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1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 11,t 'Parcel > Permit#
Health Division • Date Issued 3-4
Conservation Division + fee "R,50'i
Tax Collector
Treasurer
Planning Dept. ,
Date Definitive Plan Approved by Planning Board t
Historic-OKH Preservation/Hyannis c
' t
Project Street Address,
Village
Owner e"11 Address
Telephone '
Permit Request lns,,4f;�.� _� E<
—• s
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost !ZMg' Zoning District Flood Plain Groundwater Overlay
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
3
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other f
Central Air: ❑Yes O No Fireplaces: Existing New. Existing wood/coal stove: ❑Yes ❑No
Detached garage:❑existing ❑new size Pool:0 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
I •
BUILDER INFORMATION
Name !(A/Y1 - Telephone Number
Address `� 11:)r4 N 1 (J-n 0/i License#
Home I �.�r
mprovement Contractor# //'i
Worker's Compensation# ►� '/�'��= �`�%' `% ,
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO )�61111AV11%JU
SIGNATURE l DATE _ a�
FOR OFFICIAL USE ONLY
PERMIT NO. , ', • r , •` r: - ^ i i - -
DATE ISSUED
MAP/PARCEL NO.
ADDRESS M VILL-AGE "
OWNER : T ?y • _ i
Jf
DATE OF INSPECTION
` [
FOUNDATION ,
FRAME-
INSULATION
FIREPLACE '.
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
3 GAS: 'ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. ` - }
The Town of Barnstable
• assrrar�ar.�. • .
Department of Health Safety and Environmental Services-
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
Permit no.
Date
N �
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: Estimated Cost oo�)
Address of Work:
Owner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
OJob 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:
51
Daie Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affidav
The Commonwealth of Massachusetts
Department of Industrial Accidents
== Office ofinlyestigaftos
600 Washington Street
�i Boston Mass. 02111
s.
Workers' Compensation Insurance Affidavit
name:
location:
city Alt- ,f d j r phone#
❑ I am a homeowner performing all work myself.. p
1 am a sole proprietor and have no one working in any ca
acity
Jpr I am an employer providing workers' compensation for my employees working on this job.
company name:
':. : .: .
address: �yl.,L
cirv: / phone#:
insurance co. 201icv#
❑ 1 am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who
have
the follo«zng workers' compensation polices:
company name:
address:
city phone#:
insurnnce co.
companv name:
address: .... ...
city phone
insurance co. olicv# M.
FaIIure to secure coverage as required under Section 15A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a titre of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification.
1 do hereby ce un ;_Aeyp4axins �penaft�ies of perjury that the information provided above is true and correct
Signature Date ��� �i _
Print name Phone
o
fficialuse only do not write in this area to be completed by city or town official
own: permit/iicense# ❑Building Department
❑Licensing Board
k if immediate response
is required ❑Selecnnen'a Office
❑Health Department
person: phone#; ❑Other
.
yeviva 9i95 P1A1
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any coati.:"
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 c:
trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority. ,
Applicants
Please fill is the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
-date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the'law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of 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. The affidavits may be retrrraed io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
�
please do not hesitate to give us a call.
//�i�/%%/%///%%/%%/////%/%/%%/%%//%%%% %%%//////%%/// �//�//�i�,i ///////
The Department's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Ottice of Invesugatfons
600 Washington Street
Boston;Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406, 409 or 375
y ,
HOME IMPROVEMEN:
Board ofi CONTRACTORS REGISTRATION
Building Re3ulations and Standards
One Ashburt ;n Place - Room 13St e
8osto n `
iW ssachusetts 02108 `
HOME
. IMPROVEMENT CONTRA,'TpR
Registration
. 112536
Type - DBA ExPiration 04/06/99
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FRASER CONSTRUCT16P!
DEAN C'.. . H0� TbPROO!(�T`CONTRACTOR
ERASER Registration 11536
71 TARRAGON CIR
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i COTUIT MA 02635 ,� EXPiraties
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/8 Camp Strael,unit 6,Hyannis,MA 02601. -
tel.508.778-6060 /aa $08-778-4558
S/even M.Shuman,RA Alice L.Oberdorf,RA
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�.. ,+ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map a`g 1 Parcel Oe7 Permit#
Health Division L1 Date Issued
T
Conservation Div'sio !✓ A Fee
Tax Collector
Treasurer ( `�
Planning Dept. IVIA
If
Date Definitive Plan Approved by Planning Board N
Historic-OKH Preservation/Hyannis ,
Project Street Address . tk wl
Village Ole 1\J
Owne C�L�AJ`t U = A f-2A L59 Address D�
Telephone Z 7 6"3
Permit Request /09M, 11 /A ti/cl
61a; ,411 ARMA,. N,E tcJ k� �d, A rMoyt. z'x4s fig 10144�w
AiVd 400 4 gfiJk4,Cg_
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost Zoning District Flood Plain N b Groundwater Overlay
Construction Type LcJ66D 1'hfI
Lot Size e /•c-ta03 Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family jE( Two Family ❑' Multi-Family(#units)
Age of Existing Structure sd yfAQS Historic House: ❑Yes 1"No On Old King's Highway: ❑Yes >No
Basement Type: XFull drawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 0 Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing Z- new O Half:existing / new O
Number of Bedrooms: existing new y
Total Room Count(not including baths): existing 7 new First Floor Room Count
Heat Type and Fuel: ❑Gas KOil ❑Electric ❑Other
Central Air: ❑Yes klo Fireplaces: Existing / New d Existing wood/coal stove: ❑Yes ,8(No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Y
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 D 4 . Telephone Number wa 775—c) ��-
Address License# Gs DD 92 6
'C �)22FIQVIllg, /W4, OZ43z, Home Improvement Contractor# 12-
Worker's Compensation#/
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUREI�W-ADATE
FOR OFFICIAL USE ONLY y
PERMIT NO.
DATE ISSUED . —
. . f'... . • e; . Val
MAP/PARCEL NO:
ADDRESS VILLAGE t'
' OWNER
c, DATE OF INSPECTIG
FOUNDATION t
FRAME
INSULATION
FIREPLACE :
ELECTRICAL: ROUGH FINAL x .
PLUMBING: ROUGH FINAL -�
GAS: ROUGH FINAL
FINAL BUILDING r f
DATE CLOSED OUT '
ASSOCIATION PLAN NO. #
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° The Town of Barnstable
asaxsr�
Department of Health Safety and Environmental Services - -
Eo '' Building Division
j 367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230. Building'Commissioner
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements. 4 � �
li//k Estimated Cost/avant -
Type of Work: ! z el
Address of Work: 33 w &IA td r.�;
Owner's Name: CI J�qxlz)
Date of Application: . "Z
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
01ob 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.
2.
Date Contractor Name Registration No.
OR
Date Owner's Name
q:fomis:Aff►dav
MCURAppooftj
_ TaWalttlb(osantfeaed)
1'mafpttm Paduga for ane and Two-F=o*Rea dunW Boidtop Seaad wA F0289 Fuds
MAXIMUM MINIM M
Glazing awe Ca1in8 Wall "itl
BaasSlab�'(%) U-valu = R-value' &val�m'- &v Wall � C°?
wvduo� &valid
EMa
5701 to 6509 Heating Degrer Darr'
Q 12% 0.4o 38 13 19 10 6 Normalit 12% 0M 30 19 19 10 6 Normal
S 126A 0.50 38 13 - 19 10 6 85 AFUE
T 159A 0.36 38 13 2S WA WA Nonmri
U 13% 0.46 38 19 19 10 6 Noemsi
V 15!5 0.44 38 13 2S WA WA 8S AFUE
W 15% 0.52 30 19 19 10 6 SS AFUE
X 18% 0.32 38 13 2S WA WA Normal
Y 19% 0.42 38 1 19 25 WA WA Normal
ZE181/4
19% 0.42 38 13 19 10 6 90 AFEIE
AA 0.5o 30 19 19 t0 6 90 AFUE
1. ADDRESS OF PROPERTY. 33
2. S , EXTERIOR WALLS:
SQUARE FOOTAGE OF ALL
3. SQUARE FOOTAGE OF ALL GLAZING.
4. %GLAZING AREA(#3 DIVIDED BY#2): ,(J ✓-�'
5. SELECT PACKAGE(Q—AA-see chart above): Z'A-
NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS
ARE AVAILABLE. ASK US FOR THIS INFORMATION.
A u Z 0 31
BUILDING INSPECTOR APPROVAL.
YES: NO:
q-forms-080303a
780 CMR Appendix
Footnotes to Table J5Z.1b: lr ts, and
r Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, sky igh
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 fmm a building design with 300 fl 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 (NFRC) test procedure, or taken from Table JI.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-3 8
insulation and R-38 insulation may be substituted for R-49 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 EM ER
by R-19 cavity insulation OR R 13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to
wood-flame 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 wails. Windows and sliding glass doors of conditioned
basements must+be included with the other glazing; Basement doors must meet the door U-value requirerncnt
described in Note b.' '
'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 moire 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
ROTES:
a)Glazing areas and U-values are,maximu acceptable levels.insulation R-values are minimum ac leve
m ceptable Is
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 035.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 035).
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(035 for doors).
r
r
43
- - The Commonwealth of Massachusetts
Department of Industrial Accidents
Office nilmvestigations
600 Washington Street
..���v,•, Boston,Mass. 011ll
Workers' Compensation Insurance Affidavit
rrir�lci�-rrOr ar- lrii�riirlIY�aiirrrrrWX
���� ����OWN rr �/������������������������������� %"<,,...
name:
location: l !� Li
�4yb
citV J �II4zykJ��Q 2� Ai'7�''MM
ri phone# �7�'079`—
❑ I am a homeowner performing all work myself.
,a a sole roprietor and have no one workin in anv ca aE
y
%//// /%� �%/ /% ���/%%%/%%%%%%��%%%%//%%%%%��%%%%%%%%��%%//%//%/�%%/.r`:;�;;;
❑ I am an employer providing workers' compensation for my ployees working on this job.
compnnv name:
address:
city phone#-
insurance co. nlicv#
Jam`'am a sole proprietor general contractor or homeowner(circle one)and have hired the contractors listed below who
have
the follo«ing workers* compensatio olices:
com anv name: 4444.4A rl
address.
dtv: phone#:
insurance co. olicv#..
camnanV name:
address:
citri: phone#'
Insurance co. Rag#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S 1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of 3100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DU for coverage verification.
1 do Aifr t e dpenalties ojperjury that the information provided above is truce and correctSigmaDatePrintV Phone# -7 7S--d 79-Z,
Uoinciaiy do not write in this area to be completed by city or town otIIcial permitNcense# ❑Building Department
❑Licensing Boardediate mponse u required ❑Selectmen's Office
❑Health Department: phone#; ❑Other
tmvea 9/95 PIA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law",an employee is defined as every person in the service of another under any cotter.:..:,
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 receive:cr
trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein;or the occupant-of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renews:
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority. ,
Applicants _
Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and
supplying company names,address and phone numbers along with a certificate of insurance,as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you
are required to obtain a workers' compensation policy,'please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of 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. The affidavits may be retuned io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
P FEE
ENN
The Department's address,telephone and fax number-
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Iwesduadons
600 Washington Street
Boston;Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext 406, 409 or 375
s.o-Ntd,;AD Cora uetzoN
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DEPARTMENT OF PUBLIC SAFETY
y CONSTRtf 1IOH SUPERVISOR LICENSE
Nprber g
._, Expires:
1
E =Restrte r� 00
JOHN �`flEtANEY
36Y RAINBOY OR
c
•�•+�.r- 8W CENTERVILLE, MA 02632
_0 e et mwseeaea/d o/./�amuc%uaetta
HOME IMPROVEMENT CONTRACTOR _ r
Registration 125529 a
Type — INDIVIDUAL
Expiration 01/15/00
JOHN J. DELANEY
��AIN806d DR .
ERVILLE MA 02632
ADMINISTRATOR