number ...42
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THE TO�y
Sewage Permit number :.....::.� ...... !'�L .. l�'✓� °,►
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House number .........................::.......:............`..................;......_ � TITLE � '°o,, 1e39
�fl>1bIROAiMEMT^;
w TOWN OF . BARNSTrAt:ABLE
BUILDING J.NSPECTOR
APPLICATION FOR PERMIT TO ..... /...t ..�v G .......� .....................:..........
-
TYPE OF CONSTRUCTION ........ ....................................:
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19. %
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TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location . .C-,-,P S......<r�- 1':...J... �z✓J,t�^+4� ...i•r,c ......................... ...........4D.7. ...........
Proposed Use
ZoningDistrict ........................................................................Fire District ...... ..............................................
Name of Owner . �rt.R... �S�D/V/��. �r�. .......Address 3-7#..&5-0,. .. � .a.../c[ jS......�ss
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Name of Builder ., ../.(� ....... , ,�. .....Address e:.7.. ... . ���„l?G�, A. i
Name of Architect .. .� ,PI/ �G f;td............,e .:............:Address .....� .�,,7�. . �'�....A ......................................... �
Number of Rooms :.../..... .g� .t'Cc,�y'�2.....................Foundation ......eft'..?'J.l°/1. ,..............................................
Exterior ., .. ,/ /,gs ...............Roofing ....... `jl#,( yL
Floors ...................................................Interior . . r�f �f��`........ .... ..... .....................................
Heating ....................................................................Plumbing ......../V.., .............................................................
Aj,/�/ .// ......Approximate Cost /Fireplace Fireplace ...... .yl ......................................................... ...............................:....................
Definitive Plan Approved by Planning Board -----------____--------_------19_______. Area ......33.9-�.......................
Diagram of Lot and Building with Dimensions Fee 75
..�.a..............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
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hereby agree to conform, to all the Rules and Regulations of the Town of Barnstable regarding the above
construction:
,.
. � �. .. Name . ................................
BO izzo neaut t, petet r
Nci2.1•531...... Permit for .Add!•n.•to..dweZetin '
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Location .......32....$Z4hops.....T¢u,................... ,
.................. .Nyanki.�a.......................................
Owner ..Fete ..iiQ QnvieavAt
Type of Construction ...:...4A4me........................
............................................................... �} }
Plot ....................... Lot ................................ ;
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Permif,Granted ........... .Au.g"t...�......... 9 79 -
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19
Date of Inspection ...........................:.......
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Date Completed L�..: �` `19
PERMIT REFUSED
...... ... € ........................i t.I................... ' •; J '= /� ',•'}'"+. - IJ �! Y -
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Assessors map and lot number ...,........................................ �-=-
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Sewage Permit number .........e�� �Q °.................... �. . - .
Z BA"ST�LE, i
House number ......................................................................... Sao NAG ♦�
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .....
'? �fi�'i�l / c- i2�..............................................
TYPE OF CONSTRUCTION ///�a
............ �.r..../....................19.2
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location
ProposedUse ....../N. ...............................................................:............................. ..........................................................
� Zoning District ........................................................................Fire District .......�7,� fflif
Name of Owner iC/iICC!a 414 P I/ t �?`7ll lSl.5#19AS 1g.� V1/,,4x, �1��S�
...... ......Address ... ...... ... ...
Name of Builder //��.. ��....... � !� ,. ^ -^....Address , '7
Name of Architect .A....... / t
....... ......................................Address ........................................✓
Number of Rooms ......................n M-� "r.�.....................Foundation ............................n
r / . .... ... _ _ ............................................
Exierior �� /✓!, /�..... Roofing .......;!3.` .,?'.!.. `....................................................
............... ........................................
InteriorFloors ...................:........................................ .......................................:. ..........................................
Heating
r.::.............................................................Plumbing .............,..�...-!............................................................
Fireplace f'-`/!-1..............................................................Approximate Cost•'/w , .+
Definitive Plan Approved by Planning Board -----------____---------------19________. Area ..... ?.........................
Diagram of Lot and Building with Dimensions Fee ' / -7V75
t.. ............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
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I are to conform to all the Rules and Regulations of the Town of Barnstable regarding hereby agree g g g the above
construction.
Name : !,...... /
.Boi,&6onneautt, P8teA A=250-74 '
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No' ' W.V—' Permit for Ad&N^ta.. .
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Owner ........ ----- ` ^
Type of Cpnm,mpmn
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Permit Granted �
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� uo,e or Inspection
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~~'~ Completed .
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PERM REFUSOD
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