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HomeMy WebLinkAbout0010 NEWSPAPER ROAD �� ��. ��� m� r THE TOWN OF BARNSTABLE .Permit No. 33053 • BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash �► HYANNIS,MASS.02601 Bond ...... ........ CERTIFICATE OF USE AND OCCUPANCY Issued to John Falacci Address Lot C, 10 Newspaper Road Hyannis, Mass. USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. August �i....... 19.....90........ .......... .../.��..,�..�........ Building Inspector . ..� °.. TOWN OF BARNSTABLE BUILDING DEPARTMENT = asaaeTasc % TOWN OFFICE BUILDING � rua i i639' HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by BuildingPermit #.......... .................I......................... , ............... ...... .._................. .»................. .. ........ issued to ! ... ..................6 . ........ -............... Please release the performance bond. tr.t' .. '•A.� >r n va✓- ..�. a7• fs Rm 'rii 1Wr"Wdll'•'r-�..T ' r..w-..•• . .:4':''. .y.'•,.r..';';: ,.f,;:..!. rr�iaY. r t�'�Y.:%- R "T: cast• ?'��i1=*1H' >�'rbi.^,M'Xt�"'R'R" � � u � ERMIT ..FBARNSTABLE, MASSACHUSET BUILDING =L5.3-012-003 39 DATE 19 PERMIT NO. TQ T John Ilat7iAPPLICA � - ADDRESS OU1.02b, (NO.) (STREET) _ !CONTR'S LICENSEI PERMIT TO Bulls dWC111L!6 ( J ) STORY J1..b l e a-omii-✓ dwelliT1E NUMBER OF 1 DWELLING UNITS (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) 10t C 10 Hyannis ZONING RC I t AT (LOCATION) // DISTRICT_ (N0.) (STREET) NC_7ULp>ja.�TL, )(' BETWEEN t/ AND (CROSS STREET) (CROSS STREET) SUBDIVISJON LOT j LOT BLOCK SIZE BUILDING IS TO BE FT. WIDE BY FT. LONG BY F.T. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION ! TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION ! • - (TYPE) REMARKS: aLW?'(: i�89--.!i)L B _D AREA OR _ .VOLUME 1}:SiSA;iC�• ifi. ESTIMATED COST $ �J'0I, FEEMIT l3S.G0 (CUBIC/SQUARE FEET) .JOa?', P':i. ^.i OWNER - ADDRESS U. JL;Ltb:),f_'Cl �.a. I :1.'..el:!. p :`li BUILD ING DE PT. BY ��•FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANTFROM � ' p TINEIOND OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL INSPECTIONS REQUIRED FOR APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR 1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REINSTALLATIONS.PLUMBING AND 2. - MECHANICAL PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. OCCUPANCY. POST THIS CARD - SO IT IS VISI13LE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTIOWAPPROVALS-' I b1► P1 2 2 3 HEATING INSPECTION APPROVALS •� ��— ENGINEERING DEPARTMENT Sv �z7- ja GcJAit/�it. OTHER /� BOARD HEALTH WORK SHALL NOT PROCEED UNTIL THE INSPEC PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CtP.0 CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SI: MONTHS OF DATE THE CONSTRUCTION PERMIT IS ISSUED AS NOTED ABOVE, ARRANGED FOR BY TELEPHONE OR.vRITTEN NOTIFICATION. S Y.�•1"v}Jy}\.��,.,,,.J#'t'�i..�yr..w✓f��:�,i'..v..•y:r;Y,�fi+��/y/--..'f�.}'Ys��.`\tiv.�...,.��,yb.r+-'y-'.^y...Y�nv>�,r„��'----«.,.�v'r t o�TNC>, TOWN'OF BARNSTABLE 33053 PermitNo. ................ BUILDING DEPARTMENT TOWN OFFICE BUILDING Cash 7 •Yl �7 �650. 11 1�tcur HYANNIS,MASS.02601 'Bond f CERTIFICATE OF USE AND OCCUPANCY Issued to John Falacci ;— Address Lot C, 10 Newspaper Road Hyannis, Mass. USE GROUP FIRE-GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL-NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING r INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND.IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. August 7 90 f /✓� � --�=--� 19................. �1................ Building Inspector IIr y6.;;.+'!^C�' :: ••. .. v.4' P exT %dy" f! 'j?j¢k'9r°:F!Yr4t?^rr,-'a..r1 �"'..r....,.e/. TOW--N,OF BARNSTABLE, MASSACHUSETTS BUILDING P MMIT 1 A=253-01Z-003 89 DATE 19 PERMIT NO. APPLICANT John �lutl(y;i ADDRESS U l6 -F (NO.) (STREET) (CONTR'S LICENSE) ' I Build dwelling ! Single , m a Cini. weil.L TIS NUMBER OF PERMIT TO (=) STORY 1` DWELLING UNITS i. '(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)' - SOt C 10 � Y'�6F fl ii �zv Hyannis ZONING' RC I k AT (LOCATION) y DISTRICT— f .. (NO.) _ (STREET) NevusFOIAIn r f BETWEEN,:- AND - (CROSS STREET) � � (CROSS STREET) i I !: SUBDIVISION LOT BLOCK S�E 1 BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION TO TYPE� USE GROUP BASEMENT WALLS OR FOUNDATION i �_ • (TYPE) I REMARKS: Sewao e #89_2 OL - .. ! k BOND !!11 AREA E ._, £ 'r "0 i PERMIT 13,.(3.OV VOLUME .L�`.>cj 'r'i° i - ESTIMATED COST � �-)�t�L'if •FEE (CUBIC/SQUARE FEET) 5- + ' OWNER •J0:1r, L'iu'.i:'>:.:% ! 1� r )' ��C BUILDING DEPT. ADDRESS L ;if Cl .L+:Y. 1,'I'.li:ia..L,-:i j ..1.�. BY j: J U n ... FYAY eE Q6r'AfNEo'-._ FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL?NSPECTION HAS BEEN ELECTRICAL, PLUMBING AND I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. 2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERS(READY TO LATH 3, FINAL INSPECTION BEFOREE (FINAL INSPECTION HAS BEEN MADE. OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS -go us �, Pig nle Ic 1 HEATING INSPECTION APPROVALS ENGINEERING DEP RTMENT ja OTHER BOARD OF HEALTH / WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT '✓I!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN CONSTRUCTIO<. ll PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. a.a AN Irs AN L—o 6 1J 17It, , tS'dr(J i liI s•�•d e• — � i . i �� �C.•l/ FiYi 40a r1.Gl�L. =g '��k r+Ila�'e n. . �— ._... _ wm H ti It I6.1+ r Im.l 1 �'rlc I ! �ia I � _ .� Or Q,.O'� t • r:. QIOI � M . I + � gl 4. F �i Ivci!,1_� .`i`._J ICI' .., - .'__,1--•�' p,P.�`.I'uY.sCQ7 64 Ewa Derr r (� la0*,,. Ji?i ' -.-'�C .I _ ro I0 tcn .`firms►t I .L _ I� . FAZE P I� J Y i t cc a , TCWH OF BjSTLF 1� u�iji g Inspection! a irt�i�rr� y -- __ - - -IL q'.Id . . ( �Cm'� µlb.• �.`^ �v=� � � `t`,4 r �,• 00 .. _�_.... f i �r $I' AA .r' .. tv r ��, ,. . I:I I ��*'• .7'•-,' a��i * o•'i{�1clC_corms furl►.+. r-v.u•- IV ILIA i. Tri • _ Obi i ' pro;,�. •. l� ' - I I r ` rcs ���►' � � I� I I i� I, '►�' ram' I I �� ' I� 14„"tU I a :;' I •li _�uIH4- •..ice( Pw acl l,Nrr i tuJ '. I t 4 __ -- __._�_.__—~? =tom--- � ._ � �� L#a/ .c. (���1�1)��s-A���r{�•. y�� :e�, — n TACK I�ml 1-7 7? rill - 1- or TT F=T" 5 FRO CiT Is - - .------ - J' tvt --_ _ ---•-==,,,:,.,._,,, tom" �--- -----r.- -- ---- _ '' qL�1 w ;��� pp - 1 _ —7777= - . . — a �.L r- A _.. IIII 11II M111 f � s — -- 1oCll�bi: j r. ii7 1 $Qpt Jurt., — T 1" �) �. tu Y vw t ., *f': °`r- _ 7 =._ -z -� 1 v,• anT K f's! •z.a_ •. t1' ' nay -- � • - ✓,,YID .f�„1 � ,�• ---- - _ -- - .'�. - � _i .__-^ _ - ___ v d � � _^ _�1''j a•M�Wrse:..�rste+�:_�pr _ G-� _ : r s i i i P ley _ R p ! .. Wow Ver cw� AMD r 1-4 gg 4�- -wr , ) 1 ' -�-' i• f'c�,a `na.�T H/�r".+ci.a sf � �`. a LL • r ' 4 4W .,.M...ra�r1 'aw I ' ; _�s+!+L r+v�++• �t � , s,1 4DO low w r,.+ j,.40* Iw aroma� �. �i,�• � 1" s+.r+a Kro...- �''::,`� ; :,� a , i, -, �uvip�in..�. ��.'L.utL oa .p•..w� 'r'P. L.• `� � � '� f,�j� 4 J *Serving_ MID CAPE INSULATION, INC. Cape& P.O. Box 207 East Dennis, MA 02641 Islands 385-2041 1-800-626-9276 L -------- ---- - DATE ——2 2 8---/89 - OWNER) CONTRACT NO. .___- —_ STATE --THE CONTHAV7.-m..,.-.o. ,II H AND INSTALL INSULATION IN ACCORDANCE WITH THE NATIONAL MINERAL WOOL ASSOCIATION IN THE HOME OR BUILDING LOCATED AT _ F A_L A C C I ,_0 1 d S t-r a w b e r r y__H__i l l_R d_.-_,--Hyannis......MA CEILING 9" R-30 Kraft Faced Insulation WALLS 6" R-19 Unfaced Insulation with poly . vapor barrier STAIRWELL 32" R-11 Kraft. Faced Insulation BSMT. CEILING 9" R-30 Unfaced Insulation . G . H. WALL 6" R-19 Kraft Faced Insulation CATHEDRAL . 9" R-30 Kraft Faced Insulation CEILING with proper vents PLATES 32" R-11 Kraft Faced Insulation CONTRACT PRICE: $2 , 125 . 00 *OPTION : BATH WALLS Insulated with 32" (R-11 ) Unfaced Insulation = $100 . 00 Additional . ------------------------------------------------------------------------- TO SUPPLY AND INSTALL SEAMLESS ALUM. GUTTER AND LEADER . ' CONTRACT PRICE : $585 . 00 WE PROPOSE to furnish material and labor,complete in accordance with above specification,for the sum of: As Quoted Above dollars �_.-___ ._( _ _ _. __ _ _ ) , payments to be made as follows Upon Completion of Job If payment late,monthly service charge of 2%may be added. NOTE:This proposal may be withdrawn by us if not accepted within Thirty ( 30)----------------------- days. Cliff Friedman C Contractor Salesman Acceptance by Purchaser,and Title Any alteration or deviation from 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. Owner to carry fire.tornado and other necessary insurance upon above work. Workmen's Compensation and Public Liability Insurance work to be taken out by MID CAPE INSULATION,INC. F i ' I I yANOF�- Ij OTC �0 p h' v CONC. I FOUNDATION � Q g9 53 190,4,0 CERTIFIED PLOT PLAN PPEPAFEO FOR. LOCATION. LOT C STRAJVBERRY HILL RD. HYAI/NIS i i SCALE.- 1 " = 40 ' DATE: 05/16/89 REFERENCE.- PB. 231 P6. 17 -161 /V F4 L A CC-T I HEP.EPY CE.PTIFY THAT THE EiJILDIN� SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SNJn'.N HEREON. 0f bar^ JOHN s� o McELWEE I down cape engineering, inc . No.33602 LIVIL ENGINEERS J'4a0 LAND SURVEYORS MAY i ROUTE EAYARMOUTH MA DATE RES. LA.. JP'✓EY5P .Assessor's office(1st Floor): Assessor's map and lot number ai;��3 r &4 OOP s 9C SYSTEM RRUST DE Q�pF'rNE Board of Health(3rd floor). 127-0Ri;rr LLED IN COMPLU QCE +Sewage Permit number % WITH TITLE 5 BAJUSTULL Engineering Department(3rd floor): ENVIRONFAE TAL CODE AND �a rb O 79 House number -A� TOWN FWULATIONS AjF 6� Definitive Plan Approved by Planning Board 19 o ypY APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following inform Location Proposed Use Zoning District Fire District --✓`� �-c - Name of Owner Address P o � �ua�.dJ il,, 1� R Name of Builder Address <N - Name of Architect Address �Vl Number of Rooms Foundation Exterior Roofing Floors �� (�o� Interiorus GCS Heating Plumbing Fireplace I'� S Approximate Cost 7� r lT �l7 Area II 1 2 C> Diagram of Lot and Building with Dimensions Fee D a b C OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name A &=Y& ' ,��, Construction Supervisor's License �® / � t FALACCI, JOHN No 33053 Permit For BUILD DWELLING Single Family pwelling Location Lot C 10 Rd. Hyannis Owner 'John Falacci .a Type of Construction wood game Plot Lot f Permit Granted July 11 19 8 9 Date of Inspection 19 Date m ete 19 4 Assessor's office(1st Floor): ��� Assessor's map and lot number w'"Qyo`T"E Board of Nealth(3rd floor): ` - Sewage Permit number / - �a C BAB33TSBLE i Engineering Department(3rd floor): �o rasa House number 1639• em°j Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-930 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO or /� TYPE OF CONSTRUCTION • - r ,,11 19 9 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following informatie Location �-, t*a 7- Ci Proposed Use LAi, A , T v Zoning District 2 Fire Districtp- Name of Owner t�" - �/i�L� �' Address .x Name of Builder Address Name of Architect �/ Address Number of Rooms Foundation Exterior u -,�� Roofing l Floors �f� Interior IS:-liJ jt Heating I,LG"� rrt< • Plumbing x ' Fireplace �`� S Approximate Cost � It� �T'Yt-� W f _Y Area l i 20 ►"'' 6 Diagram of Lot and Building with Dimensions Fee D J tf t � t t OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name, ` A � vu - Construction Supervisor's License) 44—P .. FALACCI, JOHN A=253-012-003 No Permit For 33053 BUILD DWELLING Single Family Dwellin IV�u>Sp�,-p B r Lot C 10 �=- �hPY� ' ' I Rd. Location r Hyannis Owner John Falacci Type of Construction wood frame Plot Lot Permit Granted July 11 19 89 Date of Inspection 19 Date Completed 19 l t 12 E t _ I -2K P— 'n:7-02:� catl.A ra-v;71�= i.7 )(064 WIx —tom--- —'—n•{_—T- T.. —. _ is 11 A W � W J W F Q W op G I - -- RN i Any o; f reilminary plans and layouts by DCD.are for the use of them customers only . rn >eern i t — _..S►a�K,IES i(7 M�ttu txtsn�t ---• - . . . ...... .. I• i tl� .......... - - - t WUA ---- {� _--_.. ------- TJ _. --- - ...... _...... ioovr Erie FWSt1 00IMt0..........__._... _7113sIW4r L`LIN111� ^}� I I:� 0 m I !stnRoom--- rr 6tr. CALE eavaxua c i�l 1� 508.428.6191 --• - LVlffl ce IAA4 w _- a e @ustom - A a esigns ,r• � I � copyright 0 1999 .. ...._.... �F -- All Rights eserve - 1'.G•p:sv t _.. ._- .gyp;•IbaAAtl. .. "� I "- N fry NL\V cCJN514LXTK7IY. Pr Himinary plans and layouts by DC.D.are for the use of tnerr customers only.Any other use is strictly plohibite c CO MMO NWEAL,TH OF mASrsACHIJSE�.-_ )F-TA-T:1`/MNTT OF TND US1-R1A1v*ACCI D EIT S _ 600 WASHi-NGTON STO-= ' liOSTO;N, MASSACHUSETTS 02111 James I i Sc— :ss•�ne woRK£RS'COMPFTISATION INSURANCE AFFIDAVIT 1, Y jhV rGt1a-C-Clr 01ccnscc/permittcc) 1`1'D(qP !(�W✓��{� 1 w;tkt--a-prin�t . . , ... i �J NPws �r M © (O (Gty1Sta(ciz ) do hereby eertif-, under the pains and penalties of per)ury; that: [) I am an cmplovcr providing chc following workcrs' compensation coverage for mycmployccs working on this job lnsurancc Company Policy Numbcr "rop,!iZ72n 0' ��2 ; 1m 2 � ar d have no one working for mc- , 2 ` o�gcnczzl conuaaor o'r homeowner(cirdc onc) and have hircd,ihc concraaors listed bclow 'who h2ve the following workers'eompcnntion insu=cc politics: Ymmc of Contractor Insurance Company/Policr plumber amc of Contractor lnsusancc Company/Policy Numbcr 1,12mc of Contractor lnsurancc Company/Policy Number Vam 2 homeowner performing 211 the work myself 1\"OTF— Plcase be a..•:te that wbsae bogcOWnCn vrbo employ persons to do caiiateazace,eoastrvetioo or repair work on a 2..�cllins of not ruorc sham tbrcc ua;ts it)WL;6 6,C botacowacr also resides or oc'tbc grouads appuctcoant thcccto arc not Ecac"MY I cens Jcrcd to be employers t: &r the'1or:'<ri Compcasat;oa Act(GL C.152.aces. 1(5)),applkztioa by a boroco-Mee for a I;CCDS< or perr..m r..:y evi&Ce< the lqJ- st:tii cf z=cr_rloycr voder tic Wotl crs'Cornpcosat;on Act ", i cnccrstarc tnzt a coPy or iris sutcr:acnt-it 6-for,.uecd to the Dcpz.rc-cri of Industri:.l Acodcnu'Ofiic<of lnsc:zna for.covcrzvc vcrifrcation and that f_.;lurc to secure covcrgc zs required undcr Section 25A of MGL 152 can kad to the impos;tion ofstirni"pcnaldcs .consisting of a f nc of up to 51500.00 zn&cr iraprisonrncnt of up to onc year aril civil pcnalda in chc form of:stop Vock Ordcr and a I fine of S 100.00 a day against me Si"ncd this- d2yofPGPwI lob/ , 19 �l Uccn cc/Pcrmirtcc Liccnsor1Pcrmiaor I _ d TOWN OF BARNSTABLE BUILDING DEPARTMENT ? v HOMEOWNER LICENSE EXEMPTION Please print. DATE . JOB LOCATION ve-W.S APev- oat- Lk'7 f? Number Street Address Sec ion Of Town "HOMEOWNER" ©G9,-7 I o�l�r� s �0: 1-177229oq I f s Name Home Phone Work Phone PRESENT 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 such homeowners to . ' engage an individual for hire who does not, possess .a license, provided that the owner`'aCts as supervisor. DEFINITION' OF HOMEOWNER: . M y 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 to six family dwelling, attached or-detached structures. accessory to such use and/or' farm . structures. A personywho 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) The undersigned "homeowner" assumes responsibility for compliance with the. State Building Code and'other_ applicable codes,-.,by-laws, rules and'=. regulations. .. The undersigned. ".homeowner"-. certifies_ that;.he/she understands the Town;of Barnstable Building Department minimum 'inspection procedures and". requirements 4 HOMEOWNER'S SIGNATURE _ APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State. Building Code Section 127.0, Construction i h HOME OWNER'S EXEMPTION The code states that: "Any Home Owner 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' Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for Licensing Construction Supervisors, Section 2.15) . This lack of awareness often results in serious problems,' particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the unlicensed person as it would with licensed supervisor. The Home Owner acting as supervisor is ultimately responsible. To' ensure that the Home Owner is fully aware of his/her responsibilities, many communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. Assessor's office(t st Floor): a rz, SYSTEM SEPTIC MUST BE Assessor's map and lot number. rna 3 2r J INSTALLED IN COMP o` Conservation(4th Floor): WITH �P e Board-of Health 3rd floor. ' IROMM ����� w Sewage Permit number �" � 7r�q Z DAs»r►Dc Engineering Department(3rd floor):_ /J 16 House number to McW4pgaP/ , OG�r/( Definitive Plan Approved by Planning Board Yur? 19 q APPLICATIONS PROCESSED 8:30-9:30-A.M.and 1:00-2:00 P.M.only TOWN F �,BARNSTABLE BU DING INSPECTOR APPLICATION FOR PERMIT TO act Frprg ✓ti'IevS 'h ifeh✓ I%N11 S 6P,/ 1.W1! TYPE OF CONSTRUCTION Q )l I`f rJ r` r r7 I' �X rfa/ O L e 19 _ TO THE INSPECTOR O/�ies S: The undersigned herebypermit according to the following information: Location ✓ 0 Proposed Use Ie PS' Zoning District P i Fire District f Name of Owner :50 Itj rA. Address to Newt, rP✓ RO,, ,r/1 1 C4gr7r7, Il 0 Name of Builderie Address CI I �IrLAcf- i Name of Architect „� P it 1 r✓1 Address 0��f ) Num 'r of Rooms ,Youndation .t S I r ✓L Exterior �or�/� RIB Tam ' 6_X iG1i 1.. Roofing A S AM 1T Floor Interior o Heating ( r'/ 6!a Plumbing sbOC41,r .Lif/, in�o�ipi ��o�Qj Fireplace Approximate Cost _ f ©, a06) Area '700 01. (, Diagram of Lot and Building with Dimensions Fee -�D 0 COT B 0 s o wi Q � � 6 90 ofD SfRAwB E R2y W [o, oo ° OCCUPANCY PERMITS REQUIRED FOR N &ELLINGs SF' 6,� �6o0o I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name � L Construction Supervisor's License • FALACCI, JOHN M. No 36407 Permit For BUILD DORMERS Sin le' Family Dwelling Location _10 Newspaper Road Hyannis Owner{ John M. , Falacci F r Type of Construction Frame ; t x Plot Lot Permit Granted December 22 , 19 93 Date of Inspection: i Frame 19, , �. Insulation rt , Fireplace 19 Date Completed `� a� 2' 19 '1 E• ,dry .ke • 3.d 4 s e•�) n • Town of Barnstable "Parnell# !1 . � � IL�gouu f mcnthrJl-om tr�kgdau i Regulatory Services FICc -- MAN. � Thomas F.G,eiier,Direct= ° Building Division Tom Perry, Building Commissioner 200 Main Strect, .Hyannis,MA 02601 ' Office: 508-8624038 - Fax: 508-790-6230 ! N 3 2004 EXPRESS PERMIT AppucAmON - US)MENr L1U. ONL`�: Not-Valid without Red X-Frei,Imprint TOWN OF E3AR�S- r � Mapiparcol Number cJ 3 12 DO 3. Proporty Addtcse (`� t�S,D��P 2 A Ap"`r�r 00 t�Rcsidcntial value of Work l SOD Owaer'n'Name dt Address_ �` '-.•-•-� Ct'��1J Jy O _ Contractor's Name G•y , l+ 'ck F6 i:63 tT TcicpW)no lumbcr�`_�D�J `�'J^1\-1—] Home Improvement Contractor License#(if applicable) �U 3-71 Construction Supervisor's License#(if applicable) )6' 5workmau,s Compensation Insurance Chock ono: r ❑ I am a sole proprietor ❑ I am th5 Homeowner I have Workt:r'9 Compensation Insurance Insur=cc Company Name l�('G y eAe rf) d.2r,n r t y .Cb, of S Workmen's comp.Policy# —1 PJ y B— a a 7C 5 3 - `jO2 Permit RequWt(chock box) Re-roof(atripping old shingles) All construction debris will be taken to Q M0 J ❑Re-roof(not stripping. Going over exinting layera.of roof) [] Re-aide [] Replacement Windows. U-Value (maximum.44) f C-e— Other(specify) Y-Q \rb0'F I /�T" a -e C n o N _ cobk'er CF I NC 'Where required: Issuance of this permit does not exempt compliance anth other town department mgutao one,I.e.Alatmc,Conscrvatian,ctu. Az Signature Q:Forwv:expmtrg Revised111901. 1 Y PROPERTY OWNER MUST COMPLETE AND SIGN THIS SECTION IF USING A BUILDER / ROOFER (Please return this form to Cazeault Roofers with your signed p;•oposal/contract) viVtOY , as Owner of the subject property Hereby authorize Paul J. Cazeault & Sons Roofing__ To act on my behalf, in all matters relative to work authorized. by this building Permit application for (address of Job) R ignature of Owner Date \ ,P—!C vLe_ G Co vx K OY Print Name , `'.ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE(MWOIYYY) PRODUCER THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE XcShea Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DDES NOT AMEND, EXTEND OR 749 Main Street, Suite#H ALTER THE COVERAGE AFFORDED UY THE POLICIES BELOW. Osterville, ma. 02655 INSURERS AFFORDING COVERAGE 508--AaL.9011__ - — _ — INSURED paul J Cazoault & Sons Roofing Inc. INSUHER A, INSURER 9: El TT,aveler Infl,1 mwLty_ Co o.f Illingl- 1031 Main Street INSURER c. _ OSterville, ma 02655 INSURER D — i IN:iUHFR E. I COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE`1100 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR PpLIt:Y EfFEGTIVE POLICY EXPIRATION LYRTYPE OF INSURANCE POLICY NUMBER TE MM/ E MMIOWY LIMITS GENERAL LIABILITY EAC A OCCURRENCEf e Q x COMMERCIAL UtNFRAL LIABILITY TIRt DAMAGE(Any one lire) S I CLAIMS MADE I OCCUR ME[ EXP(My Ono Perron) A _... SCP0467325 04/30/03 04/30/04 ItHSONnLIADVINJURY S ,.000 ... .. GEP ERAL.AGGREGATE_ $2,00�.�00 . GEN'L AGGREUAIE LIMIT APPLIES PER: PRC•DUCTS-COW/OP A(:G S.� �0 0OQ POLICY vH0_ LOC JECT , AUTOMOBILE LIABILITY I — -- CDIABINLD SINGLE LIMIT S ANY AUTO IEa accid-ml) ALL OWNED AUTOS ROI)ILY INJURY S SCHCOULED AU 105 (Pe'Do's".) _ HIRED AUTOS DOINLY INJURY S NON-OWNED AUTOS (Pe acc�denl) .._ PNI)PERTV DAMAGE S - (Pe'eccwent) GARAGE LIABILITY AUK O ONLY EA ACCIDEN/ S ANY AUTO OTHER THAN EA ACC S AU TOO ILY: AGG S EXCESS LIABILITY - LAI;HO(,CVRRENCE S OCCUR I ,CLAIMS MADE _ AG3RE6ATE S. - — g _... DFDUCTIDLE �.—.. ... $ . HtTFNTi0N ; S WORKERS COMPENSATION AND x IQ!IY LIMITS Ill EMPLOYERS'LIABILITY 7P=-922X653-502 - 08/10/03 08/10/04 C.L EAcHACCIOENT $ 8 E.,L DISFASC•EA EMPLOYEE S _Q0 ._ - Et DISEASE•POI ICY LIGHTIS500,Dog OTHER i DESCRIPTION OF OPERATIONSILOCATIONSNEHICLE&!EXCLUSIONS ADDED BY ENDOR6EMENT/BPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED:INSURER LETTER: CANCELLATION -- ----------------- —_. .—___- _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIE6 BE CANCELLED BEFORE THE EXPIRATION v DATE THEREOF,THE ISSUING INSURER'PILL ENDEAVOR TO MAIL 1� DAYS WRITTEN NOTICE.TO THE CERTIFICATE HOLDER NHMEO TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIASIOTY.0:ANY KIND( ON THE INSURER,ITS ACIEN73 OR REPRESENTA 1 3. r AUTHORIZED R RE T NA ACORD 25-5 t 7197 o ACORD CORPORATION 1288 :. 0/ sl Board of Buildil-111 I\c -'L11;11louS �lnd Stan(Lli &S One Ashbu aoll P i<ICC - I�oonl. I O l Boston. Mass�IC ILISC s 02108 Home Improvement Contractor Rc gistrati'IIl Registration I :)3711 type 1�7ival( Cor{��n,ilior Expiration 7?9/200•1 PAUL J. CAZEAULT & SONS, INC. _ Paul Cazeault P.O. Box 2781 Orleans, MA 02653 ll{ldale Address and 1 ,1111 n card. �I:u9; reawn fur clean{,c. ' :\dtlri•ss Rcn i�'al I;nilllu;nx•nl I.u>I (':n I J - X Illlarll of Building Regulations and Standards I,iVcusc or tcl;r,U'alion valid fur iutlivili ll n.c onl'r HOME IMPROVEMENT CONTRACTOR beloi c 16,:espiialiun dale. II found rcl nv iu: ISu:u-d of L' Registration: 103714 uildinL Rcl,Ida iious and Sla alai ds Expiration: 7/9/2004 One Ashhurlon Place Rut 1301 liutiln,Type: Private Corporation IN la. 112108 'AUL J.CAZEAULT&SONS, INC. maul Cazeault 2 Giddiall Rd. (� .« fuA�. u t yP ✓fir ovr,"au/a/eccl//i u�,... .//. /�rJJi/cLlcJe CGJ gleans,MA 02653 1+1 � BOARD OF BUILDING REGULATIONS Administrator I`lu ' 1 a License: CONSTRUCTION SUPERVISOR ` Numl,er: CS 026325 h Expiies: 10/20/2005 Tr. no: 8603.0 Restric:.ed: 00 PAULJ CAZEAULT 1031 MAIN ST OSTERVILLE, MA 0:'65E- - Administrator I � .�'ac"v.il�l� l - Board of E Ming Reglulationc One Ashburton Place, Km 1301 Boston, Ma 02108-1618 License:. CONSTRUCTION SUPERVISOR LICENSE Number: CS 026325 Expires: 10/20/2005 Restricted Tcl: 00 PAUL J CAZEAULT — —- 1031 MAIN ST OSTERVILLE, MA 02655 Tr.no: 8603.0 Keep top for receipt and Change of address notification. Hof THE)p�\o A." Expires 6�nonr ts1m.- I� . � - V Re-aulatory Services Feed�- � K►ss. ch I Thomas F.Geller,Director Building Division - Peter F.DiMatteo, Building Cowndssioner X-PRESS PERM 367 Plain Street. Hyannis,MA 02601w 2001 Office: 508-S62=038 Fax: 508-790-6230 EIPRESS PERMIT :APPLICATION - RESIDENTfA ' 'U BARNSTABLE - Not Yaitd without Pad X•Fr=Itaprint Map,parcel dumber 2S (e Tel Property Address 0 ewS R, er N � r Work [E Residenrial Owner's Name R Address R i c v) � G ,✓�f ��� �G4 �a C C / lyudY� l r0�� NOy►�PS Telephone Number Contractor's Tame v7 Home Improvement Contractor License 4(if applicable) 1 O Construction Supervisor's License-(if applicable) r ' orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeos aer J", have Worker's Compensation Insurance �m Insurance Company Name 7z �r IC_ 13y-y3 s 0© Workman's Comp-Policy 7�-' — Permit Request(check box) ❑ Re-roof(stripping old shingles) ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement indoTzs. U-Value o 3 (1naxnMUK1•44). ❑ Other(specif}) t regulations.i.e.Historic.Conservation. •Where required: Issuance of this permit does not exempt compiianeo with other town d�m Signature Q:Forms:e-,Prn=:r.-V-(1%oho I r II ✓X. e w anvnzoouue a ✓�a�sac�ivavtla BOARD OF BU ILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 069152 Expires: 12/11/2002 Tr.no: 4705 r• —--Restricted To: 00 ,i JOHN M FALACCI _ 1# POBX 1224 1441 RTE 132 � HYANNIS, MA 02601 Administrator • _. ___...- - S?TY._. �...._v.�....v ._,___, .. � ✓�ee i9am�naxusea�i a�✓t�aaicac�euJeCla HOME IMPROVEMENT CONTRACTOR Registration: 106109 Expiration: 7122102 ' Type: Private Corporatio HAMILTON HOMES, INC. John Falacci ADMINISTRATOR 1441 ROUTE 132/P.O. BOX 12 Hyannis MA- 02601 Engineering Dept.(3rd floor) Map o?;5, ParcelPermit#. r � House# /d 3 Date Issued Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) Fee Conservation Office(4th floor)(8:30-9:30/1:00-2:00) ALL�® '�ed `�b s C Planning Dept.(1st floor/School Admin. Bldg.) �I��B o 11(i� T ®0`e U MNil �g � Definitive Plan Approved by Planning Board 19 BARNSTABLE MA TOWN OF BARNSTABLE : Et6j Building Permit Application Project Street Address f P w_&. Q t0 Village CDPI 1. w Owner vt.y �,r� J- Addr. s t- Telephone Permit Request -7—o a r` d( -P,,t.r p DD First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ �� D7l—z/ 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 Name91U6Z1t_11 Telephone Number � 0 ? / (0 Address l (� "P -�L License# �- d 'Eot C/1 al(o Home Improvement Contractor#�/ d ® L d Worker's Compensation# 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 ),h Z614 oe SIGNATURE 6Ceti DATE BUILDIN . RMIT DENI WIN ASON(S) I FOR OFFICIAL USE ONLY r PERMIT NO. DATE ISSUED . - MAP/PARCEL NO, r s ADDRESS VILLAGE OWNER DATE OF INSPECTION: i FOUNDATION FRAME _ INSULATION , FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: 1 ' ROUGH FINAL GAS: .� `ROUGH FINAL F i FINAL BUILDING �a , DATE CLOSED OUT - - , ASSOCIATION PLAN NO. ' , , ............ ............... .......... r. STANDARD LEGEND 11 note;not all symbols will amptou on a map 8 GOLF COURSE FAIRWAY } t `I I !r , l I f)� - \ 'r \\> �\ <(' \ •.... DECIDUOUS TREES 1h y EDGE OF BRUSH j... 0 178 X; ORCHARD OR NURSERY CONIFEROUS TREES .................... MARSH AREA EDGE OF WATER 6� /�< �. �- / i 1 \\ �1\ �;\ — e LURE ROAD �x v DRIVEWAYS PARKING LOT PAVED ROAD .............. DITCHES ------------ 7f ....................... PATH TRAIL x 'A' J PROPERTY LINES 41, 181A 1114 q • LOT ACREAGE 3�1 BER UM 21—PARCEL N ..................... HOUSE NUMBER _I t X 2 FOOT CONTOUR LINE .......... A 10 FOOT CONTOUR LINE 3.0 • 3 X­ SPOT ELEVATION ........ ....... .......... ------ STONE WALL FENCE K, It i t It > .......... V 7:1 < 87/ RETAINING WALL \J IT 0 -3 A, RAIL ROAD TRACKS Vv I TELEPHONE POLE STONE JETTY c SWIMMING POOL #20 . 3 �O/A PORCH DECK 9- BUILDINGS/STRUCTURES fir DOCK PIER JETTY ................. - --------- J ASSES SOR'S BOUNDARY 'g .......... ........... "J; --------- ........... 7_J f 0 7 F- SITE MAP A, T,0,6.GEOGRAPHIC INFORMATION SYSTEMS UNIT -------------- ........ ...... SCALE: in feet 80. 7 0 30 60 80.9 60 FEET I INCH 7_�k N W-N 4, E Jt ............. ........... -------------- d,An S 7 PARCEL I INES ARE GNiY GRAPHIC RrPRISFNT THE A 'T2 IR"Gl mJNDARjESnHYARE NOT TRUE LOCATIONS ATI:1011730-F94 Iv. X\1 0 VEGETATION,TOPOGRAPHY ANO PLANIMETRIC DATA INTERPRETED FROM 1989 AERIAL OVERFLIGHTS,PHOTOGRAPHY AT 1-800' MAPPEDAI 1-1-JOE'.PARCEL DATA DIGITIZED FROM 1-100' ENGINEERING ASSESSORS MAPS 1995 _77= ■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■E■■■ ■ ■ ■■■■■ ■■■■■ ■ ■ ■■EN■N ■■ ■E■ ■■■EN■ ■ ■ ■■■Ion ■ ■ ■■■■■ ■ ■ ■E■ ■EN■■■ ■ on ■ ■ No BE ON ■ ■■■■■■■■■■ ■ ■■■■■■■ ON ■ ■■ ■■mom Emm ■ENOMONEE■ ■ ■■■■■■■ ■■ ■ ■■■■■■■■■■■■ EERNMEEE■QElE ■■■■■■■ m MMME NEON No ■■ ■ j N■EEE . ■■■■B� 1 ■BEEF ; ■ E- QEi4 ©E 00 ■■N ■ �.---------iiiii�.!�� ■■■ ■■■■■■■ ■■Bill■BEEN■■ ■ENE■■■E■■■NEEN■■■■EN!B■■■ 1�®E■�1 E" E ,�Immommomm 7■■■■■■■ ■■■■■■■■■■■■■■■■■■■■r MEN ■■■■ ■■�■ ■ ■NEEN■■■ENE■ENE■■EIS■� NONE o■©■■■■■■■■■■■® AWNEE ■■■■■■■■■■■■■■■■■■I ill i■EN E■■■■■■■ill■■■■■■ ■■■ immoommommmommommommi 01r ■E■EN■ENEE■■NE■ENE■BEE■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■B■■■■■■■■■ ■■■■■■■■■ ■■■■■ ■■■■■■■■■ ■■■■■■■■■■■N■■■■NNE■ ■■■■■■■■■ ■■■EN N■■■■■:■" .+■■■■.■■■■■■■■■■■■■■■ �®■■■■■■■■E■■E■■■BIB■■■■■■■■■■■■■■■■■■■■■■■■■B■■ ■■ ■■■■■■■■■■■ ■■ ; ■■■■■■■■■■■■■■i■■■■■■■■ ■■■■ ■■■■■■■■■■■■■■■■■ �■■■■■■■■m■■EN■■i■NE■■■E■ ■BEE ■■■E■■■■N■ENNEE■ I EE3�1 �r,EE�S�� C�� „�I■■■■■■■■■EB■■ ■ ■IN ■■■B ■■■■■■ ■■ ■■■ ■■■■■■■■■■ NEENEE■ENE ■ EON ■■■■■■■■■ ■■■ ■■■■■■■■■■ E■NEENEENE ■ ■■■■N■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■EE■E■EE■E N■ ■ ■■■■■■ ■■■■■■■■■■■■■■■■INEEMEN■■■■■EN■NE■ ■ BENN ■ ■■■■■■BEE■■■■■■■ ■■■■■■NEB■NNNONE B ■ N■ ■ ■■N■ ■ENN■ ■■■NB■■ ■■■■■■■■■■■■■BBEE■ ■■N ■■ ■■■■ ■■ ■■■■ ■■ ■ ■■ ■■■■■■■E■■■■■EENBB 0B■ . ... t' I DEPARTNENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE Nus ' Expires: RestricteUTo !8 GEORGE J AIIAIH "~ 31 JOEL RD; S YARNOUTH, NA 01664 �\ HOME IMPROVEMENT CONTRACTOR Registration 100105 Type - -INDIVIDUAL Expiration 06/09/00 GEORGE ALLAIN 116 SHEAFFER Rd. MA 02632 ADMINISTRATOR dFTMe The Town of Barnstable � g Department of Health Safety and Environmental Services BuiIding Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen BuiIding Commi: Fax: 508-790-6230 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./Y Type of Work: e `ec- Est.Cost ea ®d d y of Work: /0 `c'&Q g Address Owner's Name tl )A Date of Permit Application: 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: DEALING _ OWNERS PULLING THEIR OWN PHERNIIT OR E WORK DONOT�HAED CONTRACTORS FOR APPLICABLE VE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as fhe agent of the owner. 0 Date 11L,actor Name Registration No. _ The Commonwealth of Massachusetts Department of Industrial Accidents OiffCC oflnlyestigatiolls 600 Washington Street Boston,Mass. 02111 Workers' Corn ensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity I am an employer providing workers compensation for my employees working on this job. company name* B--ec- k address: �r a city ( •Ql/I ��' �/e• / l e D`-�-ftti phone insurance co. Zd t'C-4 - t" C N Lt olicv# ?__S ( � X$3D ❑ 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: ......... com anv name: address: tits- ;::...:... -- -phone#: insurnnce co. ... alley • ///i//oa/aa//a/////iai//////a//i///O////i/a///ai//i/�/aiaiaiioa///io//aa�i�/a/a/a/oi/// /////i/// / /////a/a///////////aia/alai/i/i/a/// / a/' com anv name: address city- . :. .. phone# ...... .. .. alley# insurance co.. %%///%%/ Failure to secare.coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penaides of a Me up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of SI00.00 a day against me. I understand that a copy of this statement may be forwarded to the Ounce of Investigations of the DIA for coverage verification I do herebv cert under the pains and penalties of perjury that the information provided above is truo and correct Si lure �'t't' Date aY V,9 _ t 4 Priest name ® -e f �l Phone# �� 7 [dtyor ly do not write in this area to be completed by city or town of vial.permit/license# QBuilding Department❑Licensing Boardunediate raQonse is required ❑Selectmen's OMce❑Health Departmentn: phone#• ❑other �(mvuen 9i95P)A) Information and Instructions Pi Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees: However the owner of a . dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants ` Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of tlbe 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 perniit/kicense number which will be used as a reference number. The affidavits may be ret<iraed b 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. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Invesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375