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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel a 7 ':±. Application#, �� a
Health Division
Conservation Division Permit#
Tax Collector Date Issued
Treasurer Application Fee crv:
Planning Dept. Permit.Fee f ��
Date Definitive Plan A iproved ning Board IC
Historic-OKH �� Pr ervation/Hyannis
Project St J4&AAtkk_5
t Address a- - ` ids
Village l
Owner v L'h -1�-�. Address G✓►nti
Telephone
Permit Request Tz, A G �Q
0\11N o� LAAj,,e-� ce pt A CZ./ ro 4_e/yl,
4
Square feet: 1 st floor:exist�tg proposed 2nd floor:existing pro osed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 364 aw Construction Type
Lot Size 31 a C r-e—a r Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ' Two Family ❑ Multi-Family(#units)
Age of Existing Structure 0 Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑WAlkout U15ther 0 0 c ' 1 V1 C4 O%A 6EN IJC P l
Basement Finished Area(sq.ft.) q 3( Basement Unfinished Area(sq.ft) 1600
Number of Baths: . Full:existing'. new Half:existing Q new
Number of Bedrooms: existing new 01
Total Room Count(not including baths):existing L new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric Wbther h 6h P —
Central Air: ❑Yes ®No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ElNo
Detached garage:%d/existing ❑new size Pool:❑existing ❑new size Barn:0 existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
4
Zoning-Board of-Appeals-Authorization, ❑ Appeal# Recorded❑ ,
Commercial ❑Yes ❑No If yes, site plan review# — }~
Current Use Proposed Use
BUILDER INFORMATION
Name ACX 6 Telephone Number
Addr ss 6 License# '0 —7 4 ( r] `f'
✓ I f, Home Improvement Contractor# I J Z
Worker's Compensation# ' o cL:v'i.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Al
SIGNATURE / r am�-- - DATE
r
FOR OFFICIAL USE ONLY`
r
PERMIT NO.
r ,
1
DATE ISSUED
MAP/PARCEL NO. `
ADDRESS VILLAGE
OWNER
r DATE OF INSPECTION: f
FOUNDATION 171< !� O�
FRAME
{ r
j INSULATION 1
1
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL 1
GAS: ROUGH FINAL
FINAL BUILDING
r r -
DATE CLOSED OUT
1
ASSOCIATION PLAN NO.
F+
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApPlUcant Information Please Print Legibly
Name (Business/Organization/Individual): �- C s.S LAI
Address: 0 F-3+
City/State/Zip: �L(W( C Afa. 07_(.J! Phone#: 20L Gil,V-
}
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
Amployees(full and/or part-time).* have hired the sub-contractors
2.ZI am a sole proprietor or partner- listed on the attached sheet,": 7, ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. g. Building addition
[No workers' comp. insurance 5.
❑ We are a corporation and its
.officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.7 Plumbing repairs or additions
myself.[No workers' comp, c. 152, §1(4),and we have no 12,[1 Roof repairs
insurance required.] t employees. [No workers' 13.[L]'Other_ 6dcn.A�
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
FContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
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$1,50Q.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 certify under a pains andpenalties of perjury that the information provided above is true and correct
Si atur Date: ZZ 0
Phone#: 7, :0-.-V!
Official use only. Do not write in this area,to be completed by city or town qf,ficial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk a.Electrical inspector 5.Plumbing Inspector �
6. Other
j
Contact Person: Phone#:
3
°FTME Town of Barnstable
Regulatory Services
i A
1 iARNSTABLE, " Thomas F.Geller,Director
i039, p Building Division
�fD MPS
Tom.Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
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.
1
Type of Work: �c ✓�Q tl� [ ,rvi Estimated Cost _4 ! o
Address of Work: f
Owner's Name: w �- 13 �( I G
Date of Application: � Z 2' 6
I hereby certify that:
Registration is not required for,the.following reason(s):
[]Work excluded by law
❑Job Under$1,000
[]Building not owner-occupied
[]Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
27-0 �- q
Da
te
Contractor Signature Registration No.
OR
Date Owner's Signature
Q:wpfiles.forms lomeaffi d av
Rev: 060606
�oFTME T Town of Barnstable
Regulatory Services
Y •
• BAMSTABLE.
MASS. g Thomas F.Geiler,Director
�pIEDMp'�a�e 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
I, �A e 1 , as Owner of the subject property
hereby authorize L4, C ZQC S- I- to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
�) r
Signature of Owner Da e
Print Name
r
8
Q TORM S:O WNERPERMIS SION
/laa nc+mvrrxo�r2cueat%�i, a�✓��c�.fl�,tc�ui.AeLx
Board of Buildin_,Rcgulatimis aat'-Standards
y
HOME IMPROVEMENT CONTR -ITC?
3,
Registration: 128528
Expiration: 4;15/20.0
Type. Individual
PAUL N.CROSSEN
PAUL CROSSEN
317 MAIN ST <-
HARWICH, MA Q2645 Admiiiistr v�r�-
i fr
��ie;`�onvmaruvealC/ a
BOARD OF BUILDING REGULATIONS':;
�s License CONSTRUCTION SUPERV(SQR,
Zt Number GCS ' 074174
I Birthdate 12/14/1958
Expires 12/14/2006
Tr no. ,92 6.0
Restricted:,"00
PA N.CROSSEN " +'
317 MAIN ST
HARINIGH; MA 0264561
CommissionPr F
Town of Barnstable Geographic Information System August 18,2006
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DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:287 Parcel:037 Owner:BICKEL,HARRY C SR Total Assessed Value:$1112600 N,
boundary determination or regulatory interpretation. Enlargements beyond a scale of cted Parcel Sele ® F{,
1"=100'may not meet established map accuracy standards. The parcel lines on this map `"�,.,:' ,
are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner. Acreage:0.34 acres Abutters ti�'-4`44 a'E
boundaries and do not represent accurate relationships to physical features on the map
�t such as building locations. Location:35 GRAYTON AVENUE Buffer
,y.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel / Application# U Ob
Health Division
Conservation Division Permit#
Tax Collector Date Issued
Treasurer Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board (�
Historic-OKH �� Ann Preservation/Hyannis
Project Street Address r a TZ z
Village
OwnerP.k li �-�� Address v
Telephone
Permit Request 4L_1y\ACA_(__A_An U Vk `
c
Square feet: 1 st floor:existing proposed ® 2nd floor:existing proposed Total new C
Zoning District Flood Plain Groundwater Overlay _4
Project Valuation Construction Type C
Lot Size 0 "2� �T �Cc �-e A'5 Grandfathered: ❑Yes ❑ No If yes, attach supportingcumentatlon.
cs)
Dwelling Type: Single Family Wr" Two Family ❑ Multi-Family(#units) '.
Age of Existing Structure 0 Historic House: ❑Yes ❑No On Old King's High y: ❑Y'eess C�No
M
Basement Type: ❑Full ❑Crawl ❑Walkout Other o but ( Y I �<_ 5
Basement Finished Area(sq.ft.) "1 Basement Unfinished A ea(sq.ft) .�( -0
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing— L new 0
Total Room Count(not including baths):existing L5 new Q First Floor Room Count
Ller—
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other k ain.-LI.
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:ffleo�isting ❑new size Pool:❑existing ❑new size Barn:0 existing ❑new size
Attached garage:❑existing ❑new size Shed:0 existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION /�
Name PAU, L, 54-5 S-A/ Telephone Number �g_"! ��-
Address 3 s4 License#
Home Improvement Contractor# /
Worker's Compensation# S-Ae-e- a-+—i- I n(eq .y I
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE h q - 0 41 .�
t
FOR OFFICIAL USE ONLY
z
`'fERMIT NO.
DATE ISSUED
r MAP/PARCEL NO.
{ ADDRESS VILLAGE
i
OWNER
DATE OF INSPECTION:
r; FOUNDATION ®�� (p p P(Z--
x
FRAME
z
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
r '
FINAL BUILDING
II
DATE CLOSED OUT
I
ASSOCIATION PLAN NO. r
The Commonwealth of Massachusetts
( h Department of Industrial Accidents
Office of Investigations
i IMP�y)"/ .'
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual): ?A u— L_
Address:
City/State/Zip: 'tnal Y"&• (j `'CC Phone#: `�_ �Z
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
ployees(full and/or part-time).* have hiredthe'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. workers' comp,insurance. ,
Y P h'• 9. Building addition ,
[No workers' comp. insurance ; 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions .
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]t 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
lam 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 coverage verification.
I do'hereb c er the ins a d penalties of perjury that the information provided above is true and correct
Date: —0
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 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,l-A.02111
Tel, #617-727-4940 ext 406 or 1-8.77-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.govfdia
THE Town of Barnstable
°�' Regulatory Services
BARNSTABLE, ` Thomas F.Geller,Director
v Ass. $
Building Division
Tom.Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
)ffice: 508-862-4038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVri
HOME IMTROVEMENT 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 W h other
requirements.
Type of Work: Estimated Cost e-P-`i'd
Address of Work:. 3 S— 4
Owner's Name: C&-e'(Y l
Date of Application: �o X�'�d (a
I hereby certify thatk
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 FOP,APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
IGNED UNDER PENALTIES OF PERJURY
I hereb or a p as th agent of the owner:
Date Contractor Signature Regis1ration No.
OR
Date Owner's Signature
Qvpfiles.forms:homeaffidav
Rev: 060606
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August 18,2006
Town of Barnstable Geographic Information System
287_ 3002
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DIMAWERS.This map is,for'planning purposes only.,It is not,adequate for legal
Map:287 Parcel:037 Sel~Ct�d?afl
boundary determination or regulatory interpretation. Enlargements beyond a scale of Owner:BICKEL,HARRY'C SR Totat Assessed Value:$1112600
1"=100'may not meet established map accuracy standards.The parcel lines on this map Co-Owner: - Acreage:0.34 acres Abutters
are only,graphic representations of Assessor's tax parcels. They,are not true property
boundaries and do not represent accurate relationships to physical features on the map' Location:35 GRAYTON AVENUE Buffer J