HomeMy WebLinkAbout0020 WAYLAND ROAD y
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i r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION v
Map / > Parcel � ,s . Permit# Y
Hearth—UPti, I J1 D' `� �'_ ABLE Date Issued
Conservation Division M A lication Fee
C�. Y ( 4 F ; 36 pp
Tax Collector L t Permit Fee `�/ 3 S.
Treasurer
EViSlG' SEPTIC SYSTEM MUST BE
Planning Dept. INSTALLED IN COMPUANCE
Date Definitive Plan Approved by Planning Board VM TITLE S
ENVIRONMENTAL CODE AND
Historic-OKH Preservation/Hyannis TOWN REGULAT.IONS
Project Street Address 0 W N &VAA1421s /414-
Village N� ry/u ! .S
Owner o r di'k!�/ r� Address n-i
Telephone v�0 8 '7
Permit Request
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation ® d D0. Construction Type
ry�Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family J1 Two Family ❑ Multi-Family(#units)
Age of Existing Structure 2 l rs Historic House: ❑Yes l No On Old King's Highway: ❑Yes No
Basement Type: XFull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 4�g� r"::?&siS-ott Basement Unfinished Area(sq.ft) 96,0
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new
r �
Total Room Count(not including baths): existing new First Floor Room Count v�
- f
Heat Type and Fuel: V Gas 0 Oil ❑ Electric ❑Other
Central Air: A Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 4 No
Detached garage:❑existing U.new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:'X existing ❑new size Shed: existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial 0 Yes ®No If yes, site plan review#
Current Use rr,4 q i_ 1A4Q ry o(r y Proposed Use 1
_ BUILDER INFORMATION
Name L—
Telephone Number
,Address Q License# 4
IZV�zl lylz/o s A467• Q 26 01 Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
In
SIGNATUJ4 DATE Z — (z 3
FOR OFFICIAL USE ONLY
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PERM; :.
DATEISV4 ED
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MAP/PARCEL NO. - •
ADDRESS ' ^ = VILLAGE
OWNER
DATE OF INSPECTION:
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FOUNDATION
FRAME i(y
INSULATION 6/^/S V
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL ^
GAS: ROUGH"? tl
1-j FINAL
FINAL BUILDING } ig
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DATE CLOSED OUT
ASSOCIATION PLAN NO. .
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°FINE Tok, Town of Barnstable
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Regulatory Services
` BAMSMBLE. ` Thomas F.Geiler,Director
nsass.
039..�a`�� Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-403 8 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type.of Work: ,/'/1V/S 4 — U9 Q ry 1 S h1__d/ Estimated Cost'cS�o U 6wo
Address of Work: 0 /U/l/ S �4 M O lv
/-�y rV F� v.4 / O/
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Owner's Name•�b/:2-2 /L
Date of Application:
I hereby certify that:
a
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
OBuilding not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date Contractor Name Registration No.
y-�s 02
Date dwner'§Yame
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The Commonwealth of Massachusetts
Department of Industrial Accidents
= Office offnYOS1192APHS
600 Washington Street
J Boston,Mass. 02111
Workers' Compensation-Insurance Affidavit
name: Q
location:i/ O WAV A 22
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city Y��C�77 /� S �17f� Doi lOt� phone#,W— 7,74f- /JZV,
'F� I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
OI am an employer providing workers' compensation for my employees working on this job 3
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I am a sole proprietor,general contractor, r homeowner(c, le one) and have hired the contractors listed below who
have
the following workers' compensation polices
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Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 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 the nd s of perjury that the information provided above is true and correct.
Signature Date
Print name Ohet!t d Phone# '��'•�7CP' ou�
official use only do not write in this area to be completed by city or town official
city or town: permit/license# nBuilding Department
❑Licensing Board
❑check if immediate response is required []Selectmen's Office
[]Health Department
contact person: phone#; nOther
(revised 9/95 PIA)
Information and Instructions 4.
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the"law", an employee is defined as every person in the service of another under any
contract of hire, express or implied, oral or written.
An employer is defined as an individual, partnership, association,corporation or other legal entity, or any two or more of
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required.
Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if
you are required to obtain a workers' compensation policy, please call the Department at the number listed below.
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
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 returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Ma. 02111
fax#: (617) 727-7749
phone#: (617) 727-4900 ext. 406
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The Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
Building Division
Tom Perry, Building Commissioner
200 Main Street,Hyannis MA 02601
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: �J �o� O 3
JOB LOCATION: jD Qi[/��7l[]L 124gl
number L r street G ^d village
"HOMEOWNER': TAD!/ l'� / �D�P.G1 _ -771J -L'S ZS7
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.
DEFJNITION 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
proced
zes and re ts.
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,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.
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+ RESIDENTIAL BUILDING PERMIT FEES
APPLICATION FEE
New Buildings,Additions $50.00 Q • D d
Alterations/Renovations $25.00
Building Permit Amendment $25.00
FEE VALUE WORKSHEET
NEW LIVING SPACE r/
ys square feet x$96/sq.foot= 7 x.0031=
plus from below(if applicable)
ALTERATIONS/RENOVATIONS OF EXISTING SPACE
square feet x$64/sq.foot= x.0031=
plus from below(if applicable)
GARAGES(attached&detached)
square feet x$32/sq. ft.= x.0031=
ACCESSORY STRUCTURE>120 sq.ft.
>120 sf-500 sf $35.00
>500 sf-750 sf 50.00
>750 sf- 1000 sf 75.00
>1000 sf- 1500 sf 100.00
>1500 sf-Same as new building permit:
square feet x$96/sq.foot= x.0031=
STAND ALONE PERMITS
Open Porch x$30.00= '
(number)
Deck x.$30.00=
(number)
Fireplace/Chimney x$25.00=
(number)
Inground Swimming Pool $60.00
Above Ground Swimming Pool $25.00
RelocatiowMoving $150.00
(plus above if applicable) .
Permit Fee
K
TOWN OF BARNSTABLE
SIGN PERMIT
i e
PARCEL ID 271 191 GEOBASE ID 18140
ADDRESS 20 WAYLAND ROAD °'" PHONE
HYANNIS ZIP -
LOT 11 LC 3 BLOCK LOT SIZE
DBA DEVELOPMENT DISTRICT HY
PERMIT 61006 DESCRIPTION REPLACING SUBDIVISION SIGN - 13 SQ FT
PERMIT TYPE BSIGN TITLE SIGN PERMIT
CONTRACTORS: Department of Health, Safety
ARCHITECTS: and Environmental Services
TOTAL FEES: $25.00
tOND $.00 THE 'r
C6NSTRUCTION COSTS $_00
753 MISC. NOT CODED ELSEWHERE * HARNSTABLE.
MASS.
BUILD NG DIVISION
DATE ISSUED 05/09/2002 EXPIRATION DATE
- Town of Barnstable
Regulatory Services .
Thomas F. �Geiler,Director (9 C D(9
{ snxxszaac.e, -
9� 1639. ��� Building Division
ATEo �°i Peter F.DiMatteo, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Tax Collector
Treasurer
Application for Sign Permit
Applicant: e',� (7 W
aU Assessors No. � Q�
Doing Business As: Telephone No. F4 aZ -p 31
Sign Location kopPlaci t\r��
Street/Road: h
Zoning District: Old Kings Highway? YesED Hyannis Historic District? Yesco
Property Owner
Name: Telephone:
Address: Village:
Sign Contractor
Name:Tln S Telephone:
Address: C %'
. Village:_ n�'.
Description —
Please draw a diagram of lot showing location of buildings and existing signs with dimensions,location and size of
the new sign. This should be drawn on the reverse side of this application.
Is the sign to be electrified? Yes(g) (Note:If yes, a wiring permit is required)
I hereby certify that I am the owner or that I have the authority of the owner to make this application,that the
information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of
Barnstable Zoning Ordinance.
Signature of Owner/Authorized Agent:-(- Date: �a
Size: - Permit Fee: %,' J -Co
Sign Permit was approv : Disapproved:
Signature of.Building
�— Date:
Signl.doc
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14,,,,Assessor's map and lot number !1/� t.(:,✓..... 7�... !... THE
yoF roe
Sewage Permit number
li EMSTADLE, i
("'louse number .........................u. .U ....... 9O MUL
.............................. p 1639.
D(-
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TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO Construct Single Family Dwelling
............. .... ......�.........................
TYPE OF CONSTRUCTION ...190.n ..F..rame..........................................................:............................................
... .:, . s . .. �...........19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies{ for a permit according to the following information:
Location ...,. .......� ►.......... ................................. ...................................
ProposedUse .............................................................................................................................................................................
Zoning District ....R.:A?..........................................................Fire District JW4X1T11 g.........................................................
Name of Owner CapK;icornRealty �ou-tRoa . Uy.nn,„ IC ,,,,,,,,,,, ... S
Name of Builderl x:M -Q!! ... !a41. !s;tate„I)!a,, G,A.Address 7F S,.,Falz>1Qutk� Road.. Hyarn,iS...............
Inc.
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms .3-X.........................................................Foundation ..P.c.Q.a..................................................................
Exterior .................Roofing A.,ap-N1..It...5bin le.s.........................................
Floors ..... .................................................................Interior ... he.e,t,.fJ.o.c 1 ......................................................
Heating ('x . ...... '. 1 ... ....................................................Plumbing ......UND........ !C!afil,,r..............................................
a
Fireplace Yr,)ne......................................................................Approximate Cost .......................................
Definitive Plan Approved by Planning Board _______________________________19________. Area A.0.5.6...SSl.....F 3 It..........
Diagram of Lot and Building with Dimensions Fee *::}%..'
SUBJECT TO APPROVAL OF BOARD OF HEALTH ('�}t1I
s
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Named%."�'�( � �Z�'V.�
; CAPRICO RE+ATY TRUST
23
Single Family...pW.ejjj
Frame
Date ~' ^Inspection ....................................' ^
� .
Date Completed ...................................... '
- `
PERMIT REFUSED
,
----..--..--...---------.. 19
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Assessor's office(1st�loor):
Assessor's map an of nu er ����.�� tMt
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Conservation INSTALLED'N���� �p •�'
Board of Heal m floor): WITH TITLE 5 ani
Sewage Perm n mbe � o
za
Engineering Department(3rd floor): r TOWH ENVIRONMENTAL COD r6 0`•`��a°
House number GU tr
Definitive Plan Approved by Planning Board i)g' L/Q��H°�
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN , OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO A X Q beck +0
TYPE OF CONSTRUCTION _ -COL IM e
Lt11 19�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: ,ten
Location 'L 0 titJrA OL ►� !' �l 4
Proposed Use R -e e r r cc—f►o lg
Zoning District ' \ C Fire District
Name of Owner R b Le t+ -f- "� "t G< r 5 e ��'S Address a ►1 u 5
',/n� s
Name of Builder ��Y' �� Address_ Bec,U e1- Yla ►,,� AJ eSi d-t al
Name of Architect ._ Address
Number of Rooms Foundation
Exterior (� Roofing
Floors I!V Interior
Heating Plumbing
O °
Fireplace Approximate Cost
8®o .-
Area
Diagram of Lot and Building with Dimensions Fee .
OCCUPANCY.PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable reg rdirig the ab a co s coon.
Name
Construction Supervisor's License
FOLEY, ROBERT & MARGE
3 4� ADD DECK
No Permit For TO DWELLING
a
Single family dwelling
Location ._ 20 Wayland Road
Hyannis
Owner-, Robert & Marge Foley -^ >
Type of Construction- Wood Frame '
Plot p rLot -
Permit Granted June 15 19 92'.
�i Date of Inspection 19 .
+
Date Completed 19
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Southern Mo ss re%hone Co Esmt.
deck
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cERrfy rmr ME" 8UILDING(s)IS c qCArED TITLE REF RENCL:800K 589°`PAGE,20
AS SHOWN AAG CONFORM/ 70 r/f
ZONING SY-LAWS. Of $4e,0-'r gc W IN
EFfECr. NOW OR Ar THE r/ME OF CQ4rRUCm
H ZAX Z AS D ELRMINEO���Hf��I�A NT NSTRywENt SUgEYwAw Is��r
DEPARTMENT C' HOWING AND URBANDEIELagwE)vr. GAGE POVOSE'S ONLY, LMYDER AV CIRC�MI k
F w �y STANCES AIV O►FFSEM M.BE USED FOR �v
AW/r/ONS, FENCES,WW LL S,ETC,
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R£GISUWED LAND $11RWYOR DATE
lit man bf LandOF
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Born-Stoble. CM EY�
Prepored For Nip. z00 %`
R'oCkl4�IQ� w .TrllSf COn7 aI1y
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Scale :An,=2Off April 16, 1992
C. W. GAR VEY CO.,INC. SURVEYORS 'NG/N�`ERS
36 wEsr STREET - WH/rMAN, MASS.
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JC SAFETY
DEPARTMENT OF P I31 AVE
1010 COMMONWEp` . CAUTION
COMR�OF EALTH SOSTON,MA 02215
L T C E N S FOR PROTECTION AGAINST
MASSACHUSEV f.G N S T R• S U P S R V 15 fl
THEFT,PUT RIGHT THUMB
UC-NO. PRINT IN APPROPRIATE
p(pIRATION DATE EFFECTIVE DATE BOX ON LICENSE.
Ob/301199 06/30 Z C'BLp,STIJ�IIOPER
RESTRICTIONS 6 HOT .�
GARY ELUDE
NONE `'1'A C G U Ali S 13 2 MUST tt�
n SRIGNTONR 02 �992
023-44-1909 m �JUt� _
CENSEE p OFF G LY
S S ER
FEE: a Q� NOT
STAMPVALID
D OR SSIGNATUREIOF THE COMM'
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PHOTO(BLASTING OPR ONLY') 1 ^b
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HEIGHT: « SIGN NAME IN FULL ABOVE SIGNATURE LINE
8 127 l 19 5 y I SIGNATURE OF LICENSEE i I
THIS DOCUMENT MUST BE� COMMISSIONERS
CARRIHOLDERE. 4 NNE F I THE H pUPAno .
OTHERS-RIGHT THUMB PRINT
GAGEDINTHIS OG I -
5'
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As3essor's'Uffice(1st =- � Parcel Permit# 7
Conservation Office(4th floor)(8:30-9:30/ 1:00=2:00) S� 9� Date Issued S ✓`� 9
Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) j —11 F �1 Fee_' Y�0?J�,�_D
Engineering Dept.(3rd floor) House# ��U SINE,
g) ' .
BARNSTABLE,
MARS.
19 t619. .aC
TOWN OF BARNSTABLE.
Building Permit Application
Project Street Address o?0 (o 14 y J,41vd wQ A4
Village , /Y y�Al AtIl S
�II
Owner ` �, D� AddressQ
D AYE c�
r �Telephone -
- o c�'" (7
Permit Request
First Floor square feet.-
Second Floor square feet
Estimated Project Cost $ �� Rao,
o�
Zoning District ; Flood Plain Water Protection
Uot Size AM X /(10 s Grandfathered ?
Zoning Board of Appeals Authorization Recorded
Current Use Proposed Use
Construction Type
Commercial Residential X
Dwelling Type: Single Family •� Two Family Multi-Family
Age of Existing Structure y FRS Basement Type: Finished
Historic House Unfinished X
Old King's Highway
Number of Baths o2_ No.of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel f� Central Air -- Fire
YP S Places
Garage: Detached Other Detached Structures: Pool
Attached X Barn
None Sheds
Other
Builder Information Namep/,4/e 4�lpd al WoduG�S Telephone Number / °s kS 0 70
Address 31�7'1-) !11VY Re)u 'W0#1 License# Q '7 �13
Home Improvement Contractor# _/0 91 °7Y'
Worker's Compensation#
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FO LOWING REASON(S)
FOR OFFICIAL USE ONLY
4 ,
PERMIT NO.
DATE ISSUED '
M11
P/PARCEL NO.
DRESS ' VILLAGE
OWNER r r
DATE OF INSPECTION:
FOUNDATION +
FRAME _
INSULATION =
FIREPLACE ,
ELECTRICAL: ROUGH FINAL
1 1
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
LF
c
DATE CLOSED OUT
ASSOCIATION PLAN NO. '
1 F
r
PLOT PLAN
FOR LOT
Indicate location of garage or accessory building
Additions with dashed lines --------------
Sewerage disposal (cesspool)
Well RA
M14 7 I (Lot.. ............ft. re ar) I -440-G'{'
Abuttor's
Abutter s Name
Name
' ( /D3
Lot# �� Rear Yard Loth
.................ft.
a If.this is a
U this is a ° i 07
o d corner lot,
corner lot, -10, z'
write in
write in w
� came of
name of
other street.
Sideyard
other street. HOUSE Sideyard
�. Cq// ft.
s I �
Set Back
......� ....ft.
I
I
I
4V-
(Lot....... ••••••••••ft. frontage)
/ ------ --/� J ----- 1` Qj--------------------
/ (Name of meet)
/ Information
/ Supplied by
Mark North Point
w
Tile ConunonH-calth of Alassachwelts
Department of Industrial Accidents
LS
`'tip 60011 irsliinA7on Street
Bimlon.11hum 02111
Workers' Compensation Insurance Affidavit
Ant�lic��nt nfbrmation:�� Please PTUR '1 hy'
name,
location• -
cin, nhnne#
❑ 1 am a homeowner performing all work myself.
❑ 1 am a sole proprietor and have no one working in any capacity
77
❑ 1 am an employer providin;workers' compensation for my employees working on this job.
cmm��ny nnmc•
atldrece• .
city: nhone fh
incurince co _-- noiicv#
❑ I am a sole propriet enema contracfdr,o homeowner(circle one)and have hired the contractors listed below who
the following w •ers' cum en /' es:
comnany u
re /
incurnnce ce neiicv ff •••• •
j.. -- ...• -- Kse•�,•..r._•.saws-n+eri►-r•-'T•'r"s*�ras:e � - -- - - ,�3!Pel�?7!�?:r_4.� 'i r.�.,.r.��� _ -•
tmm�anv name•
address:
city. phonefh
M1911--nee neiicr ff : ..
Atiachadditloeai'aheeeirXiieessa �+�: w�^ ;+y '�"•�"' .-.':•; :""'•�
Failure to secure coverage as required under Section 2 SA of AIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 anu
une rears'imprisonment as well as civil penalties is the form of a STOP WORK ORDER and a fine of S100 00 a day against mr- I understand for
copy of this statemen may be forwarded to the Once of Investigations of the DIA for coverage verification.
i do herebt•c j}•under lite p a bids of perjury that the information provided above is ime and correct
. )1 � " /9)6
Sicnature see
1 Print name0Phone# 2`7 $—
r
oMCW-use only do not write in this area to be completed by city or town ofiieiai
dtv or town:
nermiMleense# rrfiuiiding Department
(3Licensing Huard
check if immediate response is required OSeleetmen's Ounce
Ot1ealth Department
contact person•
phone#t nOther��
„
Information and Instructions
Massachusetts General Laws chapter 151 section 25 requires all employers to provide workers' compensation for t
employees. As quoted from the "law”, an emplitree is defined as every person in the service ofanother under any
contract of hire, express or implied. oral or written.
An cmplorr is defined as an individual. partnership, association, corporation or other legal entity, or any two or m
the foreaoin-, 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
owner of a dweiling 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 i
or on ��rounds or building appurtenant thereto shall not because of such employment be deemed to be an emplo,
MGL chapter 152 section 25 also states that everT 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 ♦.•fro 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 Nvork until acceptable evidence of compliance with the insurance requirements of this chapter
been presented to the contracting authority.
^� .. i• '1. .. •1!}' a ••� • .ohr! ..• ►,:5�•:..a�•v.YJ.+..•
Applicants
Please I'll in the workers' compensation affidavit completely, by checking the box that applies to your situation anc
supplying company names. address and phone numbers 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 require
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
the affidavit for you to fill out in the event the Office of Investigations itas to contact you regarding the applicant. F
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be rettrmec
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 questi(..
please do not hesitate to ;;ive us a call.
►•wM�•A•� .�r...�!'.•f.•nt• .. ..:. '.... r ••rt'.--. � .i.! .. •fir
•.�:: i:.s. .aa :fir: i77
The Department's address. telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents r,
Office of Investigations
600 Washington Street
Boston,Ma. 02111 +•
fax#: (617) 727-7749
The Town of Barnstable
M S Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 0=1
Ralph Cmssea
ofr= 508-790-6227 Building Commis
F= 508-775 33"
For afca use only ,
Permit no.
Date
AFFIDAVIT
HOME n"ROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires the"reconstruction,alteadOM renovation.repair,modern °n►conversion,
that
improve:nesrt,.r=o%al, demolition. or construction of an addition to any P�'� W 0 ODQlpred
bniIding containing at least one but not more than four dwelling units or to structures which are adyacent
to such residence or building be done by registered coatracwts,with certain=Cpaous+ along with other
tegtri:rsaetrts.
Type of Work: Est Cost a7
Address of Work. OW ) / —
Owner.Nama `
Date of Permit APPlicuion:
I hereby certify that:
Registration is not required for the following rrason(s):
Work exduded by law
Job Hader SI,000
Building not a mer-occupied
Owner,palling own permit
Notice is hereby green that: CONTRACTORS
OWNERS PULLING THM OWN R WORICEUVOT OR G DSO N HAVE ASS TO THE
APPLICABLE
HOUEARBITRATION PROGRAM OR GUARANTY FUND UNDEiI MGL c I42A
SIGNED UNDER PENALTIES OF PER MY
I hereby apply for a permit as the agent of the owner:
Date
Contactor aurae Regismation No.
N TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE �-'� Q .......
JOB. LOCATION Q �q
Number S reet address Se ion of town
"HOMEOWNER" F. �-D
Name Home phone Work phone
PRESENT MAILING ADDRESS
ity town State Zip code
The current exemption for "homeowners" was extended to include owner-occupied
dwellings of six units or less and to allow such homeowners to engage an in-
dividual 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 re-
side, on which there is, or is intended to be, a one to six family dwelling,
attached or detached structures accessory to such use and/or farm structures.
A 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 Officii
on a form acGeptAble to the Building Official, that he/she shall be responsib'
for all such work performed under the building permit. (Section 109. 1.1)
The undersigned "homeowner" assumes . responsibility for compliance with the StE
, The
Code and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department minimum inspection procedures and requirements
and that he/she will comply with said procedures and requirements.
HOMEOWNER'S SIGNATURE jj
` APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35, 000 cubic feet, or larger, will be required `
to comply with State Building Code Section 127. 0, Construction Control
- - -A
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for which a^ building
permit is required shall be exempt from the provisions of this section
(Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that if
Home Owner engages a person (s) for hire to do such work, that such Home Owne
shall act as supervisor. "
Many Home Owners who use this exemption are unaware that .they are assuming
the responsibilities of a supervisor (see Appendix Q, Rules and Regulations
for . licensing Construction' Supervisors, Section 2. 15) . This lack of iwarene
often results in serious problems, particularly when the Home Owner hires
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home "Owner acti
as supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities, ma.
communities require, as part of the permit application, that the Home Owner
certify that he/she understands the responsibilities of a supervisor. On the
last page of this issue is a form currently used by several towns. You may
care to amend and adopt such a form/certification for use in your community.
i
i
5
i
�"QvoF Stx4" RAFTERS
NoT� ; �JLL Woo r5
�LL 17iMENSIDM t �rNE, �k� TV f4A7?-:$ �
' ALL SHEDS lrLAVE � yXy" SuPPvQ'>" /3,e�C�s
G��LE AND �.DVVE+�S
4 x q
toIZNGrL ix4" PUP L1K14
pcS7'Q
" pLyw000
v�� Bt.oCKING
r
r
As4assor's map and lot numberFTNET
Sewage Permit number ..,.. ............................
SEPTIC
SYSTEM Mu t'IAWSTABLE,
House number IKSTALLE 9� M"8' 0
ON` 'WITH TITLLI
E 5 n MP a.
TOWN OF BA�RNSTT v � � ,-
BUILDING INSPECTOR '
APPLICATION FOR PERMIT TO Construct (,Single Family Dwelling
..... ?..............................................:. ....................................... ,.
TYPE OF CONSTRUCTION ...WQ.Q d..ZVAMIQ................................................................. .................................. .
1...........19........r .
r
TO THE INSPECTOR OF BUILDINGS:
The undersigned` hereby applies`` for
--aQQpermit according ��to the following information:
Location ...... ..1. .`... ..,........C �/ .!n. ���1....................:...................................................
ProposedUse .............................................................................................................................................................................
. I
Zoning District ....R B... Fire District Hyannis
............................ ... ........................
Nome of Owner Capricorn Realty,..P.rus,t Address .7. 5..,Falmouth Road,„Hyannis „
Name of BuilderFranco, ,Real„Estate. Dev....Co,Address .7.6 Falmouth Road, Hyannis,,,,,,,,,,,,,,,
Inc.
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms .SIX.........................................................Foundation ..R c.e..................................................................
Exterior cla.pbQ XA..a;??,dAr...S.k?.inglq.�;.................Roofing AS.pk ptlt...ahi1?.glu.........................................
Floors .....Carpe...t.................................................................Interior ...;a�?het..:ZQ.G ......................................................
...
Heating (za.S........k..K...A....................................................Plumbing....t.WD.........CQP.pQz:..............................................
Fireplace .NOXIP......................................................................Approximate Cost ...$.40q.Qj).0..OQ
Definitive Plan Approved by Planning Board --------------------------------19________. Area A.Q5.6...sq.....:E t............
..
Diagram of Lot and Building with Dimensions �J Fee ......... ..... .. .........................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
t
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name /�` Y6� �`G •�! d/. �/ .. .
T
r: rA CAPRICORN REALTY T UST
r
Nd ,,,23842, Permit for ...One Stgl;y.........
Sg�,�„k'ami.l Dwelli.a
Lot #11 20 Wayland Road
Location ......................................... .._.........
Hyannis
. ...............................................................................
Owner
Capricorn Realty Trust
..................................................................
Frame -
Type of Construction ..........................................
tiT ... ........•.. .... .......................................•................ 1 �w
Plot . ..............:...... Lot ............................... ' .
- f r
Permit Granted ..:.Aarc?.... .................19 82
Date of Inspection ...................19 '
Date Completed 19
PERMIT REFUSED
............. 19
..................................
.............................................................................
f
............... ... .....................................................r
.............................................................................. .: •I
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proI.... ...................`............ 19
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TOP D vA//>ATi0IV ZNOF�
3 . 3 'A-13a CERTIFIED PLOT PLAN
a ,
OHN
• � � ti /--� Y.�1 ntf�f fs
IN
L E
SCALE: / �3o DATE : / K/& Zr
I�EI
LDREDGE fNG/NEER/NG CO.INC) FR,y..,,� , I CERTIFY THAT THE LOVA/01172u j
CLIENT EOISTERED REOLSTERE SHOWN ON THIS PLAN IS LOCATED
D �
JOB NO, 8"?-0 S ON THE GROUND AS INDICATED AND k
CIVIL I LAND CONFORMS TO THE ZONING' LAWS . E
ENGINEERIV SURVEYOR DR.BY,.
OF /3,�!1?Wr7Agcc- , M"S.
712 MAIN ST CH.BYj
HYANNIS, MASS. . 01•6241L _
SHEET` OF ;. DATE E LAND SURVEYOR
TOWN OF BARNSTABLE Permit No. ----------_----------
-----
t &
Building Inspector�..� _
Cash
A
'sO ___
'FO PY h\� ____
OCCUPANCY PERMIT Bondz—
"No building nor structure shall be erected, and no land, building or structure shall be
used for a new, different, changed, or enlarged use without a Building Permit therefor
first having been obtained from the Building Inspector. No building shall be occupied until a
certificate of occupancy has been issued by the Building Inspector."
Issued to Address
Wiring Inspector Inspection date
Plumbing Inspector Inspection date
Gas Inspector Inspection date
Engineering Department Inspection date
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS.
......................................................
Building Inspector