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Home My WebLink About0032 FIFTH AVENUE (HYANNIS) �� 1 I 1 1 i f Application numbeJ .. �..1... ... r v� Fee......................................... ..................... IJ�...v ....... ................... ... Y 3 0 2019 '� Building Inspectors Initials...(.el , .................. .... 8AHIV6 t1} BLE Date Issued.:.....^3...1.. .l...l.............................. Map/Parcel.... �`�..� ............................. TOWN OF BARNST-ABLE- -- - -- -- EXPEDITED PERMIT APPLICATION: ROOF/SID1NG/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 3 L—� Q. W �� .n\. C,,` NUMBER STREET VMLAGE Owner's Name: Phone Number Email Address: _�� 1<^, S c.� 1� L�g Cell Phone Number 61 J--g59-4gL 5 Project cost$ l.�d(' Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize &/®Jc to make applicatio building p 1 ccordance with 780 CMR Owner Signatur : Date: 30 , TYPE OF WORK Siding Windows (no header change)# (7 El Insulation/Weatherization Doors (no header change)#_�_ Commercial Doors require an inspector's review Roof(not applying more than 1 laye/F of shing to L—vCC rnoin Is Construction Debris will be g !'cam CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# / �j s (attach copy) jA Construction Supervisor's License# (attach copy) Email of Contractor (' <4 Phone number ALL PROPERTIES THAT HAVE RES VER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. .r APPLICATION NUMBER.......................................................�... *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No______, if yes, a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date PLICANT'S SIGNATURE Signature Date 1\� _� f 1 V 1j/ All permit applications are su ect to a building official's approval prior to issuance. "a'�.� Town of---------Barnstable Building :Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept e =Posted Until Final Inspection Ha---------s Been Made. �errillt +° Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final In---------------spection has been made. Permit --- Permit No. B-19-1807 Applicant Name: DANIELJOYCE Approvals Date Issued: 05/31/2019 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 11/30/2019 Foundation: Location: 32 FIFTH AVENUE(HYANNIS), HYANNIS Map/Lot: 246-189 Zoning District: RB Sheathing: Owner on Record: TELLIER, EDWARD A&DOMOS,CANDACE Contractor Name:' Daniel J Joyce,Jr Framing: 1 Address: 93 BIRTH HILL RD Contractor License: CS402512 2 BELMONT, MA 02178 Est. Project Cost: $30,000.00 Chimney : Description: Siding Windows(17), Doors(3) Roof Permit Fee: $153.00 Insulation: Project Review Req: Fee Paid: $ 153.00 Date: 5/31/2019 Final: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. - Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on thispermit. Minimum of Five Call Inspections Required for All Construction Work:' Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: The Commonwealth of Massachusetts Department of Industrial Accidents USF Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information rr p Please Print Legibly Name(Busines Or ganization/Individual): Address: City/State/Zip: W- 4(YrAAv Jt_A Phone Phone#: 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 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors , 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. employees and have workers' Y P t5'• $ 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No 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. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I 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'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 cover ge verification. I do hereby cert' un r the pains and pen 'es of per' that the information provided above is true and correct Si ature: - Date: / Phone#: Official use only. Do not write in this area,to be completed by city or town official 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#: 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)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 permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)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.##617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.gov/dia _i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Construcf on-'Supe.rvisor CS-102512 x, Ekpires: 12/13/2020 DANIEL J JOYCE,JR . PO BOX 117 '% r' + WEST HYANNISPORT MA 0267- ,J Commissioner A P��e rlla�rv�reara�aet[�G�o��l/��ut�ac�cfbr,� office of Consumer Affairs&Business Regulation e9 HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration'.: EXDiration Office of Consumer Affairs and Business Regulation 158.158-_:- 12/16/2019 10 Park Plaza-Suite 5170 DANIEL JOYCE Boston,MA 02116 DANIEL JOYCE 14 DOLPHIN LN. NO Va�i W o signatur` HYANNIS,MA 02601 Undersecretary Anderson, Robin From: Mckechnie, Robert Sent: Thursday, November 08, 2018 4:01 PM To: Anderson, Robin Subject: RFS: 32 Fifth Avenue, Hyannis, Site visit I visited the subject property at about 12:40 PM today, 11/08/18. The following was observed: 1.) A motor home was in the front yard on the right side. No utilities were connected. No one was living in it. It had a license plate. 2.) Three motor vehicles were in the driveway on site: A registered GMC pickup truck, a registered late model Chevrolet (Impala?)gray, and an unregistered VW Golf(?). 3.) A small construction trailer was at the end of the driveway. 4.) Several 4 wheel ATV's were also on the property. I knocked on the door and engaged a young woman in conversation. I told her that my visit was a result from a complaint to our department about the RV and the vehicles on the property. After 5 or so minutes, her uncle (presumably he rents the property)came to the door and I explained everything again to him. I asked them if anyone was or had lived in the motor home and their response was No. They told me that 5 people lived in the house. The young woman also said that they were moving soon. Robert McKechnie Local Inspector Building Department Town of Barnstable 200 Main Street Hyannis, MA 02601 508-862-4033 1 Date: Nov. 7, 2018 To: Building File RE: Unsafe Electrical Work Address: 32 Fifth Ave, Hyannis Originator: Bob Dryer(703-768-4580) Complaint: Rental Property with Ocuppied Camper and multiple unreg vechicles Enforcement Process Steps ® 1. Initiate local investigation: YES 2. Document/enter into system Yes 13 3. Contact 4. Property Owner Edward Tellier, 93 Birth Hill Rd, Belmont, Ma 5. Seek access to subject property 6. Seek administrative warrant (if necessary) NA 7. Notify state authorities of findings NA ® 8. Document conclusion OPEN ® 9. Referred Bob McK/Health/BPD Property—246-189 Property is developed with a 1 story ranch (1950) containing 4 bedrooms and 2 baths on 0.18 acres in the RB zoning district. 11/07/2018 Property is not a registered rental. Property reported to have multiple unreg vehicles on one side of property and a camper on the opposite side. Caller believes that the camper maybe occupied and maybe registered to another address but has been there since June Town of Barnstable Building Department ComplainVInquiry Report Date: _//7/ — J Rec'd by: Assessor's No.: Complaint Name: �� Location Address: M/P Originator Naine: Street: Village: State: Zip: Telephonc: D/E Complaint a . Description: Inquiry 0 Description: For Office Use Only Inspector's Inspector. Action/Comments Follow up Action o�' Additional Info. Attached apy Dismbudon: «-71ite-Department File T'Pilo w-Inspector To Date Time" WHILE YOU /WERE OUT of /J Phone Area Code Numb Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU URGENT RETURNED YOUR CALL Message Operator ^'1 AMPAD 23-021-200 SETS �JL] EFFICIENCY® 23-421 -40oSETS CARBONLESS Low . . I I TOWN OF BARNSTABLFE BUILDING PERMIT. PARCEL `ID 245 189 GEOBASE ID 15113 ADDRESS 32 FIFTH AVENUE PHONE W. Hyannisport ZIP - LOT 411 & 4 BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 1.5184 DESCRIPTION RESHINGLE LEAKING ROOF PERMIT TYPE B: OOF TITLE BUILDING PERMIT ROOFING CONTRACTORS 'WASHBURN TIMOTHY A. Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: BOND $.Q(? �T CONSTRUCTION COSTS $950-.00 750 ROOFING AND SIDING 1 PRIVATE P c* '>�NSTABI.E. f MASS. i639. OWNER TEILLIER, EDWARD A Ep ADDRESS 93 BIRCH HILL RD BUILDI1 DIVIS `ONE BELMONT MA BY DATE ISSUED 05/16/'1996 EXPIRATION-.DATE .. ' THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE.SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD • IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 . 2 3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT 2 BOARD OF HEALTH OTHER: SITE PLAN REVIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION.. I I BUILDING PERMIT Parcel ermit# , 14 Date Issued a�r I b Fee.'V-f ngineering Dept. (3rd floor) House# 114E Tq;_ BARNSPABLE. MARK 19 rED MP'�A TOWN OF.BARNSTABLE Build*n Permit Application Proje Address Village ' Owner zr Address Telephone Permit Request First Floor square feet Second Floor square feet a-d Estimated Project Cost $ �— Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial / Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure J�� Basement Type: Finished Historic House lid Unfinished Old King's Highway /J d Number of Baths o2 No.of Bedrooms Total Room Count(not ' c uding baths) `� First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None L/ Sheds Other Builder Information Names uJvyU Telephone Number /,��p ,3 7 Address a2So2 License# CS 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 CO TRU DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 14, SIGNATURE DATE_ �� h BUILDING PERMIT DR4ED FOR THE FOLLOWING REASON(S) . FOR OFFICIAL USE ONLY i( 4 P w MI= N D' TE S P/ AR L NO D IvSS VILLAGE OWN I{ DATE F I SPECTION: FOUN ATION ' FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r � " PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING Ap, I I� �C� - ' 6 } BATE CLOSED OUT v v Lob i ASSOCIATION PLAN NO. i A. w The Conunonwealtk of Massacbusen 1 ---�� Department of Industrial Accidents z ` _ ! OfBceollo�est/galloos �� #' _i•;�' 60011'ashiigmon Street Boston.Alas. 02111 Workers' Compensation Insurance.AlMdavit rol 1 am a�homeo�tnerpea orming all work myself. ,&Iam a sole proprietor and have no one working in any capacity 0 1 am an emplover providing workers' compensation for my employees working on this job. compnnv name, -- -- --- address• - •• nhone#• . ipcur�nce ce ILS)'# I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comnam•name• address• catx• phone#• incurnnce co policy# bTA•Ytr.4:.••.•71��!f!!^"7==�'•Ft!7/F'•1C � - _ S!7r�� 7M•��5!!-'_' _ �" _ — e�pam•name• • address- city: #: - incurtnce co policy# _ Attach additional-sheet if rieeasary�-•� :- w�a �+:��^� sr a ;_�::.;:•,+fi, rs�.. u`�i�.".Srim Failure to secure coverage as required under section 25A of 51GL 152 can lead to the imposition of criminal penalties of a fine up to S1S00.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Once of Investigations of the D1A for coverage verification. Z11d here .r cctr/fj•unr/c /ke pains d penal o rjurp that the injonnadonptm7ded above is true and omew, ureV ate �" name. 4&/ �ne# -r official use only do not write in this area to be completed by city or town official city or town: permittlicense 0 r1guilding Depariinent �Liceasing Baard ` check if immediate response is required C3Seleetmea's Office C31lealth Department contact person• phone#; Mother Irevised R95 P)A) 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 emploree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An empletyer is defined as an individual, partnership, association.corporation or other ;cgal entity, or anv two or more of the fore=oin enga�cd in a joint enterprise, and including the legal representatives of a deceased emplover, 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. ate or local licensing agency shall withhold the issuance or MGL chapter 1'52 section 25 also states that every st 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 in 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 havf been presented to the contracting authority. .�,w*.�•.�.p.n�.��ylw. .w. .e., r.r .1 i Via ..,:•' '} :w g •..�'14��y-^.� S::YA►:^ f,,.?.�;•.:. - . •-�-�_ �" _,... . ,..:..:. .....:. .. L 1`• .-. -• :ram' .';....L.+:•;s,L y�; . 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. ..,,.. +wrierte..s+•!.•ar.rn.....,.a.•�•ew�+��!�►;.:.. _ _ '.:...•.b•..«W1, �+w-_.r:..''',r2�•.C£`J`?:: R+s�`re';•�`:.. iY•. .-. .. 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 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. 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 `ive us a call. �+,a..1...�.-.-.r-.'•i-.ems.--m.nS.ac... _ — .s1:Ye _ «' "' The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents K Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 ext. 406, 409 or 375 f F , The Town of Barnstable '6BuildingDepartment of Health Safety and Environmental Services Division 367 Main Street,Hyannis MA 02601 Ralph Crosser Offue: 508 790-6227 Building Commission F= 508-775-3344 For office use only Permit no. Date AFFIDAVIT HOME moROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the-reconstruction,alterations,renovation,repair,modernization,conversion, improvement,.mmonal, demolition. or construction of an addition to nay pre- ad'acent at least one but not more than four dwelling units or to structureswhichbuilding containing other on with certain ens,along to such residence or building be done by registered�nua�ss.with �!a mquirementS- Type of Work: Est'Cost Address of Work: �-C,� ' ✓1 Owner.Name: (�� Date of Permit Application: I hereby certify that: Registration is not required for the following rrason(s): _Work excluded by law ob under S1.000 Building not owner-occupied Owner pulling own pan# Notice is hereby given that: CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEALING Wi 7 UNREGI3'T'EftED FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT 4H HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the m1ler. � i Date Contractor a Registration No. OR ' n.,,o Owner's name . � lee i�omU.noozurea� a��ar,�ivavtld , Restricted To: 00 ;e7 currant .q_ DEPARTMENT OF PUBLIC SAFETY �, _1#9P,.;��n� CONSTRUCTION;SUPERVISOR LICENSE 00 - None Nu�ber Expires: 16 - 1 8 2 Emily Hoes Restricted To:4.00 TIMOTHY A MASHBURN PO BOX 252 CENTERVILLE, HA 02632