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HomeMy WebLinkAbout0104 CHESTNUT STREET �� CheS-�nu� �+re��' j. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application#-2!61 Health Division Date Issued I Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village Mvc.,.nn iS Owner Air. r6ed DrAI r,nr:%.L L- Address Soule-e_ Telephone Sod -9a`7 -S'S U l Permit Request Ann+ S,-6 f�D rGk �� 7 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 7 00-00 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 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 Number 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 Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing 0 new size_ f :2 CD Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:- _ =" D C> Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ `Commercial ❑Yes ❑ No If yes, site plan review# �' = Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name In"ao-ed Telephone Number K Da "D,1-7 S'50 / j S ! Address 10 � �� tJJ' .� License # �A cVAY►S , al, (910 1 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE / DATE "Y =' 25--J1 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. E ` ADDRESS VILLAGE OWNER 7t `€ DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL v GAS: ROUGH FINAL z FINAL BUILDING DATE CLOSED OUT i ASSOCIATION PLAN NO. f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �Name (Business/Organization/Individual): 'Address: g-� City/State/Zip: . 01 Phone #: 0 3 7- 5- ®_7 -Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and_I employees(full and/or part-time). * have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet.- 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working forme in any capacity. employees and have workers. 9. 0 Building addition [No workers' comp. insurance comp. insurances. required.] 5. ❑ We are a corporation and its, 10.❑ Electrical repairs or additions 3.>d I am a homeowner doing all`work officers have.exercised their_H' 11 EJ Plumbing repairs or additions myself. [No workers'•comp., right of exemption per MGL r 12.0 Roof repairs insurance required,],t c. 152, §1(4), and'we have no. 13 ,� �� employees. [No workers .® Other l'®^ comp. insurance required.] 4. *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.. xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number; 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Policy#or Self-ins. Lic. #: "Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensatian policy declaration page(sh owing ahe`policy number andexpiration date). Failure to secure Coverage as required under Section 25A of MGLc. 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 again t the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage ye.-ification. I do hereby certify and r the.painspandpenalfies of perjury that the information provided above is true and correct. x Sigriature: Date: Phone#:. ® Official use only. Do not write in this area, to be completert hy'city or town official City or Town R 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#:_ . F , Information and Instructions. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,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, §25C(6) 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,MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other,than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit 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. Self-insured 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 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 pen-nit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(iftiecessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A.copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each 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 would like to thank you in advance 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;.9.617-727-4900 ext 406.or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia r t t Town of BarnstAbrIe Regulatory Services anxrtsrasLe 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE:. Y—.1 J 'rD�I p JOB LOCATION: numbee]r A�^t street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS:S6YV1,Q,' city/town 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 constructs more than one home in a two-year period shall not be considered a homeowner. 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 with 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 minimum inspection pro ures and requirements and that he/she will comply witlr•said procedures and require men Signature of meowner 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. HOMEOWNER'S EXEMPTION The Code states that: "Any 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 s; work,that such Homeowner shall act as supervisor." ` Many homeowners who use this exemption are unaware that they are assuming the responsibilities ofa supervisor(see 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 he/she understands the responsibilities of a.Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt i r a r pF THE r aaaxsraste, 9� hUs& Town of Barnstable prED MA'S�` Regulatory Services Thomas F. Geiler,Director. Building Division Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 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 ff Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary fntemet Files\Content.011tlODk\DDV87AAZ\EXPRESS.doC Revised 072110 oeck Slot v"tw �� dac ��i '�' GIR Sw►�a (��� ice + wnrtR 2r+uc/� w 11, io cepollz''l- Deep Cptp ��1�! l " STwwuf Luc' 14 " 5 + Pb% ax g Cara �/ '/� x (� �° c.oVr eve"® @uf.rZy 3c�i5'f - t W Qr��mAT Ll Spy► Dtvl1 a o1 Cot)r)eGf'o?2.- �` 'Pool, Stj�l�, even./ Soijr A Qr S►rn ri+.v T Sr+��►ps� 8"Salvo jV e &1&,, (o2r1Jt Q tt3 3/g TC0)tr FROe_q uitow Moir I Rim -Toirr ?Fair, Rob" pr &JW)M. spr axw Pr ror &M,4 at a To i ry t e� ®e V-lF Si+",;wj 7 srnip *0 m obi rr pr L'1 X v Pori- 6 Ow l� � C� A)0 ( \� ucax>t�: 0 e I ma v loeatioYt ofproperty: fNarlvifs Wt 35 130).051 Lod' lot 433 o OJT 2 Story N � awel1,v19 104 ° N' 30 (00.03 'S-wie e ref: C 15003 1004 pan'X 250001 DOD5C OOG �OtLe: C �TA of v+s +�` 't+� PAUL SN J here61�CErtt{y'fh(LtSUS mortgage .inspection wa5,0rVpar"-For o T. GROVER ) rdd-o&Associatcs omol W ohal Ci' Mortgage �No 3 It o ate dw ufng shown, hereon, doesnot ,4f�,ix in a special. TEX&f W& h ham-& area witK am oRctive daze of 8 -19-85 art4 qhe locabbri/ oP � the dwelling Ofoes . conform�-to the local eorung 6y-laws in/e*W. cwt the tune oFwt strucrion with, respect:to horisonfrd dime' *siona� Scale: 1" _ 40 sethack t egwrCrnel'ttS or is mnpr,{vm vtblatton, ariforcem-enr' Date:. 5 10-04 dctl.on, under Mass. GouraL laws aw4t r40X•_Seatiory T File No. 04 -122l0 PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a precise determination of the building location and encroachments, if any exist, either way across property lines. This plan, must not be used for' recording purposes or for use in preparing deed descriptions .and must not be used for variance or building plan purposes. This plan must not be used to locate property lines. Verification of building locations, property line dimensions, fences or lot configuration can only be accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. Please note that this is "NOT A BOUNDARY SURVEY" and is "FOR MORTGAGE `PURPOSES ONLY". W COLONIAL LAND SURVEYING COMPANY, INC. U t Y 269 Hanover Street Hanover, Mass. 02339 - Phone: 781-826-7186 Fax:781-826=4823• , F gineering Dept.(3rd-floor) Map �� af Parcel -� Permit# µ House# /d '`0 ' Date Issued �- d(2:1 (Q� Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) �'!K� Z7 �/Fee Conservation Office(4th floor)(8:30- 9:30/ 1:00=2:00) SYSTEM BE Planning Dept. (1st floor/School Admin. Bldg.) NSTALLED WANCE Definitive Plan Approved by Planning Board 19 "' wI �ilViRONNFI Aar., �: E•AND 9. TOWN OFiBARNSTABLE. # Building Permit Application Project Street Address /O ev Village Owner s 14' Address /e!�/ - - 1 Telephone 776- Permit Request , 3 �-> ell ,First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ OCR© Zoning District I 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, 34o On Old King's Highway ❑Yes 2' o Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) F 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 p 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 ,/Ajy� ///2 Telephone Number s,4/Z Address/ c..&7y1-,j License# 624"!743 2- Home Improvement Contractor# /OD i VO . Worker's Compensation#,0AW13f32 2,6 2 G 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 HE FOL ING REASON(S) r FOR OFFICIAL USE ONLY PERMIT NO. '36 DATE ISSUED '>, MAP/PARCEL NO. ADDRESS '� VILLAGE 1 OWNERilt DATE OF INSPECTION: f r FOUNDATION FRAME INSULATION- FIREPLACE . ► ELECTRICAL: ► ROUGH FINAL PLUMBING: ROUGH ° FINAL GAS: `` ,:ROUGH FINAL s ; FINAL BUILDING -i �. t Ij DATE CLOSED OUT qq ASSOCIATION PLAN NO. ♦ s THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M A�C(, I DATA 'i�-♦ ! r•._2_ �� �•C-, •.• _-►�t._♦c �_ . � �����t+�� �'._��_y`-cam' • , � �. .� .01 r -� c� E•,=j c=ram F_S-��tcts ��.� cr I Z_icr, . :-F . - •. T� F �' _ �--;:�'�.: ICE:� • C77e DEP�Ril1EkT OF PUBLIC SAFETY COHSTP.UCU09 SUPE_VISOR LICElm '. � Aunber: Expires: Restricted To: 11 THOAAS I CAPIZZI IR 281 PERCIVAL OR LE . . . _ A STAB,,, M„ I,Eofi The Commonwealth of Massachusetts w Department of Industrial Accidents 2. Offlca a11fftsff2tf*Ars 600 Washiab on Street Boston, tYfass 02111 Workers' Compe:uation Tnsut•aace Affidavit nIt 7 nIr- Ic�c t+nr ell — / //7 OL G l am a hotsteowner performing all work myself. A am a sole proprietor = have no no one worting in any capac;t: I am an e np10�'er pr0�i�rnQ worker CoR;re::Sc;on for(Zip'e!^Olo�'e_s work;n� On tI;IS jCO. ninanv name- addr^s - In Ur^RCS co e'J ne!(circle 1 an" RdY� l :h 2 sole :r7Cr;etCr. getler3l cbntr3C:Cr.ar hoc; w circ a orre the �ol[o��in� «or��.: :em-ecsa:icn �oiice_: r. 1rt� rt�me: nddrTss- h rte s- inSUrRrtC^ co. Orrt 1mv name' +<t' city- • tU csz n p aadJor Failure to secure co.em;e as required under Scz:aoo ZsA of%GL M=a Iced to the impact at crcrosasl sides o=ant as I uderst;sd chst: one reirs'imprisaarsent as xeil is a-nl penalties in the fora of a STOP WORK ORDER and a titre of SI00-oG t ds7 t copy of this statetrteat msY be rorwirded to the offer of iaresti�doos of the DU for cTrers;e veriiictioa. I do hereby crrif andier 11r,--&FatAS and Fen a of perfard that the inforraadam pravfdrd abaw is=c and carr" ._ Sigrtatura Print name �i"rfrfi�l_� A- ��l 1?ltoce 01rci=1 use oaiv do not w rite in this are=to be completed by city or tnwn official permittt'icrase ft rS Bcildia;Departateat city or town- _ ai�erssin;Board • a5e1ectae2'3 Dtnee Q check if immediate response is required --- - ._... afital�Departtaeat phone#: caetsct person- . _.. __ .. ... ................... .... . ........... . . ..................... A CORD `X" 04/09/98 ........... ............... ........... .... ............. ............ ....... X .. ........... ....... ............ PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NORCROSS & LEIGHTON INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR HTTP: //WWW.NLINS.COM ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 437 STATION AVE COMPANIES AFFORDING COVERAGE S YARMOUTH MA 02664 COMPANY A MARYLAND INS GROUP INSURED COMPANY CAPIZZI HOME IMPROVEMENT INC B THE HARTFORD COMPANY 1645 NEWTOWN RD C COTUIT MA 02635 COMPANY . ...................... D ....... .................... ................................................ ....... .. . ....................... ...... ... ................................................... ....... ............... ...... ............................................... ................. ......... ........... ............................... .............. ................... . .................... ............. — .1. :- ' . ' . : X.............. . ............. THIS Is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTIR DATE(MM/DDNY) DATE(MMIDDfYY) LIMITS k GENERAL LIABILITY RGP28192822 04—/01/98 4/01/99 GENERAL AGGREGATE s2, 000, 000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG s2, 000, 000 CLAIMS MADE OCCUR PERSONAL&ADV INJURY $1, 000, 000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $1, 000, 000 FIRE DAMAGE(Any one fire) $ 50, 000 MED EXP(Any one person) $ 10, 000 B AUTOMOBILE uAmn 08MCP399948 04/01/98 4/01/99 ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $1, 000, 000 —HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $1, 000, 000 RI PROPERTY DAMAGE $ 500, 000 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ......-........ ................ ........... ANY AUTO .......... ............. OTHER THAN AUTO ONLY: EACH ACCIDENT S AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ ............... ...... .......... B WORKERS COMPENSATION AND 08WBBZ2826 04/01/98 4/01/9-9 —X—FTw—oCg'y—STjAm—TTuj OETRH. ......... EMPLOYERS'LIABILITY EL EACH ACCIDENT $ 100, 000 THE PROPRIETOR/ INCL I EL DISEASE-POLICY LIMIT Is 500, 000 PARTNERS/EXECUTIVE — OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE 100, 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVENCLE—"PEC[a ITEMS FOR VARIOUS CONTRACTED JOBS ....... ....... .................... ....................... .......................... ...... ..........Xm, K...... ... ........... ....... ......... ........... ..... . ........................ .. .. ................. ... ................. ........... .......... ....... ... ... ...... .. ................. .................. ... ... .............. ..................................................... ................ ..................... SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED To THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHOREMD REPRESENTATIVE Michelle Connors MM C ACC ................ ........................................................... ................................ ............ ..... ................... ..... .... ............. .......... ..... ................. ..95. '.11 °F tNE tp� The Town of Barnstable • swxxsrnBU& • 9� MAS& �m� Department of Health Safety and Environmental Services iOlEc►9't' 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: 11Aly� k_/J , awl Est.Cost �d Address of Work: Owner's Name Date of Permit Application: 1 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 I hereby apply for a permit as the agent of the owner: 22 le67LfC) Date Con ractor Name V Registration No. OR Date Owner's Name