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TOWN OF BARNSTABLE BUILDING PERMITAPPLICATION
Map , Parcel // L mSEPTIC SYSTEl141 yU1USTPermit# �<�5
y INSTALLED IN ' EE
Health Division C®IlIIR
�a��•♦ � LIAIs7��lssued
�;. WITH TITLES f ,
Conservation Division d XL ENVIRONMENTAL CQDE
�.
Tax Collector �. . .� �o� %IN
Treasurer
Planning Dept.,
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
�� I tc•>9
Project Street Address 3 i If y
Village 1161 In
Owner y9l ee l Se,�` Address 3 `�
Telephone 3 - q? 2-7
Permit Requests f Re..- ,elle t, 5�-eYc -,xc_ . ` Ae��,:
Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new
Estimated Project Cost 1 0g0yo Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: O Yes U No If yes, attach supporting documentation.
Dwelling Type: Single Family 2r'- Two Family ❑ Multi-Family(#units)
Age of Existing Structure l `7 570 Historic House: ❑Yes . L P4u-- On Old King's Highway: ❑Yes —to
Basement Type: •mull aTrawl ❑Walkout ❑Other
e
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: �s ❑Oil ❑Electric ❑Other
Central Air: ❑Yes Qf�fo Fireplaces: Existing l New Existing wood/coal stove: ❑Yes Erfqo
Detached garage:❑existing ❑new size Pool:❑existing ❑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 a o If yes,site plan review#
Current Use 5,., `�. �+./ 1,9/�c. Proposed Use �
BUILDER INFORMATION,,
Name qbsSetf 6 Telephone Number -5 4� -5 2 2 7
Address 3 gl.A< rp_4 License# f-S-L. 60 1 g.s
yl G��:t��ywYLdi�� rlsl a 6?S Home Improvement Contractor# %Yid
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO ' � �
SIGNATURE �.CB� �/[t DATE
Y FOR OFFICIAL USE ONLY ..
PERMIT NO. '
_ r
DATE ISSUED'
MAP/PARCEL NO,.-
ADDRESS VILLAGE
OWNER t r +
DATE OF INSPEC'ItI
x FOUNDATION !
FRAME'T 4I`' <
INSULATION r
i' FIREPLACE"yy' "
ELECTRIG,4107% C ROUGH FINAL
PLUMBING: 'ROUGH FINAL }
GAS: 3 :ROUGH FINAL
a FINAL_ BUILDING
.. DATE CLOSED OUT
ASSOCIATION PLAN NO. c r
. j n
_� The Commonwealth of Massachusetts
---.. - Department of Industrial Accidents
OJ�ca of/01/eSrigatiOHS
Jd
600 Washington Street
"Boston,Mass. 02111
Workers' Co m ensation Insurance Affidavit
�����
C �2 % 0 A �
name:
location
city
t�l'✓Vg, hone#
Ef I am a homeowner performing all work myself.
❑ I am a sole rietor and have no one workingin any capacity
r //O//////%/////%%/////%
rovidin workers' compensation for my employees working on this job. : :;:;: :;::>:::.
❑ I am an employerp ;;g::.:.:: .:.. :.::: :.:;..:::.:;::;:::;::.
tour anv name:
address.
ci :. oX.
ne
: :.. ::::::.
insurance co.
a sole proprietor,general contractor homeowner sir le one)and havehired the contractors listed below who
workers' compensation polices:
the following w mP .... .::: :P
wm anvname. .
::.> :;:.:::.::::::.::...................
::..:.::::::.:....:...:::. :::::.:::::. .:...
::: ::..
address. ::,......,.:,..,..:....:.:.:.. _::... . ..... MEL
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''fie# '0 I.
.......RON. .... . .....
............................................................................................................:::::::::::::::::::::......................................................................................................
...............::::::::.........................................................................................................................
.........................................................................................................................................
................................................................................................................
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::.;:.;::;;:<.;;:::.;;;: ;:.;::.:....:.: ion
............................. .
li _
or
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a thm up to understand
th"and a
one yeah'imprisonment asb well�divil penaides in the forut to the Once of InvestigationsofaSTOP
of the WORK
ORDER
and a crag�r�ftlon of 00 a day against ma I mtderstand that a
COPY of this statement may
1 do hereby certify a pains and penalties of perjury that the information provided above is tru,and correct
Signature Date
Print name �(JSS Phone#
Mail
2111
official we only do not write in this area to be completed by city or town official
perimiUHcense# ❑BuildinDe
city or town: ❑Licensin❑Selectm❑checkif immediate eesponse is required ❑Health
Other---
(contact person•
phone#; - ❑Other
(tensed 9/95 PIA)
TAbJL7.Ib( md)
press ivdve Packages for One aad TwaFimilT Reaidmdai Boildlags Sated with Fosot Fuck
MAXIMUM bla"m M
ahzing cilasiag ceiling wall Floor g slab H '��g
'('K) u-..Wn & due' R.Vziw Rrv,lua, w.0 P� EM�r' -
Pasklae Arvdue' R►rdua'
5701 to 6500 Heads;Dcq;m DmW
Q 12% 0.40 3E 1 13 19 10 6 Nomml
It 12% am 30 19 19 10 6 Nomm1
s IrA 0.50 3E 13 19 10 6 85 ARM
T is% 036 3E 13 23 WA WA. NmmW
U O46 3E 1 19 19 10 6 Na=W
r ..r I ivol .-...
w am 30 19 19 1 to - 6 U AFUE
X IE�/. In 3E 13 • 25 1 WA WA Namw
T IEY. 0.42 3E 19 #25 WA WA Nomml
Z 19% 0.42 3E 13 10 6 90AFUE
AA Iv/. 0.3o 30 19 10 6 90AFUE
1. ADDRESS OF PROPERTY:
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS:
3. SQUARE FOOTAGE OF ALL GLAZING:
4. %GLAZING AREA(#3 DIVIDED BY#2):
S. SELECT PACKAGE(Q —AA-see chart above):
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
BUILDING INSPECTOR APPROVAL:
YES: NO:
q-forms-080303a
i
The Town of Barnstable
sniuvST"LE,
9�A Department of Health Safety and Environmental Services
rFnMara 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: {' V�o�� Estimated Cost 4
Address of Work: 3 At Le S
Owner's Name: &ed A' 6 ttbDw
6 Z0
Date of Application:--
i
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
❑Job Under$1,000
❑Building not owner-occupied
[]Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the a t of the owner.
Date Contractor Name Registration No.
OR
Date Owner's Name
g1orms:Affidav
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HOME IMPROVE_ C�ONT �CT;O c
a -MENT i RA RS,hREG1�.5TRA.TI0P1
Board f Buildin` "`.,E
:`; 'k ti,y"; ,, - 94z,Regulati.ctns aTnd Standards" I,'r,,;1;>c �, rk ,,, r �< Y 4 .,1 ' r
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E T CONTRACTOR
'tri r %RlJSSELI ;bA "G' BSON,JRr{ t f, i ,,4ti�f Y 1 �� 'IuV ,'4Registrat so tJr,� �. a � s ' ` . EzP T. n 07/I4%QARN M " � �� �` I t u OU�HRORT• 2 }�,f ; ` � � ..r: 1 a, l -, `a:� , c
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r 4. .FRussell A fiI son, Jr.
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d1�MID PINE
{�ADMINISTRn7oR YARMOUTHPORT MA 02615 �