HomeMy WebLinkAbout0172 IRVING AVENUE c��
Town of Barnstable
�. Expires 6 months from issue date
Regulatory Services. Fee� J 1 _�
snrwsraBt a Thomas F.Geiler,Director
.m� Building Division —
prfD
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
Not Valid without Red X-Press Imprint
Map/parcel Number ,,� ? V3 —/
A
Property Address �t� �tit ri Aeti u� h r T
residential Value of Work ao 0 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address f't
..SA—r"e—
Contractor's Name Of LT 0A07- Iry(- - Telephone Number 3 7 LF 771P
Home Improvement Contractor License#(if applicable) J F
MW"orkman's Compensation Insurance XPRFSS
.
Check one: APR
2 20Q$
❑ I am a sole proprietor
❑ I am the Homeowner ��� ®�
have Worker's Compensation.Insurance -f
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
2/Re-roof(stripping old shingles) All construction debris will be taken to da-,-n J'/k, Of- j Cal-
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum
*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 icenw -1 uired.
SIGNATURE: 4i
QAWPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia '
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APPUcant Information / Please Print Le bl
Name(Business/Organization/Individual):
Address: ,rr le
City/State/Zip: (1"�e/ailt`e 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
. employees(full and/or part-time).
s have hired the sub-contractors 6. ❑New construction
2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g• 0 Demolition
working for me in any capacity. employees and have workers', , 9 Building addition
[No workers' comp.-insmance comp.insurance J
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 11.❑Plumbing repairs or additions
myself[No workers' comp. right df exemption per MGL 12.64'00f repairs
insurance required:]t c. 152, §1(4),and we have no-
employees. [No workers' 13. Other
comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'cornpensation 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
ttontractors that check this box must attached an additional sheet showing the name of the sub-contractnrs and state whether or not those entities have
employees. If the sub-contnactors have employees,they must providt 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.#: Q, Expiration Date:
Job Site Address: 7� y/n �/U City/State/Zip: glt,no 4,1r24
Attach a copy of the workers' compensation policy declaration page(showing the policy nnzber and expiration date).
Failure to se'cure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crim�rial penalties of a
fine tip 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 maybe forwarded to the Office of
Investigations of the WA for insurance coverage verification.
I do hereby certify under a paws•and enalties of perjury that the information provided above is true and correct
Signature: G'rLt Date:
Phone67
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 representative's 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 numbers)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
(Le. a dog license or permit to btim.leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would lice 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 Cammonwealth of Massachusetts
Depar mont of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 4-06 ar 1-977-MASSAFE
Fax# 617-727-7749
Revised 11-22.06
www.mass.gQv/dia
RightFax C1-2 4/23/2008 8 : 58 : 36 AM PAGE 3/003 Fax Server
ACORD. CERTIFICATE OF INSURANCE DATE(MM\DD\YY) 04-23-08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
EDWARD A GRAZUL INS AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
PO BOX 337 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
MARSTONS MILLS,MA 02648
COMPANY
28Y2K A HARTFORD GROUP
INSURED COMPANY
B
R L T CONSTRUCTION INC
COMPANY
31 MANNI CIRCLE C
CENTERVILLE,MA 02632 COMPANY
D
COVERAGE
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE
AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY
PAID CLAIMS.
CO POLICY EFF POLICY.EXP
LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE(MM\DD\YY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
CLAIMS MADE OCCUR.. PERSONAL&&ADV.INJURY $
OWNER'S&&CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE(Any one fire) $
MED.EXPENSE(Anyone person) $
AUTOMOBILE LIABILITY
ANY AUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS BODILY INJURY(Per Person) $
SCHEDULE AUTOS BODILY INJURY(Per Accident) $
HIRED AUTOS PROPERTY DAMAGE $
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTOS AUTO ONLY-EA ACCIDENT $
OTHER THAN AUTO ONLY-
EACH!ACCIDENT
AGREGATE-_$
EXCESS LIABILITY `
UMBRELLA FORM EACH OCCURRENCE $'
OTHER THAN UMBRELLA FORM AGGREGATE ;$3
WORKER'S COMPENSATION AND
A EMPOLYER'S LIABILITY UB-1051CO45-07 12-24-07 12-24-08 STATUTORY LIMITS X
THE PROPRIETOR/ EACH ACCIDENT -� $ 100,000
.
PARTNERS/EXECUTIVE X INCL DISEASE-POLICYrIf4�IT $ 500,000
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE 100,000
CD
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS
THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTQVG WORKERS COMP COVERAGE.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE.ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
TOWN OF BARNST'ABLE � _ EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
ATTN:BUILDING DEPARTMENT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY
200 MAIN STREET KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
HYANNIS,MA 02601 AUTHORIZED REPRESENTATIVE
ACORD 25-5(3/93) Ramarll Ayer.
`i . Board T.
uilding Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registra Qn,L 134286
Ex iratro Q0/22/2009 Tr# 133426
RLT CONST. INCo DB.-!ISLAND S.IiDI.NG&ROOFIN
RONNIE TAYLOEt ! �
31 MANNI CIRCLEjC
i CENTERVILLE. MA 02362. L. Adinims,,rator
f
• License or registration.vaLd for individul use only
i
before the-expiration:date If found return to:
Board of Building Regulations and Standards
j One Ashburton'Place Rm 1301
Boston,Ma.02108
r .
t ji e without signature.
w •.
)4,? ° 3 Isfandsidw` g oo
and�. fing
.9 3 " 9
a division of RLTConstruction,Inc. -
September 14, 2006 n
Mrs. Dempsey
172 Irving Avenue
Hyannisport, Ma. 02647
--We are:_pleased:to.:submit the following specifications and estimates for reroofing ^
Strip existing asphalt shingles and flashings
In new aluminum drip edge and pipe flashings
Install 3 ft. Ice&Water Shield to eaves, interwoven w/step flashing on cheeks& skylights
Install 151b. roof underlayment to remaining roof
Install 30 yr or 50 yr. architectural grade shingles
Clean up and haul away all debris to landfill
We hereby propose to furnish material and labor- complete in accordance with the above
specification,for the sum of.
For 30yr. $28,000.00,Fo SOyr. ' 1,000.00, or ice shield on entire roof a d $2000.00
PAYMENT TO BE MAD
Payment in full due Upon Completion
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner
according to standard practices. Any alterations or deviations from the above specifications involving
extra costs will be executed only upon written orders,and will become an extra charge over and above the
estimate. All agreements contingent upon strikes,accidents,or delays beyond our control. Owners to
carry fire,wind damage and other necessary insurance. RLT Construction,Inc. carries General Liability
and Workman's Compensation Insurance. Certificates of Insurance provided upon request.
ACCEPTANCE-OF PROPOSAL: The-above prices,.,spccifications and conditions are
satisfactory and hereby accepted. You are authorized to do the work as specified.
Payment will be made as outlined above.
Date.of Acceptance: �a x Signature .
Start Date: Signatur*,a,614,
31 Manni Circle Centerville, Massachusetts 02632
Telephione 508.420.5243 and 508.833.5249 .fax 508.420.1776 Enmi(caperoofer@caperoofer.com
�oFt lo�ti Town of Barnstable *Permit#
yVP O,� Expires 6 months from issue date
` Regulatory Services Fee* sARTtsTABLE, �
9 MASS.
c� i639.. Thomas F.Geiler,Director
prED1"°`p Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038
Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number t�)Y 7(D-?
Property Address U)yk�s. O -Q #V-,YV ks Pd a
. T
CS-Residential Value of Work ro 0-0
Owner's Name&Address 17'1/421.`Qy?-1 S- tsl
Contractor's Name ::Elg A-c.3 1f!2, c"L -+ Telephone Number cy a lclj� —10 2r
Home Improvement Contractor License#(if applicable) l I :S_ 6
Construction Supervisor's License#(if applicable)
9SWorkman's Compensation Insurance
Check one: X-PRESS PERMIT
am a sole proprietor
fl I am the Homeowner MAY ' 9 2002
E 'U have Worker's Compensation Insurance
Insurance Company Name 4G, L+-& a C LTOWN OF BARNSTABLE
Workman's Comp.Policy# - / Y
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to cJ�lyC Ct-�t C�1
❑Re-roof(not stripping. Going over existing layers of roof)
❑ 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
t
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION R
rt;
Map Parcel Permit# Q 0
featlyGmsion Date Issued
r -
Fee
Tax Collector
Treasurer
Date Definitive Plan Approved by Planning Board
Hinter G QKH P-weeoakg npis_ =
Project Street Address
Village YftAII 'AMF
Owner _Alm Address 50 i 4 r�7
Telephone — 6 d
44fb
Permit Request
Square feet: 1st floor:existing proposed 2nd floor: existing proposed Total new
Estimated Project Cos Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered:' ❑Yes ❑No If yes, attach supporting documentation,
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) -
Age of Existing Structure" Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type:. ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new -
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas . ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New ,Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing 0 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 kNo If yes,site plan review#
Current Use ,Proposed Use
BUILDER INFORMATION
Name C 722_i if MF-- �/�+ Telephone Number --��J
Address 16 CL / 1661 T1JW L License# �S d N '7
Cat- AM k G 3 5 Home Improvement Contractor#
Worker's Compensation# fi� S�a(o
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO a
SIGNATURE DATE
. F
3 FOR OFFICIAL USE ONLY _
PERMIT NO.
2• _
DATE ISSUED
MAP/PARCEL NO.
441 -
ADDRESS , ;t ' VILLAGE # `
OWNER`
w
DATE OF INSPECTIOI • j -
FOUNDATION
FRAME _ #
t
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL f —
PLUMBING: ROUGH +. FINAL{ '
GAS: 'ROUGH FINAL' ti b
I FINAL BUILDING-
DATE
DATE CLOSED.OUT
h` ASSOCIATION PLAN NO.
®1 Window & Door *I c� Prime Products • Pa of
. r-•r.�aVE
AN . Order Form Harvey Industries, Inc. 725 Huse Road Manchester, NH 03103233e
Dealer Name count ll Ship Via Delivery Request Dale Ordered
U Warehouse Truck U Standard
Address U Factory Direct U Special Cust. P.O.
r U Factory Pickup
L ►P� _ U Pick up at
'� Ordered by
Job Name
(Delivery Area) lC/G
Window Specifications: Interior Exterior Glazing: Scre�en: Bay/Bow j
j Type- / . Size:,/ Color: Color: Cl gear /h'Hall
j �,�n' Yl-� enln �7 l to-Whie -While ow la Full U DH
Angle: Flankers: Wall Depth: Veneer
" y( p 9 E U CSMT U 100 U VY U 4 9/16"(STD) Interior:
O Wood U Buck U Almond U Almond U Low-E Argon U None •
iI U Center DH " Cl 30 U 1'9" U Other U Oak
U Aluminum U TTT U Bronze U Med.Bronze U Obscure U Center PW U 450 U 2'0• U Birch
U Stock U Pine U Dark Bronze U Special Temp. Grids:
Sash Type: U Catalog Size U Oak Frame: U Other U Colonial In-Glass U Multi-point lock U 2'4
O Mpchanical U Oaktone U Replacement U Colonial Snap-In (p of tiles)
r 'U'Welded U Nail Fin U Diamond In-Glass
COMMENTS:
ProductQuantity
•. glass-bottom
'Eli
S v 3 E,3 /77 Tc Q oT'lp� 9 sc v ► Q__
I. ✓� —� 3 G/LA/ry 9 r—oorvl
--�
a o 9 sc y r
II
II Vinyl Pallo Doors
Colonial
Quantity Size Style Grids Glazing Color
O Standard
U ,Low-E
U Argon
U Bevelled
I Q
/ Wall
Depth Hardware Prep
Wood U Brass U Mulll•poln'Locking
O Stainless system Includes custom
Deadboll Steel Wheels pollshed brass handle
I '
`. Customer Signature:
The Town of Barnstable
9 KAMM& Department of Health Safety and Environmental Services
r ; ►�� Building Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
// Est. Cost �� ��Y
Type of Work: ( f�� �' / • ��
Address of Work:
Owner's Name -
�J
Date of Permit Application: _L_ 1
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
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:
Dat �Y Contractor Name Registration No.
e4 P I,
OR
Date Owners Name
_ i ne
Department of Industrial Accidents
.e # _— MC$911bresdooffoss
- !- 1 600 Washington Street
- v- ,
Boston,Mass 02111
— Workers' Com ensation Insurance Affidavit
name: r�
location: /oZ
city hone# 7S- Afo2_�>
❑ I am a hd=wnrz pm-forming all work myself.
❑ I am a sole et or and have no one rkin in anycapacitv
y///Jr
I am an employer providing workers' compensiii ati n for my employees working on this job.
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insuratrce ca. ;C M .... ...: .. bolicv#: (/�✓ 5Y� _ _
❑ 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:
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Psis to seems coverage b required under section 25A of MGL 152 can lead to the imposition of crbuai penalties of a tlae up to s1,500.00 and/or
one years'bnprisonmmt as well as civil penalties in the form of a STOP WORK ORDER and a 8ne of$100.00 a day against me. I understand tbst a
copy of this statement may be forwarded to the Omce of Investigations of the DIA for coverage verincadoa
I do hereby cce�errt wider the pains
�a d penalties of peerjury that the information provided above it tru,anY.zqq
Signature L%�Z zc�/,a %I � '// /t'Cz _i-s Date
u
Print name C loEz!(� 6�- l2"�S,f H �L-OAP1 22 one Ph # '/�e— 9,_1�5
offidai use only do not write in this area to be completed by city or town official '
city or town: . pendulicense# � • ❑Building Department
❑chock if in mzd atc response is required ❑L�g Board
❑Sdn�aen's Office
_ ❑Health Department
contact person: phone#; Other
Uemed 9195 PJA)
i
• f ✓he Lominzarzcaeat a��/l/lczJJacfiuteGi-I F\'
OEPARTi1ENT OF PUBLIC 3AFETY
!i CONSTRUii1ON SUPERVISOR _iCENSE
Number K�i.es:
5 CS 00145�' a2i24(2000
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ReglsEratlon L00T40 - 1645 NEWTOWN RO
TpePRIVATE CORAORATION '� '.I COiUlT, :NA 02635
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W,YCAPIZZ:I HOME IMPROVEMENT, INC
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s DMI�TRATOR 1 45 Newton
��� Cotult MA 02635 x 3
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DEPARTMENT OF PUBLIC SAFETY
( � 1 CONSTRKTION'SUPERVISOR LICENSE
Number: Expires:
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THOMAS`Xt CAPIZ'zI 1R
7iriV'280 PERCIVAL 0R
;I W BARNSTABIE, NA 02668
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Number.:_-y_ Expires: '
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Restricted To 00
FREOERICK V RASCH IIi
ey'�/1060.80.URNE RD,
i PLYMOUTH, NA 02360
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'Engineering Dept. (3rd floor) Map Parcel Permit#
M House# Date Issued 3 �/ 7
Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30)'� ',-t0+`/e�< Fee
(4th floor)(8:30-9:30/1:00-2.00)
A��[!(1st floor/School Admin. Bldg.) SEPTIC SYSTEM MUST E, '
JDJ- A ed by Planning Board ' 1 -
" BARNSTABLE.
ENMON
TOWN OF BARNS 6 nON
rFD MPS
Building Permit Application
Project Street Address
F
Village air&NA:5n Yt
Owner u(L,0. /Spu Address
Telephone �5704 l4
Permit Request r2ILL ;
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ 4Z:
Zoning,District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House ❑Yes ❑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
No.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 -
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review# -
Current Use Proposed Use
/ - Builder Information
Name �jZoy WA-t(S Telephone Number 394J—/Z0S—
Address Cry License# 4/4 N-Ll7
5� Y V"m n Home Improvement Contractor# /0 S/7`j
Worker's Compensation# (fBk /co-2q,4
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO S �L
SIGNATUR DATE
BUILDING R E E FOR E FOLLOWING REASON(S)
4
a�y7
FOR OFFICIAL USE ONLY
PERMITINO. "
DATE ISSUE '
f
MAP/PARCEL NO. r -
ADDRESS .VILLAGE
'OWNER
DATE OF INSPECTION: '
=... �, r. � - ^' � ,.-t' w. .� f mow. '•
FOUNDATION
FRAME'
INSULATION in ix>.
ca
FIREPLACE
ELECTRICAL: N ' FINAL _ z.
" . 1co`7. �, FINAL
PLUMBING: C
01
GAS: Q FINAL r
FINAL BUILDII -
w Q ` - - -
DATE CLOSED OUT s t µ
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ASSOCIATION PLAN NO.
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The Cot11t1tomveafth of Alassac•huscM
a_i! -;--_:=�;_�- Dcpart»tcnt oj1»rlustrial.9ccidents a
;;, bi office ol/nyestigat/olds >
600 N aAhi ton Street
4 Boston. A1u.Ys. 02111 .w
Workers' Compensation Insurance Affidavit
--' __.r'_ ..._P 1 ;,'• ,. .,.� -- - -
name;
location; ! 4c,,e
--��
cityVa V hon•# VC
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
._.•. .._.......... L.r--P^ �Y N.YY •Y.:x1T^s�nn:+j•.S.nt�f> PTA .!!`�T.=A'a.al..w.s+�Rs�sr++.w•.w.a+.-+�..�al� +`M.._._t.,�„—Y....�.. ...
.......... ,..... .i .r - ..�..r ...cam.:.-.r...... - .�.c.:�t.•" �.-..�.........__�._......_._
1 am an emplo/Iveaar provi ing workers' compensation for my employees working on this job.
com ianv name: tJ
address:
d'V t� G�
cih•: /Y VUIc phone#•
insurance co. i—eos t noiiev#
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 nnmc:
address:
city: Shone#•
insurance co. nolicv#
� .. ..••iu-..-:... .yam^.__.._..._.....1,.;�...,r._•...._�..__ __ - _n;�P —a•..c,nva.. _ .. .o--�....
__..____.... .._ ._.�_—....._. -I.l:..✓�Y.�r...w..a��.rr1Y-..w.w.J�:vi.r..r�r __ - Z� � _._r��.iO�Y- .Y—___
company narne:
address:
city: phone#:
insurance co. noiic� #
Attach additional sheet if neccssa ,-�. _�_ - ^'_-�_ —•-�*""' -� � _ ;� ••"''" 4;•`,�'�--�• `�; "• -
---•' ----.... .--'----•- •----�.:..��. :.,.�.z._�_::r :ti•:.=�_ - .�:�s:s?sue �•.x• -�.�s�,.=•� �ir•�.,t:_:a..:w_:...:+s.
Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a line up to 51.500.00 andiur
one�cars' imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of MOM a day against me. I understand that a
cope of this statement mnv be forwarded to rile Office of Investigations of the DIA for coverage verification.
1 do herebv eery' the pa' s and penalties ojperjun•that the information provided above is true and Corr let.
Si^_natu c Date ,/77
Print n eIL1411' Phone# !,`7T -2O
�.,....:.r.�..•
'olTicial use only do not write in this area to be completed by city or town official '
city or town: permit/license# MBuilding Department'
[3Licensing Hoard _
rr D check if immediate response is required EJSelectmen•s Office
k [jIlealth Department "
contact person: phone#: 1`101hcr E::
Information and Instructions . "
Massachusetts General Laws chapter 152 section 25 requires all emp lovers to provide workers' compensation for their
enployees. As quoted from the "law". an empinree is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An emplt�rer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more cat
the foregoing enzaged 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
d\\•cl line house of another who employs persons to do maintenance , construction or repair work on such dwelling house
or on the .:rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that even, 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.
A6ditionally, neither the commonwealth nor any of its political subdivisions shall enter into anv contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter ha\':
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 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. Tile 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.
Ti-.e Office of investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to uive 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
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
I
The Town of Barnstable
NAM ,$ Department of Health Safety and Environmental Services
� Building Division
367 Main Street,Hyannis MA 02601
OT= 50"0-6227 Ralph Glossa;
F= 508-775 3344 Building Commissioner
For office use only
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c 142A requires that the"reconstruction,alterations,renovation,repair; On,conversion,
irnproverneru,,x=cn-1, demolition. or construction of an addition to any pre-Cdsting Owner Occupied
building containing at least one but not more than four dwelling units or to structures which are adlacerd
to such residence or building be done by registered contractors,with certain eooepdons, along with other
tzgttirzmentL
Type of Work: I Est Cost 64 Z:0-
Address of Work:
Owner.Name: /VLF.✓� S
Date of Permit Application:
I hencbv= fv that:
Registration is not required for the following reason(s):
Work excluded by law
Job tinder SI,000
Building not Owner-occupied
Owner pulling cam permit
Notice is hereby gi♦en that: ;
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITHUf1ItEGIST D 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•.
6"AA
Date contractbr name Registration No.
OR
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S YARMOUTH, MA 02664
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ADMINISTRATOR tiOn Ave s ;r _:.
yS Yarmouth MA 02664'
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