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0018 GROUSE LANE
/� �� r .t -_ _ - 7ewage e sor's map and lot number .°1 ,$°:....... -..... ..... O.C�: �l 3' �y-�� �Usr �/� ,� � �vs o��� Q�oFTNE roe` Permit number ..............TX l-�..�..' : Ile Z 33AUSTADLE, i House number 18 " 9� MAO& ......:.................................................................. • , p ,63q. `0� TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO Construct a 14'X 16' Addition ....................................................................................................... TYPEOF CONSTRUCTION ......V0.0d.................................................................................................................... Mar.Qh...1.4 19.7.9.. P TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...18...Grouse Lane.....Hyannis....................................................................I............ ............ ............. Proposed Use .0 b;Lna;tion. Dining and...Fam lY...Room......... .................................................................. Zoning District ...R...E..........................................................Fire District .....Hyann ,S......... .......................................... Name of Owner Sidney..+..Eileen.,Chas,e..............Address ...18.,Grouse Lane,.........................................i Name of Builder .............. ........... Pbell..............................Address .9S...F.Q.:rr I.J.P..RS .,.�1 yaX1 ?�.5. .................. Nameof Architect .N n!1 .....................................................Address .................................................................................... Number of Rooms ....QT.I.Q.........(1.)......................................Foundation ...C.RX met.e...B.I.Q.r..k...................................... Exterior .2h'.P1.YWQQ-d...W/Ce.d r..Sh.i1J&LeS..............Roofing ...,Asphc' ult....S17 ingLes..W/.Pa pex..17.7C der Floors 5/.8.......348...S mer.Iay. ..Flywao.d... /Qa.�p.6i erior .2 fit .....Shp-etro.ck..+...PanneIling................. Heating ..3QOQ...Watt..Elect.r.ic...Heat...................Plumbing ....... one................................................................. Fireplace .None.................. ..................................................Approximate Cost ...$7.raOO:..0Q......................................... Definitive Plan Approved by Planning Board ________________________________19________. ArecV;.....z�........................... Diagram of Lot and Building with Dimensions FeeL SUBJECT TO APPROVAL OF BOARD OF HEALTH rqo�se I hereby agree to conform to all the Rules and Regulations of th Town of Barnstable re ardin the above construction. Name ...... .................. .......... .................................... Chase, Sidney & Eileen No Permit for. AdditiQX1............... 1i Location ... ............... ' Owner ..S.7.dney.:. ................. Type of Construction ............................................................................... '- Plot ............................ Lot ..°............................. i F " I t � Permit Granted ....March...1.4..................19 79 Date of Inspection ............................:.......19 Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 - 4 r - ...............................'.............. ........... . ......... .... _ .. ................................................................... ........ F I L ............................................................................... i y Approved ................................................ 19 ..........:..................................................................... .......... ........ ......................................................... FRILDLINR&CARTER ADJUSTMENT, INC. 436 Main Street, P. O. Box-338 Hyannis, Massachusetts 02601 Tel. (508) 771-3232 FAX (508) 790-2344 TO: (,Building Commissioner or Inspector of Buildings O Board of Health or Board of Selectmen ( ) Fire.Department TOWN OF BARNS TABLE TOWN HALL HYANNIS, MA RE: Insured: GROUSE LANE REALTY TRUST Property Address: 18 Grouse Ln' = " Hyannis, MA 02601 Policy Number: HM00401305 Type of Loss: Power Surge Date of Loss: 9/25/2018 rn File* 130416 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. General Laws, Chapter 143, Section 6 to be applicable. If any notice under MGL, Ch. 139, Sec. 36 is appropriate, please direct it to.the attention of this writer and include a reference to the captioned insured, location, policy number, date of loss and file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by First Class Mail. B. OSTIGUY Adjuster 10/1/2018 s t . t Town of Barnstable Building e 2ostThiCard SoFThatlt Is:Ulslble:From the Street A rove.,dPlans•Must be Retained on,J.ob,.andthis Card Must beKept * > txsYews. �''`__u' ;..':_.. R az":'" :, �A°'" f,,,. f #pp, ,"`F` 'aY ."g��" y' s .z, " "� �•M't - Posted Until Final Inspection Haeen Made ; r y s� yam s =Where a Certificate of Occu anc :Is Rye•aired;such Building=shall Not:be=Occupied anti!a F�nallnspectlon=hasbeenmade Permit ;w. ,max Permit NO. B-18-2848 Applicant Name: James.Curley Approvals Date Issued: 08/30/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 02/28/2019 Foundation: Location:_ 18 GROUSE LANE, HYANNIS Map/Lot 268 262 Zoning District: RB Sheathing: x Ell Owner on Record: KIELY, BRIDGET N TR " Coniractor_Name AJAMES P CURLEY Framing: 1 ". Address: 31 TURNER STREETa �Co tractorticenseCSSL-099138 2 SALEM,MA 01970 �. Est P�oJect Cost: $8,000.00 Chimney: Description: Strip and re-roof approximately 20 s uare of as halt�roof shin les. Permit)ee: p p pp y cl p g $40.80 Insulation: Fee Paid' $40.80 Project Review Req: Final: ®ate 8 30 2018 p \ t R fL v .r dry- -.. Plumbing/Gas _.._.. lain h 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. Rough Gas: All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. M� a- All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoninbyfaws amend codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or roadand shall be maintained open for public inspection for the entire duration of the work until the completion of the same. r ='4 Electrical 41 The Certificate of Occupancy will not be issued until all applicable signatures b the Building and;Flre Qfficia is areprovlded on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work:` - y ` •_ 1.Foundation or Footing r Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 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). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT i4�c 564J'J— Assessor's map 'and lot,humber' or to Y . .. st'� .,'`• �U ' Gua:f/✓ `r' fa t.7f�.�.. /.J// ... v /[�/ /� ._• N..iLk-t�" f✓r'�if�/t�'�i } af��'�r�r� ��urF �- �jrfd.G/f�/S O(cli/�,• PyOiTNErp�` " . S G• C i r t ry :. O Sewage w Permit .number' ! s !m ' .`..i.... } } , [ i HAHd9TADLL. i 1$ House: number rs hJ' M 6y ., F T®WN : O BAR NSTA LE , * J ' . 1 � 'Y Y1 4 h UUI LOIN G �1N'sPECTOR` : i uct tt 14, X 16'' Addition " r > APPLICATION FOR PERMIT TO COri51rr E OF CONSTRUCTION •Wood - .: March 1 G q 74 •1 . t,� - - } v y s t _ i •fi..i+-'r��-t'y. n-' r....v.•i... 7 ;,r' r y. ,TO THE INSPECTOR OF BUILDINGS The .undersigrieds.hereby applies. or a permit,according 'to the'following information J , , t 1$ Grouse Lane, Hyannis Location' ...,.. .... ... ...... . ..... ....:. ' t , I} '•.n -' Dinine. and Fam:. v Ro,jamProposed Use . r � o .,.y.•• •• ..1. . . ... ' 1,^ `Zoning `Di'stricT .. .:: ...Fire District VanniS Name of, Owner SiGjTle +.Tile�11„Cl13se. Address,.. 18„GYot1sP L�3nt? RvTarnis ... ... Name. of Builder .David Camr�bell Address 95 FarndAI P Rd - Hvanni a Name of Architect None .Address ' s , Number 'of Rooms ....nn3F. . .. Foundation- C nnrratp Rl nrk 1 F Y Exterior, Pl;vwn�.....C,f/C'adr�r 4hti.nvlpc Roofing 4cnhAillf-.. rh�r�aloa td/Manor. to Ar , yak... - .- Floors SR 4: /RvAv P1vwreiri �u/rarnnteri �� l I'm 4. Pari"ol l ina• o yo0f� 1jin t•t•. V101+t'r$rr .(inah - tl 'r. S�7nnm a �3 - rieating Plumbing..... . ..... Fireplace tJnnc ... : Approximate Cost G7...nnn..nn. ...... Definitive Plan.Approved by Planning Board _ _. 19__ Are .. 2.. ...... .... o -Diagram Lot•and'Buildin with Dimensions'' " 4 9 . Fee ::v .. SUBJECT TO.APPROVAL'OF .BOARD OF `HEALTH n ":)cop h-+-w.-- --:.-�.a«:tip--^ -Y^ - ��+-tc.. `i a-.:e } .�i-r-'� ''n.+...t.. b._.,¢.7i! S. —+�--rs.`» ri�..�w:.+..�-..w• ,4.to .,'—...,- -•-s•: r , 1,hereby, agree toconform to all the Rules and Regulations of the Town of.Barnsiable_regardirg the above construction. 1 7 : Name k7r v r 4 � e Chase. Sidney & Eileen 71 No ...... Permit for ldditawn. ...... ........ .................................................................. ............ Location JQ...Qr.QW;5.e..Ln.....Hya=is................. ............................................................................... Owner ..Chase................... Type of Construction . ........................................ ................................ ................................................ Plot ..............I........... Lot ................................ Construction/. . /............... Permit Granted*.............Mar-0...1.4.........1979 Date of Inspection ............ .......................19 Date Completed ............... ......................19 PERM REFUSED .................................................. ..... t .................. .. .... .... .... .......... .......... ................ .... . . ........... .......................................... ................................................................................ ........................................................................ ...... Approved ................................................ 19 ............................................................................... ............................................................................... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ` EPTID SYSTEM 1W1jST p, Map Parcel 6 INSTALLED IN trmit# CON9pLggN Health Division N�i��I TH TITLE a e Issued �D Conservation Division - �� ` �'O�r°�° �kNT rI , ��+ u€ f°RfA Fee ��, Tax CollectorI a A Z Treasurerei ate De' ' ' d by Plarining Board istoric- Pres nration/Hyannis k Project Street Address / 6rVVs65 Ln Village Ilt 11 i> Owner Address' Telephone Permit Request la X aL Adc�,'H -Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Ut Size 1/3 ACTe- Grandfathered: ❑Yes ❑No If yes,attach supporting documentation. Jweiling Type: Single Family CK Two Family ❑ Multi-Family,(#units) Age of Existing Structure -30 Years Historic House: ❑Yes , it No On Old King's Highway: ❑Yes No Basement Type: 'dFull ❑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 IF F Heat Type and Fuel: &Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes N No Fireplaces: Existing J( New Existing wood/coal stove: ❑Yes ki No Detached garage:❑existing ❑new size•--�O Pool:❑existing ❑new size Barn:0 existing ❑new size Attached garage:❑existing ❑new size-0 Shed:C<existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes to If yes,site plan review# c Current Use Proposed Use BUILDER INFORMATION Name W 1 LLz', M ( �n f Telephone Number Address_3�f� � � S� 0 2 •License# Oaf-� 3 Home Improvement Contractor# r 0��9� Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO -� SIGNATURE DATE FOR OFFICIAL USE ONLY _ PERMIT,NO. a _ DATE ISSUED-: MAP/PARCEL NO. �, -I l- ADDRESS VILLAGE OWNER ' DATE OF INSPECTION: R FOUNDATION FRAME INSULATION= 'A k FIREPLACE F. )^fie.dap • - . e - . - _ - .e ELECTRICAL:, ROUGH FINAL PLOMBING - ROUGH FINAL. 1 GAS: ROUGH FINAL 4 FINAL BUILDING' -; 6 r, t DATE CLOSED OUT 4 ASSOCIATION PLAN NO. ' _ 3 IDEPARiNENi OF`PUBLIC SAFELY ON CONSiRUCiI '-SUPERVISOR LICENSE , �CPires. Birthdaie _ CS; 044013 O8/25/1449 08/25/142] 1 00 — - Restrictedio YIIIIAM RIM �„ _�eg8 6003EPQINT'RD CENiERVIIIE, NA 02632 HOME IMPROVEMENT'CONTRACTOR s gk Wstration''105592 �TYP6 ;INDIVIDUAL , ,T xpiration 07/20/00 � aILLIAM A RICCI �= 04 CAMP STREET 8302 YARMOUTN MA 02b73 ADMINISTRATOR a. TableJL=(eondaned) Ps eso pdve Packages for Qae and Two-Family itesideatW BaildlaW Heated with Fond Fuels , MAXEWUM MINIMUM Glazing Mooing Ceiling wan floor Basement Slab Hetriag/Coolimg Arm'(@A) U.value= it vaiol It-value wvaluea wail POtimeter Eguipa:tat Emdaw? Paslaw &vabrej &valuer 5701 to 6500 Headat;Degree DaW Q 12% 0.40 38 13 19 10 6 NormalS2 R 12% 0. 30 19 19 10 6 Normal 3 12% 030 38 13 19 10 6 85 AFUE T 13% 0.36 38 13 2S WA WA Normal U is% 0.46 38 � -19 19 10 6 Normal V IS-A 0.44 38 13 25 NIA WA 8S AFUE w 15% 0M 30 19 19 10 6 85 AFUE X 18% 032 38 13 2S WA NIA Normal Yrise/. 18-A M42 38 19 2S WA WA Normal Z12% 0.42 38 13 19 10 6 90 AFUE AA 030 30 19 19 10 6 90 AFi1E 1. ADDRESS OF PROPERTY: Af 6/4yL-.T�' Loy C 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING. 4. %GLAZING AREA(#3 DIVIDED BY 92): 1 s ° 0 d� S. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q•forms-t980303a w Footnotes to Table J5Z.1b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area, expressed as a percentage.Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area. Z After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table JI.5.3a. U-values are for whole units: center-of-glass U-values cannot be used. 3 The ceiling R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R 30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding,structural sheathing,and interior drywall. For example,an R-19 requirement could be met EITHER by R-19 cavity insulation OR R 13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. `The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing., Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ` If the building,utilizes electric resistance heating use compliance approach 3, 4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed'the eff ciency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5Z.I a NOTES: a)Glazing areas and U-values are maximum acceptable levels. Insulation R values are minimum acceptable levels:. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building"envelope must have a U-value no greater than 035. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value' in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35). c) If a ceiling,wall,floor, basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 �\ .. p � =.. The Commonwealth of Massachusetts 0 Department of Industrial Accidents Office 811AY85 8HONs 600 Washington Street -. ---- `� Boston,Mass 02111 — Workers' Compensation Insurance Affidavit iiiiiiiiiiii name: Al.," h4I{A4k /?f G C- t © n S� �/' n location I O � y iC ^/T city ,L/� At/N/ I �1 phone�! ❑ I am homeowner performing all work myself. . . 4I am a sole rietor and have no one worki>i in cap aclty ❑ I am an employer providing workers' compensation for my employees working on this job. cooanv nam . :;.....;::.;:.»;::;;: ::::::: ...........:.. ........................... . .. Biel$fees>:::::::::::>::«::;:<::;:: :::.:::::::NONE. :.::::::.::-.:.;::.;;>: ...... .:.:>..:::::>:.-.;:;:::::::>::>::::::::; ...... . nhane#.. ...> ::;.>;::;::;.;.::; .: 1hiukanee�a ...:.. ....::.::. ... ..: ... . . I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who the following workers'..compensation polices:...........................-....................................:................................................................................. ... .......... .:::::..:...............................................:........................................................:.........................................................:..::................::...............................".e.e ......................,:.:............... ..::s:.:::. ::::::.:::::::::::::::::::::::::::.::::.....::::::::::.::::::,-.I.:::.:::::::::::::::::::::%.....:...:....................:.........:...................:::. romoanv:name /`., _ ..... ........ r. > '' '` <» >ltes I. >::' sd ..........:.:.:...,...... :::::> ::::;;.;:.:.::::. ............................ :.:.:.:::..:::..::::::::::.;::.;::..::.::::::.:::::.:::::::::::;:.::.:. ::.::.:...... ..:.:...:... .:.::.,.:........... aw. •.'d:....t:�. .Y::... ::::>: 1. ::in.•::::..• :.:-.- •::.. ::.. ::::................................................. ....... . ::%::::: :��.•-.%- :.; .. IN' ::: ::Y.:.%:: :x:... :.�:::::.;:.;:.>:.;:.:;.i ::.: ::::::. .. :: ::. :::. :..: :::.;:.;:.-,X.--:: :::::.:::............: :::: :.:.... :::.:: on i-. %: v.................:........::.... ::.::::•.:::::•:•.::.::.::....: N. +'::: ::.y:: :: ;;:•. :::: �i:. :::..:•..�::r:::•.::..:..: .. ... ...... .... .............................................. t19'Branco.CD:...... ... A�1 #................ ... ..... ......3 ............ :: :: :::`.>r>: .::::: :.:<:::::.:::,:.::::.............:: //I% :::::::.:::.:..::::::.:::::.:.................................................................. :..:. '<>>><. . :.. address..:::. ..................................................................:::.....1. ...... :.�:...:::::::.. .......................�:.........::--:::. r. :. ..............................:*.....::.:.:. .........:.... 11 e. :: >:: ................. ::::::::::..::::.:::::.:::.:::::::.:::::::::::::::::::::::::..::::......................... • ..:.:•. ...... :.... .....::.�:..�:.�••:.:.:::.::.....................:.:......::.............................:....:.......... ... ...................::..:.:.....::.::::-:.:..........- ::::.::::.:.-..:.......................................:.:................. ex. FsOme to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of etimiasl penalties of a tine up to 51,500.00 and/or one yenta'imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a One of$100.00 a day against me. I understand tbst a copy of this statement may be forwarded to the OOice of Investigations of the DIA for coverage verlOcation. I do hereby certify under the pains and pen ' of perjury that flee information provided above is trrn and corned Date 6'-�- l^ ?^& signature _ a,/ o Print name V"(4-L'AA, / ( 1✓ / Phone# `7°?�^ `� 2 Z ofndai use only do not write in this area to be completed by city or town official • ` city or town* . perudWcense# QBuilding Department • ❑Licensing Board ❑check if immediate response is required . ❑sdectnen's ofam • _ ❑HealthDepariment contact person. phone#, ❑Other (revised 9/95 PJA) — s. 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,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 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 been presented to the contracting authority. 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 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. 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/liceose 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. MONN The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Me of Invesdoadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 ____ --� � �. � 1 �. a � 6 I �ll k � f (�U } �� � . ,�.:, -� - ::,. z' <, a:s ,a•;a: .z„ate ':.,, :- ::� .: .ab ... � � u� gym;{' .�.:✓�, .$_z � .�. `� �' '�ate• �,�., �:�ar*nsta�bI� q 3 _ • fun-Jun-99 .,. x , . =y k 3 gg 3b �s �N m\ 9� 6$ ah�:c oar. s1 , 'Rif -462°4 1 a" y \ v � `; �H•.�annis'MA� 260 z a y.: SHE O 6/18/99's x its F gqR ry F. BARNSI'ABLE CompaBy we c�� ess PA W E � O `' ,. + �' MASS. .. ,"; � :s ' y, � !6'fr9• sty StateF , Lip ork >bo�ge,j(500)790-8308 g 4 ' a u}�nber frEEl ma�l:¢ ap llescr►itron Srte Map �Com I trd.ra 0/18/99 File aerie m268p262 $3.00 "�•v a �� abo I'l oun U 0.0 ;,..�. $ 0 $0.00 ota1:- $3.00 Fmt Paic�i 3.00 eCei` t cit�.r�al a . 'd .x • ."sue,, ` s; "; n oF"E The Town of Barnstable BAMSTABM MAM Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: OIV A r)", Estimated Cost Address of Work: f Q- 4 rz„54.5 Lev Owner's Name: Date of Application: 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: Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav n _ P 268 STANDARD LEGEND c� DEUOIIOIKIlHS 1\ O FO6F W BRUSN .. # 2 OBOMRDD[NUIR[Y z. ..-✓ [ONIfE[OUS TICS MMSN A[FA n EOGE OF WAIEA bg MAP 2 6 - PMA�N6�IOT _ f--DRNHYAYS 21" ^ �APED LOAD owls ............ 4 , _ P[OPFAIY LINES E�MAP• ,-_.- _ _... 2FOOT MOtlA LINE TOFOOTCWMUNE X. 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