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HomeMy WebLinkAbout0024 WELLESLEY CIRCLE d d i Q O 9 _ 1 f i i 1 I i I i I ` I 3I(�Ia�1 � t lk ok Q-K(- i 1Nl/ I � � � i � �� I Town of Barnstable BUlldin Post This Gard So That it is Visible From the Street-Approved Plans Must.be Retained on J,ob and,this'Gard Must be Kept MASS. �639. Posted Until Final,lnspection Has Been Made: Permit Where a Certificate of Occupancy is Required'suchBuilding shall Nowt be Occupied until a;Fina FI Inspection hates been made Permit No. B-19-3427 Applicant Name: DE ALMEIDA, MOACIR Approvals Date Issued: 10/30/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 04/30/2020 Foundation: Location: 24 WELLESLEY CIRCLE, HYANNIS Map/Lot: 270-101-012 Zoning District: RB Sheathing: Owner on Record: DE ALMEIDA, MOACIR Contractor Name:,,_ Framing: 1 Address: 24 WELLESLEY CIRCLE Contractor License: 2 HYANNIS, MA 02601 # - � Est. Project Cost: $4,000.00 Chimney: Description: FINISH BASMENT TO PLAY ROOM -FRAMING'INSULATION' Permit Fee: $85.00 LAMINATE THE FLOOR i Fee Paid:E $85.00 Insulation: : Date: /'et 10/30/2019 Final: Reviewers Note: Need to add one more smoke.detector tci _ basement and a Combination smoke/co near the bottom of the '` Plumbing/Gas stairway. RMCK Rough Plumbing: -- Building Official Final Plumbing: Project Review Req: I ) . This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas All work authorized by this permit shall conform to the approved application and the6approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning-by-laws and codes. Final Gas This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspecti on for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officialsare provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons c ng with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department 'C� Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT IME Application Number.... BUILD11V ...... G DEPT BARNMABL14 MASEL Permit Fee.......................................Other Fee:....................... s6.19. . OCT 11 .2019 TOWN Total Fee Paid........ A - ..,................. OF BA RIVS TA 6L E ... ................................. ..... TOWN OF BARNSTABLE Permit Approval by..... .........On... BUILDING PERMIT map.... .................Parcel....../..Q/..........6.(.. APPLICATION Section 1 — Owner's Information and Project Location Project Address- N Uz e I Les 1.e,4 6\ c.ti r,- village—jr)MAIU LL VJWJ2, Owners Name— VA0,9 C*%(Z I t1w JL Owners Legal Address L-e, Zip ip ®9.601 Owners Cell # 'J Li Cl 5 E-mail Section 2 —Use of Structure Use Group— r-1 Commercial Structure over 35,000 cubic feet El Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling Section 3— Type of Permit ❑ New Construction ❑ Move/Relocate [] Accessory Structure ] Change of use 0 Demo/(entire structure) El Finish Basement El Family/Amnesty El Fire Alarm Rebuild El Deck Apartment El Sprinkler System ❑ Addition ❑ Retaining wall Fj Solar ❑ Renovation ❑ Pool El Insulation Other—Specify Section 4 - Work Description WA LrC -ro A 6 Q n 14 c ti 49 _j K)Su LyFf7ing2 ALL e ►n(CL S _AJ1 JL Iq m i n14T-c in Al Ttf d Jf3o v- JOA 5e Al tA r) Last undated: 11/15/201 R Application Number.................................................... Section 5—Detail Cost of Proposed Construction a6d Square Footage of Project ©(944 ' Age of Structure Dig Safe Number ' r # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors i ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom i� Water Supply ❑ Public ❑ Private Sewage Disposal El municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No I� Section 7—Flood Zone i Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information j Zoning P District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage # of Dwelling Units (on site) 1 Setbacks Front Yard Required Proposed i Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No ' Last updated: 11/15/2018 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Binders/Contractors/Electricimm/Plumbers Applicant Information Please Print Legibly Name(Businessiorganizaiionandividual): tQ 4c/r2 CL k -►e+o Address: w cULe Lo ,► C i Vq C L e City/State/Zip: A. V 1j,'.) I k A _a2AoJ Phone#: IA Lt Q Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with- 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. �]Remodeling ship and have no employees These sub-contractors have g. El Demolition working for me in any capacity.acitY• employees and have workers' _ 9. ❑Building addition [No workers'comp.insurance comp•msurance. required..] 5. We are a corporation and its 10.❑Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.❑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 hue 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 worker;'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.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 sectae 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 of perjury that the information provided above is true and correct Signature: ate: l Phone#• f�2N 01 S 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 k 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 inchiding the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance'coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for firture permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commove ealth of Mas%6usetts Department of Industrial Aeeidents Office of Investigations 600 Washington Street Bostan,MA 02111 - Tel.#617-727-4900 ext 406 or 1-877 MASSAFB Revised 4-2407 Fax#617-727-7749 www:mass.gov/dia Application Number........................................... Section 9- Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable:Attach a copy of your license. I Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip k Registration Number Expiration Date k I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 -Home Owners License Exemption Home Owners Name: tAC)0,c�Q 01,H c k c4 A Telephone Number gam( 5 Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 786 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE 6 Signature Date k Print Name Telephone Number �y p Se?f 6 y g 5 E-mail permit to: 01.gE ij4g 9=a2 eig Oy 110 A. C-014 Last updated: 11/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval Section 13— Owner's Authorization L , as Owner of the subject property hereby authorize to act on my behalf, in all J� matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date a Print Name I I Last updated: 11/15/2018 L LL Li job 00 jA vos We �les ��� 5 j 2 ©1 �v � PO4cTrz u/e Z��s Ley Crrc�c. `6 qSc 2 r l All c� , rL Ira V Iv mot' ;, •i� e TOWN OF BARNSTABLE Permit No. ___2737'� Building Inspector, nw�rai Cash OCCUPANCY PERMIT ;Bond ----------- Issued to Capricorn Realty Trust Address Lot 12 . 24 Welleslev Circle. Hvannis `. Wiring Inspector r fig --" Inspection'date Plumbing Inspector : c � f 'Inspection date Gas Inspector o ��-� Inspection date X Engineering Department Inspection date Boa d of-Health 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 AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTI STATE BUILDING CODE. Building Inspector L--- -JOSEPH D. DALux 4TELEPHONE.'775-1120 Building Comminiontr EXT. 107 .. TOWN OF BARNSTABLE BUILDING INSPECTOR TOWN OFFICE BUILDING HYANNIS, MASS. 02601 MEMO TO: Town Clerk FROM: Building Department DATE: May 7, 1985 An Occupancy Permit has been issued for the building authorized by Building Permit # 27481 issued to t Please release the performance bond. > r u i ��b' fps`r�'t �" t...s ..'- a• .. IL -78 kn 0 7 RZ A Vx Y !r ol r r L ,SL� fr96 �S 5,i( �,!'G...��n Imo"•— .....' A CERTIFIED PLOT PLAN r Z—O ..In/�.:7� C.G..C.6.���L Y ��/!-• I r ELM) P IN• {Y�'t r��{��fLY�.:Ht gyp¢ _�r� s y�a - - 5\.5 /•� qw I,(�. 49 DATE: c�.o � i CERTIFY THAT THE Uvr►r�A"rf0 A SHOWN `OAi THIS 'PLAN 93 LA�ATL"p 4 +•.C.IVOL' . t LAN' 409 NO,- , ,,�,G.,.,,...,, ON THE '�.RAUND AS INDICATED AIM "ENGINEER SURi0EV4R COMFOR 3`..T® CIE ZONING LAPS OR.BY sue•• .; ., r k F 4ARN3T'AI .E, MASS y r n� ' , 7 l 2 M A.I N . S T R E E4' d 6H, Xs ow� {k HYAN,t�OS, MASS. $HEE'1'.L„O�', fi A E' ,: REG. LA ND b311R10EYoR i 1T I o / L 0 T_ 5-.7B°25 4157' Co/-0 aE7) LOT j` LOT z U N / T /Z Z9. 9/ oo N7d i d c�v+n CJ i✓� 2 Co n/J 7-�i_7 c ..: r�,rj 9 � t OUCf21 � F?F-urE , r., ELDRED i LEGEND s, EXIBTING SPOT ELEVATION 04 CERTIFIED PLOT PLAN 'EX i YiNO ' CONTOUR -- 0 —-— 11NI'SHED SPOT- ELEVATION F9�11-SH�:® CONTOOJR 0 LoT OTE:' The location of any existing underizvound sewerage, *Y wells, or other utilities shown on this plan is approx IN 'imat,e only as determined from records and/or verbal t J •�.D s ,. .�+1 -in£ormaton. The contractor is responsible for the vx,tp verification of the existing locations in the field. SCALE, / "— gip DATE 9/ 4DRE®GE ENGINEE"Ve co IN �Af/'o CLIEN7� I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 82 cz s BUILDING SHOWN ON THIS PLAN 3{N° CIVIL LAN®. CONFORMS TO THE ZONING LAWS Y ti DR.BY r4A , A `� EM0 NE,.ER RV OF BARNSTABLE , MASS. 4712 MAIN STREET CH. BY' -------���_= ?' tf HYANNI S," MA9S. LAZTE SHEET-2 OF E REG. [ AND SURVEYOR / w Assessor's map and lot number ..:,E � � t �✓ TH E r s c,x ie BU�GD,./��s.2M/T Alveu&v 'Tb nrNE�T QypF ro�o Sewage Permit number Q�'� r olir/8(� d CONNECT TO TOWN SEWER- ON✓- 6, J r� Z B8HB9TADLE,i House ,number .... G. Aea 1039. J. r. TOWN OF B.ARNSTABLE £ . BUILDING INSPECTOR - APPLICATION FOR PERMIT TO Construct �121g1e Faml�y DWB,�.�,J}}g TYPE .OF CONSTRUCTION ..........WOO Frame .- ............ :F y ' �$ September 26 4 ` TO•THE INSPECTOR OF BUILDINGS: 4 } r i The undersigned hereby applies for,a permit' according,to, the following information:.' location ::ZOO..#..:..12 Wellesley Circlet Hanrils, Nlass. ..... .... i Proposed .Use ....... .......................... Zoning, District':.. . .. .... Fire.Distnct .... . �iyr nni8 ... Name of Owner.Capr-icoTYl..-Realty.-.2-rust............ . .. ..Address ..763...Fa)_1Tmoii:f.Yl �S$ i Name of.. Build''rr i 0.0...$eat...EBt.Dev...CO.R.i.Ino.Address ... ,Same s , Name of Architect- : ....... Address Number'.of.Rooms ......S.J.X .:`..... .............. :, . . :".... ... .....,.:.Foundation P 10 r. t I • y Exierior -Clap)Saar.d...and/.or...Sb1ngle.s..::, ........., .Roofing ...'. ..Asphai:t •Sh3r�gles Floors :......8r A.t:.:......: .... .......... C p ... ... .. ...... ..Interior S13e8-�•flOjl...... fi (i Heating , Sze,$.... Fs:W..A.. ....... .., g ;:„ :.. - - ti t4 G p :.Approximate 'Cost ::.: C�,QJQ�. QI�Fireplace. Non.9.... ...:,... ....... ........ ......... ......... Definitive Plan Approved byrPlanning Board __ ______________ ______19 ______ . Area A.C56:,.gq�:.:�'t....�. Diagram of 'Lot' and.Building with Dimensions .� ' ' _�. ' . Fee .. • ` SUBJECT TO APPROVAL­OF BOARD OF- HEALTH OCCUPANCY PERMITS REQUIRED -FOR NEW.`'DWELLINGS 4 } I.hereby agree to conform to all the Rules'and `Regulations of the Town.of Barnstable.regarding-the above' construction. .Nam .... . Pr'£i$i• Construction` Supervisor's License s , =Oa©989.. CAPRICORN REALTY TRUST 2779 One Sto o .. . ...:....... Permit for .................. '.............. Single Family' Dwelling " Lot 12 24 Wellesley Circle _ Location ..................c................................:............ - Hyannis ........................................................ ............. i Real t Trust Owner -Capricorn......... . .................. '.. ........... , Type of"Construction ..........................................ae , ..:.................................................................... Plot' . ..................... Lot .......................... fix.:�.�- :. - t • "Permit Granted ....January 3,' 85 ...................i:......19 t Date:of' Inspection ........................... .'......19 Date E•ornpleted ..........r...................... z- `" 1 4Y'• •. '..,.'i � � •- - - � �, � .. .' {ate engineering Dept. (3rd floor) Map Parcel PZIE�k rmit# P�4 House# G Date Issued 02 Board of Health(3rd floor)(8:15 -9:30/1:00-4:30)0__ -/�& Fee v76 d`o Conservation Office(4th floor)(8:30-9:30/1:00-2:00) LE. a Planning Dept.(1st floor/School Admin. Bldg.) APPLICANT MUST CONNECTION P8 Definit' an Approved by Planning Board 19 CoINI;rEt�SypIt� 01 F�/N�YV i`YN • BARNSTABLE. �rFO TOWN OF BARNSTABLE Building Perm't Ap lication Project Street Address , Village -Owner a 06 Address Telephone Permit Request // .. f First Floor square feet Second Floor square feet Construction Type OK4 _ Estimated Project Cost $ T Zoning District Flood Plain Water Protection Lot Size 11 .-R fxo, Grandfathered ❑Yes ❑No 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.) A Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing_ -2, New Half: Existing New No.of Bedrooms: Existing 3 New Total Room Count(not includin baths): Existing_ -� New First Floor Room Count Heat Type and Fuel: as it ❑Electric ❑Other Central Air ❑Yes o Fireplaces: Existing New Existing wood/coal stove ❑Yes No P g g ❑ Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) e ❑Shed(size) • ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use TC Builder Information Name L _ Telephone Number �n?�) 6)2 W Address License# Home Improvement Contractor# 1���16�g Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRU ION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Jr Ax� SIGNATURE - DATE ,;2 ' BUILDING PERMIT DFXIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED J MAP/PARCEL NO. ADDRESS VILLAGE ' J OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: r UGH FINAL GAS: 'UGH FINAL o'es FINAL BUILD DATE CLOSET` ASSOCIATION PLAN NO. k.i 1 20 � 78 -:—IV' 7(3 zf 0 Z0/1 Olt o GOT /A /✓mil S j' i' E DR t a1✓, 1 IN U fi e , SCALE= /��_�� ®ATE i / Z�/E��q GC E ®A kF• ING �rz� �✓co g. CERTIFY 1'NAT' �•p�� fv�nr�^-r1o/✓ CLIENT E®ISTE�tED RE®ISTERE® �!�®�fN ON THIS PLAN 19 1.®CATfQ LAND � >8?�s Chl THE GROUND AS 114DICATED MW ENGINEER St�R�E��R .IIIsY� %4 ,.4.�, CONFORMS TO THE ZONlW � LAWS T l� 1�1 A 1 N STREET . Ck By' � ®F A iR Id S'TA I�L E , AAA/�.3 , WYANKIS, MASS. / / �� SHEET�OR n._ ..�. Y+AE—' RE®. LAND SUtR� EYCR v -91 - i j :. 9 °F THE l°� - °� The Town of Barnstable BABNSCABIZ 9� "ASS 9. 10� Department of Health Safety and Environmental Services prEDMA'�A Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: IaAEst.Cost _nzj. Address of Work: Owner's Name Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of th wner: D to ontractor Name Registration No. OR Date Owner's Name r - r -� The Commonwealth of Alassac•husats Department of Industrial Accidents ` Office ofinyestiyations 600 N'asNii-lotr Street Bustott, Alms. 02111 `-' Workers' Compensation Insurance Affida-vit �hplicant information: Please PRINT lebiU��, name• � C l � � iA ®. location• c'tv GAL hon•# 72 L 1 a hom4owner performing all work myself am a sole proprietor and have no one working in any capacity =7`1• paor `•T' .F::>f+`^. ...,,lee�w .!L'+R[$T F.•'^4?"+'ez+'"�y� Ta ,rXT'r!T s"law""`grfr, •a1'vn'P,'..^a'�°•nrs3.jN'R'"e""'s• tRr""•r^"'.Atr °Tr". r..,i,,.n...�,.....r•s.•.„,r,. :-�r,..,.,.+.n..:r.:rr,-....:..�i.a.,.,::y I am an employer providing workers' compensation for my employees working on this job. company name: address: 4 cih•• v phone#: ��G3 insuran o. QZ- u-e-e- - lic •# , ..:, .' .�•r •,,•'.a^ ,.r,^._._-'.n,r���w�a,,.us•,r,:(� -. �m.`.r?em sx,. .wy« .r,.ae.,,,lf�7^„nx,!ar,�_T,z�4�•,,�,,,y.yk > 1 am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' co pen lion polices: - .. I I I company name l i /V�Zicv address: n ci • hone#• v,? insurance co Q. Policy# � .,.:•, n;Fi'«:.;�.,:�'ay'^t.^.:a..-;..,..; '^S �•: "Y.n ��.�^•.:T-'�rt^cl,�^•.Z,��ST•f�r+H...g; :r � y/' .. �r+.,._�.y��.....-.__-.4* ._:..__ _.._..:.__.,•..s....�:_:._-_ ...)�c:w+is....:•.:.�.:.L.w.+�..�.w•J:iw• —.-=�l.�iL..f' .. s " ar.:�..1.tw�v:�w.a.�._w3. company name: address: city: phone#: insurance co. policy# :Attach additional' _ _ .shcef dnecessarx� �' ,.���„_.�.z-r ,�„a,,.�,y�r,..v.'rem,..m�."d:,•i�.,s3�tt�,:tL,s,,.;sr„s.+a, Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andiur one years'imprisonment as ivell as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 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 to di or th p in enaitie of perjun•that the information provided above is true and cornet. Si_nature Date Qw Is Print name © f Phone# 0 official use oniv do not write in this area to be completed by city or town official city or to%vn: permit/license# r,lluilding Department OLicensing Hoard O check if immediate response is required oSelectmen's Office 0I1calth Department contact person: phone#-, MOthcr (rmsed 3M;PJA) 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 en►ploree is defined as every person in the service of another unti'er anv contract of hire, express or implied, oral or written. An einphnrer 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 irounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL cha}iter 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 contrast 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 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. ..ral.'*„v�r 4.4 City or Towns Please be sure that the affidavit is complete and printed legibly. Tile.Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations leas to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. Tile 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. s^ aw,.,:.,..,.-_... ,.,.._.,.,,;.,s.• ---. ..vim••.v.s.v-•r..-�"'rsus-;....ew•-r.�......,...�.n.rXmox,q. ..s...7.^o ..q +.+m.n-t.-.. w +.`',!n►.,.,ca..wz'T'°';*Px.1r�r -r:r:v-.+-�+tw+++.y ..,.,.+++.+' Tile Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations . . 600 NVashington Street Boston,Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 ✓:< fn �` , Assessor's map and lot number .... %`!...... ~,,J� 4 THE �� ff'(/!�. �.pi tpl` t G��1-+�t-.��..,r..•o/. cif' rl 1 0�i1�Sr^!L fp�P I'� Sewage Permit number ......................................P6.................. „ 89$d9TODLE, i House number...............:..... ........... ............ NAM !Js 9 'Fa NPY A`. TOWN OF BARN-STABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO :..Construct. . ...Single. . ...Family. . ...Dwelling............. ....... .. ..... ....... .. .. .......... .. ..... ...... ...:.............:..:..............:.......:.. TYPE OF CONSTRUCTION ........•�Ood Frame ' September ,26, 84 ........... ...........19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..:ht # 12 Wellesley Circle, Hyannis, Mass.: ............. ......................................................................._.................................................... ProposedUse ................................................................................:......................u.........................................::.::.........,.............. Zoning District ,.R'..8.'..........................................................Fire District ........'."a A2�21'18......................................... _ ... Name of Owner CapriCOrn R@3�. (, Thrust„„•,,..•,Address .7.6S...Falmputh Road,,.. Hyann ,,••,• �s, 'Name of BuildFrr. nco Rea.l...Est,.DOY.CO .,.InP.'Address ..............Same .. .. - i Name of Architect .................Address . ' ........................... Number of Rooms ....... SaX..........................:.........................Foundation ....... P.C...................... :.: ..:........................ { Exterior ...Clapboard andrOY' ShlIlgl®S ..Roofing ............: MIt..t5.h1ng1,.0*S............................. Floors ..... 'ark. ....................................................................Interior ...............s5,�2eEe.tX'C3.R$.............,.:...::.•.....:.:............:. Gas...::" F�W:A I Heating .......................................Plumbing ..:.........`�' f!?.....�.....L'Q�? 2� .... �. 0 Fireplace Non .......................................................................Approximate. Cost ......0qr. DO•..Q�............. Definitive Plan Approved by Planning Board -----------_------_-----------19________. Area . OS6:..p.g.#...::.r........... Diagram of Lot and Building with Dimensions Fee ...................:....,.....:... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �. ��� �i✓! % i. Construction Supervisor's License ...00a9g9.................. |CAP,zICuzno zxALIPz ' 2�=370-I0l Y � ~' 27 &� No ----379-.. Permit for -.{���. -.~71�°^?- ---�������.��pg=�K.J�Y�11jag...................... Location -IQLN.-..24.. .jCixxzJe Hannis .~----'��'............--------------- Owner - . ..Trzuat.----. � Type of Construction ...Frame........................... ` -------------------------- Plot ............................ Lot ----------' ' ' Permit Granted .......J.=Uac.Y..3.0...........lP 85 ' Dote of Inspection -----------']9 Dote Completed ------------..lV ' ' ~- ' � | ' ^ - '