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Home My WebLink About0048 LINDA LANE �� c/� �I �� ao sd3 y Town of Barnstable *Permit# 4` y� Expires 6 months from issue date Regulatory Services Fee BnxxsTABM Asa $1639. Richard V.Scali,Director �� ,eTFD�p Building Division Tom Perry,CBO,Building Commissioner®P ES PM Il 200 Main Street,Hyannis,MA 02601 PER MY JUN 08 2015 Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENVALOON300STABLE Map/parcel Number c2 Q Not Valid without Red X-Press Imprint Property Address [jp4esidential Value of Work$ <,q Q , Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name C 6 Y/o/�&� Telephone Number Home Improvement Contractor License#(if applicable) 17K I Q Email: Construction Supervisor's License#(if applicable)- C S -0 4 G ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner have Worker's Compensation Insurance _ Insurance Company Name Workman's Comp.Policy# Vj C�-Li L)D^ 7 0>z) ?,�< — Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ` ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Lit p(� Q jw� [O'Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: _ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc., ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is equired. SIGNATURE: Q:\WPFILES\FORMS\building permit fomis\EXPRESS.doc Revised 040215 07 Ka;fa a,-A M;r t t .T t`�FSIt�T�rfiarFr Fncrrr�nrs� r aztf-. s�rZ¢rsc ��Lt 4Th*rrfi-vrS aiT U l "Z • �a•e�sit em�Itrgsr? i� �bcrs T ��i�� = -- I' L1 1 ata a e�p7�y�r �_ 4 •❑ I=iaV=mia=fm=fcr=d t r��csYees{�nI1�€�Part-�ns�_ ❑ I mm a sole gt r arFazf3fr- hsied cm The sbff&t 7- ❑ ng ship Eud harms no em£alcsyees have g- g su ng-for is airy aa3.have wogmz€' n°�-m=eata�$ 4 ❑- B= mg adtTifim 5. ❑ We ate a catFmcEiiam=ff ifs 10-0 i=�ar ad3iti. ❑ I mn a homwwxzcr doiv,-aUvmk aff=zsh&va cm=isea$cr I ping�asus ar �s =Y-,elf INp '=rP- 35�ofM=MFfi6aFVrMGL M]I?nufmp ids t irecLl I t`I5Z�1(4} adW5hmam c=3p- nx[aamcLj �� ; r�s�Vdm- u i ffipy cm dam..,III--T f,—Wm o¢dri&rDntcKrn=mmt so asrnr mo H tkt b�m� r�m x iff T sheet 6e m3-tEdP• $y95g 5�+ a�3vyePs_Ifi a�h cm��ac r�I�seQs,ffieg�t gmaide 8!k woes'erg_po3icg�mbe� isn t if pmiffmg mrkers'cnu far t$�eaIayass BeIata is ffiepocy mid jab.sda T Gotttattg �+�+a FaitnM{a sMMM 2M=TifEAUnCTCr SeCfbD-sA ofNiM r-152 lmd to the impar t=arrrimntal peas of a ig-��aSMFMRYC�ana$� of•ap t �5Q-oo a�a�fhe vicidn Be tat a copy offfiiz maybe arwacdod ta Ifie OfEce of T �t;rxrc of ffie DID�r couer�ge - , - - •I�.��P rt�rx' 17, �} S Gay ar TOW= L Board o-€�ca�2.Bing � a�a c�� .Ise�icalF�ec#nr �.PhmzhFn�T��ecfr,r I.,L-m cEagtcr 152 req=m aH mqIoy=to prods 'ca n f3r 6=7='PIDY Z. PrCa—tea$gs y an mvpL7y=is daflued as=--=Zy pion M.foe spice of gmn�ffider say=mt-act'bf hae, 4 e�pre�cFr implied, oral or tom" An mph7yar Is dcfiamd as uk1 mancba1,p ,==Bkom,coTDIEd=m der lenal=±Et3l,or aCT tV7O Or more v - offf3e foregoing=gam m a joint and ill, iffi legal rnF=mtdiv=of a decried eimployq-or the receives ofr trustee of en .pztamzhrp,am-Dc�ron or other legal emtty,employing employees E'DV5Ver the 047n=of a.d fftnghouse havingnotmore ffim flee apmtmmds and who resides ti=aem,or file occngant of the dwelling house of ancsther-Who eangIoys peEsons to do M3fitMMICe gDnalxvoi km or repair work on sorh ChYCHi ag house or on file grounds or bu2c mg appnitraart$eadu shag not bmm=of mrh employmeat be deonceed to be-an.employer." MCE ch�I52, §25C(6)also staffs thAt'evmy state or local licensing agency shall wifiihold ffie issuance or r mewal of a B=t.se or pewit to operate a business or to construct butld'm.gs in fhe cnmrnonwralth for any _ppHc=t�lito.has notprnduu d xcmptable evidence of coi Hance with the insIIT"4nmcoverage requireCh' Adff±im z y,MCA chapter M,§25C{7)sistcs=Teithm -fe commmwmhbt nor any of impolitical subdivis-'D= shall euj=iiztn nay fie prance ofpublic wo until acceptable evidence of conrplisnce with�ile m „ce r,-_( e emts of this chapter have been pmmttd to$>e coming auto orrty.- A.gplican Please:Ell ot± the wu�ers'c=pmsaiion affidavit completely,by chug tire.boxes that apply to your siturtion End,if ne SSaIy, S pply sUb--con me Dr(s)narnc(s), ad3ims(es)alldpll®C Tn eS(s)along FY�1 ffi:ir cez a e( .0= ;nsr ce_ Limited Liabay C on3pames(LLC)or T=ItcdLmbE*Parhzmm4s(LU)wfino emplo3'=S other than the members or partners,are notnxFdrsd to cant'wa&='compensation io ace- If an LLC or LLP does have employees;a policy is regtmed_ Bc advised that this afndavitmay be submitted ti)the Department of Indus iial Acxidrmts for canfrrmation ofn+�;Mnce coverage Also he sure to sign and date the affidavit The affidavit shout-d be retained to,the city or towz that the application for the pence orlic: n is being reguested,not the Department of Ind Accidents. Should you have any gnrsOT C reo r t�e I aw o-T iEyDu are regns�d to obtain a�rorkers camp=sation policy,please call the Department at the nran.ber Es elf below. Self-fi sored companies should enter their self-m mom=license number on tie sggropriAr,line. CTIty or Town Officials Please be sure i h the affida is ccnuplei�and p 3legr�ly 1�e Department has provided a space of the brit a ofthe affidavit for youln fiIl out in the event file Office o+ ; n.;�has in conlaCtyoureg�ding�e applicant :.: Please be sure:to fill in the P m m it/i; =member which wM be used as a-r mfermce number. Iu aaiLitio3z an aPplicant e en need o snhmit one affidavit indicating current e "ee�s Ii>xiions in >�y I emziflh yam, n� �Y�that must submit p app _ a locations m or and mob Sim Address'the - Iir.�t should write'all (�3' policy infornmfion(ifnetxssary)and � aPP . town)."A copy of the affidavit that has been officially s upped err mz06 d by the city or town may be Provided.-to The applicant as proof that a valid affidavit is an file for fvtnre pmmits or licenses Anew affidavit must be tilled o-ut each year_Where a.home owner or citizen is obtaining a license or pewit natrelah d to-any business or commercial Yeatiue Cie,a dog licem r,or permitto bum leaves etc.)said person is NOTrec u to complete this affidavit The Office of InvcSigations would hkC tD ihankyon in advance fDryour coop=ation and shouldyouhave any.questions, please do not hm tat c to give ns a call_ The Departmemf's addrmss,t nlcphone and faXnumb=:: `- aI commmru7 1.caf I as hu s .Direr caf Indus±�al At-� _ C IAG21II Q�±4766 ur I 477 hLA SAFE. . ' RevL-err 4-24-07 -. . . OT 9� MASS. ,�� Town of Barnstable .erfD�p Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.ba rnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder I,��1'►r�G� ( • c C,/OKG�%� �' , as O eft of the subject property '►.4Ve&7 SC* it AA hereby authorize S0c'Vep) L. l fr L C o A- to act on ray behalf, in all matters relative to work authorized by this building permit application for: 98 L rwo* CJWe. (Address of Job) Signature of Queer 0lL.'7� �'�'� Date Print Name /t7.h.-4014t /?yAr6-4-4 — If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORWbuilding permit forms\EXPRESS.doc Revised 040215 Town of Barnstable Regulatory Services oEIKE TAfy,` Richard V.Scali,Director I. Building Division ly • r ' a r * s MAS& Tom Perry,Building Commissioner 16,59. �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# . CURRENT MAILING ADDRESS: 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) w 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 inspection procedures and requirements and that he/she will comply with said procedures and requirements. 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 do 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 Iack 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:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 040215 No. of ealth . LETTERS OF AUTHORITY FOR Docket 542EA Common The Trial Court Massachusetts PERSONAL REPRESENTATIVE BA14P1 Probate and Family Court Estate of: Barnstable Probate and Family Court 3195 Main Street Frances E Scioletti PO Box 346 Also known as: Frances E Scioletti Barnstable, MA 02630 Date of Death: 08/16/2014 (508)375-6710 To: Daniel C Scioletti,Jr. 500 Ocean Street,Unit 152 Hyannis, MA 02601 I You have been appointed and qualified as Personal Representative in ❑ Supervised ❑X Unsupervised administration of this estate on October 29,2014 (date) These letters are proof of your authority to act pursuant to G.L.c. 1906, except for the following restrictions if any: ❑ The Personal Representative was appointed before March 31,2012 as Executor or Administrator of the estate. ■ (Do Not Write Below This Line-For Court Use Only) ■ CERTIFICATION I certify that it appears by the records of this Court that said appointment remains in full force and effect. IN TESTIMONY WHEREOF I,have hereunto set my hand and affixed the seal of said Court. �s Date October 30, 2014 Anastasia W Perrino, Register of Probate MPC 751 (3/31/12) Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-049879 STEVEN L MEL1^ 199 PERCIVAL DR W BARNSTABL$ 6 �c. Expiration Commissioner 05/22/2016 Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991m)of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.Gov/DPS ✓!ie-�amirnovuuea�i o�./�aaaaclu..aelta Office of Consumer Affairs&B°siuess Regulatiou License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:; ..1.17610 Type: Office of Consumer Affairs and Business Regulation Expiration:_;10/.25/2016 Individual 10 Park Plaza-Suite 5170 a ST 'EN L. - -= '{ Boston,MA 02116 STEVEN MELLORl� =="=a _=' 199 PERCIVAL DR .. W BARNSTABLE,M402668 Undersecretary Not valid without signature Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee �, ,o0 rThomas F.Geiler,Director Building Division ® Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 o�C www.town.barnstable.ma.us TOl% 1 200 Office: 508-862-4038 FvftAA 0-6M EXPRESS PERMIT without RI APPLICATION Press Imprint ONLY t �Srge N F [ap/parcel Number \ t � roperty Address 1 ),$esidential Value of Work Minimum fee of$25.00 for work under$6000.00 owner's Name&Address d��\� �� y�► Q—� 'ontractor's NameREk-A-, '�' CA, Te ephone Number [ome Improvement Contractor License#(if applicable)_ 's-hizem-v*(-if-aappheabk) ]Workman's Compensation Insurance Check one: VL1am a sole proprietor u I am the Homeowner ❑ I have Worker's Compensation surance ssurance Company Name V�' Vorkman's Comp.Policy#_ ;opy of Insurance Compliance Certificate must be on file. -ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Z, -Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Ov t sign roperty Owner Letter of Permission, A copy of o e Im r -im=e is required. IIGNATURE: !:Fomu:expmtrg .evise061306 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers'*Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly, Name(Business/Organization/lndividual): . Address: City/State/Zip: e�c u v�� ' Phone.#: Ste` vZJ Are you an employer?Check the appropriate box: .Type of project(required):. 1.&1 am a employer with 4. ❑ I am a general contractor and I * • have hired the sub-contractors 6• ❑New construction . employees(full and/or part-time). Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑ g ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] ' 3.❑ I am a homeowner doing all work . officers have exercised their 11.❑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 13.❑ Other 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. (Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Ifthe 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:TP__Av le S• Policy#or Self--ins.Lic.#: C,Q l Expiration Date: Job Site Address: A,c �A,4- ��-- City/State/Zip: \ ANK c Attach a copy of the workers' compensation policy declaration page'(showing the policy number A 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 v' lator. Be advised that a copy of this statement may be forwarded to the Office of Investigations e DIA for ins a e vera a erification. I:doereby rti and a pen 17 that the information provided ab a is tr a and correcfore: - Date: Phone# � � �`t"C 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): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: intorination anct 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 withthe 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-contractor(s)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 Offi ev of Investigations 600 Washington Street Eostonx.MA 02111 Tel. 617-n7-4900 ext 406 or 1-877-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov/dia Town'of Barnstable Regulatory Services BnxrrsreBM * Thomas F.Geiler,Director fp 91. p� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-403 8 Fax: 508-79076230 Property Owner Must Complete and Sign This Section If Using A Builder I ,as Owner of the subject property hereby authoriz to act on my behalf, in all matters relative to work authorized b7 this building permit application for: (Address of job) f l Signature of Owner ate Print Name Q:FORMS:OWNERPERMISSION Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Reg'strat'ion Exp�ratior�' 11/28/2008 Tr# 125453 c - Type',:Intlluidual DEAN F.STANLEII DEAN STANLEY " 359 CAPT.LIJAH RD CENTERVILLE,MA 02632 Administrator Engineering Dept.(3rd floor) Map Parcel 06 c Permit# � House# ' Date Issued Board of Health(3rd floor)(8:15.-9:30/1:00-4:30) Fee d, —. v D Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning De s floor/School Admin. Bldg.) �TME ip; Definit' e PI A ro/ved by Planning Board 19 • BARNSTABLE. MASS QEDM.se$ TOWN OYBARNSTABLE Building Permit Application Project Street Address / /hJ�i9 l�•� Village J40 d9'u^j,S Owner A�� 1)914 641my" Address ,Telephone Permit Request Xe zsl:; yev c. First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ 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 FRASER CONSTRUMI�QN Telephone Number Address 71 TARAG®N CIR. License# COTU IT MA 02635 Home Improvement Contractor# 112,:Q 6 (508) 423-2292 Worker's Compensation# 4&e7/2/S Yf2)3g 3.6/ '7 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 i�2dZ/ f'I I SIGNATURE DATE / / A�f BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) q FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. �' `"` r�4 ' "'.• b.;`_a •yam, �`-: `"- ADDRESS VILLAGE "w OWNER _: `"; M j ^, • t DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING E DATE CLOSED OUT ASSOCIATION PLAN NO. - �'�"� ✓� V/al�t/17Z49ZUleQ►.LUL, O�i.i��Q,Q6�tf�P�4 J ow HOME IMPROVEMENT CONTRACTORSrREGISTRATION Board of Building. Regulations and"`Standards s '" I. One Ashburton Place Room 1301 . t Boston Massachusetts.,` HOME.' IMPROVEMENT CONTRACTOR y ' K `� r ------ Re istration' 112536 `;`. 4' ` rT 1 g Expiration 04/06/99 [ TYP@. _ :DBA _HONE IMPROVEMENT CONTRACTOR Registration 112536 FRASER CONSTRUCTION DEAN C . ERASER ' +_ � � �� TYPs - �DBA � . r1 its?' r s T s M 3 Expuatiaa; 04/.06I99 71 TARRAGON CIR . COTUIT MA 02635 ERASER CONSTRUCTION C. FRASER aoLMSTRM,ow 11 TARRAGON CIR L COTUIT NA 02635 The Commonwealth of Atassachusctts Department of Industrial Accidents �.+,_ l Office01111 stiyatioas ._ ;.il' = -�` 600 lVaslrin��tun Street Boston,Man. 02111 Workers' Compensation Insurance Affidavit �nitc�nt rnfnrmation• .,/.�; �__ ._� Please PRINT'leb._..�-��_...__._.._ .._:..._. -..----z--_r..:._.._:.__::_ name• r locitson• `1 1 T►�� OCCY-) / l�Z =i!)' l D± )1 /Y?/q . phone# 0 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity L::.:d'a.�.."`m'w ' -`"°'"."'' '-?pt'"' er�.vr7'^'ti'4'SF"-'•rA"`s�1': ..3.�vT7 I am an employer providing workers' compensation for my employees working on this job. • r company MAW: cox)sArwc.,+l address: 17 l / /gtz vK G�1 ax . may: Co phone#• . insurance co &,z� III&I Ja- policy# r .. ..,,,.. .-....,. i....,► ..., y..��1+ ' ,x;�•r-...yr •",�+s!T++�.wwsirmr., .o.rr�.........rs tu..w,+= S .. .. ..:.: . ,. �._ :- _v..._..•.,+..:.. :::e c....-.-.. .....:: ..ems.:. •ram.. s .b'_ _ 1 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 n•rne• •(ldress• may• phone#• insurance co Policy# ., .� _.. ,.,,:rn:. �:+��•ee-a—r.s....,-T•rr.^'c^a '�=^;r-;�.'r!^*.�?, rd�3*Ar.�• ,..,, .•..:?4y'••,o.test,-•re-.e..•...._.•,� !....�...::.:..mot_. ..._.._...:..sea• - -.:+.�•� '�A'C'.._ _ 3i�Fa:7 •?c/�r''S6`.. ._it ..c��N��.a.rr.xuc company name.- address: city phone#• insurance co n4licy# _.. r. :Attac_h addihonal sheet tt necessa "��r -- �+ tr s«� ;= _._::,r3. .7a_77 :;t.:»',, ,,•_ r'''W' `.. "'�-.:" _a!x,. ..� :.. r.<.,�_.._. Failure to secure coverage as required under Section 25A of AIGL 152 can lead to the imposition of criminal penalties of a fine up to SI.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. I do lierehr certif t/re aims d erralties of perjuq•dial the information provided above is true and correct. Signature Date .. / r/h g Print name ---C>et00J C' # Echeck ly do not write in this area to be completed by city or town official permit/license# nBuilding D7�d QLicensing mediate response is required QSclectmen's Oce r QNealth Department ' n• phone#• rlOiher �A.>..�e,• - '""'.,•�'°"""•.".� (revised 3,95 PJAi Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted loom the "law", an emphtme is defined as every person in the service of another under anv contract of hire, express or implied, oral or written. An emp/nt,er 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 `rounds or building appurtenant thereto shall not because of such employment be deemed to be an emplover. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or rencival of a license or permit to operate a business or to construct buildings in the commonwealth for an), applicant aho 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. - ,..ti__......_,..,_.........—,..........mo w..--._...... -i � N' ..: •• ,L_,7_ .7. . _.- � . . 7. . �7: . d": ---� '. 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. Citv 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. - 77777-77777 w.ncew� 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 } The Town of Barnstable • �ernB�. • Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 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: Estimated Cost v Address of Work: / 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 a ply for a permit as the agent of the owner: 45� F,4 De Contractor Name Registration No. OR Date Owner's Name q:fortns:Afftdav