HomeMy WebLinkAbout0639 PITCHER'S WAY (039 �Pi-�c,�prs C.v�
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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+ Map ( Parcel
Application #orb
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Health Division .'Date Issued tt
Conservation Division Application Fee
Planning Dept.. Permit Fee
Date Definitive Plan Approved by Planning Board (—
Historic - OKH Preservation/ Hyannis
Project Street Address 21
Village (_P p nY\1!n
Owner "� •���c Address
Telephone
Permit Request Re S Y
Square feet: 1 st floor: existing proposed �_2nd floor: existing_ proposedM1 _Total.newt
Zoning District Flood Plain Groundwater Overlay ,
Project Valuation ON) Construction Type J T
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting cl �menfation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) -3
Age of Existing Structure Z? Historic House: ❑ s�Yes No On Old King's Highway: ❑Yes ❑ No
Basement Type:� Full ❑ Crawl
❑Walkout ❑ Other
Basement Finished Area (sq.ft.) y Basement Unfinished Area(sq.ft) 909Z '
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing o new
Total Room Count (not inclu ing baths): existing new First Floor Room Count
Heat Type and Fuel:\'6jl Gas ❑Oil ❑ Electric ❑ Other
Central Air: ❑Yes V No Fireplaces: Existing(New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑existing U 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 ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Namer` Telephone Number
Address' v 1<:�-O o PCB$ License # C 26 s a c
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Gl2ti+\_V, ,&ln\� "� Home Improvement Contractor# 1
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a43� Worker's Compensation # mho
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
��i��A VYl
SIGNATURE DATE �''
FOR OFFICIAL USE ONLY
APPLICATION#
•'.�_DATE_ISSUED—
€.",,MAP/PARCEL NO .
r °ADDRESS VILLAGE
OWNER
,I
,r DATE OF INSPECTION:
5 iFOUNDATION f" b
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FRAME
AIINSULATION�_Alf
FIREPLACE
` ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
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GAS;4 i3Nr-'l ROUGH �Z JU-` ~ < FINAL
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!I-'::DAT_E CLOSED>OUT_,;-�: .:..
r ASSOCIATION PLAN NO.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
b www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): r
Address: 3-^
City/State/Zip: ooyy- �i)A.,Q �n Phone.#: S-5 i'(S)k0 D9 f jt)
you an employer? Check the appropriate box: Type of project(required):
L�E I am a employer with ' 4. I am a general contractor and I
employees(full and/or part-tim.e).* have hired the sub-contractors 6. ❑New construction
.2. 1 am a sole proprietor or'partner-' listed on the attached sheet. 7.. 0 Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers'comp. insurance comp.insurance.#
required.] 5. F1 We are a corporation and its 10.0 Electrical repairs or additions
3.'❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.0 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.
tContractors 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy#or Self-ins.Lic. #: �'�'1�a �� "� Expiration Dater - � '
Job Site Address: 3 cl 1 40LVZ_ p' City/State/Zip: Y111t
Attach a copy of the workers'compensation policy declaratt p(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 criminal 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 hereb cent` under the pains and yes o p rjury that the information provided above is true and correct
Si ature: Date:
Phone#: 77>L.0
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Infor
mation and Insttuctions
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 with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es)and phone 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 lndustriAl 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
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Massachusetts - --
Bi�ard of BuildinDClt�t'1ment of Public Satet�
er ations and Standar
'.Construction Supupervi (is
sor License '
License: Cs 76820
f2estricted to 00
KENNETH O PERRY,
19 GUILDFORD ROAD
CENTERVILLE, MA 02632 k'
Expiration:
('ununisrionc:r' 8/28/2011'
Tr#: 1362
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ACORD,. CERTIFICATE OF LIABILITY INSURANCE VAIE(MMIuD/YYYY)
04/27/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER rj I AC I '
NAME:
Dowling&O'Neil Insurance PHONE 508 775-1620 FAX 5087781218
A/C Nu Exl: AIC Nu:
Agency E-MAIL
ADDRESS:
973 lyannough Rd., PO Box 1990
INSURER(S)AFFORDING COVERAGE NAIC A
Hyannis, MA 02601 INSURER A:Western World
INSUKEu -Kenneth Perry D/B!A INSURERB:Associated Employers Insurance
INSURER C:
K.P. Remodeling &Construction
INSURERD:
19 Guildford Road
INSURER E
Centerville, MA 02632
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED_TOTHE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IYVEOFINSUKANCE ADD SUB POLICYEFF POLICYEXP
INSR uMIIS
LTR INSK WVD POLICY NUMBER MM/DD/YYY MMIDD/YYYY
A GENERAL LIABILITY NPP8014671 3l04/2011 03/04/2012 EACH OCCURRENCE $1 000 000
X Ca)MMFKCIAI C*-NIKAI IIAHII IIY - I)AMAC*- IO KFN IFII
PREMISES Ea vcvwlrnw :F 50 000
CLAIMS-MADE FX1 OCCUR MED EXP(Any una vaiaun) t5,000
X BI/PD Ded,500 PF-NSONAI R AI)V IN.IIIHY :F 1,000,000
GENERAL AGGREGATE s2,000,000
C*-N'I AGGHF GAI F I IMI I APPI+,;PFK: _ HKO011C I n-COMPIOP ACi( $1,000,000
POLICY PKCI- LOC JECT
AU 1 OMOBILE LIABILII Y C OMHINFI)SING1 F I IMI I
(Ea au;iJant) $
ANY AUTO - BODILY INJURY(re,ynlaun) $
ALL OWNED SCHEDULED HC11)II Y IN.II)RY(Prrarorlrnl) $
A11 I O;i Al I I(),;
NON-OWNED PKOPF KIYI)AMAIiF $
HIHFU AI 116SCrAUTOS rl ac.iJenl
UMBRELLA LIAB OCC:I IK - EACH 6CCIIHKFNCF $
EXCESS LIAB CLAIMS-MADE AGGREGATE $ -
I11-I1 1 1 KF IFN I ION$ $ -
WORKERS COMPENSA I ION WC S I Al ll-c OI H-
B
AND EMPLOYERS'LIABILITY WCC5005450012010 6/13/2010 06/13/2011 X n" � ;
_
ANY r'Ro RIETOR/r'ARTNER/EXECUTIVE YIN F,I FAi;H a 1.l CaL)FN I `6100 000
C)FFIC-RA,AFMHFK FXC:I 11DI-I17 — NIA -
(Mandatory In NH) - E.L.DISEASE-EA EMPLOYEE '0 OO 0.00
If Yba,daauiiba unJas ., ._.
DESCRY TION OF OPERATIONS beluw - F.I.NI;;FA;;F POI ICY I IMI I- :s'500,0,00
DESCKIP 110N.OF OPERA I IONS/LOCA I IONS/VEHICLES(Attach ACOIRD 101,Addltlonal Kamarkn Schadula,I(mora rpaca Ik raqulrad)
Job: 639 Pitchers Way, Hyannis, MA a
Kenneth Perry,is excluded from the workers compensation policy.
oll
Insurance coverage is limited to the terms, conditions, exclusions, other
limitations and endorsements. Nothing contained in the certificate of
insurance shall be deemed to have altered,waived,or extended the
(See Attached Descriptions),
CERTIFICATE HOLDER CANCELLATION
Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Bldg. Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
200 Main Street
Hyannis, MA.02601 - AUTHORIZED REPRESENTATIVE
OO 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S80323/M80322 LS1 ,
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Arm�A
Town-of Barnstable
Regulatory.Services
Thomas K Geiler,Director
Building Division-
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town:barnstable.ma.us
Office. 5,08-862-4038 Fax: 508-790=6230
Property Owner Must
-Complete and Sign This-Section-
If Using A Builder
T, 5TAWY D. K0kF^Z—P , as Owner of the subject property
hereby authorize �� N� to act on my behalf,
in all matters relative to work authorized by this building permit application for:
tkk( 6
d
(Address of Job)
;ignature Oner hate
r
Print Name
If Property Owner is applying for permit,ptease complete the Homeowners License Exemption Form on the
reverse side:
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EARNSHOUSAUTHORITY , PAGE 01/01
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s��op'"P ,eased housing Dept: 508.771,7292
ig
�. Barnstable Telephone 508.771.7222
B,nfe - - FAX: 508.778,9312
Housing Authority 146 South Street-Hyannis,MA 02601
ZONING VERIFICATION .�
TO: .Lind,a7Robin. =
FROM: Kizxa Gomez, Leased T.Xousing Coordinator
:,
PHONE NO#: 508-771-7292 FAX 508-77879312
RE: LEGAL RENTAL UNIT VERIFICATION
DATE:
-ADDRESS:
C
VILLAGE: 1 ' �
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UNIT TYPE BEDROOM SIZE o
MAP & PARCEL NO:
The owner of the above listed Property is entering into a. contract with us for rental ofthe
property listed above. Please verify by signing below that th unit is legal and meets all zoning
requirements for a rental .in the towli. of Baa-n.stable. If it does not, please list the reason below:
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Communication Result Report ( Mar, lO. 2011 10:47AM )
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File Page
No. Mode Destination Pg (s) Result Not Sent
----------------------------------------------------------------------------------------------------
4785 Memory TX 95087789312 P. 1 OK
Reason for error
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E. 5) Excee.d.ed max. E—ma i t s i zA
_ 03/09/2011 13:47 5887709312
BPR THDRXTy PAGE 01/01 -
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L—dH..ft kpC 508.771.7292
Barnstable TMVhmn 508.777.7222 -
PA)(:508.779.9312
T�+(*
•1ouszng Authority 146 8®11th Skeet•Hyennla,AAA 02601
ZONING VERIFICATCION
TO: LinaaIRobin - G
FROM:ILim Gomez,Leased Dousing Coordinatar _
PRONE NO#:568-771-7292 FAX 508-778-9312
RE: LEGAL RENTAL UNIT VERTECATION. t =
DATEc
ADDRESS: �/ ��✓ j
VILLAGE:
UNIT'TXPE BEDROOMS17-E
MAP&PARC&NO: 2,71— ISQ {!"
The ovam of the above listed property is entering into a contract with us for rental of the
property listed above. Please verify by signing below that the unit is legal and meets all zoniug
requirements for a rental in the tows of Barnstable.If it does not,please list the reason below:
on 3-44-t1-....Fr�� � bed roomaS
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03/09/2011 13:47 5087789312 BARNSHOUSAUTHORITY PAGE 01/01
09 Ha
Barn' stable Leased Housing Dept: 508-771.7292
e.nneru,,� Telephone 508.771.7222
°1AM Housing Authority FAX: 508.778.9312
i679 '� 140 South Street•Hyannis,MA 02601
M{N
ZONING VERIFICATION
TO: Linda/Robin --
FROM: Kim Gomez, Leased Flou.sing Coordinator
q I
PHONE NO#: 508-771-7292 FAX 508-778-9312 i ✓✓ :
RE: LEGAL RENTAL UNIT VERIFICATION ;
DATE:
ADDRESS:
VILLAGE:
y
UNIT TYPE BEDROOM SITE 2 6 A
MAP & PARCEL NO:
The owner of the above listed property is entering into a. coltra.ct with us Fo>I rental of the
property listed above. Please verify by signing below that the unit is legal and meets all zoning
requirements for a rental in the town of Barnstable. If it does not, please list the 1-eason below:
Thank Y :..for you our assistance i
Y . this matter.
3
Signature Print name
Date: c
VIA FAX: 508 790-6230 �� ✓ �� /
Equal Housing oppoijuil.ity Agency
Barnstable Assessing Search Results Page 1 of 2
u r
_ �:� ems•.
Home:Departments:Assessors Division:Property Assessment Search Results
New Searches
ti New Interactive Maps>>
Owner: 2011 Assessed Values:
KURTZ,STACEY D
639 PITCHER'S WAY 2011 Appraised Value 2011 Assessed Value Past Comparisons
Map/Parcel/Parcel Extension Building Value: $135,100 $135,100 Year Total Assessed Value
271 /180/ Extra Features: $15,200 $15,200 2010-$251,700
Outbuildings: $1,300 $1,300 2009-$326,200
Mailing Address Land Value: $65,600 $65,600 2008-$335,900
KURTZ,STACEY D 2007-$283,700
2011 Totals $217,200 $217,200 2006-$285,100
639 PITCHERS WAY
Questions about your Assessed Value
HYANNIS,MA.02601
2011 REAL ESTATE Tax Information: Tax Rates:(per$1,000 of valuation)
Community Preservation Act Tax $52.45 Fire District Rates Town Residential
Barnstable FD-All Classes $2.31 $8.05
C.O.M.M.-All Classes $1.33 Town Commercial
Hyannis FD Tax(Residential) $443.09 Cotuit FD-All Classes n/a $7.28
Hyannis-Residential $2.04
Town Tax(Residential) $1,748.46 Hyannis-Commercial $3.24
W Barnstable-Residential $2.65
W Barnstable-Commercial $2.34
Community Preservation Act 3%of Town Tax
Total: $2,244
Construction Details
Building Property Sketch &ASBUILT Cards
Building value $135,100 Interior Floors Hardwood Property Sketch Legend
Style Saltbox Interior Walls Drywall
Model Residential Heat Fuel Gas - -
t:
Grade Average Heat Type Hot Water �...
Stories ACT e. None
YP
Exterior Walls Wood Shin t!a Bedrooms 4 Bedrooms
Roof Structure Gable/Hip Bathrooms 3 Full "�° e `. r.t
Roof Cover Asph/F GIs/Cmp Living Area sq/ft 1,575 ,tea ,
Replacement Cost $148,467 Year Built .1977 �'
Depreciation 9 Total Rooms 6 Rooms
Land Gross Area sq/ft 2,940
CODE 1010
I Lot Size(Acres) 0.23 As Built Cards: 1
Appraised Value $65,600
http://www.town.bamstable.ma.us/assessing/2011/displayparcell1map.asp?mappar=271180 3/9/2011
Barnstable Assessing Search Results Page 2 of 2
Assessed Value $s5soo View Interactive Maps >>
Sales History:
Owner: Sale Date Book/Page: Sale Price:
KURTZ,STACEY D Aug 30 1999 12:OOAM 12507/269 $126,000
MACARTHUR,ROBIN&ELIZABETH L Jan 15 1986 12:OOAM 4868/257 $85,000
MENNING,BARBARA E Oct 15 1982 12:OOAM 3591/208 $51,000
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
FPL1 Fireplace 1 story 1 $3,400 $3,400
BFA Bsmt Fin-Aver 864 $11,800 $11,800
SHED Shed 80 $1,300 $1,300
Property Sketch Legend
BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
r
http://www.town.bamstable.ma.us/assessing/2011/displayparcelll map.asp?mappar--2711 80 3/9/2011
�• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Ma o�' P cel 160 A lication# �Z00(0�05
p ® 7'�`6�33 pp L Health Division 6_141
Conservation Division 1 Permit#
Tax Collector Date Issued
Treasurer Application Fee
Planning Dept. Permit Fee aC�
Date Definitive Plan Approved by Planning Board O O l o
Historic-OKH Preservation/Hyannis �—
Project ress P
VillageStreet 2
Owner C Address
Telephone
s ,
Permit Request ry.,� 0,2!� :�?4" aaz
4�L
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new`
Zoning District Flood Plain Groundwater Overlay
Project Valuation 0 Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation
Dwelling Type: Single Family ®,"'Two Family ❑ Multi-Family #units
Age of Existing Structure Historic House: ❑Yes %No On Old King's Highway: ❑Yes to
f t
Basement Type: Full ❑Crawl ❑Walkout ❑Other I
Basement Finished Area(sq.ft.) �'� Basement Unfinished Area(sq.ft) , ,
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing new J—
Total Room Count(not including baths):existing new First Floor Room Count 5f
Heat Type and Fuel: ZGas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing �i •2� New Existing wood/coal stove: ❑Yes O"No
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 ONo= =If-yes,-site_plan_review#
Current Use Proposed Use
i
BUILDER INFORMATION
17
Namea /9�* � Telephone Number
Address— C 74_,elC License#
Home Improvement Contractor# 3 fr 11�_l
Worker's Compensation# j
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE S-fi,
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED "
MAP/PARCEL'NO.
ADDRESS i VILLAGE
-OWNER a
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION �—
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL ,
'# FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
t
The Commonwealth of Massachusetts
Department oflndustrial Accidents
I'r 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/Individu4: /Z L1116( / �
Address:c�Odb
City/State/Zip;;o�, �-LtIG `L % � Phone#: L
Are you an employer? Check the-appropriate box; Type of project'(required):
1.❑ I a employer with 4. ❑ I am a general contractor and I 6. ❑;New construction
loyees(fall and/or part-time).* have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet I 7• , - deling
ship and have no employees I These sub-contractors bane S: Ej�Demolition
working for me in any capacity. workers' comp.insurance. . g, ❑ Buil�addition
[No workers' Gump.insurance 5. ❑ We are a corporation and its
required,] officers have exercised their . 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.[j Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.[] Roof repairs
insurance required.] t employees.(No workers' 13.❑ Other
- comp.insurance required.]
*Any applicant that checks box#1 mast also fill out the section below showing their workers'compensation poHcyinformation.'
t Homeowners who submit this affidavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such
ZContractm that check this box must attached®additional sheet showing the tern ofthe sub-contractors cad their workers'comp.policy information.
ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
Information.
Insurance CompanyName:
Policy#or Self-ins.Lic.#: 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 criminal penalties of a
fine up to$1,500.90 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.
1 do hereby certify u der the in nd penalties of perjury that the information provided above is true and correct.
1
signature: Date: -
Phone#:
Official use only. Do not fvrite in this area,to be completed by city or town official
City or Town: Permit/Licease#
Issuing authority (circle one):
1.Board of Flealth 3.Building Department 3.City/T'owr.Clerk 4.Electrical inspector 5.Plumbing lnspe&tor
6. Other
Contact Person: Phone#:
iniorniataon ana 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,.offal 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 bean employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shalt withhold the Issuance or
renewal of it 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by.checkmg the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s),address(es) and phone numbers)along with their certificates) of
insurance. Limited Liability Companies (LLQ 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 conipaii=gLou-Id their
self-insurance license number on-the appropriate line.
City or Town Officials .
Please be sure that the affidavit is complete and printed lelplAy. The Department has provided a space at the bottom.
of the affidavit for you to full out in the event the Office of Investigations has to contact you regarding the applicant =
Please be sure to fill in the permitlicense 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 st piped 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. Anew 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. r 617-727-4900 ext 406 or 1-o77-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
w-wW.Mass.gov/&a
°F Town of Barnstable
Regulatory Services
T!ST'ABM " Thomas F.Geiler,Director
ass.
059,ya``� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
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:, i�&i �oP 19,Q® d�� y�t�� A&kTst=tedCost
Address of Work:
Owner's Name: C
Date of Application: ,5 `y G
I hereby certify that:
Registration is not required for the following reason(s):
FWork excluded by law
❑Job Under$1,000
OBuilding 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 PEM-RY
I 7b�apply for a permit as the age t o e owner:
��.
ate or Contrac ame Registration No.
OR
Date Owner's Name
QAmulomeaffidav
Ito CINR Appendix
Table J3 2.1b(continued)
Prescriptive Packages for due and Two-Family Residential Buildings Heated with Fossil Fuels
mmamUM MINIMUM
Glazing Glazing Ceiling Wall Floor Basement Slab Heating/Cooling
Area'CAD U-value= R-value' R value' R-valuc' Wall Perimeter Equipment Elriciency'
Package R-value' R-value'
5701 to 6500 Heating Degree Days'
Q 12% 0.40 1 38 13 19 1 10 6 Normal
R 12% 0.52 30 19 19 10 6 Nonmal
S 12% 0.50 38 13 19 10 6 85 AFUE
T 15% 0.36 38 13 25 N/A N/A Normal
U 15% 0.46 38 19 19 10 6 Normal
V 15% 0.44 38 13 25 N/A N/A 85 AFUE
W 15% 0.52 30 19 19 10 6 85 AFUE
X 18% 0.32 38 13 25 N/A N/A Normal
Y 18% 0.42 38 19 25 N/A N/A' Normal
Z 18% 0.42 38 13 19 10 6 90 AFUE
AA 18% 0.50 30 19 19 10 6 90 AFUE
1. ADDRESS OF PROPERTY: 3
2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: ZM2
3. SQUARE FOOTAGE OF ALL GLAZING: �Sz
e
4. %GLAZING AREA(#3 DIVIDED BY#2): /.2
5. 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-f980303 a
780 CMR Appendix J ,
r
Footnotes to Table J8.2.Ib:
Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and
basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall
area,expressed as a percentage.Up to 1%.of the total glazing area may be excluded from the U-value requirement.
For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area.
2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance,with
the National Fenestration Rating Council (NFRQ test procedure, or taken from Table J1.5.3a. U-values are for
whole units:center-of-glass U-values cannot be used.
' The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full
insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38
insulation and R-38 insulation may be substituted for R49 insulation. Ceiling R-values represent the sum of cavity
insulation plus insulating sheathing(if used). For ventilated ceilings, insulating sheathing must be placed between
the conditioned space and the ventilated portion of the roof.
'Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathing (if used). Do not include
exterior siding, structural sheathing,and interior drywall. For example,an R-19 requirement could be met EITHER
by R 19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to
wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction.
The floor requirements apply to floors over unconditioned spaces(such as.unconditioned crawlspaces,basements,
or garages).Floors over outside air must meet the ceiling requirements.
'The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must
meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned
basements must be included with the other glazing. Basement doors must meet the door U-value requirement
d::scribed in Note b.
7 The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. -
' If the building utilizes electric resistance heating use compliance approach 3;4, or 5. If you plan to install more
than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest
efficiency must meet or exceed the efficiency required by the selected package.
'For Heating Degree Day requirements of the closest city or town see Table J5.2.1a
NOTES:
a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels.
R-value requirements are for insulation only and do not include structural components.
b)Opaque doors in the building envelope must have a U-value no greater than 0.35.Door U-values must be tested
and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door.U-value
in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the
glass area of the door with your windows and use the opaque door U-value to determine compliance of the door.
One door may be excluded from this requirement(i.e.,may have a U-value greater than 0.35).
c)If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with
different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to
the R-value requirement for that component. Glazing or door components comply if the area-weighted average U-
value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors).
43
�pTNE 1p� Town of Bainstable
Regulatory Services
MASS. $` Thomas F.Geiler,Director
019.
4''°yEo►ape",� Building]Division.
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Owner bust
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize / to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job)
�42 -
ture of Owne D to
r �
Print Nae
Q TORMS:owNERPERMIS SIGN
1; BOARD OF 'UII-41N R P
Pcense CONSTRUCTI G 1-ATI.ONS
Nwm�er cccc n r�ON SUPeRVISOR
x " ed�c7 04'2'302 '
ell t �If'fl
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SM S. REVIEWED
BARNSTABLE BUILDING DEPT. DATE
y FIRE DEPARTMENT DATE
BOTH SIGNATURES ARE RE UWO FOR PERMITTING / X
ANT - UPGRADE RE U R efL
S TE BUILDING CODE REQUIRES THE UP IN OF
( SM DETECTORS FOR THE ENTIRE DVVE G N
OR MORE SLEEPING AREAS ARE ADDED R
"NOTE: A SEPARATE PERW IS
INSTALLATION OF SMOKE DETECTORS-THE ELAL
PERMIT DOES NQT SATISFY THIS REQUIRE N .
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SERVICE OFFICER
CLERK
PRINCIPAL CLERK
SUPERVISOR
CHIEF PLANT OPERATOR
PLANT OPERATOR
PLANT OPERATOR
LAB TECHNICIAN
PRINCIPAL CLERK
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I m �C&
DATA
a0 0B/09/2011 13:47 5�87789312 BARNSHOUSAUTHORITY PAGE 01/01
op �
®® Barnstable . Leased Ilousing Dept:-508.771.7292
a'D `�^ ' Telephone 508.771.7222.
Housing Authority FAX: 509,778.9312
14( South Street•13yannis,.MA 02601
ZONING VERIFICATION
TO: Linda/Robin e;
FROM: Kith Gomez, Leased F.Tou.sing Coordinator
PHONE NO#: 508-771-7292 FAX 508-778-9312
r
RE: LEGAL RENTAL UNIT VERIFICATION
DATE:
ADDRESS:
VILLAGE:
. _ y
UNIT TYPE BEDROOM SIZE 0'e.
MAP & PARCEL NO: a7
The owner of the above listed property is entering into a. contt'a.ct with'us forrental of the
property listed. above. Please verify by signi.>>g below that tile unit is'legal and meets all zoni .
requ..tremet�ts for a rental ill, the town. of Barn.sta.ble. If it does not ng
, please list the ,1 eason below g
. m
)421310 WdIONNd
N` OINH03i OV I
2�O1d2j3do 1Nd�d
2JO- J3dOINVId
2101"3dO lNt1-1d J31HO
HOSIM3dns
>N310 WdIONrdd
>RJ3-10
?13013d0 301n213S -
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� � 9 � �w
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ors � �° �
� � 5 �
Fo- '� �,"",``
f .
disposed of.
t
g that sewer has been capped
han one person will be involved in the
te must be on file.
r of Permission.
TELL APPLICANT THAT A DUMPSTER
A PERMIT FROM THE APPROPRIATE
�INEllh.- TOWN OF BARNSTABLE Building
Application Ref: 20060308 i
BARNSTABLE. Issue Date: 04/05/07 Permt
9 MASS.
1639. A� Applicant: DESMOND WILLIAM Permit Number: B 20070665
Proposed Use: SINGLE FAMILY HOME Expiration Date: 10/03/07
Location 639 PITCHER'S WAY Zoning District RB Permit Type: RESIDENTIAL ADDITION/ALTERATIO
Map Parcel 271180 Permit Fee$ 25.00 Contractor PROPERTY OWNER
Village HYANNIS App Fee$ 50.00 License Num
Est Construction Cost$ 95,100
Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND
GUT OUT/REPAIR FIRE DAMAGE AND SECOND FLOOR DORMER THIS CARD MUST BE KEPT POSTED UNTIL FINAL
INSPECTION HAS BEEN MADE. WHERE A
CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH
Owner on Record: KURTZ, STACEY D BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL
Address: 639 PITCHERS WAY INSPECTION HAS BEEN MADE.
HYANNIS,MA 02601
Application Entered by: PC Building Permit Issued By: """" P4_vv,�.
THIS PERMIT CONVEYS NIG RIGHT'TO'OCCUPY ANY;STREET,ALLY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY OR?ERMANENTL-Y.
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 TIIE'APPLICANT FROM THE CONDITIONS OF ANY 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.
3.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 CONSTRUCTION.
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).
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
1 1 1
2 2 2
3 1 Heating Inspection Approvals Engineering Dept
Fire Dept 2 Board of Health
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ,
rl
Map Parcel ` �v Application ooa�
a 6
Health Division
Conservation Division Permit#
Tax Collector Date Issued
Treasurer Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street ddress lSl� s (��
Village
Owner Address
Telephone
Permit Request it A
MA at
Square feet: 1st oor:existing ing proposed 2 d floor:existing proposed "F' To al`new="
Zoning District Flood Plain Groundwater Overlay j �k
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting Jocumentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization 0 Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
Current Use Pt posed Use
BUILDER INFORMATION 'J�c, n\qe Telephone Number
Addres l License#
Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 6Lx-tl) R� X
SIGN E DATE
FOR OFFICIAL USE ONLY `•�
PERMIT NO.
DATE ISSUED "
MAP/PARCEL NO. J ,
ADDRESS VILLAGE, r '
OWNER
r
DATE OF INSPECTION:
f t FOUNDATION
FRAME
INSULATION T
FIREPLACE ~
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING i
DATE CLOSED OUT
I
ASSOCIATION PLAN NO.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel Application#mil
Health Division
Conservation Division Permit#
Tax Collector Date Issued
Treasurer Application Fee z _
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board �-
Historic-OKH Preservation/Hyannis
Project Street ddress P_ � 1 1,(I'LA
Village V\
Owner Address
Telephone
Permit Request nil n
WHIM . I)e 6U
1 ' k'
Square feet: 1st Poor:exis ing proposed 2 d floor:existing proposed _ To al`new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:❑existing ❑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 ❑No If yes,site plan review#
Current Use i . posed Use r {
T BUILDER INFORMATION
e �►' � Telephone Number 12U
Address License#
CL h I Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO / �Yl
J
SIGN4URE A7 DATE L L
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
�oFtMEI� Town of Barnstable
Regulatory Services
saxM .SASS Thomas F.Geiler,Director
'OrBp,gplp Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.Duu a T
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: l Estimated Cost
Address of Work: LQ(3q L�k �
Owner's N
l�- _:iiry (,u P
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 apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
LVAL
Date Owner's Name
Q:forms:homeaffidav
Town of Barnstable
Regulatory Services
BARNSTAB9 ''r�" Thomas F.Geiler,Director
�A 16gq 10
rfc n►a+• Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
NOTICE TO THE BUILDING DIVISION OF
LICENSED CONSTRUCTION SUPERVISOR
ASSUMPTION OF RESPONSIBILITY
0
# rib ou U ,hereby certify that I have assumed responsibility for the project under
construction, as authorized by building permit , issued to
(property address) 1� L 1 C�
on - , 2000�
The following documents are attached:
copy of my Massachusetts State Construction Supervisor's license
or Homeowner's License Exemption form(if applicable)
copy of my Home Improvement Contractor registration (if applicable)
Commonwealth of Massachusetts Workers' Compensation Insurance Affidavit.
Road Bond(if applicable)
/ A E
q/forms/newcontrb
FTw,ti Town of Barnstable
Regulatory Services
sa MASS. ' Thomas F.Geiler,Director
1659. 10�
lFc 16 Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
NOTICE TO THE BUILDING DIVISION OF
CHANGE OF LICENSED CONSTRUCTION SUPERVISOR
owner of property located at
4uctrkloiP Y
W -s _ ,hereby certify that
Yv�2 is no longer Construction
Supervisor listed on the application for the project under construction as authorized by
building permit#,B issued on `7 200_(a.
moo co 308
I understand that the )project under construction must cea
se ase until a successor licensed
Construction Supervisor, is submitted on the records of the Building Division.
41,310-7
PROP O R D TE
q/forms/newcontr
reference R-5 780 CMR
rev:080102
s�
t � The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation InsuranceAM
davit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print I.,e ilal
Name(Business/Organization/Individ
Address: C-
City/State/Zip:_ &A _ CJaC.Q__Ck Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):.
1.❑ I am a employer with 4. I am a general contractor and I
employees(full and/or.part-time).* have hired the sub-contractors 6. ❑New construction .
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• � . 9. ❑Building addition
[No workers' comp,insurance comp,insurance.t '
Electrical repairs or additions
required.] 5. We are a corporation and its
3. ham a-homeowner doing:all work officers have exercised their 11.El Plumbing repairs or additions
:myself�[No wok s'comp. right of exemption per MGL 12.0 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.
tContractors 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: 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 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 violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi ations of the WA for insurance covera a verification.
I do here tify under the ai nand enalties of perjury that the information provided above is rue and correct.
777
Si = _ Date:
` V0 31
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Ins ructions
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 trustee of an individual partnership,association or other legal entity,employing employees. However the
owner of a dwelling.house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for:the performance of public work until-acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-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 c
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.
is address telephone-and number:
fax
The Department's r .
The Commonwean of Massachusetts
Department of Industrial Accidents
Office of Invesfagataous
600 Washington Street
Boston, MA 02111
Tel. ##617-727-4900 ext.406 or 1-877-MASSAFB
Fax 4 617-727-7749
Revised 11-22-06
w.mass.gov/di-a
l _
oFt�ra,.
Town of Barnstable
ti
Regulatory Services
BAMSrABLE, : Thomas F.Geiler,Director
v MA&&
1639. ,•A Building Division
rFD MAGI
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: � _ 1,•
JOB LOCATION: � anti J SZ
numbw street village LR�
"HOMEOWNE _ CX q0 3 L 0 Ul sue'
name hom one# work phone#
CURRENT MAILING ADDRESS:_ CA&-,a--
A�av\v\t\s, t ba 40\
city/town X 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)
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
I
ments.
Signs re of Home er
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 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 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:forms:homeexempt
� _ i
r
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
k
Map oZ7 11 9D Parcel �� Application
60(o 6
Health Division
Conservation Division Permit#
Tax Collector Date Issued
Treasurer Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 6 3,7 f`7C At r_r3 /
Village &2&Ali S p1A_ OoLL61
Owner .STA Vr`rZ Address 635 f/TNz.3
`Telephone
o
�/4fd Permit Request -4/
F-c,,, <i
.� (�Q
Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Tota.I newt'
Zoning District Flood Plain Groundwater Overlay -- ,
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑ Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ®'Electric ❑Other
Central Air: O"F6s ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes tft
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- ❑No - If yes, site-plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name e4M e;_1 4"? 1Y7, o-4 17/0 1K e> Telephone Number gbv
Address S`l moua<_ (?-,-4 License# E I( 15
fr Vc j md,.;K en Yj Od i S-1 Home Improvement Contractor# 166 3 S�v
Worker's Compensation# ' _3o 10,41
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO No 1&4 S
IGNATURE DATE S^ to
FOR OFFICIAL USE ONLY
F r
%
PERMIT NO.
DATE ISSUED '
MAP/PARCEL NO. '
ADDRESS VILLAGE
OWNER"
DATE OF INSPECTION:
FOUNDATION
FRAME
i
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING "
DATE CLOSED OUT
ASSOCIATION PLAN NO.
51 Moore Road
Weymouth Industrial Park
East Weymouth,MA 02189
(781)331-0333
American Mobile homes,Inc. 1-800-232-9991Fax(781)335-0707
T91e Temporary Housing Specialists
Est. 1972 PROPOSAL
Date
Name Est. delivery date
Address L'
a
American Mobile Homes,Inc.hereby propose to furnish the materials and perform the labor necessary for the
completion of installing Citn p JZ ' X leased mobile home containing:
Refrigerator,stove,dining set,living room set,curtains,bedding i s 2nd &,�L 3rd�washer
and dryer,air conditioning.
a'Tamporary Plumbing installation to mobile home >-Applying for building permit for mobile home
I9'Temporary Electric installation to mobile home ❑ Remove necessary trees,tree limbs or shrubbery
❑ Temporary LP gas installation to mobile home ❑ Remove any necessary fencing
❑ Other:
- Any resulting damage to said property as a result of the installation,removal and existence,of mobile home and its
its utility connections shall not be the responsibility of American Mobile Homes,Inc.,specifically driveway,fence,
stonewall,septic system,trees,lawn or any other type of landscape items and/or:
American Mobile Homes,Inc.,is not responsible for the re-installation of any of these items.
Costs:
The monthly rental of the mobile home�i mos. The delivery and pick up charge of S
Air conditioning -' Pet fees other
There will be additional charges for utility connections,permits,fees,site preparation.
There will be a profit and overhead charge of 10& 10 for all sub contractors and fees paid out.
Any applicable sales tax.A 5%carrying cost will be billed and payable on all invoices not paid within 45days of billing.
A$1,000.00 security deposit is due on delivery of mobile home.Uwe agree to sign a lease for the mobile home rental at delivery..
Projected job cost: %� 11�-- t yIr L� 7�au,Ywm i u s ✓e 1— ,t L �kqc�0 1l/�.k e2 C�lcz1/gZ-!j,,
Payment Method : B'Milled directly to insurance company with a signed assignment of payment.
❑ Other:
Any alteration or deviation from above specifications involving extra costs,
will become an extra charge over and above the estimate. All agreements Respectfully submitted
contingent upon strikes,accidents or delays beyond our control.
ACCEPTANCE OF PROPOSAL
The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as
specified. Payment will be made as outlined above.
If insurance company is not willing to honor assignment of payment,I/we understand I/we will be responsible for full payment of
all services.
NOTICE OF RIGHTS TO CANCELLATION
You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the Seller,which may be his
` main office or branch thereof provided you notify the Seller in writing at his main office or branch by ordinary mail posted,by telegram
sent or by delivery,not later than midnight of the third business day following the signing agre ment.
See attached notice of cancellation form for an explanation of this right.
i
Sign
Date 5 Signature
H 51 Moore Road
Weymouth.Industrial Park
American Mobile Homes,inc. East Weymouth, MA 02189
The Temporary Housing Specialists (781) 331-0333
Est. 1972 NOTICE OF CANCELLATION 1-800-232-9991
Fax (781) 335-0707
Dated:
You may cancel this transaction, without any penalty or obligation, within three
business days from the above date.
If you cancel, any property traded in, any payments made by you under the
agreement, and any negotiable instrument executed by you will be returned within ten
business days following receipt by American Mobile Homes, Inc. of your cancellation
notice, and any security interest arising out of the transaction will be cancelled.
If you cancel, you must make available to American Mobile Homes, Inc. at your -
residence, in substantially as good condition as when received, any goods delivered to you
under this agreement; or you may'if you wish, comply with the instructions of American
Mobile Homes, Inc. regarding the return shipment of the goods at American Mobile
Homes, Inc.'s expense and risk.
If you do make the goods available to American Mobile Homes, Inc. and American
Mobile Homes, Inc. does not pick them up within twenty days of the date of your notice
of cancellation, you may retain or dispose of the goods without any further obligation. If
you fail to make the goods available to American Mobile Homes, Inc., or if you agree to
return the goods to American Mobile Homes, Inc. and fail to do so, then you remain liable
for performance of all obligations under the contract.
I hereby cancel this transaction.
Date Buyer
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u45r-QJAAa% t j 4,- 'Ti1E= c�«=�Sc►'S SEtc�t_n I,APPL2CAo-l-r
t4:T IBA. u5co u DareCMit4t_ Lc:;;r 1_►► aS # CAS WIDe
Assessor's map and lot. nu er + ....... d/�- AG� S' - 7 7
.....,, .. .
t. SEPTIC SYSTEM MUST DE
4 7 7 • INSTALLED IN• COf- PLIANCE
Y` Sewage-'Permit number,,. .. ... ........................................ .. 1;^;J'I'!1 ARTICLE II 'STATE 4
r
SANITARY CODE AND TOWN
o�THETo TOWN OF 'BARNSTGALB -
Z BBBHSTABLE i • f
}
` Ao M6 81.11-tDING ' INSPECT-OR
APPLICATION FOR PERMIT TO . ... ���� ."" . ....
TYPE OF CONSTRUCTION ........ � '.... .... .... ....................... ................. ...................
..............:...... O........ .l 9
TO THE INSPECTOR OF BUILDINGS:
The undersigned/hr...by applies for a permit accordin to the following information:
• P
Location °�.././.'�...1/..�C.... v .��Z' ....................................
7
ProposedUse ,. �� r ..........................................................................................:..................
Zoning District ............j.........................................................Fire District .... �- -
/..."a`
Name of Owner _ ..... .e-�� ....Address
......... .
Nameof Builder .....................................................................Address ....................................................................................
• o
Nameof Architect ..................................................................Address ......................................:.............................................
Numberof Rooms ..................................................................Foundation .....��.r........... .. .. ..................................
Exterior ...................................................Roofing ......
Floors ........................Interior ............ „�Gt''.
..............>,......,.i...`.�:............... - ...............
..... .... . . .....
�' L�J
Heating ....../.. .. a.... °.............................................Plumbing ............ ..........:..................................................
o�
Fireplace ........:.........................................................................Approximate Cost'c ,...r..........................................................
Definitive Plan Approved by Planning Board ______________ /-
-----------------19--------. Area ....................... . ........
! .....................
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the n of Barnsta le 'r�eging the aboy,d
construction.
• Name ............ ....... .............
Capewide Development
1 No ..1.9Q1.4...... Permit. fer'an „1/2 story....,.,
.....Aingle.. sm3.1 .d�d� . .3ng.........................
Location Lat- Mutchrr.a..Way.....................
..........H.y annia.....................................................
Owner ..Cap&vidP_JDaxe.1RPM.vR%....................
Type of-Construction ...........frAMe....................
Plot ............................ Lot ...ON....... .........
—Permit-Granted .....,Max- h..,1.5................19 77
Date of Inspection .. ..�� ? ...........19
Date Completed ..... �. ...........19
. .PERMIT REFUSED
.... ....................................... ... ... 19
........................ ..................................................... .
............. ....^............................s........:•+.................... _ r
Ap' rove' ....................................i.......... 19
I z t� �G t o —/s" _ 7 7
`7 l a
Assessor's map and lot number ....L7
... ..T.. ..........
Sew age Permit number ...................................
°FT"Er w• TOWN OF BARNSTABLE
�s BAWSTADLE. i
4 6 Ya�e r BUILDING INSPECTOR
MO
or
APPLICATION FOR PERMIT TO S /_ d. _
' TYPE OF CONSTRUCTION ' ............................................
r ...................... �, ... ........... .......
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies
y�fforpermit,
according r the following information:
sr f� jM. /l .r" f /WKs+ci? � -/^-7�, 1 I �—/1..�'r••L,,�+'�..
Location .... .: ...... ..... .............� .. .................ff ..............................................................
ProposedUse ........:..:.... ................:r;..................................................................j................. ..:......................,.........................
41
ZoningDistrict ................................. ...........r;...........,...Fire District .. : ................................................................
Name of Owner ..... `� ' r�
...C� 'L::............. .� !' ....Address ....................................................................................
Nameof Builder ....................................................................Address ....................................................................................
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms .............:....................................................Foundation ......
........................................................................
w
/...-F 'Y-
Exierior �` Roofing .r
Floors g
—!....................................................Interior
Heatingf.....: l..:'i.v.....`r.......................................Plumbing .............. ...............................�..............................
Fireplace ...................!..................................A...........................Approximate CostE-' :� ........................................... .......
Definitive Plan Approved by Planning Board ________________________________19________. Area ....................................
Diagram of Lot and Building with Dimensions Fee .. ....d
SUBJECT TO APPROVAL OF BOARD OF HEALTH
r
f •
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ................... ...;r ';:,..fcf .._........,................
Capewide Development M271 L1M1
No ... Permit.Z6r
fgqKt.jy dwelliqng................... .........................
&3
Location ....LQt...�Aji. .t.qher.s Way„.,_„_...........
. ........ .
..............HYA M14A.4 .................................................
Owner ........................
Type of Construction ....frame...........................
...........
................................................... ............. ... .........
Plot ............... ........... at .......... ...........
Permit Granted r-Gh•..L�5.................19 77 t
Date of Inspection ..... . ............................19
......... ......
Date Completed ...\........... .......................19
...IN ...................'.....�P MIT
j T..'..i..E...f.
.Q.)...D
..............................X. . ...
.............
........1..9
.. ....
................ ........................... ..\ .......................
.
.....................................................N.....................
Approved ................................................ 19
...............................................................................
...............................................................................