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Home My WebLink About0560 WEST MAIN STREET - - �` l _ __ _ _ ,,-- i E 0 url!=bLh PYALLO r ,yU4INT. WAC BATH ROOM FLR S. F.S70NEWALLS' '` TOILET ROOM FLR: z S. F. S� g INISH S. F.BASEMENT AREA LA MISCELLANEOUS S. F.'b_ '/z I 1/� FULL DR ' FIREPROOF CONSTR. S. F.. EXTERIOR WALLS WA MILL CONSTRUCTION S. F. iOLID COM. BRICK UN FIRE RESISTING e7 :OM. BR. ON C. B. STEEL FRAME -ACE BR. ON COM. BR. PARTITIONS STEEL BEAMS & COLS. r •. -ACE BR. ON C. B. LATH AND PLASTER TIMBER BEAMS & COLS. IS'f! "ACE BR. VEN. DRYWALL STEEL TRUSSES :EMENT OR CINDER BLK BRICK REIN. CONCRETE C. BLK. SPRINKLER SYST. ,UT STONE FACING dc9 !. 16 PASSENGER ELEV. STONE OR T. C. TRIM HEATING FREIGHT ELEV. y7` S81a S STEAM INCINERATOR 2 SIDING OR SHIN LES 5, HOT WATER � � FIREPLACES PAR"W MS CHIMNEYS �y . PLATE GLASS FRONT GAS Zo OIL BURNER STEEL FRAME SASH G� zQG b ROOFING COAL STOKER WOOD FRAME SASH / REPLACEMENT VALUE 3 7 COMPOSITION OR T. & G. NO HEATING RENTAL CAPITALIZATION LOCATION /S Z7 METAL AIR COND.—REFRIG. LAND 0 FAIR POORlczz-5D WOOD DECK G� AIR COND.—WATER VACANCY LISTER DATE _ S t METAL DECK HEATING WIRING WATER FLOORS FLEXLUME OR EQUAL / ELECTRICITY OCCUPANCY DETAIL & INCOME t B IST 2N 3RD PIPE CONDUIT JANITOR p•J• ;74. eoro vil'(,. CONCRETE MANAGEMENT ' Q A$xwl �, PLUMBING y� SPIN p �� BATH ROOMS / TOTAL FLAT EXPENSES `` �dA GeJ iC f HARDWOOD ,,,S TOILET ROOMS ;SINGLE F . WATER CLOSET EXTRA GROSS ANNUAL INCOME G04 D(y/ls-5: 5C!"i/rCF'MG "ASPH. TILE LAVATORY EXTRA LESS FLAT EXPENSES ` >,TERRAZZO SINK EXTRA /' BALANCE FOR CAP. t.WOOD JOIST URINALS CAP. RATE A C "STEEL,JOIST NO PLUMBING REFLECTED CAP. VALUE .I- rf > Kh v s;REIN. CONC. 67 OCCUPANCY CONSTRUCTION SIZE AREA ,.�CLASS AGE REMOD CONE). REPL. VAL. Phy.DeD• PHYS. VALUEy Fu,:.D P. ACTUAL VAL. 30 no o / Z t � > z rr e•• TOTAL I xx �iw.� 9RGx,',Yj?•`Y�t„M'k.•.i'.•T.�r. � _ _ _. COMMERCIAL PROPERTY FIRE DISTRICT SUMMARY MAP NO. LOT NO. 269 216 STREET 560 West Main St. annis �3 LAND H BLDGS. `� 7<0 .24 OWNER TOTALy , ' LAND L�SL�QO RECORD OF TRANSFER DATE XKIREMARKS: LO G 0) BLDGS. �� 1�O Pd TOTAL 9 7-5 SO P Pr Ahokas, Elis 5 20/55 79LAND8 9BLDGS.` TOTAL ;Cc /, �� G2✓ ALAND of a LAND 4 I BLDGS. at TOTAL LAND 6-g D R S !! BLDGS. Y Ex-PA. m TOTAL LAND BLDGS. TOTAL LAND BLDGS. 0) INTERIOR INSPECTED: - TOTAL LAND DATE: BLDGS. ACREAGE COMPUTATIONS TOTAL LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE LAND HOUSE LOT O S �Omc7J OO O > BLDGS. CLEARED FRONT /a� - -GZ/ -� _b Q TOTAL REAR Z ° /A J �'2f �" CCf�.f1!-: �/ LAND WOODS&SPROUT FRONT - I _21 ov BLDGS. REAR 6� 3d Q TOTAL WASTE FRONT . / 3 LAND REAR _ Q BLDGS. TOTAL LAND -- 71 BLDGS. LOT COMPUTATIONS LAND FACTORS TOTAL FRONT DEPTH STREET PRICE DEPTH % FRONT FT. PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND ry ROUGH TOWN WATER BLDGS. HIGH GRAVEL RD. TOTAL LOW DIRT RD. LAND SWAMPY NO RD. BLDGS. ----------- -- ----- -- mTAi - COMMERCIAL PROPERTY ? FIRE DISTRICT MAP NO. LOT NO. STREET SUMMARY 269 216 6o West Main St-4 annis. LAND - H rn3 BLDGS. y' OWNER TOTAL _ jLAjNDRECORD OF TRANSFER DATE BK PG I.R.S. REMARKS: ��5/20 55 Ctf. 1776 g T Aho$as, EI1S LAND Prob 9 u/53 33 9 TOTAL i LAND BLDGS. '- TOTAL LAND BLDGS. 01 TOTAL LAND BLDGS. TOTAL LAND BLDGS. 01 TOTAL LAND BLDGS. INTERIOR INSPECTED: TOTAL LAND DATE: ACREAGE COMPUTATIONS (3) BLDGS. LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE TOTAL LAND HOUSE LOT BLDGS. CLEARED FRONT TOTAL REAR LAND WOODS&SPROUT FRONT BLDGS. REAR - TOTAL WASTE FRONT LAND REAR � BLDGS. TOTAL LAN D BLDGS. at LOT COMPUTATIONS LAND FACTORS TOTAL FRONT DEPTH STREET TPRICEDEPTH FRONT FT. PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND ROUGH TOWN WATER BLDGS. HIGH GRAVEL RD. TOTAL LOW DIRT RD. LAND SWAMPY NO RD. � BLDGS. FOUNDATION CEILINGS TILING L, tsUILUlriVa .JF�u r� w l CONCRETE WALLS LATH & PLASTER BATH RM.A-& WAINS. Iq L15 S. F. /. �& ' CEMENT BLK. WALLS COMPO. BOARD TOILET RM. FL. & WAINS. '� S. F. 70 yy BRICK WALLS ACOUSTICAL BATH ROOM FLR. S. F. STONE WALLS TOILET ROOM FLR. S. F. INTERIOR FINISH S. F. BASEMENT AREA LATH & PLASTER MISCELLANEOUS S. F. . /. I y, I 3 FULL DRYWALL [ FIREPROOF CONSTR. S. F. EXTERIOR WALLS WALLBOARD MILL CONSTRUCTION S. F. SOLID COM. BRICK UNFIN. INT. FIRE RESISTING I COM. BR. ON C. B. STEEL FRAME FACE BR. ON COM. BR. PARTITIONS STEEL BEAMS & COLS. FACE BR. ON C. B. LATH AND PLASTER TIMBER BEAMS & COLS. FACE BR. VEN. DRYWALL AAiwL. / STEEL TRUSSES tCEMENT OR CINDER BLK BRICK l� i REIN. CONCRETE C. BLK. SPRINKLER SYST. 'CUT STONE FACING 9? ? PASSENGER ELEV. STONE OR T. C. TRIM HEATING FREIGHT ELEV. 'STUCCO ON STEAM INCINERATOR C� SLDWf SHINGLES HOT WATER FIREPLACES / PARTY WALLS M➢Js�NR 47�� CHIMNEYS ) !PLATE GLASS FRONT GAS I: r OIL BURNER STEEL FRAME SASH ROOFING COAL STOKER WOOD FRAME SASH REPLACEMENT VALUE • COMPOSITION OR T. & G. NO HEATING RENTAL CAPITALIZATION LOCATION , f METAL AIR COND.—REFRIG. LAND OOD IR POOR yWOOD DECK AIR COND.—WATER VACANCY LISTER DATE METAL DECK _ HEATING S l . WIRING WATER 's. FLOORS FLEXLU ME OR EQUAL ELECTRICITY OCCUPANCY DETAIL & INCOME B 1ST 2N 3RD PIPE CONDUIT JANITOR ECONCRETE MANAGEMENT I EARTH PLUMBING IPINE�� 6i BATH ROOMS TOTAL FLAT EXPENSES f HARDWOOD TOILET ROOMS V.SINGLE FL. WATER CLOSET EXTRA GROSS ANNUAL INCOME 4.ASPH. TILE LAVATORY EXTRA LESS FLAT EXPENSES — ! TERRAZZO SINK EXTRA y BALANCE FOR CAP. ';,WOOD JOIST URINALS CAP. RATE STEEL JOIST NO PLUMBING REFLECTED CAP. VALUE REIN. CONC. 1 t OCCUPANCY CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL. 2 3 i 4 5 _ TOTAL ROPERTY ADDRESS I I ZONING I DISTRICT CODE SP-DISTS.I DATE PRINTED(CSTATE LASS I PCS I NBHD KEY NO. 0560 WEST. MAIN STREET 07 H88RB 400 07HY 01/04/96 0311 OJ HY09 R2b9 216. 176008 LAND/OTHER FEATURES DESCRIPTION i ADJUSTMENT FACTORS T,, UNIT ADJD.UNIT Lana By/Dale Sze Dim"' jLOCJYR.SPEC.CLASS ADJ. COND. PE PRICE PRICE ACRES/UNITS VALUE oaxrivtion AHOKAS. JOHN AXEL MAP- CD. FF-De tNAcres CARDS IN ACCOUNT — BATHS 4.0 u X C= 100 14000.00 14000.00 1.00 14000 B 03 OF 03 - NO BSMT S X C= 100 5.95 5.95 1456 8700-8 COST — JMARKET INCOME 746500 A i IUSE (APPRAISED VALUE A 572.30:":. PARCEL SUMMARY D AND 156400 > TI �LDGS 400100 Q—T,M,OS i 5 ace !; /�OTAL 512JVL IN CNST 2781010 N DEED REFERENCE Tye DATE R«-od I-P R I O R YEAR VALUE a T Book Page lnst. MO. Vr.p Sales Price I� A N D 156400 F S IBLDGS 415900 TOTAL 572300 BUILDING PERMIT Number Date Typo Amount LAND LAND-ADJ INC ME SE SP-BLDS FEATURES OLD-ADJS UNITS 5300 C—sl. Total Vear Built Norm. Obsv. Class Unils Unils Base Rate Atll.R.I. A 41t9 Age Dap,. Contl. CND. LOC. ^h R.G. Repl.Cost New Atlj.Real.Value Stories, Meighl Room4 Rms Botha I It. Portywall F-, 04C 000 100 100 66.20 66.20 67 75 19 80 100 80 167304 133800 2.0 12 4 4.0 16.0 Description Rate Square Feet Reel,Cost MKT.INDEX: 1-00 IMP.BY/DATE: / SCALE: 1/00.80 ELEMENTS CODE CONSTRUCTION DETAIL SAS 100 66.20 1456 96387 GROSS AREA 2912 FOUR FAMILY DWELLING CNST GP:00 D FOP 35 23.17 336 7785 56-------- STYLE 00 0. 3 820 60 39.72 1456 57832 ! B20 5 PSIG N ADJ MT_ 00 0. EXTER-.WA _ LLS 01 OOD FRAME 0. J ! A EATIAC TYPE _090IL-HOT__ ______WATER 0. INTER.FINISH 04DRrYALL 0._ r ! ! I NTER.LAYOUT 12A 9T?I ORMAI 0_ . 26 BASE 26 INTER.�VALTY 02S4111 _ E AS EXTER. 0. ! FL _ OOR STRUCT 01W006 JO_I_S_T ________ :(I- D W! ! EFLook COVE _R 04CAR0ET 0. E TotalAraas AOx_ 336 Be.._ 1456 ! ! ROOF TYPE 01 GABLE-ASPH SH 0._ BUILDING DIMENSIONS ! ! ELECTRICAL__ _01 AVERAGE_ ____ d._ A BIAS W56 N26 E56 S26 .. FOP SC6 ! ! FOUN5ATI0R 01POUREO CONC 99. N 6 E56 .. 820 N26 W56 S26 *---------------------56--------------------X --------------- -------------------------- W56 E566 6 --------------- --- ---------------------- • - ! FOP ! LAND TOTAL MARKET *------------- 56-------------------* PARCEL AREA VARIANCE •0 t0 STANDARD o M 1 J-6 voo *l — ems ,-- ♦ A _ a Pet G iC - - ---- — - - - ; a �ec � All Y!s i�...- w -. ._SrV,+ Pima kYN�e%-•-#-.. 'Y �5 t.:,e. .. _ s`d.- `�..5 s q^' �� t.J SL 9� a /* SSG WJYAIs sr ��Q�°f7NE.r°w•� TOWN OF BARNSTABLE 8AHB9TAIILE. i "b BUILDING INSPECTOR �0 �FQ YPY a' APPLICATION FOR PERMIT TO 4/ y /v. / PG�i``�6 /�.T�e..j T k1 TYPEOF CONSTRUCTION ..............................................................................................................." 1...:.! C G:.W.....11:�/ ...19....1,.. D TO THE INSPECTOR OF BUILDINGS:The undersigned hereby applies for a permit according to the following information: Location o "..�.5 R� GJ b.-- J`� C/,"1 �./� ///, l SS. . 1 . .............. ... ........................ ............./..... 7..... r................................ ProposedUse ....7/ �-.�!.z ../.....................................................................................................................:.................. Zoning District !rJ 5.,. �/ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Fire District ..................................................... Name of Owner A.—A-5 ......A.A !� ...5. � O ..1/v.:......... � �!y... .. . . l{ Address . .... "!... ...�.. ..... .. Name of Builder � ..� �� ........... ..............................................Address ..... ............�1...e....................................................... Name of Architect .......�J e'................................Address ....... e..r................................................... Number of Rooms ... ./.,6..............................................Foundation ....1........ r�.U/L- Exierior / �..�C........ . Gj ... . .................................................Roofing ....... .....Q./.. ...... Floor/.. SG�I�e Cd ��J i s� , ,Interior S-, f'e /71,�:G .... /y................... ..................... /.................� ................. .............................. . Heating ��.. .......�.r�YF�P"`.::........ ...........Plumbing ... �i ....... ................................................... .. p l��G YI D O Flre lace .................................................................Approximate Cost ......p4.�...�1. ...........��............................... ..... Difinitive Plan Approved by Planning Board -1I !_1_,/ 19 J ��' -' a Diagram of Lot and Building with Dimensions THE PROPOSED METHOD OF PROVIDING fOrR SANITARY WATER SUPPLY, SEWAGE DISPOS' AND DRAINAGE IS HEREBY �PFPIRGVP-D TOW6 TF AiNSTAFLE, BOARD OF HEALTH 6 °P Ier]VS-ED INS L IT, AND INST �L ES S uSr OBTAIN Fn�. sEwA0 1-4 a food � ro a i I hereby agree to.conform to all the Rules and Regulations of the Town of Barnstable re arding the ve construction. Name .......... ...................................................... Ahokas, E13'.S 660-3 1 1971 No ...IZ93.Q... Permit for unit apartment ........................ .........bui.l.ding..................................................... *1-j Location .....56q..Tn st Main Street .............................................. ....................gymiftq........................................... Owner .........Elis...Ahok.a.s............C.................. ......... ........ . .. Type of Construction ..........frame...................... .......... O Plot ............................ Lot ................................ > Permit Granted ..........................March 18..............19 70 Date of Inspection ......ZI.—ZZ...........19 7a Date Completed ......................................19 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................. 19 ............................................................................... ............................................................................... TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l ` Parcel ut Permit# " Health Division &�fLt 9L/ 5 Q7- � Date Issued g l 0 Conservation Division l% Fee �� Tax Collector / �80/ (_'► l ��Z a� ASUCANT MUST OBTAIN A SEWER Treasurer CONNECTION PERMIT FROM THE ENGINEERING DIVISION PRIOR 10 Planning Dept. OUCTION Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis 4f Project Street Address S i Village n ?i r If Owner �h �dhd`cam Address S(o �Pf� rn� Sa � .Telephone /�f Permit Request t?�� ► / �ac�� Square feet: 1 st floor: existing proposed 2nd floor:existing proposed Total new Estimated Project Cost - 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 t Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing Cl 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 BUILDER INFORMATION k Name (o Telephone Number ' \Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO xSIGNATURE DATE _ _ FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED, MAP/PARCEL NO. ADDRESS _ VILLAGE - r � t3w 1. a _ •., w � d E - - i - X OWNER DATE OF INSPECTION;^ FOUNDATION FRAME INSULATION • . _ .{ �� :- ..,,. ; i ', _ -. ^ . � � `- f -„ ; • FIREPLACE `*s ��t ti �.. 1 .. e y 2• f I - � w +' r' ..4 ELECTRICAL:-' ROUGHS FINAL r , PLUMBING: ROUGFQ FINAL GAS: x ROUGH r�5' FINAL -ram • . . -, _.. • : `w A' • FINAL BUILDING - -c. ' DATE CLOSED.OUT ' S ASSOCIATION-PLAN NO. j -:�•_,, -=_� Olfica nfloyestfgatfoas `---- 600 Washin on Street Boston,Mass. 02111 Workers' Comyensation Insurance Affi�d/avity//��//-/ i� �/051 i �� E� i % / /% %�i ?%/%// %/ �r...... name: location: city phone it ❑ I am a homeowner performing all work myself ❑ I am a sole roflrietor and have no one workin in aav atdty • ❑ I am an employer providing workers compensation for my employees working on this job. comnnnv name: H DIM . address: ' ' • city. MCI 02 hone, #: �5 IV"J& insurance cn. L" oy) oiicv# 3 i ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the foIloning workers' compensation polices: comaanv name: address: ,.. :;;« •.<';,.., city: phone#- lily# , '.sr :y : se.."'• wmnnnv name: address- CIh" phone : ........ :: ',.'':'. ...... •�:•�:......>t..�SFd•.::'.;.. ...w;::::....,�;,.;r.�yi;:i;::s:E2•;•':'.ofS:i�•;•:�''t,'::'':;.:::;::>::•: iruarancc co. oii[v,# ... Fliure to secure coverage as required under nderection2� Section 25A of MGL 152 on had to the imposition otabninai penalties o[a floe nP to 51300.00 aadlor one vears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a Mine o[SI00.00 a day against me. I understood that a copy of this statement may be fogywarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under she pars and penalties ojperjury that the information provided above is trw.and correct Signature Date _ Print name Phone 0 oindzl use only do not write in this area to be completed by city or town of Wai city or town: y raftecensco ❑Buildittg Department . Dl.icensmg Board ❑ check if immediate response is required Meleetmen's Office ❑Health Department contact person: phoned: ❑Other. f • • Usvucc r,95 P1Ai • P Massachusetts General Laws chapter I52 section 25 requires ail.employers to provide workers' compensation for thy.: ��-• employees. As quoted from the "law", as employee is defined as every person in the service of another under day curs- of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or anv two or more c: the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the recce,•e: trustee of an individual,partnership, association or other legal entity, employing employees. However the owner or a dwelling house having not more than three apartrneats and who resides therein, or the occupant of the dwelling house cf another who employs persons to do maintenance 1 construction or repair work as such dwelling building appurtenant thereto shall not because of such I house or an the grour employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shag withhold the issuance or renew: of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who bar not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall eater into any cm=ct for the performance of public worst uarii acceptable evidence of compliance with the insu-+nce requirements of this chapter have been presented to the corttrac- s authority. - Applicants Please fill in the workers' compensation affidavit completely, by checidng the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of i*+su*-+*+cP as all affidavits maybe submitted to the Depart meat of Industrial Accidents for confirmation of insures=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 Depmrtnrent of Industrial Accidents. Should yaa 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 Departm=has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to canract you regarding the applicant Please be we to fill in the permit/license number which will,be used as a reference number. The affidavits may be re=aid io the Deparmicnt by matt or FAX unless other arrangements have been made. The Office of Investigations would Ir1ce to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. /%/// The Departmem s address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents 0MC8 011=800awas 600 Washington Street Boston'Ma. 02111 fax#: (617) 727--7749 phone #: (617) 727-4900 eat. 406, 409 or 375 f ................... .._ ..,. DATE(MM/DD/ YUACORvCERTIFICATE OF LIABILITY INSRNE /HLPCONI 16/99 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS..UPON THE CERTIFICATE Paul Peters Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P O Box 669 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Falmouth MA 02541-0669 COMPANIES AFFORDING COVERAGE Robert N. Lynch Jr COMPANY Phone No. 508-548-2500 Fax No. A Legion Insurance Co. INSURED COMPANY B HLP Construction DBA COMPANY Upper Cape Foundations& Floors C 88 Fox Run Lane COMPANY East Falmouth MA 02536 D ................ COVERAGES . . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE(MM/DD/YY) DATE(MM/DD/YY) GENERAL LIABILITY I I GENERAL AGGREGATE $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ CLAIMS MADE OCCUR PERSONAL&ADV INJURY $ OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ MED EXP(Any one person) $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND WC STATU- OTH-::::::::::::........:::................... TORY LIMITS ER EMPLOYERS'LIABILITY EL EACH ACCIDENT $100,000 THE PROPRIETOR/ INCL -PARTNERS/EXECUTIVE EL DISEASE-POLICY LIMIT $ 5 0 0 0 0 0 OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $10 0,0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS Concrete work CERTIFICATE HOLD1. ER CANCELLATION . MIDPM01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Midpoint Motel 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, John Ahokas, Mgr. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 580 W. Main St. Hyannis MA 02601 OF ANY KIND UPON THE COMPANY,ITS AGWjS OR REPRESFIrCATJV2S , AUTHORIZED REPRESENTATIVE Robert N. Lynch Jr ............ 5 ACDRD ORA7H 988.' •• ��°� �°rya �� tableTeawf® Barns . MAIM $� Department of SenIth Safety and Environmental Services . 0. Building Division 367 Main Stan,Hymmis MA 07-601 Raipn C-n_.r� Ogee: 5084 90-6Z7 Building Con Fax: 508►90-6=0 For office use only Permit no. Date AFFIDAVIT ; HOME MeROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ` air, modernirtzion. MCL � 142A requires that the "tecanstruction, alterations, renovation,dditionp to any prrexiiting conversion, improvement, removal, demo Iifzon, or consiraction of owner occupied building containing at lest 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 Worlt. o Est. Cast c-, O Address of Work: Owner's MarneG Date of Permit :application: I hereby certify that: Registration is not required for the following renson(s): Work exciaded by law _ _ ob under 51,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEID. OWN PERMIT OR DEALING WITH UNREGISi'TR1ID CONTRACTORS FOR APPLIG�B GRAM OR GUARANTY FUND UNDER MGLO I4Za AVE HOM]E IMPROVEMENT WORK DO NT EL ACCESS TO THE��g�ATION PRO SIG,IED UNDER PENALTIES OF PE'L=y I hereby apply fora permit as the gent of th�er•. ` Cantrnctar Name Registratioa No. Date TJtc• Cirr11r11Ur1)t'01111/1 o :I fl ssachusctts .r, l --_•-j.,: Deparl"ICltt of ludrrsrrial Acculefus --�fft t�9 IN= 9.71,ons 600 Washiti rutr Strec'r Bttstorr.Mass. 0111 Work-ers' Compensation Insurance AMdavit �—' rfc7nT infrirmatinn' // Plc'tse i'R(NT Z-iliiv nark n _ / �^ Q nhttn•Ci e 1 am a homeowner performing all work myself. L-1"a'm a sole proprietor and have no one working_ in any capacity I am an empiover providing workers' compensation for my empiovees working on this job. enmunns• nnmr- �(i(irr�c• tiff•• Ri1nnC�• incnrnnrr rn. n�licv>Y _ .� ....• _ — ..... -r _— i am ;.•sole, proprietor. general contractor, or homeowner(circle otte) and have hired the contractors listed beio« u r c the "011owin^ .vori:en compensation polices: cnmmim' nninr- :ltitfrr— cir— nhnnc a• incur^err rn Rnlict•ii .—• .77 cmmnnns' n-imv- :1ti�irr<c- pits•• nhnnc f�• in,mr^nrr rn neiicy Altach additional Shect If R[[eS37ry �- -.;�..._.., ��1:'<':a..a►.i.:. ..,.�. .�......•r. ••..._..�.. �.++.....re.�....v_..��..�_- .a F:uiurc to secure cnverat a as required under�ectton..SA of 51GL 152 can Iead to the Imposition of cnm:n21 penaltl[s 01 a line up fo 51.!00.00 anus: unc 1 cars' imprisonment :1. %sell:IS citii p[naitics in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 understand that copy of 111is st:flemcnt ma► be furs nrded to the Ofrice of Invcstirntions of the DIA for coverage vetific2non. i do herc:51•c ruIIIIef /r�,,�ains at pettaitirs of perjun•that the information prot•ided above is true and correct. �i=^aturc Date Print name o�ciai u�only do not ss•ritc in this area to be completed by tit}•ar torcn otliciai permirilicense 0 rTtluildin_Department cite or tuts n: ❑laeensinr Huard if im check Selectmen's Ufticc r.. i. checkmediate response is re quired ❑ �- �: c1lealth Departm[nI phone so: r'Uthcr��— ` canract ncrsr�n: Information and Instructions MaSsaCfillSettS Gencral L.i%vs chanter 152 section 25 requires all employers to provide workers' ct)rllncils;ttic»i emnloyces. As yutlted from the "lane". all entplul•er is defined as every person in the service of ali()thcr tin e: contract of hire, express or implied. oral or-%vrinen. y An employer is defined as an individual. partnership, association. corporation or other legal entity. or ally two or the foregoing_ enunged in a joint enterprise. and includinL the le_al representatives of d deccascd,enlpfoYer, or recciv er or trustee of an individual , partt>,ership: association-or other iecaI entity, emptoyin employees. Ho��e. c o"Iller of a duelling House Ila%,ing not more than three apartments and who resides therein. or;the occupant of:he is to do maintenance construction or repair work on such dwc!Iitic dwelling house of another Nvllo C11flpION s persons or oil the _rounds or ijuilding appurtenant thereto shall not because of such employment be deemed to be an e::-:. • state or local licensing agency shall withhold the issuance o: ti1G;_ chanter 152 section ,S also states that e�•er% buildings in the commonirealtl, for any ,,, crate a business or to construct bu S - �lral uf:1 license or permit to op � is::nt who lies not produced acceptable evidence of compliance with the insurance eoverni, required. AaL.:io 1:11Iv. neither the commonwealth nor anyof its political subdivisions shall enter into any contract for rile per:Urnl:.::ce of public work until acceptable evidence of compliance with the insurance: requirements of this c! a, bey:, prezznted to the contracting authority. Apl)(1canls PIC:ae ail in the workers' compellsation affidavit completely, by checking the box that applies to ;your situation sucpi� in , coinpaliv names. address and phone numbers as all affidavits may be submitted to the Departmc^t of Aidustrlal Accidents for coniirinatioll of insurance coVerage. Also be sure to si rp gn and date the andati'it• The should be returned to the cin- or town that the application for the permit or license is being requested. r :he Depar tnnent of'Industrial kccidents. Should you have anv questions recardine the "taw- or if you are .o obizin a wcirkers coillpctlsatioil policy. pie-se -all the Department at the number listed below. City or Twxns Ple��e 7e urc that the affida�it is complete and printed legibly. The Department has provided a space at the bor.:,r. the for yciu to fill out in the event the Office of Investigations has to contact you regarding the applicant. F be _ : to till in tite permit/license number which wilt be used as a reference number. The affidavits may be return: -:le D,�partnlent by mail or FAX unless other arrangements have been made. v in advance you cooperation and should you have an-, quest - thank you for The Office of Investigations would like o P piecse do not hesitate to uive us a call• a ...�-.�.,� Tile Deparerlr`s address. telephone and fax number: ttn The Commonwealth Of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, ?Yea. 02111 fa-. Pr: (617j) ',Z7-7749 phone =. 61-) --1900 e�:r. 406. 400 or _-- Engineering Dept. (3rd floor) Map �j = ''` rcel_ /to y Permit# ' House# _ T � �� Date Issued 1 0` yBo rd of He 3rd floor)Vanning 1:0 4:30) Fee , C sery on O ice(4 fl3 / .00 2. 0) - ' P g Dept. (1st oor/Sld ) ' �tME►q•_ D initive Plan proved bard 19 BARNSTABLE, TOWN OF'BARNSTABLE' 'E°"�'�� Building Permit Application i' Project.St et Address 390 %t- Village Owner Tcdel /z/v Address O P4 Telephone - Permit Request t4 O O 0 it, _First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ �� C 0 + Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family' ❑; Two Family ❑ Multi-Family(#units)_ Age of Existing Structure Historic House ❑Yes �`., On Old King's Highway ❑Yes &o 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 No.of Bedrooms: Existing i New Total Room Count(not including baths): Existing New First Floor Room,Count Heat Type and Fuel: ❑Gas &611 ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Attached(size) ❑Barn(size) ❑None ❑Shed(size) i ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes , ❑No If yes, site plan review# Current Use Proposed Use a--1 Builder Information Name f C 1 �� c l'`�Pt�C��i?�/� Telephone Number l' Address �'� � U License# G' _ e � O Z6 S G Home Improvement Contractor# �a Worker's Compensation# c�— 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 BETAKEN TO �l SIGNATURE C'�- -�-- DATE l �' BUILDING PERMIT NIED FOR THE FOLLOWING REASON(S) 3 FOR OFFICIAL USE ONLY 00 PERMIT NO. DATE ISSUED '' • ._. _' _ -. --• .R r- e - •- � •,._� ' • l? - * p d.•• �hJ♦ '" "' � t ^ t • ..., i ,.... -. 71 a . a d' . • , l• + .a,. `• + MAP/PARCEL NO. — ., i w — y -f '�.1 rs e f - . . • ' — .p -� —' .. '• `• _ � . ♦ 1. • o; ..� � � . r. ' . ; ADDRESS _ VILLAGE - tv t OWNER foF E y d t t { • ,m. . ' e... J t r ' i ' .E � _ ' ( 4' ..ate. .� : � a �' { ' 4 j f .. � ! . DATE OF INSPECTION: ;a - _ _ I d + •r FOUNDATION - 1 FRAME i >~ INSULATION f FIREPLACE ' r t ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH s - FINAL ' FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. , , Engineering Dept.(3rd floor) Map q Parcel 2 I G Permit# House# Q j�2Y Date Issued — f, Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) OONN ,, S® N—'�7 N PRR Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) KW6 A Wo Dly N p 01►1 N 0 �0$ tHE tq;_ 19 �� - - - : BARNSTABLE. MAS& J 039. � (,O QED MPS s TOWN OF BARNSTABLE Building Permit Application (� Project Street Address Q ,� J ' Village Owner `c< Address Telephone 5-Z. - ;_ - Permit Request First Floor square feet Second Floor square feet Construction Type e-v Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) _ Age of Existing Structure Historic House ❑Yes ❑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 No.of Bedrooms: Existing New Total Room Count(not including baths):Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Anpeals Authorization ❑ Appeal# Recorded❑ Commercial Zes ❑No If yes, site plan review# Current Use Proposed Use Builder Information 7�or Name �p,r ' ,/1.Q Telephone Number 1407 Address ��,�,,a pr o License# 0 O U L2 k,( v, & Home Improvement Contractor# ' 0 o U 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 qNIED FOR THE FOLLOWING REASON(S) 7Y + n�.,..Y..:3. '...:i..%M ypYy.pRiAN,4.::YJfiM°3JiW-"Rik\<if'::.SYI9W6!!':�NMe'Mr.:�isY.vryt,..:i'�vASNPtT.ibi:'HtYYMi.Y^ - �pQ.W:is,Fin:va..r?F�"ti^!""b,.Ge19r:AKF:'.t.'�l:,�Ai.tJ{I[, xPNkAA tr+Jleay.,�yxri. k i r r , i t v Map Parcel / Permit# �S - �/ � Conservation Office(4ih floor)(8:30-9:30/1:00-2:00): o Date Issued Board of Health'(3rd floor)(8:15 -9:30 0:00-4:45) Fee, c(� 7 Engineering Dept d�fl. (3roor) House# � o APPLICANT A$EWER ' coNNECI'IO OM TIE ldg.) ENGp��r TO I - oUiV �RNSMBLE. ad b.? Pilamim d 19 MAS&a39. .� . FON10�a TOWN OFBARNSTABLE k 1 Building Permit Application Project eet Address �`o o PS ► �i � ". Village 2 Owner �o y1r /�_ - ho *24 i Address . S4 -Telephone 7 7 s-- Permit Request E t .First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Q Proposed Use Construction Type Cy°` — Commercial i/ Residential Dwelling Type: Single Family Two Family Multi-Family v Age of Existing Structure Basement Type: Finished Historic House Unfinished . Old King's Highway Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name "N-L Telephone Number '7t�o -- / `/a Address License# noz-_:> 9,P Home Improvement Contractor# 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 DATEMY BUILDING PERMIT DENIP6 FOR THE FOLLOWING REASON(S) pp- FOR OFFICIAL USE ONLY IMIT NO. •. _ ' D ISSUED Z P/PARCEL NO. ADDRESS - - VILLAGE OWNER DATE OF INSPECTION: f FOUNDATION FRAME INSULATION ` FIREPLACE y ELECTRICAL: ROUGH = FINAL r PLUMBING: ROUGH t# FINAL �nton GAS: nC-ROUGH ® ; 'FINAL t '" FINAL BUILDIN 9r ' DATE CLOSED � ASSOCIATION FI, g NO. ve. �LY 'tsi e cap IV QQ � � I • •� '� QS see ��•p 'el. 6� do AV Ily S � \. eT.µ• ✓psi r ZO N 1 NG p�STR1CT,"::;;.;' � � • V ` )00t [ r V ee �1(j aec'G � ' _ B s:, • '�'"'� •` T.lie Cu�rnrr nN�caltlr 1 Afassachusetts Departnnent of Industrial Accidents 6110 !f ieshin�7on Street Boston.AM= 02111 '-- Wori;ers' Compensation Insuraacc.AMdavit Mat In ion- I am a homeowner performing all work myself. � I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this lob. asiti e• __ __ phone# ipcurtnce co noiicv# 1 am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who ha the following workers' compensation polices: ..v 'city: phone#,. curnnee n mInv"RMC! cilh phone#r �—�R �s ay.neLY.—� . ?•etti..i.d •rFt� � 1Y�✓�it ;Attach addltionai'sheet itneees��,;, � +—�!� »�•-✓ vl.S Failure to secure coverage as required under Section:SA of AIGL ISZ can lead to the imposition ola7mtoat penaauo v. iuo op... srO and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of SI00.00 a day against me. 1 understand that g coin.*of this statement may be forwarded to the OMce of ltnvsdpdom of the DlA for coverage va'itiadelL Z/ierebr 1�•ua /i pains and penalties ojperjurp that the iajorasQn/oa provided aboae is ttxe mid catrrrtaturr am . Print mate J1 • C tine# / %(1 7 -7 FC3 only do not write in this area to be completed by city or town oeRcisd permiNicense 0 nBuildia0 Department • (3Ueensing Board mmediate response is required 13seleetmen's Omce �tiealth Department on: phone f!; pother IN •O�— t��a"'f'""yr�#a`r."�'a 1". i� fit. a `•..r�,ti - � . b /y 4,C :�at'.c `F -v„�"+ r'"� s fry , lsrt�4 •ry..}••„ „," .. � ':.. • bah,riot R � ��pr�-�a{'�ts,��•ti4� 7,��z 71,+ayAs'v�,r r�°- a •�p .. - y,. axr ar7'y,.�'m 'ti•cgM t d`1 +,.r„r., OR d . 10 s \�O. ,fir �` �;9�r,� .tx'�•�l� r"..��-`r� �,✓r.��r .'Q � ..'�• � "'t •Fs ' 44* //A � �'� x 4�y rr'<' 6° r a•Y.�+"�"•••aa��Y�}•`^ ':34�. r- 7� �j t.' 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'. "' .:,�1"S. \.. •,oytir .k ytr ,:,-,_ •, ,L-V _ �a ��. ;.5r .7 ,5 -.�'F ,.l _..:,. aS.7t� -`R'fµ t:..r.:fr.•^-. .:m "•v ,:.;• -L...4 ,.( 4 h_a.3,.r k�. u.. a.2. .•r..g.r ,,. A'w,,. f•' ,r+\ � :-ice' v.. a ... , •.... I rri ,.•. , .y. �...., .....� � _ ... .. . t -roY +r �•t 't, :1 �S. 4 \i y� f 1S .1, k a\ r.to 7 g�' 4� �i• •#'-`_ "1a ram•.:" „k - .'.: > , ifd'. t••v a, e�.�. %1• `�• • . r ,..y...r}+.ax^t..� ,..� .,J.. ..�. ,,.... ., ,. "$w. .. ,. .. 4+,. , ... „ „' ,. d. 7:. r7 'Y.r\ • .Y �'�.. .1 t ` ,� v:K .0' t ., .x v ....��,..v 1.. (., 4j. .. ..�,., a. ... -w.., v ,: a.. L:=' ^'. .. _ . :,�,•., •i•. �4"1• .2 t��•: is l7 � '� 1`u 'l w ux.t 1"VA+"' t- :. (4 .j5 P' :rj'. ��' _�. 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Cm.,";.`:`R' 1 �.L-,'i.�f, t,�Y, .�;t..�f�c�+'-' \„ \. .�,...,\ \.J .•a+. ;:•,.,,:n4>:- r" •?sr^�.�!^........�... _. `i � �� , -.. ��.16;•• .Z��.Q_ .a•,��`4`L, `�`. .-;-x.,: .�.,e,._..., -_ _�•=:�:_..^ -. :... -_:'�•,�:. . -- .. ...... -,.. ,._ �._•.«n•,;arsaxerr-arrre-.-a..rc•..-•c:,�m'....•s+•.-*,•,.im^m•r.�+.•+x'H,^txar^^lt c.smw,.-^ri�•�.. �-.�' �'mwue•st:••n±.m�'ert�._ � -- - �- - �4."i�•r11 n1+c:t.•cr6:w�.4�aitiw^..2�2Z�•�,:a.t.::��` :�:`:a:,. Tire climmanlrealth ofAfassacfiusens • Department of Industrial Accidents P . Oflfeeoflayeslfg INN . 600 !1 add vn Street Bus-ion,Max `0211.1 Workers Compensation tnsurantx.AR day it . ( / - Rhone# Sim I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity .,..tea. I am an employer providing workers' compensation for my employees working on this job. cmmanm•name? address• - incrtr.inee en nniicv# _ .;r. r ....�..•. r. ... ��..•-.�R' _ - — _ems -rc.:��t. ...r... .. 1 am a sole proprietor, genera!contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company mirnei address• ... •.. . . 'eih yphone#- COMIlany narn tits phone#- --s-_- co- naiiev# Atiach additiunafshcet if r;Kt✓r�, � Failure to secure coverage as required under section 25A of AWL 13Z can lead to the imposmoa olerrmroal penalties of a fine up to 61,500A0 and/or one •ears'imprisonment as wcil 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 coin*of this statement may be forwarded to the 0Mcc of lnvestigstions of the D1A for coverage verification. !d urrbv i�•and /t pains and penalties of perjury that the information provided above is true and mmret Signature '7 -- Print name V A + /v'C one# /'� omial use only do not write in ibis area to be completed by city or town of dal an or town: permiNitense rl nDuiiding Department 3Ucensing Board 13 check if immediate response is required Oflice SeleetmeMCL n's Omen Oifealth Department contact person• phone t!; nOther °•Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for tlrci employces. As quoted from the"law",an emplgree is defined as every person in the Ncrvicc of another under any contract of hire,express or implied, oral or written• An emplityer is defined as an individual, partnership.association,corporation or other :sgal entity, or any two,or more flit forgoing engaged in a joint enterprise,and including the iegat representatives of a deceased employer,or the receiver or trustee of an individual, partnership,association or other legsl entity, employing employees. However tiu owner of a dwelling house having not more than three apartments and who resides therein, or the occuparrt of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling hoi or on the grounds or building appurtenant thereto shall not because of such employment.be deemed to be an employer MGL chapter 1'52 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 commown-calth 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 h been presented to the contracting authority. ..�...�..�..�. •rs a.� .,• r(�IL t��•n:slim:„•,:. 1, .�; w� �^�L::.YAv sn;,.�'�'�'•�-. l;r:`•.,•j�'��.� � r y,��• •..... .q.:iTl.'f '�SE •.l.:a.. ••ti.: `7`;i+'r �t+�w:^77:.tM.ti."'t�i..r i:...�, �; 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. 7.�. ..« w � ....•:4: . -:{ :••.a t:. :.•.".wr.'LF..:w:%� _C:..;.. w.: . Ai �..- City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o: the affidavit for you to fill out in the event the office of Investigations has to contact you regarding the applicant. Ple& be sure to fill in the permittlicense number which will be used as a reference number. The affidavits may be returned t 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 questior, please do not hesitate to give us a call. Ci • .•w. :�.w,...rrT :Y•"�::.::�• . •:wear.- '..n.: °� one and fax number. telephone . 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'9 .� Lois b8 fob" - Io,J 0 6s"A ; -T O 4 7 p A -i 1 t ?t A . L. / RRE •s 'gE, USErg trt coN �UNCTroN W%-�H ,Et�c.x //� / , )� `,-� C'[t1 E R ,' A5 c E S V i Lb11`(G Lc3-� . ll-- , -L / is )�_ / / e ,. / t) :. ; _ - / iS� I; �� / F� - S0, I - ; / C` ' / Q j tih,,; 6 1 - I . . N I, 1, y _ ,� ' ' � � -- - ' c�,.�.e. �. ff Found �� a , - - 1l k• ., :,i - 9�. . . ° ,, �. . - ov� m ZONING n ISTRICT .� F=e. ,d g "N;, 6.6 > , _ ' 8' 20 -v-,,., �o� �1 r-' �� % See Zoc%.v �.t1�wS , E-I j r 6 . <'` . RB \o\000 4 \ 89 - F, ,y �"' SRs. I : 'S, r .-r _ . ... ,. \00" W te� t r 9 S 68. �ounol .. S nr�Cs : ZO` �coct c \O` S,cle c•ea�- ,;.,, g.R.g. E'-36 70 " ,e. i; Found �. �� ,� _<. ' { .>. - ..-; Gross ACed o� 5vbd,v\sNonI" I _: Ci ,,.y �_ E1ERE8� CEF=T\��F�"r�4AtS�PLFiN WFis R,F Z)s .\N _ ,�.a 'I}j, GO 19b\--78 � or 4• 5Z Acr�S Ac RO�IN=s fir.! V7\i --t•Y,E SE);tNS-TRB►-E PLRNNING _ AG �� ) Oo ARo --um s-cRvc�l o NS F�Np ---vF\F.w 1��, '.Vl FkN P ►I'T Po�N--s G c oSs r@o o'F R o ods C vlO !d �cc eg P ' . � � '.``! S\AOWN \-\�Rsc-N flR� %N JCIS'TEAiC� 4}J THE GRouN•D. fir. - ,. . �o / C ri� i \r.� - a G NER OF REcc>Rd 4 5uSD1Y1UER z,' /� 'r ,-�t ' ` t ,� __ _ , . __Fl O1<FkS . - :' - ,,6. ,, •'- . _/ V m» - �------ - _ - _ _- - -- - RAG\��. RED°'LRN� /SUIr-N'f`Co ��" _ LL �, EL.15 L\LL\E -.F . F-)\-\ON<nS 1�, � 1 :. ,,;^ •„. ., .. r- , f , • 56CO \n�ES'r CC ,P,O N SFtSET '�:,; � :r � . �, i �fy H, , ` , WI(FArrN1S -MH , oz601 . ',? ;'- `''. , ", ( I - � r��I �0/ � { ; � . y 11 TITLE REFERENCE• t" AG a s\i1, HooK •1G41 PRGE -Pb _ , t! G H F� 11=IcF TT'E -7-�&4- , , c, 4.. > .: .. s- 51 .- '"'7► , PPPRoV IAL DPTE �/ _ 2 Z . i I - 4- ' 11 { = ,_: FB�R NST R B L E . L A N N 1 N G F30 fR R� . . - I . I . 6� 1 1 ,�\ - - � 11 - 6, :� I 11 I I , ' S�. . i � . ckw-0`�, 5U8D1visION pL-"N O� L FaNp I ^ '��w"l - l 1V i __ 1 t'Y�tvnriS ; pn � ! p o B 1 7-R 1 V S- 'I 1 t� L.E RSS �'c t . - - -- - - FOR , - - - ' a I p...' _ '` � - LLL 5 L1 LLI E R. R -tU�< S - - - - - _ t . _ , 1 .. - ScRLE: I" = 40, 7 RNU(p2Y , I g'LS -- -- �—._-- - ---- ---------- --- ---- ---- ___. ,.� _. __.: --�------------ —--- _ --------- ------ — - ------------ ----- - ------ ------ - -- -- -- ----- --- ------- --- ---- —------ -: � d" - SRF�nrG-r'R 8V.__E: 'SuRvE`( CQNSQ.UT'�N't'S MNC. - : ,; - _ , S't R EET I y =w>~S'T `(aRmov-rH -ma SS. �S . HOWARD W. SEA _ __, - • . ,• , cLERt< ofz K- ''AW N aF A BflR►vSTF)BLE -'H EaEBY C. F,'Ct, .{ . vG \rtr Z.[csttGE opt`C E OF ApPR PrL . ,' . E B,ARNS'T`FziSLE P_F,l,,.N.1 r,S =BotAFZ, 11,Vt5" - , - . - , ,.•. RE r-oRD ;BEEN . 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