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Home My WebLink About0201 BRISTOL AVENUE - _ _ ._. _ __� �__ .. ._ ._ __, _ _ -- ��1 i1\ \ � q J �-' 9� � r .., � ', �l ' 33 is Map Parcel 1Q 8 Permit# �q c 4' House# Date Issued J l D Board of Health,.(3rd floor)(8:15 -9:30/1:00 , �1 - Fee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) THE rq De ' itive Approved by Planning Board 19 ; ?t _ BARNSTABLE. • � n MASS , TOWN OF;BARNSTABLE 'E° ''' Building Permit Application Project Street ddress c,20 (,GZL�e Village Owner 1�4�/A V �//2/7�" Address II —Telephone SO Q -- 7 7 / -/6 4 g 'Permit Request �� X?�1 First Floor - square feet Second Floor square feet Construction Type Estimated Project Cost $ `_ /` oo 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 ' (�'�Z ��-1.�.�tC , `h,..c, Telephone Number Address 7S License# Home Improvement Contractor# //6 7�," lC Z`7 O'2-�"t-7 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 ► �l �6 �' 7 LBUILDIN RMIT OR T FOLLOWIN REASON(S) - J(7(�� FOR OFFICIAL USE ONLY _ r PERMIT NO. SATE ISSUED _ r VAP/PARCEL NO. ZY ADDRESS = VILLAGE - W OWNER + DATE OFiINSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL'BUILDING DATE CLOSED OUT, ASSOCIATION PLAN NO. + Town of Barnstable Zoning Board of Appeals Decision and Notice Appeal 2000-93 -Viirre Variance-Section 3-1.3(6)Bulk Regulations-Minimum Lot Area Summary: Granted with Conditions Applicant: Estelle Viirre Property Address: 8 County Seat Road and 201 Bristol Avenue, Hyannis Assessor's Map/Parcel: Map 291, Parcels 161 and-108— Zoning: Residential B Zoning District Groundwater Overlay: Groundwater Protection District Background: The petition before the Board is a request for a Variance to the lot area requirements.According to the Assessors records, the applicant is the owner two undersized lots: • Parcel 161 -8 County Seat Road-a vacant lot of 0.35 acres fronting on both County Seat Road and Saint Catherine Avenue(Developers Lot No.22)and • Parcel 108-201 Bristol Avenue-a developed lot of 0.38 acres fronting on both Bristol Avenue and Saint Catherine Avenue(Developers Lot No. 12). The lots have merged into one in accordance with MGL Chapter 40A Section 6, common ownership of adjoining undersized lots. The parcels are owned by Estelle Viirre. Procedural Summary: This appeal was filed at the Town Clerk's Office and at the Office of the Zoning Board of Appeals on August -22, 2000: A public hearing before the Zoning Board of Appeals was duly advertised and notices sent to all. abutters in accordance with MGL Chapter 40A. The hearing was opened on October 11, 2000 at which time the Board voted to grant the petition with conditions. Board Members hearing this appeal were; Gail Nightingale, Richard Boy, Ralph Copeland, Dan Creedon and. Chairman Ron Jansson. Attorney Stanley Nowak represented the applicant. He cited that the variance conditions related to existing vegetation of the lots and the hardship it would impose on Ms.Viirre if she could not sell the second lot separately. Public Comment Joyce Killis, an abutter, commend0d that if the variance is granted, she would prefer the home be located diagonally on the lot. No one spoke in opposition or in favor of the appeal. Findings of Fact: At the hearing of October 11, 2000 a motion was duly made and seconded to find the following facts as related to Appeal 2000-93: 1. In Appeal 2000-93, Estelle Viirre has petitioned for a Variance from Section 3-1.3 (5) Bulk Regulations- Minimum Lot Area. 2. The properties are addressed as 8 County Seat Road and 201 Bristol Avenue, Hyannis, MA, Assessors Map 291, Parcels 161 and 108. Zoning in this location is Residential B Zoning and Groundwater Protection Overlay Districts. 3. The petitioner is before the Board due to her ownership of two adjoining undersized lots and the merger of those two lots under MGL Chapter 40A, Section 6. 4. The two lots are; Parcel 161 -8 County Seat Road-a vacant lot of 0.35 acres fronting on both County Seat Road and Saint Catherine Avenue and Parcel 108-201 Bristol Avenue-a developed lot of 0.38 acres fronting on both Bristol Avenue and Saint Catherine Avenue 5. Parcel 108 is developed with a one-story, 3,056 gross sq.ft. single-family dwelling. According to the Assessor's Record, the home was built in 1963. 6. Today, both of the parcels are owned by the applicant, Estelle Viirre. Her.ownership of the vacant lot dates to 1971. 7. The area is Zoned RB which went to one acre lot size in 1985. The two lots would have merged in 1990. 8. A literal enforcement of the provisions of the Zoning Ordinance would involve substantial hardship, financial or otherwise to the petitioner, and the relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the Zoning Ordinance. 9. The applicant has been paying separate real estate taxes on the two lots from 1971 to today. 10. No specific.finds have been made with regards to MGL Chapter 40A, Section 10 uniqueness of the lots, redarding soil conditions, shape and topography. The Vote was as follows: AYE: Gail Nightingale, Richard Boy, Dan Creedon and Chairman Ron Jansson NAY: Ralph Copeland Decision: Based upon the findings, a motion was duly made and seconded to grant the variance as requested with the following conditions: 1. The variance granted is only for minimum lot area. 2. Development on the vacant lot shall conform to all other requirements of zoning, and shall conform to applicable building codes, and health regulations. The Vote was as follows: AYE: Gail Nightingale, Richard Boy, Dan Creedon and Chairman Ron Jansson NAY: Ralph Copeland Ordered:Variance 2000-93 has been granted with conditions. This decision must be recorded at the Registry of Deeds for it to be in effect. The relief authorized by this decision must be exercised in one year. Appeals of this decision, if any, shall be made pursuant to MGL Chapter 40A,Section 17,within twenty(20) days after the date of the filing of this decision. A copy of which must be filed in the office of the Town Clerk. )\ Ron S. , Chairman Date Signed I Linda Hutchenrider, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20)days have elapsed since the Zoning Board of Appeals filed this decision and that no appeal of the decision has been filed in the offi the Town Clerk. Signed and sealed this day of 00 under t pains and penalties of perjury. lop Unda Hutchenrider,Town Clerk 2 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M A� L DATA y s '� �. s•....u�Jss��i. 3� ? �' 1 rr a i I wi x sgyy loll . •�^ ,p JU ' 48 3e•&�S"r I ' +� ' :�»� r.,< ,�•114,E �s�,..-! ..1 a.tittath Fr'x�f� 44 I Iy 1 asp _ Al .teuw a g l:4tt ;e a a is A eT�1 _ di110 � V'�Q-i" va 4^I �" +^" t4I 1 aR-..•}, 2. fL� .:s{mod `�t� #•4��T�.• �5�.#k��` a r �,.`�t''�..w� -.4 ya't�^w-a�S��y 3•J 'i �XF t �if:t°� � } ,sts-,� X �i`ib '"> � �y�IIIt1't-�I `b�l -•�, �, k� j ai'1 ` a Ury \\$ tit' .., ell'{ 4 1 - h �,ay.1+.�.RJ6a�� 'T'fi-1i+lk'1�• .: a ✓fd Gat�r l ; � _ . J a.+ a Il it 3-a:.e_ 11 -1..t I � �.� '�• :�' ._. Planning Labels 25-Sep-Oa RetNo mappar owners owner2 addr city state zip 93 88 GREENWOOD AVE HYANNIS MA 02601 291 059 MARKARIAN, LINDA M P O BOX 100563 FLORENCE SC 29501 291 060 KENNEDY,•DAVID H JR 6 ELIZABETH $ FLEET MORTGAGE GROUP 291 061 GILLIS, JOYCE E 31 ST CATHERINE AVE HYANNIS MA 02601 29T 062 CALDEIRA, NEIL F SR b CAROL 43 SAINT CATHERINE AVE HYANNIS MA 02601 291 063 MCNAMARA, WILLIAM J JR 143 LONG POND RD MARSTONS MILLS MA 02698 291 064 FLINT, JANICE M 67 ST CATHERINE AVE HYANNIS MA 02601 291 090 MONGER, GLENN F 6 PAULINE C 51 GEORGE ST HYANNIS MA 02601. 291 091 PINHO, EDMUND BARBARA A PINHO 86 ST CATHERINE AVE HYANNIS MA 02601 291 092 LIMA, JOSE JUDITE LIMA 16 ST CATHERINE AVE HYANNIS MA 02601 291 093 DUNCAN, ALICE A 198 BRISTOL AVE HYANNIS MA 02601 291 094 SCHWARTZ* LOUISE 2916 ERIE AVE CINCINNATI . OH 45208 291 095 HARRINGTON, JOAN Z 6 COVEY, JOHN M 174 BRISTOL AVE HYANNIS MA 02601 291 U96 MATHER—PIKE, DARYL C 6 JANICE C 166 BRISTOL AVE HYANNIS MA 02601 291 106 MORSE, RICHARD P JR TR 6 NEWELL, BETSY TR 25 BRAGGS LANE BARNSTABLE MA 02630 291 107 HOWARD, PATRICIA A 119 BRISTOL AVE HYANNIS MA 02601 291 108 VIIRRE, ESTELLE 201 BRISTOL AVE HYANNIS MA 02601 291 110 GRAHAM, THEODORE F & DIMAGGIO, PATRICIA M 56 COUNTY SEAT ST HYANNIS MA 02601 291 118 TRAYWICK, KAY W TRS %LUCAS, ROBERT 9 PLEASANT PARK AVE #2F HYANNIS MA 02601 291 158 FREDERICKSON, PAUL D6 KAREN 44 COUNTY SEAT STREET HYANNIS MA 02601 291 159 HARRIS, DOROTHY A 32COUNTY SEAT RD HYANNIS MA 02601 291 160 VENTURA, PAULA & DESCHAMPS, P 4C KEMPRECOS TR P 0 BOX 1067 DENNIS MA 02638 291 161 VIIRRE, ESTELLE 201 BRISTOL AVE HYANNIS MA 02601 291 166 BRAILEY, GERALD L CAROL M BRAILEY A 47 COUNTY SEAT ST HYANNIS MA 02601 291 167 KREITON, JUDITH B C/O JUDITH B BROOKS 35 COUNTY SEAT ST HYANNIS MA 02601 291 168 HOGAN, PHYLLIS M 25 COUNTYSEAT ST HYANNIS MA 02601 291 169 WOODBURY, DAVID E MARGUERITE A WOODBURY 15 COUNTY SEAT ST HYANNIS MA 02601 01 291 170 CLOUGH, DANA W CYNTHIA M CLOUGH 5 COUNTY SEAT ST HYANNIS MA 026 291 171 OSMOND, JOHN D III 6 ELLYN COYLE OSMOND 185 OYSTER WAY EAST OSTERVILLE MA 02655 291 172 BLEICHER, PHILLIP 98 SKATING RINK RD HYANNIS MA 02601 291 173 TAYLOR, ALIK 6 HOPE 86 SKATING RINK RD HYANNIS MA 02601 291 174 MANGAHAS, RESURRECCION R 6 PONCH 76 SKATING RINK RD HY HYANNIS MA 02601 291 232 FLAHERTY, JOHN E 191 BRISTOL AVE HYANNIS MA 02601 291 264 STEPANIANS, LOOSIA STEPAN KOCHARIAN, TORGOM 2130 MASS AVE, APT 7A CAMBRIDGE MA 02140 RefNo mappor ownerl owner2 addr city state zip 291 265 VOSGANIAN, VAHIK b VOSGANIAN, A 6 R 6 S 64 WILBUR ST WALTHAM MA 02164 291 26ti WALLACE, WILLIAM J 254 N.W. FERRIS DR PORT ST LUCIE FL 34983 291 267 CHRISTENSEN, CRAIG E 6 BACHER-CHRISTENSEN,JENNIFER 220 MEGAN ROAD HYANNIS MA 026Q1 291 268 LEFORT, LAWRENCE & LUCILLE 228 MEGAN ROAD HYANNIS MA 02601 291 269 NATHAN, JUDITH L 236 MEGAN RD HYANNIS MA 02601 291 270 BROWN, 'CHARLES S i.JANIE H 244 MEGAN RD HYANNIS MA 02601 291 .271 VERISSIMO, JOSE M VERISSIMO, LUDOVINA M 252 MEGAN RD HYANNIS MA 02601 291 272 MAXWELL, THERESA R 260 MEGAN RD HYANNIS MA 02601 291 273 BARONE, THOMAS F S MARY A 266 MEGAN RD HYANNIS MA 02601 Count= 42 2 z _ The Commonwealth of Massachusetts Department of Industrial Accidents , Office ollnsestionfaffs ^; 600 Washington Street 0 Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit Q name: location: city phone# ❑ I am a homeowner performing all work myself. : i ❑ I am a sole ro rietor and have no one workin in any ca acity ❑ I am an employer providing workers' compensation for my employees working on this job. compmnv name:. address. _.._ city phone#. insurance co. policv#- / ❑ I am a sole proprietor,general contractor7 or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: com anvname: address: 75 Sharpe St. W G. RI U2817 city. phone#. � �- insurmnceco. ' olicv# � �� +�`+�•'�?' companv name. address: city phone#. in�mm�ce co:. olicv# Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of 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 tine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage vetillcation. I do hereby certify under th d pe er' at the information provided above is true and correct. Signature \ Date Print name �/�l Jie 1 Phone# 40/ 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 ❑check if inunediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/93 PJA) 4 Information and Instructions + Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. 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 ir.the event the Office of Investigations has to cnntact 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 returned 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 Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents efflce of lovesdusuoos 600 Washington Street Boston;Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 �TME rq� The Town of Barnstable a�uvsr�►ar.�. Department of Health Safety and Environmental Services ram " Building Division 367 Main Street,Hyannis MA 02601 ` Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,.renovation,repair,modenuzation,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. Type of Work:t /�E ' // 7'-) v� Estimated Cost Address of Work S Owner's Name:i Date of Application:,t 4 /' I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied 00wner pulling own permit. Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav REG HOME IMPROVEMENT CONTRACTORS andlStandarOds Board of Building Regulations One Ashburton Place - Room 1301 Boston , Massachusetts 02108 HOME IMPROVEMENT CONTRACTOR j . , Registration 116796 Expiration 07/20/00 I 7Ae �. I Type - PRIVATE CORPORATION (: HOME IMPROVEMENT CONTRACTOR I' Registration 116796 i T PRIVA_TE. ype CORPORATION GREENWICH, INSULATION_INC I&' Expiration; ,O7/20/00 r ROBERT GRUTTADAURIA I "" 75. SHARPE ST I. fiREENWICH INSULATION INC WEST GREENWICH.-RI 02817 I ROBERT GRUTTADAURIA '`.: I G�HARPE ST ADMiNisTHnTOR WEST GREENWICH RI 02817 I Engineering Dept. (3rd floor) Map Parcel 1 N$ , I-J,° 'Permit# 1-7 �J House# p�® � 1=J� Date Issued I 1 Fee Conservation Office(4th floor - Planning D oor/School Admin. Bldg.) MRNsrABIX TOWN OF BARNSTABLE Building Permit Application Project Street Address 16( ��t SmZ Al V Village N,%J tS Owner 4y N Address Telephone gg 1 Permit Request ��v-- c f F L ✓b� r q ?cr el Q f c� 0 YK As First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 2000 , ' Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family fa' 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 �1 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 WL'-14 Builder Information Name Jt 0K,L"� V 01- Telephone Number � I Address (C-> C-Yr I ( 4-J( !`uk-4yel-0, t License# a 5'2 6S-2- Home Improvement Contractor# t f 6 I Worker's Compensation# /JO-Xi e NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT) SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRI SULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 6 BUILDING PE D NIED FOR THE FOLLOWING REASON(S) i I � e s � r w . The Commonwealth of 4fassachusetts A-".. _-' Department of Industrial Accidents • ' ` - ofice0111yesUgat/ons _' 600 11 aAhtr tun Street Boston, Alas. 02111 Workers' Compensation Insurance Affidavit Applicant information• Please PR1NT legjy r "` — name ` loc•ition CHN, h/ 6 Phone J>m a homeowner performing all work myself. I am a sole proprietor and have no one work-in-, in any capacity . ...t>,.:.""1O"•Y..+..--..r •af--x.- RSs-+.ranw»x-.m+,ev.?X.L".!,+..e!r;Rw�?-. * - .77,77 wry.,.+r= ww!.: -. ..•+f'A`.,x "'*,n' 'r'�!�+ie'=.....-:.,•.,�. _.�. _ I am an employer providing workers' compensation for my employees working on this job. coniannv name: address: city 11hone#• insurance co. ' polio•# 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city- phone#• insurance co. poliev# ,- - .. ._... �KAC:: ':�yoti�^r"rs...'•'T'C.Y;"^f�T'w"% .:T.•'!:..tr•-rf•'a�.�^, �'7�'f:►'� ►T.:� `„n.; :f-l•^r..•'•_<�!:!nai�i�i'.�":'^•"z. _...__.......�.- - ._- ..:J.ca• - ...�. --- 't_'-� - _ .,jt •y ".,'�..- .'••-•��',r��•��irr:.::�:r::�.._.a.rr:xas company name' address: city: phone#• insurance co policy# ._ _._—V -.-.,.,..r p... Attach additional sheet tf necessa ..::. "+:�: ; r�.tr r:.,,.c,r;-•- ;.,.., .�..•%' '��±'��•~.•.'" ^ '.. 3WUW-µ-'" Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 andior une •cars'imprisonment as well iv' p Itics in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement may be v r cd t the Wee of Im•cstigations of the D1A for coverage verification. I do hereby ► ruiner a pa at d penalties of perjun that the information prorided above is true anL(C ct. Signature Date � G Print name Z�=;Voz •mil - W L Phone# 40 7 xo(� ( <1 3 {' Y.fiLY �•� s�otricial use only do not write in this area to be completed by city or town official city or town: permit/license# riBuilding Department Licensing Board check if immediate response is required �Sdectmen's Office C3I-lcalth Department contact person: phone#• rJOthcr At: Ire"sed 3l9;P1A1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers* compensation for their employees. As quoted from the "law-. an emplaree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An einplt rer is defined as an individual, partnership, association, corporation or other legal entity, or ally two or more c the foregoing enI- 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 dwellino house of another who employs persons to do maintenance , construction or repair work on such dwelling hous: or on tite arounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL charter 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 Nvho 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 hay 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 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,ro-wns 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 returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of lnyestieations 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. . ►^-au.v.-.....-_....,........_�...—r.-:-v.-• ,.--..-..�.•.-...•cn...•.-..v.. a-ems.!,.._ ...--...+r..; _ _ The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 I �WE. i The Town of Barnstable Department of Health Safety and Environmental Services 9. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only • Permit no. - Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: �2,e Est.Cost 2C)0_O , a e) n Address of Work:— ��t `> (�Y 4 NNE S Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY :aVt apply for a permit age of a owner. GW7G ( 9- Contractor Name Registration No. OR Date Owner's Name HOME IMPROVEMENT CONTRACTOR Registration 117618 Type - 'INDIVIDUAL Expiration. 10/26/96 JEFFREY D WEAVER �J,EFfREY D. WEAVER �-'fy"X CYRIL AVE s.. ADMINISTRATOR PEMBROKE MA 02359