HomeMy WebLinkAbout0041 SPRING STREET � �� 7-0 � �
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
� o�y
Map a Parcel Application #
Health Division Date Issued 12, 2 ,-10
Conservation Di ision Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board `—
Historic - OKH Preservation/ Hyannis
Project Street Address 41 Su,';&� S4' Qn► 4'�t upper-
Village 112ryunn'15
Owner \4J4v►•4- �a� Address q1 SQr;"5 S4
Telephone 1 813 I Li b s d\S 6
Permit Request 9t y)UM U61 "a < go-pletz Ki-ic.L411 , 1900%e6In5 1 pw*n q
1C4,kh.o0Y% w�k�% to 17_ �nAy'n T 40� S\J mound an� V4n► +1Y.
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size i a- Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
M
Dweilng �pe: Singe Family ❑ Two Family Multi-Family (# units)
a �
Age�f Exist g Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Bas&&nt Type: ❑ ull- ❑ Crawl ❑Walkout ❑ Other
co Basdr ent Funished Area)(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full�:;existing 1 new u Half: existing o new m
Number of Bedrooms: a existing a new
Total Room Count (not including baths): existing new O First Floor Room Count S
Heat Type and Fuel: udGas ❑ Oil ❑ Electric ❑Other
Central Air: ❑Yes C!t/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 AppealsAuthorization ❑ .Appeal # Recorded ❑
Commercial ❑Yes 2/No If yes, site plan review#
Current Use 0-slCLn 11(A Proposed Use
APPLICANT INFORMATION
. - (BUILDER OR HOMEOWNER) — {
Name SLIC ��C; Telephone Number So lb 3(oq A90
Address �, Yes �� License # 9 S
Ce.n �CrJ 01lk M4 o.;k(p Home Improvement Contractor# D
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE ���`' PuL DATE
C_
s FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
t OWNER
DATE OF INSPECTION:
FOUNDATION
V
FRAME
INSULATION
k� FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
- ' Office of Investigations
IY 600 Washington Street
Boston, MA 02111
i� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): C 56,._ 0`
Address:
City/State/Zip: tom ,4Cr%h 0a632 Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 1 am a general contractor and I
* have hired the sub-contractors 6. New construction
,�,(employees(full and/or part-time).
2.I�J I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers comp. insurance.$comp. insurance 10.0 Electrical repairs or addition
required.] 5. We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ Plumbing repairs or addition
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.❑ Other
comp. insurance required.]
"Any applicant that checks box M 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.
lContractors 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.
1 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.Lie.#: 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 fit
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 cinder the pains and penalties of perjury that the information provided above is true and correct.
Signature I �QVtf G � Date la 1 a1'09
Phone.#: . 3 4 _02 L S to
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 Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or 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, constriction 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 pen-nit 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,.MA 02111
Tel. ## 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
Y r Town of B arastab-le
Regulatory Services
F F
atixxsrAsr Thomas K Geiler,Director
ems.
d 0. Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barngtable.ma.us
Office: 508-862.4038 Fax: 508-790-t
Property OwierMust
Complete and Sign This SectiOn
If Using A Builder
I, , as Owner of the subject.property
hereby authorize ����,Y,QRc; Go to act on my behalf,
in all matters relative to work authorized by this building permit application for.
` S r►n A ann'S
ss of Job)
Signature of er Date
G'�bLt)
Print Nam
1
If Property Owner is,applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
- s.,�tursnist.e, .
Cuss g• .
.16,$ Building Division
PrFDy Tom Perry,Building Commissioner
200 Maiii-Street; Ayannis, MA 026..01
)-vww.toYvn.barnstable.ma.us
Office: 508-862-4039 Fax: 509-790-6230
ITOMEOWNER LICENSE EXEMPTION,
Plcase Print
DATE:
JOB LOCATION:
number street village
— --""IiOMEOWNER":
name home phone# worlLpbonc#
CURRENT MAILING ADDRESS:
city/tovm state rip code
The current exemption for"homeowners" was extended to include owner-occupied dwellings of six units or less and
to allow hQzneowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor. '
DEFINMION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/sbe 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 Btuldiag 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 tbat..he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/sbc will comply with said procedures and
requixements.
Signature of homeowner
Approval of Building Official
Note: Three-famii1y dwellings containing 35,000 cubic feet or larger will be required to comely with the.
State Building Code Section 127.0 Construction Control.
HOhfEOWNER'S EXEMYTION
The Code states that "Any homeowner performing work for which a building pmrnit is required shall be exempt from the provisions
of this seetion.(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner cngages a persons)for hire to do such
wort'that such Homeowner shah act as supervisor."
Many horncowncs who use this rxcmptio rc n arc unaware that they a assuming the responsibi)ities of a supervisor(see Appendix Q,
Rules&R-cgulations 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
Supervisar. 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 homcowncr certify that heshe understands the responsibilities of a Supervisor. On the last page of this issue is e,form currently used by
several towns. 'You.may care t amend and adopt such a fon-rAcrtificalion for use in your community.
Q:forms:homcczcmpt
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Town of
'THE Regulate
Richard V. Sc
' BAMSfABLE. ' Buildi
,P ➢um
Tom Perry,Bui
ED MA'S
200,Main Street,
www.town
Office: 508-862-4038
PERMIT#a �l
SHED RE
RESIDEN,
200squar
35��,4-,.R--Z 4AlV9
Location of shed(address)
OQ� �i1ir0�/%O S7�I
Property owner's name
y�
me ��- �
��a �o
BARNSTABLE t=
k
ET
O.
1
Field # Total Page Break
Yr 9 Y N
11 Y N
12 N N
�l 0 N N
T
ounts exceeding 0% of budget.
s only: Y Year/Period: 2013/1:
r short description: s Print MTD version: 1.1
L account: N
1 Roll projects to obi
rN carry forward code:
o bal accts: Y
uisition amount: N
�es-version headings: N
sue as credit: Y
ue budgets as zero: N
d Balance: N
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Maps arcel : 04� Application #
Health Division G' �� t -77 Date Issued 3 d 1c)
Conservation Division Application Fe"
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
} •
Historic - OKH _ Preservation/ Hyannis
S
f
Project Street'Address
v .
Village S
Owner wa ym ?OcKec-o Address 41 S Jrinw S+
Telephone 013 14 5 3L 51�
Permit Request R'.rnyoul g +W® T�C-411 r ho&. 00
K-k6n o Tloorim Vaini. ?,emoriI $a4hro():m W.'-Vk new
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay00
,
Project Valuation 0019�& Construction Type
_0
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting docur8entafign.
w
Dwelling Type: Single Family _❑ Two Family W/ 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 0 new b
Number of Bedrooms: zX existing n new
Total Room Count (not .5
,including baths): existing 5 new First Floor Room Count
Heat Type and Fuel: 9 Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes YNo 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 YNo If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)-
Name « cam Telephone Number ® :3(o q ys�
Address j s dyes License # 92 9T6?
C��,�e��i�1e � �d���• Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE �_�/7�Gt� yr�,G/� DATE
t
FOR OFFICIAL USE ONLY
APPLICATION#
t DATE ISSUED
L
MAP/PARCEL NO.
x -
ADDRESS VILLAGE
OWNER
s .
z
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
,r
t
f `
DATE CLOSED OUT - '
ASSOCIATION PLAN NO.
The Commonwealth of Massachusetts
Department of Industrial Accidents
k' 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/Individual):
Address:
City/State/zip:' cepAto,116 MA 6a(o3 Phone #: 5oS 3bq P ,A q5b
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
,/ or
proprietor partner-
(full and/or part-time).* have hired the sub-contractors 6. V ew construction
2.L� I am a sole ro rietor artner- listed on the attached sheet. emodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. " right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: �AHt Fa CI Dater ),;L irl )n 9
Phone#:
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 Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or 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
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 6..17-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax# 617-727-7749,
www.mass.gov/dia
�THE Town of Barnstable
Regulatory Services
4 �
Thomas F. Geiler,Director
ns"ss.
Building Division
Tom Perry,Building Commissioner .
200 Main Street,Hyannis,MA 02601
www.tovymbarustable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign ` lus Section
if Using A wilder
as Owner of the subject property
1 ,
hereby authorize h GA G to act on my behalf,
in all matters relative to work authorized by this building pen-nit application for:
(Address of job)
/MAA >1�- h1)9
Signature er Date
W A N A.i. YcGha,w
Print Name
if Proyedy Owner is applying for permit please complete the .
Homeowners License Exemption Form on the reverse' side.
Q:FORMS:OIVNERPERMISSION
Town of Barnstable
ttte ram, a
Regulatory Services
• Thomas F. Geiler,Director
+ 1AANSTABM
H"0.5�9. Building Division
prFOy a Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-623,0
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: village
number street
-HOMEOWNER work hone#
name home phone# p
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 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" responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he understands the Town of Barnstable Building Department
edures and
minimum inspection procedures and requirements and that he/she will comply with said proc
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 persons)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a 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:\WPFILEST=0RMS\homeexempt.DOC
®FH C E
3
F
u�an F
- Town of Barnstable. *permit#
OF THE•Tp -, �w
Expires 6 n,n tlrs-fronre date
PSRO ITRegulato6 Services Fee
BARNSTABLE, t �'
9�a.� �g 8 ZOOS Thomas F. Geiler,Director
rEo r�u►�'' OF SARN's Building Division.
ABL'km Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 . Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number �" l
Property Address S rl-,7 S''fi /7 r,.��l i
[Residential Value of Work. 49500 LIC Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address il q V gk
Contractor's Name {'?6n t �GY��C i Telephone Number So 8 3 6 i d 4<3 G
Home Improvement Contractor License#(if applicable) I&,j`7 qo
Construction Supervisor's License#(if applicable) / 95,9
❑Workman's Compensation Insurance
Check one:
I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company;Name
Workirian's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
Replacement Windows/doors/sliders.U-Value 3 t7 (maximum.44)#of windows . /0
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property`Owner Letter of Permission:
A copy of the Home Improvement Contractors License:&Construction Supervisors License is
required.
SIGNATURE: ✓ �9
QAWPFILESTORMMuilding permit formsEXPRESS.doc
Revised 090809
The Commonlvealth of Massachusetts
Department of Industrial Accidents
I 1'r Office of Investigations
600 Washington Street
y Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual)'. 3 f 4Az ?SCI�0
Address: N3 44yes
City/State/Zip: C°'l Ae e- It qS(.0
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 1 6. ❑ New construction
loy (full and/or part-time).* have hired the stab-contractors
2.Zempasecee proprietor or partner- listed on the attached sheet. 7. j'Remodeling
ship and have no employees These sub-contractors have g„ Demolition
working for me in any capacity: employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.t
required.] 5. We are a corporation and its .. 10.[J Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L] Plumbing repairs or additions
myself. [No workers' comp right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp,insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
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
Investigations of the DIA for insurance coverage verification,
I do hereby certify under the pain a/ndpenalties ofperjury that the information provided above is true and correct
Signature: ��/�S� /�dC"/nt�a Date: D
Phone#:
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 Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. .
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or 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,constriction 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), addresses)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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617427-7749
Revised 4-24-07
www.mass.gov/dia
a
��HE rots Town of Barnstable
Regulatory Services
r r
BAR
'' '� Thomas F. Geiler,Director
1639.�A1� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.tow-n.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I
as Owner of the subjectproperty
)
c on m behalf,
hereby authorize � ) C�G� . ?C�CLU6to act y ,
in all matters relative to work authorized by this building permit application for.
-1 I ✓ Y(i n5 c� 14Vcs M U I
� .S
(XddVess of Job) T
,a]111Oq
Signature oT MnWDate
W u4ne, 1'gG��eco
"'Print Name
* If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:OWNERPERMISSION-
L
Of ME Tom,
Town of Barnstable
o - Regulatory Services ,
' Thomas F. Geiler,Director
* BARNSTABLE,
MASS.
9q,A 039. 16 Building Division
TFD µAt 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:
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 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
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 perdrit 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 dQ 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 caret amend and adopt such a form/certification for use in your community.
Q:\WPFILES\FO RM S\homeex empt.DOC
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R327 044 . P P R A I S A L D A T KEY 241553 `
YANNATOS, GERASIMOS
LAND BLD/FEATURES BUILDINGS NUMBER ZN/FL=B
16, 800 75, 500 1 A-COST 92, 300
B-MKT 92, 800
. BY 00/ BY /00 C-INCOME
PCA=1041 PCS=00 SIZE= 2008 JUST-VAL 92, 300
LEV=400 CONST-C 0
----COMPARISON TO CONTROL AREA 64AC -----------------------------
NEIGHBORHOOD 64AC HYANNIS
PARCEL CONTROL AREA TREND STANDARD
101 10 LAND-TYPE
168001 LAND-MEAN +Oo
923001 73437 IMPROVED-MEAN +3% 250-.
] FRONT-FT
] 100 DEPTH/ACRES TABLE 02
1001 LOCATION-ADJ APPLY-VAL-STAT 1
LNR] LAND LFT/IMP] ADJS/SB/FEAT STR] STRUCTURE ARR]AREA-MEASUREMENTS NOR] NOTES
COM] MARKET INC] INCOME PMR] PERMITS GRR] GRAPHIC
FUNCTION- [ ] STRUCTURE-CARD NO- [0 0 0] DATA- [ ] XMT [?]
l
R327 044 . • P E R M I T [PMT] ACT 0[R] CARD [000] KEY 241553
000000001
PERMIT-NO MO YR TYPE VALUE CK-BY MO YR .CMP NEW/DEMO COMMENT
[ ] [R327 044 . 0 ]
LOC] 0041 SPRING STREET CTY] 07 TDS] 400 HY KEY] 241553
----MAILING ADDRESS------- PCA] 1041 PCS] 00 YR] 00 PARENT] 0
YANNATOS, GERASIMOS MAP] AREA] 64AC JV] MTG] 0000
ELPINIKI YANNATOS SPl] SP21, SP31
P MARK WAY UT11 UT21 . 12 SQ FT] 2008
W YARMOUTH MA 02673 AYB11950 EYB11975 OBS] CONST]
0000 LAND 16800 IMP 75500 OTHER
----LEGAL DESCRIPTION---- TRUE MKT 92300 REA CLASSIFIED
#LAND 1 16, 800 ASD LND 16800 ASD IMP 75500 ASD OTH
#BLDG (S) -CARD-1 1 75, 500 DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE
#PL 41 SPRING ST TAX EXEMPT
#RR 1516 0055 RESIDENT'L 92300 92300 92300
OPEN SPACE
COMMERCIAL
INDUSTRIAL
EXEMPTIONS
SALE] 00/00 PRICE] ORB] 975/321 AFD]
LAST ACTIVITY] 11/18/88 PCR] Y
RESIDENTIAL PROPERTY
MAP NO. LOT NO. FIRE DISTRICT SUMMARY
STREET 41 Spring St. Hyannis ��
327 44 - x 73 LAND
al BLDGS. .24 0 0
OWNER �%G�L a �. ca-fr�� TOTAL 3A /SD
LAND
RECORD OF TRANSFER DATE BK PG I.R.S. REMARKS:
BLDGS.
Yanna.tos CTerasimos & Elnini.ki 75 321 TOTAL
LAND
.,�1: I BLDGS.
li [:.,u..,..-.--.-.�-•nc�, � � . TOTAL
LAND
` BLDGS. .
TOTAL
LAND
O) BLDGS.
TOTAL
LAND
BLDGS.
TOTAL
LAND
BLDGS.
TOTAL
LAND
INTERIOR INSPECTED: �r"' ��'( � —� BLDGS.
TOTAL
DATE: .�2 LAND
ACREAGE COMPUTATIONS BLDGS.
LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE TOTAL
HOUSE LOT -S,2 S U LAND
-CLEA FRONT ch BLDGS.
REAR TOTAL
WOODS&SPROUT FRONT LAND
REAR BLDGS.
WASTE FRONT TOTAL
REAR LAND
BLDGS.
TOTAL
LAND
i �� `u DC7 •�= �Jr / BLDGS.
LOT COMPUTATIONS LAND FACTORS TOTAL
FRONT DEPTH STREET PRICE DEPTH% FRONT FT.PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND
ROUGH TOWN WATER BLDGS.
_ HIGH GRAVEL RD. TOTAL
LOW DIRT RD. LAND
SWAMPY NO RD. BLDGS.
TOTAL
i
t'VUIVUMIIvi• , ,..., V LAND COST '
Cone.Walls fin.Bsmt.Area Bath Room Base r BLDG.COST
Cone.,Blk.Wall}', �.:' Bsmt. Roe.Room- St. Shower Bath Bsmt. '
Cena'Sleb:'. PURCH. DATE
Bsmt.Garage St. Shower Ext. '
Walls PURCH.PRICE. -
+,Brick Walls "'"` Attic Fl.&Stairs Toilet Room
Roof RENT
Stone Walls �' Fin:Attic Two Fixt.Bath 'SDP, a0
' Floors
Piers;' INTERIOR FINIS I Lavatory Extra O
8smt. r F 1' 2 3 Sink
_ I
ab 1A" 1/4Plaster Water Clo.Extra Attie / 11
EXTERIOR WALLS Knotty Pine Water Only —
'Si
t=
Double Siding Plywood No Plumbing
Bsmt. Fin. 3^
Single Siding Plasterboard Int.Fin.
$S Shingles TILING O z>
Cone:Blk. G F P Bath Fl. Heat a` d •7 .
Face Brk:On Int.Layout Bath Fl.&Wains. Auto Ht.Unit
Veneer Int.Cond. Bath Fl.&Walls
Fireplace y
Com.Brk.On HEATING Toilet Rm..Fl. --
Plumbing
Solid k. Hot Air Toilet Rm.Ft.&Wains. '
— '
Steam Toilet Rm.Fl.&Walls Tiling
Blanket Ins. AM I Not Water D St. Shower
Roof Ins. V Air Cond. Tub Area Total .
Floor Furn.
ROOFING Ne COMPUTATIONS '
Asph.Shingle Pipeless Furn. S.F. .
Wood Shingle No Heat log S.F.
Asbs.Shingle Oil Burner CjqVa S.F. '
Slate Coal Stoker S.F.
Tile Gas S.F. OUTBUILDINGS
ROOF TYPE Electric
Gable Flat S.F. 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 MEASUR-
Hip Mansard FIREPLACES S.F. Pier Found. Floor C
Gambrel Fireplace Stack Well Found. 0..H.Door 1 LISTED
FLOORS Fireplace Sgle.Sdg. Roll Roofing ri4
Cone. LIGHTING Dble.Sdg. Shingle Roof
Earth No Elect. DATE
Shingle WallsPlumbing
Pine y;.
Hardw ROOMS Cement Bik. Electric
Asph. . Bsmt. 1stS./ TOTAL Brick Int.Finish PRICE I'
Single, 2nd .f g 3rd FACTOR Al_T-
REPLACEMENT 3 U S 7 y
OCCUPANCY CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL.
DWLG. f ,, t ✓ 3 S+ S ; ? F .30S7 a-T-37C .?.5-Lfo0
I ' `` GA/v s `y 7 AF0 Z7Zq-9 s`o 0
2
3
f .
6
7
TOTAL
aOPERTY ADDRESS I I ZONING_ I DISTRICT CODE SP-DISTS.I DATE PRINTED I CSTATE LASS I PCS I NBHD KEY NO.
0041 SPRING STREET 07 B 400 07HY 07/09/95 1041 . 00 64AC R327 044
LANDIOTHER FEATURES DESCRIPTION ADJUSTMENT FACTORS I T 241553
Lana By/Dale S�:e Dimension IOC./YR.SPEC.CLASS ADJ. COND. .YP PRINCE IT AD PRICE IT ACRES/UNITS VALUE DescriPbon IYANNATOS, GERASIMOS MAP-
CD. FFDe th/Acres E #LAND 1 16,800 CARDS IN ACCOUNT —
10 1BLDG.SIT 1 x . .1d =10c 467 29999.9 .140099.98 .12 16800 #13ILDG(S)I-CARD-1 '1 75,500 01 of 01
j #PL 41 SPRING ST COST 92300
NS 2.0 U x C= 100 7000.0C 7000.0 1.00 7000 B #RR 1516 0055 MARKET 92800
INCOME
A p I. APPRAISED VALUE
A 92,300
a U - ARCEL SUMMARY
S AND 16800
T �LDGS 75500
M 0-IMPS
E TOTAL 92300
N I N CNST
T DEED REFERENCE yPe DATE S;�PPRIOR YEAR VALUE
1 Book Page MO. Yr.D AND 16800
S 975/321 .t 00/00 BLDGS 75500
TOTAL 92300
3
BUILDING PERMIT
> Type
LAND LAND-ADJ INC ME SE SP-BLDS FEATURES BLD-ADJS UNITS Numbar Date Amounl
16800 1 7000
Class Const. 'rota) e r 6 -I� Norm. pbsv.
Units Un�Is Base Rate A01.Rate A I Aga Depr. Cona. CND Loc °ro R,G RePI Cost New AOI RePI Velue Stories Heignl Rooms ea Rms Batne I fis. Partywell Fee.
000 100 100 63.60 63.60 50 7.5 19 80 90 70 107851 . 75500. 1.3 9 4 2.0 7.0
'111
--p'.— R.I. Square Feel Revl Cost MKT.INDEX: 1•DD IMP.BY/DATE: / SCALE 1/D 0.6 6 ELEMENTS CODE CONSTRJCTION DETAIL
8AS 100 63.60 952 60547
' FEP 65 41.34 48 1984 *---
13--* STYLE 1 0 LD STYLE 0.0
UWD 85 $.SD 104 884 8 UWD 8 DESIGN ADJMT- -00 ------------------c.6 '
FSF 90 57.24 104 5953 ! FSF ! EXTIER.WAILS-- -J8 3-9ESTDS---------U=0
018 52 33.07 952 31483 *-*--_ t-
13-- 31--------* EAT/AC-TYPE- -07 G AS=HaT-WAT-EtF---�.0
! ' I NT`cR:FII+IISW -04 -RYWALL-----------
NTER.LAYOUT- -T2 VER.MRMAt-- -1T 0
I ! ! I NTFR.OU-ALTY- -02 AXE A-T-EIT-EfF:--U.-O
! F LD—R-ST-R-UCT- -01 a6D'JbTST--------J.0
W 28 BASE 28 EFLDTR-CDVER-- -04 A7LPET-__--------U=O
E Total Areas Au 152 Basa= 1056 ! ! OOF-TYPF---- -01 ASCE=- SPR-'S_H U=0
BUILDING DIMENSIO 2
NS ! LErTRI -AL 01 VERAG-F —U 0
T BAS. W FEP S b W08 N 6 E 8 .. ! ! OUYDATI-O-N-- -01 WRED--CONC-----9-9.-9
A SAS W21 N28 E03 UWD N08 E13 S08 ! " B18 ------- - - --------------
I W13 .. FSF E13 N08 W13 S08 *------21--8--*---1'3--X -----NEI_GUBOR OD "64AC-NYANNTS-------
L SAS E31 . S28 .. B18 W34 N28 E34 6 6 LAND TOTAL MARKET
S28 '• ! FEP ! ' PARCEL 16800 92300
*--8--* AREA 6119
VARIANCE +0 +1408
STANDARD 25
• TOWN OF BARNSTABLE•
REPORT SUPPLEMENTARY/CONTINIIATION REPORT
NAME (LAST, FIRST, MIDDLE) DIVISION /DEPT
NOTE DETAILS i OBSERVATIONS-ITEMIZE EVIDENCE, SERIAL !S ETC.
aaaty-
PAGE
SUBMITTED BY i
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