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`r 1'1/02/94 15,48 '0508 790 1414 BRYDEN SULLIVAN �001
bryden-Mullivan insurance agency, inc.
FAX COVER SHEET
bG =j
DATE
TO:
COMPANY: _
1
FAX NUMBER: " RE:
# PAGES, INCLUDING COVER:
-
FROM: KAREN L. SCHMIDT
COMPANY: BRYDEN AND SULLIVAN
FAX NUMBER: 508-790-1414
MESSAGE:
88 Falmouth Rd.• Hyannis,MA 02501 ,1508)77&0476•Fax(508)780-1414
\ Route 6A-P.O.Box 267•North Truro,MA 02652•(508)487-3510•Fax(508)487.2040
485'Route 134•P.O.Box 217•Harney's Plaza•So.Dennis,MA 02660•(508)394-2266•Fax(508)394-2267
landmark of service ()7)
C0132i770illUC'r.Lm Oil aJJ(.7C1714,id�h
-y I� �.CJ('./JC2/'1111GIl fq 01��J
600 UVailzingfon Street
James J.Campbell Aosfon, /i~/amacLelb 02f.f f
Commissioner
Workers' Compensation Insurance Affidavit
1, LIAelzl F
lol (licensee/permittee)
with a principal place
of business at:
�0 ✓' �
cicyisuaizip)
do hereby certify under the pains and penalties of perjury, that:
() 1 am an employer providing workers' compensation coverage for my employees working on
this job.
Insurance Company Policy Number
( 1-am a sole proprietor and have no one working for me in any capacity.
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers', compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Humber
O I am a homeowner performing all the work myself.
I unders:_nd that a copy of this statement will be forwarded to the OfSce of Investigations of the DIA for coverage verification and that failure to secure
coverage as require under Section 25A of MGL 152 can lead to the imposition of criminal penalties consisting of a fine of up to 51,500.00 and/or one
years. imarisonm t as well as civil enalties in the form of a STOP WORK ORDER and a fine of S 100.00 a day against me.
Si d t is day of f/, 19
i nsee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375
3�8 I6 -7 F
Assessor's Office 1st floor MaD Lot i Permit# 1
Cgpservation Office Oth floor Date Issued
Board of Health 3rd floor
__),h1a4v ,
Engineering Dept. Ord floor House# S��f ✓ - _ � f1� �
Planning Dept. (1st floor/School Admin.Bldg.): ; &UMerANA _
KAM
Definitive Plan ApRLoved by Planning Board 19
(Applications processed 8:30-9:30 a.m.& 1:00-2.00 p.m.)
TOWN OF BARNSTABLE f
Building Permit Application!
Protect Street Address ` eCICl1 S
Village ` f,/ // .,�, Fire District �^'�-�-�
(honer -/4tz (f aml-4 Address lleL e 4 S"
Telephone .3,f
Permit Request:
Zoning District Flood Plain Water Protection
Lot Size Grandfathered
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Existing Information
Dwelling Type: Single Family Two family Multi-family
A e of structure Basement jyM
Historic House t✓ Finished
Old King's Highw77 Unfinished
Number of Baths No.of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
Name t >L f' ® f Telephone number $') -- 3 O fi? 41,E 2 l
Address 8X 72-2— License# C5>'l
Home Improvement Contractor# Z;=>113�
Worker's Compensation # U�(' 00 ®D Q /6 R 7
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
Proiect Cost
Fee
SIGNATURE d C d DATE D 5t
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
BPERM T
I
FOR OFFICE USE ONLY
ADD85 Cedar Street VILLAGE Hyannis
RI9$S _
_ • I
OWNER Herbert Clark ~� i
DATE OF INSPECTION: ;
FOUNDATION
f r
� rt
FRAME
INSULATION
FIREPLACE
f
ELECTRICAL: ROUGH FINAL r
4 .
't !r r .
PLUMBING: ROUGH FINAL r
•
GAS: ROUGH FINAL
FINAL BUILDING:
DATE CLOSED OUT:
ASSOCIATE PLAN NO.
t
f+i�S
i
*Engineering Dept.(3rd floor) Map Parcel Permit#`. O? 02
House# .a Date Issued ,OW `�7
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee A25%
Conservation Office(4th floor)(8:30-9:30/1:00=2:00) s
Planning Dept. (1st floor/School Admin. Bldg.) ��HE
Definitive Plan Approved by ing ar 19 �;
' % BARNSTABLE,
MASS
{BARNSTABLE 'F°�'`' `
i
��B�u-��ding Permit Application
reet Address C.tG1G�/
Village
Owner at ry Address �p Gam✓ 57— G n►t t
•Telephone
Permit RequestM.p���•,
First Floor (e , square feet Second Floor square feet
Construction Type_ - P,Ary►1.e �' 2 �pG(,[ 4uw d
Estimated Project Cost $ rj
Zoning District FIR, Flood Plain Water Protection
Lot Size �-1(j17� s -j� Grandfathered ❑Yes ❑No
welling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)_ 1 �.
Age of Existing Structure '. Historic House ❑Yes NNo 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: E g�,, New Half: Existing New
o.of Bedrooms: Existing New
'a
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) 5¢
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes 4NO If yes, site plan review#
Current Use Proposed Use
11,
7 Builder Information
Name � P '(ate_ Telephone Number ,08 S�, Z�
I It
Address License# Wo
Home Improvement Contractor#
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
t.,e
SIGNATURE DATE //—,,-A�
BUILDING PERMIT DE IED Fd THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY 4
PERMIT NO.
DATE ISSUED_
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER _
DATE OF INSPECTION: .
FOUNDATION
FRAME S f t
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS' ROUGH FINAL . ,
FINAL'BUILDING
DATE CLOSED OUT ,
r
ASSOCIATION PLAN NO.
T/!L' Cl1111111U11 il'cr11t/1 of 3fasruc•Ilusctls
Depurt»Icllt of Iildilslrial Accidents
• • 3 `\• ;:��. � 011ic�al/ayesygatlons '
6110 JVu.v1thz,,,tull Street
Workers' Compensation Insurance Affidavit
i ii :in inf rni inn• __.. 11`1—I, _^• -.,.....�...-._..�._..._-...._.__�__--_ —
-R TNT
Ittc�tinn• � S � ` �
Citt• /���) /' �� nhnnc� �y �� "
[I 1 am a homeowner performin_all work myself.
1 am a sole proprietor and have no one working in any capacity
I am an empiover providing workers' compensation form. employees working on this job.
n
cmm�am• namt•: �` j�
atltirrcc- x. � / ���/ •
gin lN, � nhnnc tt• �V 0 S��f`a�Z
incornnre rn (/ yW nolict t!
I am a sole proprietor. general contractor. or homeownn-er(cI'rcic one) and have hired the contractors listed below ono
the following workers' compensation police::
cnrnP•tnt• n•ttnr•
atfrlrrcc� t
Carl-- nhnne d•
in-mrnnrr rn nnllrr
cnnln:lny n9tnt•7
�f
adtimcc•
grin•• nhnnc 0•
incvrnnre rn noiie�•
Attach additional Sheet if neee33Ary-----4�..,_.._ _..,_•:..Y�....-:L__^....—i_ •.rc,'_• _ •,��.:..._..v..........r._� w"_�.�:a�r� .:w •,i.
FNdure to secure cm-crace its required undo tiectton-.SA of NIGL 153 can lead to the imposition of enmtnal penalties of a line up to Suouxo andiur
unc cars' imprisonment:t. ��ell its ciVii penalties in the form of a STOP 1�'ORK ORDER and a fine of S100.00 a day against me. I understand that a
cope of this statement mat be furtvardcd to the orrice of invcstir:tions of the DIA for coverare t•eriftcation.
1 do itrrcnr i1r urt er the pains attd penalties ojperjun•that the information prodded above it true uttd correct.
Sitnature z Date
Print name f' t,J --Phone#
w - -
ofricini use only do not write in this area to be completed by city or town(IM621
gin•or town: pennitJliecnse t# .7iluiidin_Department
❑Licensing Board L
tt ` chccf: if imtncdiatc response is required ❑
Scicetmen's office l
t. Citicatlh oepartment
contact Person: phone tY: r-tUther
information and Instructions
Massachu.setts General Laws chapter 152 section 25 requires all employers to provide workers ctcinpenstrtion for
employees. As quoted from the "1a��'". an etjrpluret is defined as every person in the service of anccther under any
contract of hire. express or implied. oral or written.
An eynpl( rer is dcfincd as an individual. partnership, association. corporation or other legal entity. or an}' M,C) or
the foregoing cn`g:i_ed in a joint enterprise. and including the legal representatives of a deceased employer. or the
recei%,er or tnistee of an individual . partnership. association-or other legal entity. employing employees. Ho«,e-:er
rn+•ner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
dN%cllin`g, house of another who employs persons to do maintenance ;construction or repair work on such dwellinu
or oil the ;.,_rounds or building appurtenant thereto shall not because of such employment be deemed to be an etnpic
MGi_ chapter 152 section 25 also states that eti•er.• state or local licensing ngency shall withhold the issuance 01-
111•:cl of a license or hermit to operate a business or to construct buildings in the commonwealth Car any
is ant wlio leas not produced acceptable evidence of compliance with tlu in coverage required.
,-�au.:ialall%,. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
periorinz::ce of public work until acceptable evidence of compliance with the insurance requirements of this chactc
pee^ prez--med to the contracting authority.
al�l�iicants
PlCcsc 'ill in the workers compensation affidavit completely, by checking the box that applies to your situation .:n:
suepivinu company nacres. address and phone numbers as all affidavits may be submitted to the Department of
Industrial .Accicicins for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The
:zi%,it should be returned to the city or town-that the application for the permit or license is being requested.
n :he Department of Industrial ,-accidents. Should you have any questions regarding the "law" or if you are requ:-
o ubczin a workers' compensation policy. please call the Department at the number listed below.
City or Tmi-ris
Ple_�e �e sure that the affioa� it is complete and printed legibly. The Department has provided a space at the bottorr.
the ::'-davit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. P'.
be _ : to fill in the permit/license number which will be used as a reference number. The affidavits may be returne:
ae Department by mail :or FAX unless.other arrangements have been made.
The Office of Investigations \vould like to thank you in advance for you cooperation and should you have any quest;
ple2se do not hesitate to _give us a czll.
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 T: (61 i7 727-7749
nhone =. :'6 i'-) 7' - '900 exr. 406. 409 or 7�
°fT"Er°�y TOWN OF BARNSTABLE
i EAHBSTADLE, i
a a BUILDING INSPECTOR
jw'x
APPLICATION FOR PERMIT TO ...... ...............................�:t,%......................
TYPE OF CONSTRUCTION U /,
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permi/t according to the follow(Iinngg' information:
Location .............. .......4:�.K..�..........�.�f.�Z:4 ......... 7... . �, ................................
Proposed Use ........C(.Gl. 1�.......... ^ / :�......... 1. .�??.. .. �..........
........................
Zoning District ..... .......................................Fire District ...........
...........
..... .. ........................
Name of Owner ./1 . fit./..:. -.4��.��. k� P �� .............
.r... ..... ....�!1...............................Address ........................ �-y:........�.. ....................
Name of Builder• t" .alv. .. .........�f��1�5�..............Address ��� � .................................Name of Architect . ......:..c'�c:Ai�l I........................Address ....................................................................................
Number of Rooms ............. � �. A.... .
.. . ...
jj /^�
Exterior ....!U...l.:.......... ......... ..................................Roofing .......0 —1 .4 .............................................
Floors ..............................................................Interior ..... ?. ...........
Heating ..................................................................................Plumbing .........4....................................................................
Fireplace ..................................................................................Approximate Cost .......... .........................................................
Difinitive Plan Approved by Planning Board ________________________________19________. pC 4 %
Diagram of Lot and Building with Dimensions
a
r•�
Y�
x
F
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
C
Name .. ��4
......... ...
.... :.......
... ........ ...........................
i
� ^ .
Culler, R. D. ` ^
. /
�
2
No . 00?�-. Permit for ---..azo�Jr............. ^
addition '
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�
Location ........ .............................. ( .
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\ �Il, I), �zilI��
uvvner ` ' (
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Type of Construction --.. -------.
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Plot ............................ Lot ----------'
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� Permit Granted -..��������.-2D- ......... gA°
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Dateof |n .................................... «
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� Dote Completed -. ------]V=~ '
PERMIT REFUSED �
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