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HomeMy WebLinkAbout366A MAIN STREET (HYANNIS) ,,. _- - - - _ ��N - _ _-- Town of Barnstable Building Department - 200 Main Street BARNW"LE, * Hyannis, MA 02601 MASS. 9�A i63� . (508) 862-4038 rFo nn�°i r ifiOccupancy Ce t catsf o Application Number: 200902165 CO Number: 20080430 Parcel ID: 327002 CO Issue Date: 10/08/09 Location: 366 MAIN STREET (HYANNIS) Zoning Classification: HYANNIS VILLAGE BUSINESS DIST Proposed Use: RETAIL & SERVICE STORE SMALL Village: HYANNIS Gen Contractor: INTEGRITY HOMES SOLUTIONS Permit Type: CC00 CERTIFICATE OF OCCUPANCY COMM Comments: SUNNY DAZE Building Department Signature Date Signed �IKE> TOWN OF BARNSTABLE," ' Ading . Application Ref: , 200902165 Permit' BARNSTABLE, Issue Date: 06/02/09 9 MASS g Qp i639• Applicant: INTEGRITY HOMES SOLUTIONS Permit Number: B 20090894 ArFO MA'1 A Proposed Use: RETAIL&SERVICE STORE SMALL Expiration Date: 11/30/09 Location 366 MAIN STREET (HYANNIS) Zoning District HVB Permit Type: COMMERCIAL ADDITION ALTERATION Map Parcel 327002 Permit Fee$ 50.00 Contractor INTEGRITY HOMES SOLUTIONS Village HYANNIS App Fee$ 100.00 License Num 148541 Est Construction Cost$ 3,500 1 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND RENOVATION, INTERIOR FOR"SUNNY DAZE" THIS CARD MUST BE KEPT POSTED UNTIL FINAL ., INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: GEORGE,THOMAS N az ALICE TR BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 17 THACHER SHORE RD INSPECTION HAS BEEN MADE. YARMOUTHPORT,MA 02675 ^� Application Entered by: PR Building Permit Issued By: b THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLY OR:SIDEWALK OR ANY PART THEREOF,EITI-ER TEMPORARILY OR PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY;NOT SPECIFICALLY PERMITTED.UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION. STREET OR ALLY GRADES;AS WELL AS.DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM•THE DEPARTMENT OF PUBLIC WORKS..: THE ISSUANCE OF THIS PERMIT DOES NOT.RELEASE THE APPLICANT FROM THE CONDITIONS OFANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTSTRUCTION WORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE THROAT LEVEL BEFORE FIRST FLUE LINING IS INSTALLED. I WIRING&PLUMBING INSPECTIONS TO BE COMPLETED PRIOR TO FRAME INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY TO LATH): 5. INSULATION. 6. FINAL INSPECTION BEFORE OCCUPANCY. ' WHERE APPLICABLE,SEPARATE PERMITS ARE REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL THE INSPECTOR HAS APPROVED THE VARIOUS STAGES OF CONSTRJCTION. PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOVE. PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). rir , I pa BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 0 C 1 1 2 2 2 / / �� a 3 © [C' 1 Heating Inspection Approvals Engineering Dept Fire Dept /O�j/b� 2- Board of Health jjl �Y-u �1HE tp� Sign TOWN OF BARNSTABL Permit * BARNSTABLE. 9 MASS. 1639. 1 3�Aim Permit Number: Application Ref: 200903266 20070352 Issue Date: 07/27/09 Applicant: Proposed Use: RETAIL & SERVICE STORE SMALL Permit Type: SIGN PERMIT Permit Fee $ 50.00 Location 366 MAIN STREET (HYANNIS) Map Parcel 327002 Town HYANNIS Zoning District HVB Contractor PROPERTY OWNER Remarks 10 SQ FT SIGN FOR SUNNY DAZE Owner: GEORGE THOMAS N & ALICE TRS .$ Address: 17 THACHER SHORE RD YARMOLITHPORT, MA 02675 Issued By: DB rx. POST THIS CARD;SO THAT IS VISIBLE FRR THE STREET' ow�NE T 'Town of Barnstable Regulatory Services + BA 04SPABLE, + v MAsB. Thomas F. Geiler,Director �'pTFo;A� Building Division Thomas Perry,Building Commissioner 200 Main Street, Eyannis, MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 SIGN PERMIT REQUIRENIENTS L.. A photograph showing the existing facade, on which has been indicated the proposed sign Location..The photograph is to include a portion of adjoining stores or building. For a proposed building or new facade, an architect's elevation may be submitted in lieu of a photograph. 2. A scale drawing of the proposed sign. A scale drawing indicating: 1) The type of proposed sign (wall, hanging, free standing) 2) Dimensions of the proposed sign and any designs, logos, or lettering 3) A cross-section with dimensions showing edge detail. Minimum scale 1"= 1'. Minimum sheet size, 8.5 x 1 i". 3. A scale drawing of the bracket. A scale drawing indicating dimensions, color, materials and method of affixing it to the sign and to the building. Minimum scale 1"= 1'. Minimum sheet size, 8.5 x 11". 4. A completed Town of Barnstable Sign Application, including scaled diagram showing location of sign on building or location of free-standing sign. Show dimensions. 5. The width of the building face. NOTE: the map/parcel number is required on the application. I „ KP Town of Barnstable ,�f�"�'°wti Regulatory Services �P O Thomas F. Geiler,Director + BAR`7STABLE, MASS. $ Building Division i639• °TEo ,y a Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 ww-w.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Permit# �� Application for Sign Permit 1 - Ali Applicant: t Map & Parcel�#91 21 Doing Business As: 5ungy AZ e, Telephone No. P'SOV -ZUS-10(5 y Sign Location Street/Road: 3(n(0 A Aho ti A synn;S� 01(co J i! Zoning District: Old Kings Highway? Yes/No Hyannis Historic District? Ye)No Property Owner, Name: h 9 , &O-Ore4if . Telephone: 1-50i - 160.2-(C' v(0 AddressA Thochue c��K�' P� �d� �fR�'m�-t paYiVillage: Sign Contractor ; Name: t�V C ie l( Telephone: Sd$'r1 7S-;t'S01. Mailing Address: 6% CeA+'r &t Anl1 *19 n d0►V1n 1 S MA U2foo Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Yes/No (Note:If yes, a iviring permit is required) Width of building face ft.x 10='1 x .10= Sq.Ft. of proposed sign 1p � I hereby certify that I am the owner or that I have the authority of the owner to make this application,that the information is correct and that the use and construction shall conform to the provisions of§240=59 through §240-89 of the Town of Barnstable Zoning Ordinance. / -7 q Signature of Owner/Authorized Agent: ) W Date: t L1 " 4 Permit Fee: v Sign Permit was approved: Disapproved: Signature of Building Official: Date: In order to process application without delays all sections must be completed. 0:1TYPFILEnSI GNnS1GA'APP.DOC u rr J �'°'Ink- ;I too swe 600<01 T v -- x f t�� 1 I� .... .. ... lo Hyannis Main Street Waterfront Historic District Commission as�AIHLZ 200 Main Street n+ s Hyannis,Massachusetts 02601 TEL: 508-862-4665 /FAX: 508-862-4725 Application to Hyannis Main Street Waterfront Historic District Commission in the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, in triplicate, for the issuance of a Certificate o Appropriateness under M. G. L. Chapter 40C, The Historic Districts Act for proposed work as described below and on plans, drawings or photographs accompanying this application for: PLEASE CHECK ALL CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building ❑ Addition 4—Alteration Indicate type of building: ❑ House ❑ Garage Commercial ❑ Other 2. Exterior Painting: ❑' 3. Signs or Billboards: E�9-New sign ❑ Existing sign ❑ inting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole E!�Other �-� 5. Parking Lot: ❑ New Building ❑ Addition ❑ Alteration (Please see the guidelines for explanation and requirements) TYPE OR PRINT LEGIBLY DATE S �z ASSESSOR'S MAP NO. ASSESSOR'S PARCEL NO. �` APPLICANTT TEL.NO.,5�'r��—�7D APPLICANT MAILING ADDRESS I ADDRESS OF PROPOSED WORK a ,tmA colol PROPERTY OWNER � n TEL.NO. - '�c OWNER MAILING ADDRESS FULL NAMES AND MAILING ADDRESSES OF ABUTTING OWNERS.include name of adjacent property owners across any public street or way. This information is best obtained at the Town Assessor's Office. (Attach additional sheet if necessary). AGENT OR CONTRACTOR EL.NO. ADDRESS DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done, including detailed data on such architectural features as: foundation, chimney, siding, roofing, roof pitch, sash and doors, window and door frames, trim, gutters - leaders,roofing and paint color, including materials to be used, if specifications do not accompany plans. In the case of signs, give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). (01 1► Signed Owner-Contractor—Agent (CIRCLE ONE) SPACE BELOW LINE FOR COMMISSION USE Received by HMSWHDC [QF�Iq.�RESERVATION This Certificate is hereby 0�L, �� A� Date t D AY Signe WN OF BARNSTABLE IMPORTANT:If this Certificate is approved,approval is subject to the 20-day appeal period provided in the Ordinance. CONDITIONS OF AP OVAL: Barnstable Hyannis Main Street Waterfront OpT"e r°'+� Historic District Commission All-AmMuCity 200 Main Street BARNSTABLE Hyannis, Massachusetts 02601 v MASS. g Phone: 508-862-4665 / Fax: 508-862-4784 i67q. ♦0 Argo , a www.town.barnstable.ma.us 2007 George A. Jessop,Jr. AIA,Chair Marylou Fair, Commission Assistant SPECIFICATION SHEET FOR SIGNAGE • Prior to filing your application for a Certificate of Appropriateness, please contact Robin, the Town's Zoning Enforcement Officer, at 508-862-4027 to discuss the amount of signage allowed for your building, as well as any other Town Sign Code regulations which may affect the signs)you propose to install. • Even if you are applying for the same amount of signage as previously existed on your building, the laws may have changed since that sign was installed. • Once you have applied to the Hyannis Main Street Waterfront Historic District Commission for a Certificate of Appropriateness for signage, you may apply to the Building Department for a temporary sign permit. The Building Department can provide all information regarding the temporary sign permitting process. • Please fill out all information requested below. • If you are applying for Certificate of Appropriateness for more than one sign, please fill out ONE SPECIFICATION SHEET FOR EACH SIGN. BE SURE THAT YOU HAVE INCLUDED WITH YOUR APPLICATION: • a scale drawing of the proposed sign • color chips for all colors on your sign • a photo or scale drawing of the building on which the proposed sign location, as well as any light fixtures proposed to light the sign, are indicated • a scale cross-section of the sign, with dimensions, showing edge detail • specifications for any light fixtures proposed to light the sign • a scale drawing of the sign bracket, indicating dimensions, color, and material Size of sign X Material(s) of sign' AA f C� �� -- ( c C �J M W (� Weo I Material of Lettering (if different) c The Sign will be (circle one): carved wood ante d vinyl lettering other (explain) Location in which the sign sill hang Will there be exterior light fixtures to light the sign? If so, what type of fixture? 2 1.2009 Where will the fixture(s) be located? J y-�� i BARNSTABI-E HISTORY,PR_ *y n r:µ hT x I� APPROVED way mil. ' TOWN OF BARNSTABLE BUILDING PERMIT,�APPLICATION„ Map "- J� , . Parcel`C �, ut`'. � A licatior # >16 PP Health bivision `� �, ,� �� Date Issued 7i Conservation Division �;a � ��� Application Fee Planning`Dept: :'Permit Fee Date Definitive,Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address -SLL(Q A Jqa-;o MA ��;i VillageK: Q: Owner ddress Telephone Y- — Z- ' a9 , )" " ct�-F Permit Request Zh kv,Ldrz._ ra n is Kq L L.G �Z �L Square feet: 1 st floor: existing 1 w roposed 2nd floor: existing proposed O3 —A Total new 1� -�-- Zoning District Flood Plain Groundwater Overlay .ad. Project Valuation _39�d� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting�wdocumentation. Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(# units) Age of Existing Structure � Historic House: ❑Yes &Io On Old Kin ` s�Highway: ❑Yes Ud"No Basement Type: Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) YlovLL Basement Unfinished Area if ) 1 I Number of Baths: Full: existing 1�uhrt new Y1by� e_ Half: existing new Number of Bedrooms: \,,i existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: Y Gas ❑Oil ❑ Electric ❑ Other Central Air: U/Yes ❑ No Fireplaces: Existing MLNew Existing wood/coal stove: ❑Yes 0 No Detached garage: ❑existing 0 new size—Pool: ❑existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: A _ Zoning Board of Appeals Authorization ❑ Appeal # 13 Recorded ❑ Commercial V<es ❑ No If yes, site plan review# Current Use 31ra ' Proposed Use rintvl to%—cam `7G=� ��a,�rc�tk,���- L rZG�o•�� — APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ZcUaD gerkL4M Telephone Number 7741— T5 S Address Rv5' scwa/e z �e License # D Lll 1I` VA7.?r-5 Home Improvement Contractor# JY cf LZz If Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO bAgv1e,%.-b1 e 4,1 F'LL SIGNATURE DATE 'I 02 - v 'AW FOR OFFICIAL USE ONLY 5, APPLICATION# DATE ISSUED e. MAP/PARCEL NO. ADDRESS VILLAGE { . OWNER r DATE OF INSPECTION: FOUNDATION FRAME a r, INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL FINAL BUILDING z f DATE CLOSED OUT ASSOCIATION PLAN NO. 1 l 1 i I �? ��� ✓1ie T�anairnoouueaccsa o���UGctddcr�uQe%6 i. " BOARD OF BUILDING REGULATIONS st b' 4 License: CONSTRUCTION SUPERVISOR n � Number CS 094193 . Birthdate 0712971977 sty LL 'l Expires 07/29/2009 Tr.no: 0-0 f RICHARD J PECKHAMJR 99 PINES AVE PO'BOX 1269 � �i CENTERVILLE, MA�0260,1 Commissioner S, I — - Town of Barnstable Regulatory Services BARNGrABr LE$, Thomas F.Geiler,Director fnµ9. 16 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize h lG 7r ?eC k k RW to act on my behalf, in all matters relative to work authorized by this building permit application for: Ma t n S n n i5 A� 6 7-6 r (Address of Job) fi na Owner Date Print Name If Property Owner is applying for permit please complete.the Homeowners License Exemption Form on the reverse side. Q:F0 RMS:0 WNERPERMISSION Town of Barnstable of t�toly Regulatory Services BA,WS.,BM : Thomas F. Geiler,Director MAss Building Division lED µA't Tom Perry,Building Commissioner 200 Main.Street, Hyannis,MA..026.01. vt'ww.to wn.b arnstab l e.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOrkIEOWNER 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 Persons)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 homrQvmer. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other . applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that,he/she understands the Town of Barnstable Building Department minimum 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 sectign.(Section I D9.1.1 -Licensing of construction Supervisors);provided that if the homeogmer engages a persons)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 lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a)icenscd Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/hrr responnbilitics,many communities require,as part of the permit application., that the homeowner certify that hrIshe understands the responnbilities 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/cerdfication for use in your community, Q:forms:homeexempt y 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 Legjbly Name(Business/Organization/Individual):)7 j evV/1 1, 5 Address: ac1Y _5ev41alc-q ,tye- City/State/Zip: �ii/?l O (oe� Phone.#: 7 71- ' Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I ❑ g 1.❑ I am a employer with 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors -2.X I am a sole proprietor or partner-' listed on the attached sheet. 7.. Remodeling ship and have no employees These sub-contractors have 8.'❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 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 employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *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. If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimnial 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 may be forwarded to the Office of _Investigations of the DIA for insurance coverage verification. I do hereby certf under the sins and penalties of perjury that the information provided above is true and correct. Si ature: Date: �� O Phone#: 7�/ Official use only. Do not write in this area, to be completed by city or town offlciat M City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their.employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or tiustee of an individual,partnership,association or other legal entity,employing employees. However the a dwellin house having not more than three apartments and who resides therein,or the occupa nt of the owner of g g P 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 bommonwealth nor any of its political subdivisions shall . an contract for the performance of public work until acceptable evidence of compliance with the insurance enter into y p p P 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-contiactor(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 perm-tVlicense 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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia eDEP-MassDEP's OnlineFiling System bttps:Hedep.dep.mass.gov/Pages/PrintReceipt.aspx �a MassDEP Home Contact Feedback I Tour i Privacy Policy Wa sDEP's Online Filing System Usemame:INMGRrYHS Nickname:R2J2W My eDEP I Formsol My Profileb Help Receipt 1 Forms Signature Payment• Receipt Summary/Receipt 1 print receipt t IExit Your submission is complete.Thank you for using DEP's online reporting system. You can select"My eDEP"to see a list of your transactions. DEP Transaction ID:242200 Date and Time Submitted:5/22/2009 9:58:59 AM Other Email Form Name:AQ'06-Construction/Demolition Notification . Payment Information DEP code:38356 Date:5/22/2009 9:57:54 AM Amount($):85 Payment Detail:--AccountType--AccountNumber****1416 ConfmnationNumber: Contractor Contractor Number Name Address,, Supervisor Project Monitor Lab My eDEP MassDEP Home I Contact I Feedback i Tour i Privacy Policy MassDEP's Online Filing System ver.8.7.4.00 2008 MassDEP 1 of 1 5/22/2009 10:04 AM eDEP-MassDEFs OnlineFiling System https:Hedep.dep.mass.gov/Pages/Payment/Pay.mentConfirmation.aspx MassDEP Home I Contact I Feedback I Tour I Privacy Policy MassDEP's Online Filing System Usemame:INMGRrYHS Nickname:R2J269 My eDEP I Formsol My Profileb Help Transaction Overview Trans#242200 ID#100088668 AQ 06-Construction/Demolition Notification Forms Signature Payment Submit . Payment print$- F�cit Payment Confirmation Thank you.Your payment has been recieved. Note:Payment recieved after 3:30pm will not be posted until the next business day. MassDEP Home I Contact l Feedback I Tour l Privacy Policy MassDEP's Online Filing System ver.8.7.4.00 2008 MassDEP 1 of 1 5/22/2009 10:03 AM L7�1Massachusetts Department of Environmental Protection Bureau of Waste Prevention • Air Quality 1100086668 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition Important: Applicability Il When filling out A. `7 forms on the computer,use only the tab key A Construction or Demolition operation of an industrial, commercial, or institutional building,or to move your residential building with 20 or more units is regulated by the Department of Environmental Protection cursor-do not use thereturn (DEP), Bureau of Waste Prevention-Air Quality Control Regulations 310 CMR 7.09. Notification of key. Construction or Demolition operations is required under 310 CMR 7.09(2)ten (10)days prior to any work being performed. The following information is required pursuant to 310 CMR 7.09. B. General Project Description 1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied Instructions residence of four units or less?❑Yes ❑✓ No 1.All sections of b. Provide blanket decal number if applicable: this form must be Blanket decal Number completed in order. to comply with the 2. Facility Information: Department of SUNNY DAZE LLC. Environmental Protection a.Name notification 1366 MAIN ST. requirements of b.Address 310CMR7.09 h annis MA 02601 c.C' /Town d.State e.Zip Code (508)245-7670 f.Tele hone Number area code and extension .E-mail Address(optional) 1,500 1 h.Size of Facility in Square Feet i.Number of Floors j. Was the.facility built prior to 1980? ❑✓ Yes ❑ No k. Describe the current or prior use of the facility: TATTOO PARLOR I.-Is the facility a residential facility? ❑ Yes ❑✓ No _o m. If yes, how many units? Number of Units �0 3. Facility Owner: _N THOMAS GEORGE -o a.Name 0 17 THACHER SHORE RD b.Address YARMOUTH JIVIA OF2601 co c.C' /Town d.State e.Zip Code �c (508)362-6960 f.Telephone Number area code and extension .E-mail Address(optional) _d TORI WASHINGTON �Q h.Onsite Manager Name ® ag06.doc•10/02 BWP AQ 06•Page 1 of 3 L7�1Massachusetts Department of Environmental Protection Bureau of Waste Prevention •Air Quality, 100088668 BWP AQ 06 Decal Number Notification Prior to Construction or Demolition General Statement:if B. General Project Description //Cont. asbestos is found during a 4. General Contractor: Construction or Demolition IRICHARD J PECKHAM operation,all responsible parties a.Name must comply with 204 SCUDDER AVE 310 CMR 7.00, b.Address and Chapter HYANNIS MA 02601 Chapterer 21 E of the General Laws of c.Citvfrown d.State e.Zip Code the Commonwealth. (774)836-6654 This would include, f.Tele hone Number area code and extension .E-mail Address(optional) but would not be TORT WASHINGTON limited to,filing an asbestos removal h.On-site Manager Name notification with the Department and/or a notice of release/threat of C. General Construction or Demolition Description release of a hazardous substance to the 1. Construction or demolition contractor: Department,if applicable. IRICHARD PECKHAM a.Name 204 SCUDDER AVE b.Address HYANNIS MA 62601 c.CitvfTown d.State e.Zip Code (774)836-6654 f.Telephone Number(area code and extension) g.E-mail Address(optional) TORT WASHINGTON h.On-site Manager Name 2. On-Site Supervisor: RICHARD PECKHAM On-Site Supervisor Name 3. Is the entire facility to be demolished? FI Yes ✓® No N �0 4. Describe the area(s)to be demolished: �0 NONE �N �O �0 5. If this is a construction project, describe the buildings)or addition(s)to be constructed: INTERIOR, FREE STANDING WALLS,8FT IN HEIGHT. -o �o �d I �Q ag06.doc•10/02 13WP AQ 06•Page 2 of 3 • Massachusetts Department of Environmental Protection _ ■ Bureau of Waste Prevention .Air Quality 100088668 - Decal Number BWRA 06 Notification Prior to Construction or Demolition C. General Construction or Demolition Description (cont.) 6. a. If this is a demolition project,were the structure(s)surveyed for the presence of asbestos containing material(ACM)? ❑ Yes ❑✓ No If yes,who conducted the survey? b.Survevor Name c.Division of Occupational Safety Certification Number. d 7. Construction or Demolition: 05/19/2 09 07/01/2009 a.Start Date(mm/dd/yyyy) b.End Date(mm/dd/yyyy) 8. a. For demolition and construction projects, indicate dust suppression techniques to be used: ❑ seeding ❑ paving b. If other, please specify: ❑ wetting ❑ shrouding ❑✓ covering ❑ other 9. For Emergency Demolition Operations, who is the DEP official who evaluated the emergency? F- a.Name of DEP Official b.Title c.Date mm/dd/ of Authorization d.DEP Waiver Number D. Certification M 1 certify that I have examined the IRICHARD J PECKHAM JR =o above and that to the best of my a.Print Name �o knowledge it is true and complete. The signature below subjects the b.Authorized Signature �N signer to the general statutes . BUILDER/OWNER �o regarding a false and misleading c.Position/Title �o statement(s). JINTEGRITY HOME SOLUTIONS d.Re resentin e.Date(mm/dd/yyyy) -------------- �O ® ag06.doc•10/02 BWP AQ 06•Page 3 of 3■ 1 Rick Peckham Jr. Roofing&Siding V . _qntEgT ty 4�omF ,-Sofuti.onj Strength in Quality Lic#094193&Insured Building,Remodej'ig P.O.Box 1269 Window's,Basements Centerville, MA 02632 (774)836:6654' R A fS l� � � `y1\J ' B --- r y 1 e S _� I • J a _ 30 i - Tu �/i�► DevLiiv DEV05 SCKLET���j�t�r 'T` APPROVED BY: DRAWN BY t -=--`- HATHA , H . REVISED DRAWING NUMBER