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0122 FIRST AVENUE (HYANNIS)
IPP Fri-F t4llenac- �oF Application number ' V......... - g.. �.� Date Issued.........2/3 01 is................................... RARvsTas Mans o a ► � Building Inspectors Initials........... ......:.................. �� 2 9 � �8 Map/Parcel........ .............©.5.3............................ TO OF A STA LF � 0 b EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORmAnoN Address of Project: /2 L eC�r-S-/ J✓e- !y, NUMBER STREET VILLAGE Owner's Name: 51-sari Phone Number Email Address: Cell Phone Number Project cost$ Z L t — Check one Residential/ Commercial OWNlEWS AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: See Mcd,,� L1 rah- Date: TYPE OF WORK E-1 Siding 0 Windows (no header change)# ED Insulation/Weatherization 12�Doors(no header change)# I Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to W a sj e- a�.rP� G J-e JM o fi , M,A CONTRACTOR'S INFORMATION Contractor's name Any ,/ �w P e l -� US P� Home Improvement Contractors Registration(if applicable)# 11 Z 7 S (attach copy) Construction Supervisor's License#• D 7 L{2 y 7 (attach copy) --�`- Email of Contractor Gl,Skyee f l S—e a r (• C o/, Phone number #o/-7IV- 6 319 ALL PROPERTIES THAT HAVE STRUCTURES OVER TS YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. 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. 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 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 nay 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 /APPLICANT'S SIGNATURE Signature Date All permit applicatiolffare subject to a building official's approval prior to issuance. xz SPECIAL SERVICES CUSTOMER INVOICE Page 1 of 14 NO. H2612-85676 ' Store 2612 HYANNIS Phone: (508)778-8948 65 INDEPENDENCE DRIVE Salesperson: RHP4LE HYANNIS, MA 02601 Reviewer: VXG1123 Namo Phone 1 BARRON SUSAN (508) 364-6997 REPRINT Add:o:s 122 FIRST AVE Phonon • Company Name city W HYANNISPORT JobDo'c"p`on patio door install .2018-08-17 13:22 Sate MA Zip 02672 couna BARNSTABLE CUSTOMER PICKUP #1 MERCHANDISE AND SERVICE SUMMARY swe odrtocustomes9httolimitthequantitiesofinerchandise REF# W14 SKU # 0000-515-664 Customer Pickup/Will Cali S.O. MERCHANDISE TO BE PICKED UP: S/OJELD-WEN PREMIUM REF# S12 ESTIMATED ARRIVAL DATE: 08/29/2018 27801 WOOD (690 REF# SKU OTY UM DESCRIPTION PI TAXI 96 EXTENSION S1212 0000-581-884 1.00 EA NA/59.5 X 79.5 AP FRENCH TWO PANEL/59.5 X 79.5 AP FRENCH TWO A $1,357.49 $1,357.49 PANEL#1 S1213 0000-581-884 1.00 EA NA/(CONTINUED)/59.5 X 79.5 AP FRENCH TWO PANEL(CONTINUED) N $0.00 $0.00 PREP=Z,STYLE=00,TYPE=1- ,WTSENT=CW,XJBD=I,ROOMLOCATION_STDPK=NONE,RE PK =NO,SPECIFICINFORMATION=,SKU=581884,MVNDR_N - WENPREMIUMWOOD,MVNDR_NBR=60058104,CUS VICE=1- 800 246-9131OPTION2 MANUF SCHEDULED PICKUP DATE: Will be scheduled upon arrival of all S/O Merchandise $1 357.49 END OF CUSTOMER PICKUP-REF#W14 INSTALLER DELIVERY #1 REF# 101 STOCK MERCHANDISE TO BE DELIVERED: REF# SKU OTY I UM DESCRIPTION PI TAX PRICE EACH EXTENSION R03 0000-922-484 1.0 -=T SELECT PINE BOARD JA N 1 $13.421 $13.42 "`CONTINUED ON NEXT PAGE WILL-CALL MERCHAP FOR WILL CALL Will-Call items §OtheU store for 7 days only. MERCHANDISE PICK-UP Check your current order status online at PROCEED TO WILL CALL OR www.homedepot.com/orderstalus SERVICE DESK AREA (Pro Customers, Proceed To The Pro Desk) Page 1 of 14 NO. H2612-85676 Customer Copy SPECIAL SERVICES CUSTOMER INVOICE- Continued Name: BARRON Page 5 of 14 NO. H2612-85676 INSTALLATION #2 (Continued) REF#102 1 IRUNNER 1.001 MRI N 1 $50.00 $50.00 INSTALLATION,SITE NAME:I BARRON SUSAN INSTALL LABOR CHARGE: $135.01 ADDRESS: 122 FIRST AVE TRIP CHARGE: $0.00 CITY: V1l HYANNISPORT STATE: MA ZIP: 02672 CREDIT FOR DEPOSIT_/MEA_SURE: $0.00 COUNTY: BARNSTABLE SALES TAX.RATE: 6.250 TAX: Merchandise- Y LABOR- N F ..'.` a � "OO $135.01 PHONE: 508 3646997 ALTERNATE PHONE: 508 3646997 BASIC INSTALLATION LABOR INCLUDES: ARRIVE AT JOBSITE ON DAY OF INSTALL AND LEAVE WITH CUSTOMER: POSTAGE AND ADMINISTRATIVE). OR INSTALLER.IF DELIVERED TO INSTALLER,THE INSTALLER WILL FEES,ENGINEERING,WIND LOAD CALCULATIONS,RECORDING, PICK UP FROM THAT MUNICIPALITY AND DELIVER TO EITHER JOBSITE 'ALL FEES ASSOCIATED WITH OBTAINING PERMIT(MUNICIPALITY DELIVER COMPLETED,PERMIT PACKAGE TO PROPER MUNICIPALITY, SPECIAL NOTES: CUSTOMER IS.RESPONSIBLE FOR.PAYMENT OF THE PERMIT.ONCE: IN FULL.NO REFUNDS:ON PERMIT FEES AFTER 72 HRS.OF PAYMENT.. THE PERMIT IS PAID FOR,WORK ON THE PERMIT ASSEMBLY BEGINS IMMEDIATELY.CANCELLATIONS WITHIN 72 HAS.WILL BE REFUNDED OF tNSTAL'L#2' TOTAL CHARGES OF ALL MERCHANDISE & SERVICES Policy Id(PI)s. SALES TAX $0.00 . A:90 DAYS DEFAULT POLICY; TOTAL $2 424.49 BALANCE DUE $0.00 'The Nome Depot reserves the right to limit l deny returns:'Please,see the.return policysign in stores for details.' END OF ORDER No.H2612-85676 Customer's Signature « AS- -Page 14 NO. H2612-85676 Customer Copy 8 { q y firMA 02302 Z rrtmsss�arr _ F< The Commonwealth o f Massachusetts . Department of Industrial Accidents . 1' Office of Investigations 1 Congress Street Suite 100 Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � �Z;�1 Address:_ %�i. lCl�-. - City/State/Zip: — !�- Q Z3v;?�- Phone#: �- Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 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.[N 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 for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑Building-addition 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 I.❑ 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' 1311 Other comp. insurance required.] *Any applicant that checks box#1 must also till 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 mustsubmit a new affidavit indicating such. . xContractors 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: Yy 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 tinder Section 25A of MGL c. 152 can lead to the imposition"of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certc y under the pains and penalties of Derjury that the information provided above is true and correct Si ature. - - - Phone#: O f/cial 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: The Commonwealth of Massachusetts .�Department o DeP IndustrialAccidents Office of Investigations l 1 Congress Street,Suite 100 J �y Boston,M4 02114-2017 y www mass.gov/dia Workers'Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbers Applicant Information `f Please Print Le 'blv dame (. usiness/Grga=a adndividual): ,.HO Pi �/ b - Address: /B 1 Citv'State/Zip: � irt!wtd /� VIVI.Ir Phone#: 7 Are you an employer?Check the 94propriate box: Type of project(required): .• I am a empiover whit 4. L I am a general contractor and I employees(full and/or part-time).* have hired the sub contractors 6. 'I New construction r 1 am a sole proprietor or partner- These on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. Ei Demolition wortfln- for me in anv capes emoiovees and have workers' ' I 9. U Building addition [tio workers' :omp. insirance comp.a s,*aTce.t required-] 5. ❑ We are a corporation and its i 10.7,Electrical repairs or additions 1 officers have exercised their ing repairs or addi ons g 1 11.❑Plumb 5 • ,.[ I am a homeowner domes all wort: myself. 7No workers' comp. right of exemption per IvIGL L^.❑Roof reps r c_152,§1(4),and we have no insurance required-] , 13.V(Other �4t emplovee�. [No wo&zrs• i comp.insurance required.] I , rP la era- ,-f •Ar.y appEcanr Lhaz check box ir'_must also fill out the section below showing[heir workers'compensation pobcv information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicarong such :Cormectms that check this box must attached an addi000ai sheet showing the name of+he sub-contractors and state whether or not those entities have —mpioyees. s the orb-contractor have emplovices,they must Provide their workers'comp.policy mtmber. m lit er diat is providing workers'com ensation insurance or my loyees. Below is the policy and job sire Imnane p y P 8 P f �P information. /� Lnsurance Company?lame: /l(r,J,y—I"JLr N�L•IL/O/tl�� 1/Nl�I✓ r�/`G ,.Yit�S tl.S. Pohcy#or Self-ins.Lic.#: W 7 I % Expiration Date: Job Site Address: Z Z Z J i*r s 4 City/Stateaip:lt/, f`', 7F 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'_bIGL c. 152 can lead to the imposition of criminal penalties of a fine no to$1,500.00 and/or one-ye unprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day ag ' st a lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA r' - ce coverage verification. I do hereby,certify un e i at the informadon provided above is true and correct Si atrne: Date: - Phone T: - Official use only. Do not write in this area,to be completed by city or town of ciaL Croy or Town: Permit'License issuing Authority(circle one): ! 1.Board of Health Z.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ���- -- �•• _ �:..,<'t _.'f�'r(`.i�=F',j( '(:�> f #�� _ � ��f :..t t�r�f L`Lt�'�Z "(f:� —_- Office of Consumer Affairs andBusiness Regulation i 7 1 P 1 - Suite 1- 0 ark Plaza S e 5 0 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card HOME DEPOT USA INC Registration: 112785 c 2455 PACES FERRY RD C-11 HSC Expiration: 04/22/201„ ATLA!vTTA,GA 30339 Update Address and return card. Mark reason for change. ❑ Address ❑Reneges! ❑ Employment ❑ Lost Card -- - Office of Consumer Affairs&Business Regulation -=- HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE SuDDlement Card before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation -- 12785 041'22/2019 10 Park Plaza-Suite 5170 HOME DEPOT USA INC Boston,MA 02116 J ANDREW SWEET �� 4-�a-- j ,4 2455 PACES FERRY RD C-11 HSC 'od ATLANTA,GA 30339 Undersecretary d ithoU signature A O a DATE(MWDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 021121 8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY,THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s)- PRODUCER CONTACT MARSH USA,INC. P"'HONNE FAX TWO ALLIANCE CENTER Alc No: 3560 LENOX ROAD.SUITE 2400 E-MAIL ATLANTA.GA 30326 ADDRESS: INSURERS AFFORDING COVERAGE NAIL A CN101642069-HomeD-GAW-18.19 INSURER A:Old R icImuranceCo 24147 INSURED THE HOME DEPOT,INC. INSURER B:New Hampshire Im CO 23841 HOME DEPOT U.S.A.,INC. INSURER c:HomeRisk Came Insurance Company 2455 PACES FERRY ROAD INSURER D: BUILDING C-20 ATLANTA.GA 30339 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-004353439-16 REVISION NUMBER: 3 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS-ED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT,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. INSR I ADDL SUER POUCY EFf POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMn)D MMID A X COMMERCLALGENERALLiABILrrY MWZY3127+7 0310112018 ImAvviq EACH OCCURRENCE S 9,000,000 DAMAGE T CLAIMS-MADE OCCUR PREMISES Ea ocwnenr� S 1.000,000 LIMITS OF POLICY XS ! EXCLUDED � MED EXP(Any one person} �S OF SIR:$1M PER OCC PERSONAL&ADV INJURY S �•0�•0� GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 9,OOC.000 X POL Y PRO' LOC PRODUCTS•COMPIOP AGG S 9,000.0%, JECT OTHER: S AUTOMOBILE LIABILITY MWTB312718 03m12018 03l012019 COMBINED SINGLE LIMIT S 1.000.000 Ea atradenl X ANY AUTO BODILY INJURY(Per Person) IS OWNED SCHEDULED I SELF INSURED AUTO PHY DING BODILY INJURY(Per acudent) S AUTOS ONLY AUTOS HIRED I NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY i Per acudenl I S UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE is DED RETENTIONS s B WORKERS COMPENSATION WC 014122577(AK,NH,NJ VT) 03101112016 03101/2019 X PER CTH- STATUTE ER B AND EMPLOYERS LIABILm YIN WC 014122578(WI) 03101201E 03101)2019 5,000.CM ANYPROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT S OFFICEWMEMBEREXCLUDED� N N A 5,0M.000 (Mandatory in NH) EL.DISEASE-EA EMPLOYEE S n scri yes,debe under Continued an Additional Page E.L.DISEASE-POLICY LIMIT S 5.000.000 DESCRIPTION OF OPERATIONS below C Emess Auto 297-1-10011-00-2018 031012018 03/01/2019 Unlit: 4.000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) EVIDENCE OF INSURANCE CERTIFICATE HOLDER CANCELLATION HOME DEPOT USA,INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2455 PACES FERRY ROAD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN BUILDING G2D ACCORDANCE WITH THE POLICY PROVISIONS. ATLANTA.GA 30339 AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukhegee I ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101642069 LOC#: Atlanta AC oRi:x® ADDITIONAL REMARKS SCHEDULE AGENCY Page 2 of 3 NIARSH USA,INC. NAMED INSURED THE HOME DEPOT.INC POLICY NUMBER HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD BUILDING G20 1111111 CARRIER ATLANTA.GA 30339 I NAIC CODE ADDITIONAL REMARKS EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of LiabilityInsurance Workers Compensation Continued: Carrier:Indemnity Insurance Company of North America Pdicy.4umber WL^n C64783151(AL,AR,FL,ID,IA,KS,KY,LA,fiS.MO-WE.ta9 ND,OKSC,SO.TN;WV.,A'Y) Effective Date:03101/2018 Expiration Date:03/01/2019 (EL)Liml:S 1,000,000 Camer:New Hampshire Insurance Company Pdicy Number.WC 014122576 (DC.DE,HI,IN.AID,MN.MT,NY,RI) Effective Date:03/0112018 Exoiralion Date:03/01/2019 (EL)Limit:S1,000,0D0 Carrier ACE American Insurance Company Policy Number.WCU C64783221(QSI)(AZ.CA,IL,NC.OR;VA,WA) Effective Date:03/01/2018 Expiration Date:0310112019 (EL)Limit:S1,000,000 SIR S1000,000 SIR for the states of AZ.CA,IL,NC,OR VA,WA Carrier.National Union Fire Insurance Company Policy Number.XWC 4595580(QSI)fCO,CT.GA,ME,MI,NV,OH,PA.UT) Effective Date 030/2016 Expiration Dale:03/01/2019 IEL)Limil:Si,000,000 S1.000,00D SIR for the stales of CO,ME,NV,MI,04 PA,UT S750,000 SIR for the state of GA S350,000 SIR for the slate of CT Camer.National Union Fire Insurance Company Policy Number.X WC 4595581(QSI)(+AA) Effective Date:031012001 p ip Expiration Date:03/D12019 (EL)Limil:"51,ODQ000 SIP,:S500,000 TX EmOoyers XS Indemnity. Camer:11mics Union Insurance Company Policy Number.TNS C4916693A(TX) Effective Dale:o31012018 Expiration Date:0310V2019 (EL)Limit:S10.000:000 SIR."S t 000,C00 ,CORD 101 (2008/01) 2008 CORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks off ACORO i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel b38 Application # Health Division t�,' ( ;= BARMSTA L E Date Issued /7 Conservation Division kwyj o, 1� Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyarfnis ON Project Street Address Y�14 4VI: Village INA W IS P01rF Owner IASq-1J �"ef�� Address U40 NRO-IAOW#w:IV;XIJV�t Q TX 77316 Telephone S08 -:�6y Permit Request gpnoIdE d-IQ DECK W ITN- SAA6 LUMA) Tf i6',Na J IUD r o-ralbS Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 49�0()0,0t) Constructoon Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family t& Two Family ❑ Multi-Family(# units) Age of Existing Structure 0A'0 Historic House: ❑Yes W-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 ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name .TEffile� A46b Telephone Number 711 _ 53 Address S� 61L619-4i �I License # 0-)5)4l ak( WI PKT AJA 0A7S Home Improvement Contractor# Email i C�'1� V) GcaA�_hL� �2modd cco, Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE FOR OFFICIAL USE ONLY APPLICATION# f DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION I l� FRAME COJaJ 1 -711-4k�� INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING Q& 112-7117 r DATE CLOSED OUT ASSOCIATION PLAN NO. a C1�e�a�rL�ctarccoeccll�o�PiG`icasccc�cc�e%1.; ' Office of Consumer Affairs&Business Regulation License or registration valid for individul use only (VOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: _. _ 7 egistration: 149773 Type: Office of Consumer Affairs and Business Regulation Expiration:is 2/ /2018; Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 ,1 JEFFREY WRAGG t JEFFREY WRAGG 54 EILEEN STREET - YARMOUTHPORT,MA 02675� Undersecretary Not°val' ithout tgnature -.a - 3..a= .:: +r. sa.'+a✓-ate. S. IL Massachusetts Department of Public Safety r 1® Board of Building Regulations and Standards 1 License: CS-075746 Construction Supervisor " JEFFREY L WRAGG ~ vs 54 EILEEN ST. F YARMOUTH PORT MAx0 S 5` .sw Expiration: Commissioner 09/20/2017 a s; a The Commonwealth ofMassachitsetts z Department of Industrial Accidents l Congress Street,Suite 100 & Boston,MA 02114-2017 www.mass.gov%dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERM IITTPt'tG AUTHORITY. Applicant Information Please Print Lezibly Name(Business/Or'anization/Individual):��,F'AZ81i ML4bb Address: S� � 15N S 1 tS' P y0Q i" d�l�AN l3e�v� Phone#: 7P1{-32 `4v Y4 Ci /State/Zi Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.(No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.No workers'comp,insurance required.]t 9- El Demolition 10 Building addition 4.❑I am a homeowner and will be hirin g contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11- Electrical repairs or additions proprietors with*no employees. 12.Q Plumbing repairs or additions. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'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. tContractors 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 far my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: II►�ST City/_StatelZip:_ Attach a copy of the workers' compensation policy declaration page(shoring the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert' der the pains and penalties of perjury that the information provided above is true and correct Date: Phone#: t cial a ly. ,Do not write in this area,to be completed by city or town offciaL 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#:. ._ 15 0 12, S1 5 '' 20, 90;'ffi r 1 r� Pi 1 ` • - ¢ 71 Ep, 20. 0• *s t � R4 S ktFFpk AS { b 40 BM T 40, a : 0+ - NM I Legend Y „ a. . A n Parcels Town Boundary _ 267003 267031 Q III, Railroad Tracks 267004 #87 #90 ' Buildings #90 I iiI �� � — Painted Lines Parking Lots � .` III Paved F; Unpaved 267140 III Driveways k ® Paved 6 005 267002 Unpaved -95 .. I� Roads G Paved Roads 4 �. ❑ Unpaved Roads y, Streams Marsh y I1 Water Bodies 267 w 67 x _ :. : 266031 x ; r, �� #2 �O7 I 26602 2670 3 9 } rg"l1 ' a 266018 L #28: III ;uca �P.' C tn"c g#-2 2660230 F k lyl 2666002 #135 ,"• � - �. , 26601 4 ''I #:29��1' 2 012 266023iQ03 #12 I ,.m Map printed on: 12/13/2016 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026ot O 83 167 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: I inch= 83 feet cartographic errors or omissions. gis@town.barnstable.ma.us i ttt- , � t fi 1 C' C wAt ONE SON ■ ME mom 0 No ME MINE No mom ism mom R mom t 1 I { 4 1 e �1 r f o blt �t 000E wti 'Town of Barnstable *Permit# P Expires 6 months from issue date Regulatory Services Fee r • BAR ASS. E. 9� i6 ,�$ 'Thomas F. Geiler,Director. f rim prf1 MP'l A Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY l Not Valid without Red X-Press Imprint y—� Map/parcel Number .� Property Address 'r /v . FI "Residential Value of Work C Minimum fee of$25.00 for work under$6000.00 t . Owner's Name&Address �,/ ,� ( � 0 l c,,? as 4; Contractor's Name tV 1 v� Telephone Number Home Improvement Contractor License#(if applicable) A-PRESS PERMIT Construction Supervisor's License#(if applicable) - MAR 19 2010 ❑Workman's Compensation Insurance Check one: TOWN OF BARNSTABLE ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) —q-Re-roof(stripping old shingles) All construction debris will be taken to G' I-, ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑.' Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAVvTFILES\FORMS\building permit forms\EXPRESS.doC Revised 090809 The Commonwealth ofj11assachusetts 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): a Address: R t�1_ V C — City/State/Zip: A - fir✓ �/ 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 g• ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or addition 3. 'I am a homeowner doing all work officers have exercised their 1 I.❑ Plumbing repairs or addition 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 ttl 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. tContractors 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 andjob 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 fin of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify iynder th, pains and penalties of perjury that the information provided.above is true and correct. Signature: Date: Phone#: �`0 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#: r 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 tvho 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.refeience 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(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 bum 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 Fax # 617-727-7749 Revised 4-24-07 www.tnass.gov/dia - Town of Barnstable " Regulatory Services o� Thomas F. Geiler,Director RA.twsrwBLe, , Building Division s6 9. r �O PIED 59�a Torn 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: 3)r �/ f G JOB LOCATION: i : number street village 4. "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: P— U . d U iq All 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 inspe tion procedures and requirements and that he/she will comply with said procedures and requir rnent Signature of Homeowner Approval of Building Official . Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. 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 dQ such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(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:\YfPF.ILFS\FDPMS\homeexempLDOC THE Toh Town of Barnstable ` r Regulatory Services IWINSTABLE, ' Thomas F. Geiler,Director 9� K 9 A,O� �fo 3.t Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property 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 fox. (Address of Job) Signature of Owner Date Print Name If Proyerty Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. oFt"E,a,. Town of Barnstable *Permit.# D� v j -8 do Expires 6 months from issue date .ARP►6TABM Regulatory Services Fee MAss. ib39. Thomas F.Geiler,Director plf0 N1°�A Building Division Tom Perry, Building Commissioner X-PRESS PERMIT 200 Main Street, Hyannis,MA 02601 Office: 508=862-4038 NOV 8 s 2005 '�)8 Fax: 508-790-6230 TOWN OF BARNSTABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number A 0 , 0 3 3 Property Address , I Q P 411�') t2-T 7- /� F. (A 9 y A 11 tv'1 f P a 2 t , M A Residential Value of Work 6 do Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address L-.L-. R-C E (Z-. (h D tzo S )Li' �X 7aN T VE �N. �� Y nr'NiJ JPervfi Contractor's Name Telephone Number ev;� 5-0 8 ome Improvement Contractor License#(if applicable)_ /✓ '9 Construction Supervisor's License#(if applicable) J 'Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ® I am the Homeowner ❑ I have Worker's Compensation Insurance nsurance Company Name orkman's Comp.Policy# opy of Insurance Compliance Certificate must be on file. ermit Request(check box) ® Re-roof(stripping old shingles) All construction debris will be taken to �,9tii✓TTg f ,q/y �� �'g,je'� ❑Re-roof(not stripping. Going over existing layers of roof) Re-side s trim bow—cl-$ ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. ignature :Forms:expmtrg vise063004 ILI The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street, a Floor Boston,Mass. 02111 Workers'Com ensation��.Insurance.Affidavit:Building/Plumbing/Electrical Contractors. 40 name: 1,0 A ) A C r7 a as k,' address: ' '�i I `Q V (15 city 1/.1 A N nil ed xt state: 01la zip: Q Q 6 7 phone# work site location(full address): a a �) �f% V E• ,�7 l A vr 0 D.b �. ®'I am a homeowner performing all work myself. Project Type: ❑New Construction HiRemodel 2 oar =a I, sole�ro netor and have no one;lwCporkin to l'. � ri Addition - �8'�.:"r"`•°�'���•'Yn,'- rx'��i'�53.j..• .•{�iis'"".'F'��^.?C'•� an capacity, Buildi +�'•'•...�i'.�!r�:ti�?'7�•��.�`,l:a'.i+:Y��t"i�•v.,?�i�i�i#x �_'•t�5��,'>'''a:;'"'��,;•."•c';':5;+;7���p:t7'tYb:".;1M' I am an employer providing workers'compensation for my employees working on this job. company name: address:' city phone#• insurance co. policy# Sk�:1S3rn'c' �'kllst'ik�++dtrsa �i:1+1•deT4�.,F�1A:6�i�u6•��'�'b�:�l'��'��5,:''a:e��dtv�e+"�'...�°s!.°;s'.�ih"a`.�':..I�;i�arY•r�:�:n'�.•':ie�:A;';a�'�•:•a :i+kix�+d�?'�'.�:Y,j-a'�.Tm {�. n�tE.3r�E Ita.3av�:.�m4r ? �� I a• F .! t 'r+ •F ❑ 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: company name: address city phone#• insurance co, policy# 3'M`.�'M r-'.y"`•&X, '''�,•, •�' .i' R°x":6`-1'.._ ..>. . . e..`,�.,. cy�,> A,.,,' l �+.' .`A:.'3''}G.L f �. s• ;i.. 7• .. �,a*..�.r. >•.. y.,I „.t r- .G},. ...:.1 •i•v�': a. ' a .s ;e�', r.'`tt1?i •3'i<: .:�'r., 4 -4?�Y,',.'Y�4.',.:�:5 ,W.::k.• �:c';.•>r�n:�a::,. `�r�re.��'`.••'Setr•:;'" ..:::�2,.�i,.. 'company name: address: city: phone#:. insurance co. polig# • dd "3 '�et;� ' �'� ..n.. s ..�e ��': .r' ��'.�....5,���i�:�'�'� '-i�� ' l+'�,�s��'�. zg•.��,. r ...,. 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 fine df S100.00 a day against me. I understand that a• copy of this statement maybe forwarded to the Office of investigations of the DIA for coverage verification. ' I do hereby cerd under the ains and penalties of perjury that the Information provided above is true and correct Si afore Date /// T 0 Print name Al a � )Iv. CI-5 a 2 0 ! Phone# official use only do not write In this area to be completed by city or town official city or town: permitnicense# ❑Building Department ElLicensing oard ❑check if immediate response is required ❑Selectmen'Bs Office contact person: phone#; OHealth Department ❑Other. (revised SepL 2003) 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,partnerships 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 p been presented to the contracting authority. > l MM.{', le• i'...+ f -2, - .rY 6 .SM . , Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, 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. A f ry4f Ss:.:S ! •. ,j ,'?' n { #° .,k "1H^ .i' 4. �, r 'fig ' F+�' +1$, '-• k :�•�p`" .T�i i'�� `�ri. " Vag 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 give us a call. ,1 e:• , ti •rys: Y cre L--.ltil( 4 1"..31 l^.. 1C v4•y'•�"i ,i'a .ry�mat i'�',M1r� �°i ' �" ''�P��'k,�.+''.��icy.'�i1'r.,c '/�;� '��.��y�. .: •-frn; Ff ,l'Yfi 1 J,.. r '•A aLN4 �' 'G h��C '3y�•fa f• ! t^ - i.6_ '� titre. 1,f•r_'•±d�,"a'Iti...v..c r 'ir>.• .t'�..r'.a+.A%',? 'iv.A.:iX. "l?h :.inn ,The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,7"'Floor Boston,Ma. 02111 fax#:(617)727-7749 phone#: (617)727-4900 ext.406 . ES Assessor's map and .lot number .................................7 3PitCYiSi 13E JXSTALLED IN CONIPLWRCE .tit 1 1127 F ,. Sewage Permit number .......................................... .............. . SCE" lit. ,,.�!! ai<. 4 F� dC TOWN f�L:.a tJ:iJ I t 0. S. yo`T"ET TOWN OF BARNSTABLE i i 33A"SMULE, i "6 9 .•� BUILDING INSPECTOR o war a' ( �.,p. . . .�rd . . .. ..... ff..�.!7................................ APPLICATION FOR PERMIT TO ... /�:� , TYPE OF CONSTRUCTION ............. Mtn l L'�Q... ...... ..el I� n..................................................................... a72/ .t,,X TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the the (following information: Location .......... 7..... .. ., .........O��.1....../..(. ..4,ow-lj�...........y ProposedUse ...... .. ., � . ..................................................................................................I....................... .....Fire District ..... i7.AS_c Zoning District ...............................................:.................. . ... .......................................... Name of Owner ifi' "... .. eA,. t� .f '�C•.Address 1. ......, �... .............4..................... Name of Builder ..�i � .. ��✓�.✓. . ....6r.Address .... .a• ( ........ .................. r "r Nameof Architect ...... . ..1�!'IC,............................................Address .................................................................................... f� Number of Rooms .....�!/�. ...............................................Foundation ..... 2.17.o-/.�1����'. ....v-.b%�'. ............... Exterior ...... .. X-• Roofing .............�.1fA./I.. eS............ Floors ........��.�.�C�N..............................................................Interior .......o11e. . 'C �............................................. Heating ....A/en ....................................................Plumbing ......�✓.,p�e...���f ��./��..................... Fireplace ......... ................................................................Approximate Cost ...6Q ... . . ........ Definitive Plan Approved by Planning Board ---------------_---------------19________ , Area Q',�"�.Y......�?.. .'............... Diagram of Lot and Building with Dimensions Fee /. SUBJECT TO APPROVAL OF BOARD OF HEALTH ee. „ CA RPoR-tgo ¢S1o�ge kXtst �oom /00 �oc�se thq DP,ive 77 I hereby agree to conform to all the Rules and Regulations of the Tow of Barnstable regarding the above construction. Name ................ Latimer, Dr. & Mrs. Edgar 7412 add to single No Permit for g ......... ,....fam ... ily �W!qling................................ .......... . ' Location , F rs t �uer►ue r t,. r Owner .............. .Mrs. E'd¢ar Latimer s ..................... i � Type of Construction .......................................... _• , 1 Plot ........................ Lot ................................ , t _ t A" _ Permit Granted October.'31 `.19 74 ' Date of Inspection ...P. .11.., ....(..�.. Date Completed ... .................-19 PERMIT REFUSED ' 19 t f .................................................... ................... ............................................................................... r Approved ............................................................................... ............................................................................... Assessor's map and lot number ...... .. ........... ... ... �-?7 Sewage Permit number .......................................................... yOFTMETO�yTOWN OF ' BARNSTABLE t 13AUST"LE, 2639- BUILDING INSPECTOR 0M I* APPLICATION FOR PERMIT TO ..... A 0.e7................................ ........ .... TYPE OF CONSTRUCTION ............. d........ .. ............. .... ........................................................................... e�4z...19.2�� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..................... ......... ............................................................... ... Proposed Use ....... ............................................. ....;,......................... ................................................................. ZoningDistrict ........................................................................Fire District .................. .............................. F . . .................. ...............Name of Owner X�,.�p I.Ax5e Address ......e�f %I �2 Pr/.g.), Name of Builder .. ... ........Address ...... ///-�q /�s ........................................ Nameof Architect ....... r?f............................................Address ................................................................................. Number of Rooms ......!�7010...............................................Foundation ....(-61 e .;!rf9.1).C,,Ce4.... ..... ..........-... ... .......... ..... ..... ........... ..... Exterior ....... ......�. ...........Roofing ....... Floors ........ .............................................................................Interior .......�5 k... ............................................................ Heating ..... .Plumbing ....... .................... Fireplace .......... ..................................................Approximate Cost ............. Definitive Plan Approved by Planning Board --------------------------------19-------- - Area ............ ... .... Diagram of Lot and Building with Dimensions Fee .......... -1......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH ep A fib CA epot J00 Rive I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... ............ .....;.... ........... �-,....................................... Latimer, Dr. & Mrs. Edgar �6 77 47412 add to single No ................. Permit for .................................... family dwelling T................................................................. Location 22,,5—First Avenue ................................................................ Hyannipport Owner .............Dr. . ... ... . & Mrs. Edgar Latimer .. . . .. ....................................... Type of Construction ..............frame ............................ ............................................................................... Plot ............................ Lot ................................ Permit Granted ........... cn ?Q .. 3�........19 74 Date of Inspection ....................................19 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... a� /R: Assessor's map and lot numb . ... ..........��... ......... �*THE TG ^� Sewage Permit number ...... ... .....: �. ..... Z BARNSTULE. i House riumber .............VA) �k................................... .. ........_ r rnsa � Op t63q. 00 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO .................'.. .......... ..........-1—A.R.!f r-C.................................. TYPE OF CONSTRUCTION ...........:......W..Q..Q..Q................................................................................................ ' ............................. ..................19........ TO THE INSPECTOR'OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... ..E...1..ek,5.T........P5-utr:•.................W........".Y..f�.!`l.N.l.. .. .5?. 5 .I.........Ty\.. .............` ProposedUse ......... .. . ................ ........... :....,.............................................. ZoningDistrict ........................................................................Fire District ............................................................. Name of Owner R91..�.K\-).t \. .Address .. -aa.. ..1.YCST....A.V..E,::....W....}A.Y..N:`a.P..T. Nameof Builder ............................................... ............Address ........................................ . Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..................�..............................................Foundation ............ ..0 m f:.k ... ................................. ...........5..1 .1..N.0 t..,F. ?........................................Roofing .........:...A.SRA..1."C .......5.1..l..!`l �.................... Exterior .. FIbors .............Interior ""..................................................................................... Heig ......................... .........................................Plumbing ...............N..4.N.AA.a................................................. Fireplace .............................1N.Q...............................................Approximate Cost .............................. .. ... .... ... .... ......Definitive Plan Approved by Planning Board --------------------------------19--------. Area ....... a. ....... .... .. ..r Diagram of Lot and Building with Dimensions Fee Llr.."":...... ..... SUBJECT TO APPROVAL OF BOARD OF HEALTH a� t�esr--NT R a U S C- L Or V OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ....... . �r %!:.. + ....... ' . .... ............. �- Construction Supervisor's License �''� I LATIMER, BARBARA E. & L. 24717 - Build Garage No ................. Permit for .................................... Accessoryto Dwelling................................................................. ............ Location .....122........................................Fi r s t Avenue..................._gf Hyannisport ............................................................................... Barbara Latimer Owner .................................................................. Type of Construction ....F ra...m.e .. ............................. .. ..................................:......................... Plot .............. ............. Lot ................................ January 12, 83. Permit Granted ........................................19 Date of Inspection ...........i........................19 . ................Date Completed 19 0 Assessor's map and lot numb . .... Y.. . N Sewage Permit number ...- ...�. .. ... { Z 33AUSTADLE. i House number - r NUB.��,. ........1 ........................�r�........ , o� ,b 9. 0 't 3 �0 ' d D Nxi a' TOWN OF BARNS ' 'ABLE .c l BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...................h?A.1.LA ..C?.......... ........ T... ..�' .0 ................................. TYPE OF CONSTRUCTION ..................k l o.A.A................................................................................................ ................................................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........... ... :...... ..)•• y?T....... ..V. .................\,),-)........ ..! .!`1.i\1.?.5.. '.p. �..?... .........m.. .............. ProposedUse ......... ........................................................................................................................................ ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner ..' :.b..1->..:.` .. f7N\.►.C)!F-9.Address ... �...C.�. iST....Y�.V. :....�.��.:.. .? .!�. .!'.1'. Name of Builder ........Address Nameof Architect ................... ............................................Address .................................................................................... Number of Rooms `� ................... ...........................:.................Foundation ............:�:..:-:.��.r:.�`1... .................................... Exterior ............ .......................................Roofing .............:P1..?3A ? k�T......5.N.?..11.C��................. Floors .................w................Interior .................................................................................... Heating .' ..................`........... .............................�........... Plumbing Fireplace �� 4..............................................Approximate Cost .............................................................. ..... . ................................... Definitive Plan Approved by Planning Board ________________________________19________. Area .......�t' ...t�: ..'..L. Diagram of Lot and Building with Dimensions '- Fee - SUBJECT TO APPROVAL OF BOARD OF HEALTH L E I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................................................................. ............ r Construction Supervisor's License .................................... LATIMER, BARBARA E. & L. A=267-33 24717 Build Garage No ................. Permit for .................................... Accessory to Dwelling Location 122 First Avenue { ................................................................ Hyannisport ............................................................................... Owner Barbara. ...E... ...... Lati. . mer. ................. .. .. . .. .... ....... .. Type of Construction ...Frame .......................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ...January 12 , 19 83 Date of Inspection 19 , Date Completed ......................................19 to %9 • saxxsT� • The Town of Barnstable 9 Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 J Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner July ul 16 1998 Eileen Moroski Sea Haven 122 First Ave West Hyannis Port, MA 02647 Re: SPR-052-98 Sea Haven B&B, 122 First Ave,West Hyannis Port (267/033) Proposal: To establish a 3-bedroom B&B Dear Ms. Moroski, The above referenced proposal was reviewed at the Site Plan Review Meeting of July 16, 1998 and approved under Section 4-7.4 (2) of the Barnstable Zoning Ordinance with the following conditions: • Applicant must seek a License. • Applicant must seek a Use Variance from the ZBA. Please be informed that a Building Permit is necessary prior to any construction. Upon completion of all work, a letter of certification required by Section 4-7.8 (7) of the Town of Barnstable Zoning Ordinance must be submitted. Also, all signage must be discussed with Gloria Urenas of this Division. Should you have any questions, please feel free to call. Respectfully, Ralph Crossen Building Commissioner l Town of Barnstable *permit# ,;S(a Expires 6 months-from issue date aaxxsr�r.E, : Regulatory Services Fee v KASS• $ Thomas F. Geiler,Director �prED MA't a`� Building Division '(.PRESS PERMIT Tom perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 N 0 V 2 2 2002 Office: 508-862-4038 Fax: 508-790-6230 .TOWN OF BARNSTABLE EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red JX Press Imprint Map/parcel Number zi Property Address ( r�oZ �`- �{Uen k Residential Value of Work -3 90 0, 00 Owner's Name&Address W a!l t E+I J E'e/\ D C'J S /\ I� Telephone Numbs_ ��y y 2 y F Z Contractor's Name r Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) CO ❑Workman's Compensation Insurance t+an T• Check one: ;&I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Permit Request(check box) p (� / Re-roof(stripping old shingles) All construction debris will be taken tot f r CDML CI-S �/✓Pas�c V�C�6�f�l ❑Re-roof(not stripping. Going over existing layers of roofl I ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature Q:Forms:expmtrg Revised121901