HomeMy WebLinkAbout0464 SCUDDER AVENUE TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map O Parcel _ Application #
Health Division Date Issued !g-1� . fc-
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address
Village kC °
Owner �-�ee .. 1`� a✓ 1' +�� Address qq
b `�-� Ai� 0
Telephone
Permit Request te pcyclei
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation ! k Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach , pportiniocuu�aentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(# units) _
�. CS
Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings Highway: ❑g s ❑.No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other ''
<<r87
Basement Finished Area (sq.ft.) Basement Unfinished Area (sp.ft) -
Number of Baths: Full: existing new Half: existing anew
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 #
pp c
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �o0 Tcl�t O-A LC .Telephone Number
(� r / vh
Address q b �'T s �P License #
y�- Home Improvement Contractor#r ��
Worker's Compensation # v / 1510 P $3-
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
6r'S40 V\5 bA_.V�,-
SIGNATURE DATE C
FOR OFFICIAL USE ONLY
APPLICATION#
i
t
DATE ISSUED
MAP/PARCEL NO.
ADDRESS
VILLAGE
OWNER
DATE OF INSPECTION:
wFGUNDATI.ONI Aj it TT2 y
" FRAME
Q
INSULATIONjt-A,`,•_n-fC :..;3
FIREPLACE
ELECTRICAL: ROUGH FINAL.
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING ..
DATE CLOSED OUT
ASSOCIATION PLAN NO. �
r
T ke Cv2nvrt € qfMassachraeft
De k t of hzdasftTd Accidents
OfficelaflMIfffigIM609S
600 Wmhkpoa Street
Boston,M4 02M
wnw nass gmAdia
Workers' CampensatianInsuranceAffidavit:$udders/Can&actnr MedricianslPlumbers
pplicant.Infarmafion Please Print LegiMy
Nan=(]�smesel6�gsniz�ioaltndivicinaq: � �n J� Sy( Co c -
Address: �� (z : 6,9 -�
6xS'2-
Are you an employer?Check tke apprapnate off: T of o eict r
4. [�ajata general contractor and I 3� �' � €�red�:
I ❑ lam a employer whiz ❑New c=sWxfiou
t�rlayees{felt andVorpart�ime}* havehiredthe sub-contractors 6-
2_El I am a sole proprietor orpartner- wed on the attached sheet; 7_ ❑Remodeling
ship and have no employees These snb oozftracfors have 8. Demc1tion
Working for me in any capaciilr- employees and have mockers' Q. Building addition
[l�O WQT1CeIS'Comp_in¢trranre comp.insa anw-1
�°ir�1 5. El We area corporationand its 10 0 Electrical repairs or additions
3.❑ I am a homeovuer doing all work officers have e=cised their II.D Plumbing repairs or additions
Myself [No workers,tpomp_ right.of emraption per MGL 12-[:]RDof repairs
c 15Z§1(4),and we havenQ
in�rrAnre r�viSed.]F 13_❑Other
employees-[No Workers'
comp_insuran(m required-I
*Auy agplirnat that thus box*l amst also fiIl out the section below shooing&&wa$cessT compenseiiau poliL-a„ W
13�rmernwners who submit lhh Effid.-pit M&=tmg they an damg s3 thy*hkv ausi.&-conb:c rs= 'Submits new affidnit m t�or nc snrh.
=Coutracmrs that check this box must attached an additional sheet sho h g the mane of the mb-=ftactoa and stshe whether armot those erfifies have
employees_ If the sub-contractors hav a emaployees,they=rat provide titer workers'Comp.policy number-
lam art Below is the p-a cy and job sits
i7ifDYWtatib?tL
Insurance CompmyName: Ara' ",e d- , -27�- r'C-
Policy 9-or Self-ins-Ur- `T 9 51 P T-7-7-13 Fwplration Date:
Job Site Address- q SG, citystatelTap:a` 0-VVI 1-4 o�
Attach a copy of the mmikers'compensation policy declaration page(showing the poliq,uu er and exg Aon date).
Failure to secum cavtrage as regaired.uuder Section?SA of MGL c. 152 can lead to the impositi.orl of criminal penafties of a
fine up to$1,50Q.W andlor one year imprisonment as well as civil pezrallies in the form of a STOP WORK ORDER and a fine
of up b3$250-00 a day against the violator. Be advised that a c4)1 y of this statement rmraybe:brwarded to the Office of
Investigations of the DIA fr insurance coverage vrerfficatmn_
I do hereb p certify a its andpenaLfias ofpedwy that the in f orran ian prm' ab is hxg and correct
Siena Date- r
phone
Q&irl use only. Da trot writs in trite area,tat be completed by d47 or town of icurL
City or Town: PerwitUcense#
Issuing Authaxity(drde one):
1.Board of Health 2.Building Department 3.City(Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.other
Contact Persan: Phone#:
6
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract ofbire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other Iegal 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 Iocal licensing agency shalt 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 vrith the;n 117ance
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 certif catc-(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 maybe submitted to the Department of Industrial
Accidents for confirmation ofinsin-ance coverage. Also be sure to sign and date the affidavit The affida)zt should
be mtumed 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 obtairi a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-inmrmce 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 viU be used as.a reference number. In addition;an applicant
that must submit multiple permitlIimr se 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 lice 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 Commoawc ala of Massachu�eks -
Depatimemt Gf Industrial Aodidants
Gfice of kve� -Uous
640 Washingtan Sit
Ba o a.,lei 02111
Te1.t4 617 727-4900 W 406 or 14 MSSAFE
Fay# 617-727-7749
Revised 4-24-07 -
w .mass,,gov/dia
07/15/2014 09:06 5087710663 SCHLEGEL_INSURANCE PAGE 01/01
CERTIFICATE OF LIABILITY INSURANCE DATEIMWODmvyf
FPR�ODUCER
CERTIFICATE IS ISSUED A9 A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
07/1a/201q
ICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 8Y THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER 3
SENTATIVE OR PRODUCER,AND THE CERTIFICATE MOLDER.
A { I, AUTHORIZED
the NT: If the certJflcatg holtler is an ADDITIONAL INSURED, tNo pollcyltgg) mUat b9 endorsrd. t SUBROGATION IS Wg7VED,
ms and condltlong Of the Policy, Cerkafn pollCleg May require an andoraemont A atatpmen4 On this CDItIFlcattt done not confer rights
te holder In lieu Of BU O en a Policy,(S), subR t0
$L INS[TRANCC BROKER$ I>rTCNAMfI; PAIII SCHLEl3EL
N S'TR=T PND508-771-8391
EIO,NaErt: (AIc,ARNOOTR MA 02673 ADDREaa; SCHLEGELINSVRAN[,@ y
_ IMURRIII(S))AFFORDINno
INaUREb „�� INSUROR A:NGM INSORANCE COId�
Adtlson 38901"ni Dba SG401irti, Construction
INSURERe:AIN,t MUTDpu,
117 Hinton Lane INSURERC: �—
INWRER D;
N98t Barnatable, MA 02668 IfOURER P,; _
COVERAGES INSURER F;
CERTIFICATE NUMBER;
THIS T . CERTIFY THAT THE POLICIES OF INSURANCE LIFTED BELOW HAVE BEEN ISSUEb TO TH6 INSUR UEtISION NAMEONq p�RpOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REpU1kEMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUM@NT WITH RESPECT TO LILYTHIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED I•tEREtN IS SUBJECT TO ALL TH WHICH TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY aIAVF 8Er_N REOUCEb BY PAID CLAIMS,
LTR TYPE OF INSURANCE
A GENERALUABiLnY WSR WVD FOWCYNUMBER (MMIDDNYYY) (MMIQ
PonAryW) UNIR.
M>?TBABtiII C 05/07/201405/07 201$]( DMMERCIALOtrueRALLveIUTY / EACMOCCURRtENCC 8 2,000,000
CLAMP-MADE 2 OCCUR PREMISES(Enoccurraw) 8 500,000
MCD M-(MT one w3un) ¢ 10,000
FEMONALAADvINJURY It 1r000,000
GEN'LAGGREDATELIMITAPPLIEr,MR: 6fHdJLgLAGOREGATe S 2,000,000
POLICY � LOC PRODUCTS-CCMPwPA00 S 2,000,ODO
AIITONOSIU;LIABILITY S
ANY AUTO au�eNj 8 AUTOS AUTOS ra6 OWNED aChlEOLn,gD BODILY INJURY(For paoq) &AU
HIRED AUTOS NON-OWN12D Ea0DILY INJURY(Nf aaNdent) E AUTOS
(Pera3emenl) $
UMBRELLA UAR -
OCCUR 8
EXCESS UAB CLAIMSWADE EACROCOURRENOC g
DF,D RETENTION S AGOR=GATE ¢ '
B WORK$RacompeNa-1-Mv
AND e APC-400
ANY PROPRICTDRIPARTNER/E7OUryyE YIN �•7026025-2014A 05/23/201. 035 S
OFPICERIMPMBER UCLUOPDT NIA
t'ORV LIMITS PR
Wandatory IR NHI E.L.EA CFI ACCIDENT •—
Ifyea,du0beugdM a ZOOY FOOD
DESCRIPTION OF OPERATIONS Pebw E.L,D11MASE.EA MpLDYF� $ 100400
E,LDI:IEA$E.PDLICY OMIT S 500,000
?aCRIPTION OF oeERnnoNa LOCATroNs I VEHICLESARach AOORD 7ni,AOale
( Mnhl RMIOM[a aehcaula,a mom epacn I�faqulmd) _
,DXLSON SEGOLINI EAS CL>OCTED TO EM COVERED UNDER HIS CfJPP= NOPMR8 COMPENSATION POLICY
RTIFICATE HOLDER
7NRISE RESTORATION CANCELLATION
30 ROUTE 6A # 3 SHOULD ANY OF 7HE ABOVE DE8CRIg1ED POUGIES BE CANCELLED aePORE
PLST g7+NDWICH, HA TKI% EXPIRATION DATE THEREOF,ACCORDANCK TR THS POLICY PROVISIONS;NOTICE WILL BE DELNER!p IN
WI
I
AUTHORIZED Ra101%L0 T
DQ-5Q3-968A
�11988-2010 AI�-ORD CORPORATION. All righm reserv9tl,
'ORD 25(2010103) The ACORD name and logo are mglsteretl marks f CORD
it
.a Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor _ ;
License: CS-105323
WELLIAM M FEDJkR
24 PARRISH WAY
West Barnstable 16IA
�!j A Expiration i
Commissioner 03/14/2016
r
d '"
U12PQ�1?2�Y��iL� t2' -
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 160037
Type: DBA
Expiration: 6/19/2016 Tr# 254391
SUNRISE RESTORATION COMPANYt
WILLAIM FEDER =� _ ----
P.O. BOX 802 . .9 —
E. SANDWICH, MA 02537 �, st`--- 3, •y' -- _
Update Address and return card.Mark reason for change.
Address Renewal 1-:] Employment El Lost Card
SCA 1 0 20M-05/11
c%I1P Y nlllYlto77,tuecrlf/4 1/_1/�/-l3ClcllllJF�1
_Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
I
ME IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to:
egistration: 160037 Type: Office of Consumer Affairs and Business Regulation
xpiration: 6/19/2016 DBA 10 Park Plaza-Suite 5170
Boston,MA 02116
SUNRISE RESTORATION COMPANY
WILLAIM FEDER
480 RT.6A P.O. BOX 602
E.SANDWICH,MA 02537 Undersecretary, Not valid without si natur
Town of Barnstable
Regulatory Services
f t
9Aiv�nssBtE� Richard V.Scali,Director
f'TF163 Building Division _
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Bi ilder
as Owner of the subject property
hereby authorize_SUv\r> r�`�rx�-,��- (�. C to act on my behalf,
in all matters relative to work authorized by this building permit application for:
c� ear v Q LAv,( >POf-
(Address oflob)./
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or'utilized before fence is installed and all final
inspections are performed and accepted.
Signature of e % Signature of Applicant
Print Name Print Name s.
Date
Q:FORMS:OWNERPERMISSIONPOOLS
Town of Barnstable
Regulatory Services
�oF�+e roiry,� Richard V_Scali,Director
P ° Building Division
EARNSTASLE. ` Tom Perry,Building Commissioner
rdAss.
1639• 200 Main Street, Hyannis,MA 02601
�Eb NtAI www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: ----
JOB LOCATION: -
number street village
"HOMEOWNER':
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is;or is intended to be,a one or two-
family dwelling, attached or detached structures accessory to such use andlor 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 perform6d 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"certi ies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she'lA'ill comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control. ,
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,RuIes &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:\WPFILES\FORMS\building permit forrns\EXPRESS_doc
Revised 061313
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Assessor's office Oslt floor) r'
Assessor's map:`and lot number
Board of Health`*{3rd floor): 0 0"
Sewage Permit. number ....:�
6Hd9fSDLE,
Engineering Department (3rd'floor):
` �`�.
House number ..... ........................ ..... .... ....' :.:................. TI Rammmc YPr 6�a
Definitive Plan Approved by Planning -Board __ _______________-__-_._._____19________ .
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00.2:00 P.M. onlyt
:'TOWN £OF BARNSTABLE
.,r BUILDING INSPECTOR
APPLICATION'FOR PERMIT-.TO....AG�f�I.'.3...G
.
TYPE O� CONSTRUCTION,.....:�arVIC rZI���'.-....7 fF0J .1.Vda! .�Q:?Q...� OM4..T.1 i�..�Y�.�.
f r• ....... .. ... .?:..^.. .....19-. ..
TO THE INSPECTOR OF. BUILDINGS:
The undersigned hereby applies for a permit according to the following:information:
Location :.......:. 6•0.••(••...... l.Pl.��.... .✓.. .........# ............. ..r...............
Proposed Use ....... .. . � . :..... 4�5�. C." .` ....:....
....
7 'Zoning District � . ... N•!.S,,.::........:............... . ...................................:....Fire District ...................
Name of Owner.: lln `... ✓�` .0 ...............::....Address'' 6.�.�.• .W. Ct�G1Ql'...trVCl .aN.... .�/� .......
l'14r ��16
Name of ,Builder�6me.Lm1ROi1cl.�lrs .° CI>.. AdcJressi'I�4..N /2./..T//1�.,. . �9/1/i�/IS..... �Ct.,........
Name ,of. Architect ................. ....�..... ...........................`...Address .......... .
Number of Rooms �D N C DIUCC`fe_
.... .......
........Foundation. .....
Ext'e for ........: ......... ...... .......................................Roofing ...... .�5... aL.f Cdl�etp0�/./ .0.�....... .
Floors ..... /02..f..C.o ...... �o .':�!. "...............................Interior ............!, ... ...........r'�:�� �t ... t�
r. ... . .... .....
. .r• Heating . ........ LG`! ...........:...............................Plumbing ..........A..&....... .............................
Fireplace .........Y�.� ..........
...................................................Approximate Cost ...... .Qa�...........................:....
Area .........
Diagram of Lot and Building with Dimensions Fee' Ofl
OCCUPANCY PERMITS,REQUIRED FOR NEW DWELLINGS
1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .................
i
Construction Supervisor's License .�.Q..'.3.6..1/.........
LUCE, RICHARD A=288-007
4 y BUILD.ADDITION
r - 32701 ?- AND SECOND FLOOR . - -
No ................... Permit for .................................... ?
Single -Family-Dwelling ,1
..........
464 "Scudder Ave -
4
Location . ........ ...m............................................. ;'• -; -- -
Hyannisport
k.:?....................... .............................:................... • ( I �� ^�•f .'� i+ 4r �' .a
;Richard Luce
't)wner .......:....
y
Type of"Construction L-. Wood Frame`' ........
-
Plot ! . L'ot
Pe�mit""Granted .March.J.4... s:...:. .. .....1.9 89 r
Date of Irispection .......19
Date`Completed 1.. .. :. 1;9 ,
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Engineering Dept.(3rd floor) Map - Parcel 3S Permit# 4"7 Q
House# 14 b Ll 1� 73J, Date Issue` 7' ' 7
Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30)- Fee ���. `r 8r
7 4�_*,J,
Conservation Office(4th floor)(8:30.9:30/1:00-2:00) , eNV� �co
Planning Dept.(1st floor/School Admin. Bldg.) �'®
a '
Definfree't
pproved by Planning Board 19 �_ - , R
BARMASS.
TOWN OF BARNSTABLE
Building,Permit Application
Profdressor
Village
Owner /may_ ,C//a iC- 14G Address /2/ 2��k jMerk% Jam( "Ad
Telephone T/--8®9j(
Permit Request t j?�ILy AZ22/7-1500/ /'7T 4--OA R&kin 1-0 h5tiS7'iIVC 1=-4MJ u &.,.,m
First Floor square feet Second Floor 74 $ square feet
Construction Type -A,7107C/,l
Estimated Project Cost $ ,�9 0100
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 [d'Ko On Old King's Highway ❑Yes dNo
Basement Type: UFull ❑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)
A
❑None ❑Shed(size)
❑Other(size)
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review# -
Current Use Proposed:Vse
Builder Information.
Name Telephone Number
Address A4f5 Zg�j7— License# Gt5`�f D92. "
� jZ2/ G—' D/1,8t/GIt�J Home Improvement Contractor#
v
Worker's Compensation# d9W8,37_ ZR2 f,
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 TOe.
SIGNATURE - DATE — 9 7
BU1 I�� f%� JF
OLLOWING REASON(S)
�
FOR OFFICIAL USE ONLY
zq
PERMIT NO. � ; M
j
DATE ISSUED E
MAP/PARCEL NO.
• F
� ! A
ADDRESS VILLAGE w `^'
OWNER
DATE OF INSPECTION:
FOUNDATION
{
FRAME ' • .
-
INSULATION �
FIREPLACE
ELECTRICAL: ROUGH : FINAL
PLUMBING: ., ROUGH FINAL' -
°`
GAS:;-A-r OUGH FINAL
FINAL$Li
DATE CLOSED OUT
ASSOCIATION jPLAN NO.
.e
31
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i DEPARTMENT OF PUBL -
ONE ASHBURTON PLA
605TON, MA OZl
CONSTRUCTION SUPERVISOR LICENSE
j Numbei : Expires:
Restrfeted to: UO
_
TI10MA5 X CAPIIII JF '
:cu f CFCIVAL DR -
W BARNSTAOLLs MA 02G6C
f "
The Commonwealth of Massachusetts"
M Department of Industrial,accidents
Olflee 8"fir stllst ess
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit '
Applicant
nam•: Q ]
location' 61 51 _ir7 f/V�r/lf7�l�N �L1
citN C��'7?Ji i ��//T O�G S� •hone# ^96���
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 prop iding workers' compensation for my employees working on this job.
company name: -
address
city: phone#:
insurance co -� �T� i poles# �tWe3,d ZZ e-
I am a sole proprietor. :eneral contractor, or homeowner(circle one) and have hired the contractors listed below who have
the follo\tin2 %korker_" compensation polices:
m anv name:
address
City: Rhone#• -
insur•nce co policy#
companyname:
address.
cit. phone ff• ,
insurance co posy#
n
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a One 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 One of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. '
I do hereby certify under(#spains and pen Iles a perjury that the information provided above is true and correct
Signature
Print name �-r'1�.+�I_® �'� �c�9 Phone# 2F
official use only do not A rite in this area to be completed by city or town official
city or town:' YARMOUTIi permit/license#, r'IBuilding Department -
- - Licensing Board
check if immediate response is required 261 OSelectmen's Once
K (5 }- Health Department
contact person: phone q;._. 08) 398�2231 est. rlOther
(revised 7;95 PJA)
tM THE t
The Town of Barnstable
• �aivsrestE. •
9� MASS Department of Health Safety and Environmental Services
Building Division -
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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.
Type of Work:/ Ali/?/df✓ Est. Cost_ 39_DOa
Address of Work:_
Owner's Name_!�''/C�j¢�/��/��j�Q/CJA
Date of Permit 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:
ZLEZ
Date ctor NA
i Registration No.
OR
Date Owner's Name
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SCALE: / " J
APPROVED BY: DRAWN Wf y�
DATE: 7-o)e) -�7 REVISED
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