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It, ,,,�i t'�"� , -� I'll i1f, :15,7 1��!`,� ----i"",%,;J�,�,", I R,ts"�--.",��!i�,,,i���,?,�]�,­�,T� �' , is , F , "", * , t - `i 'i, -""J4, " � ,,� �0 A! � , i` -,, � 115", 9.,-`,�Z I , , ,�� - �i:',"��,��ii`,''�.(,�,','i:",�3,�, .'si ,*;tI",�,,' ;��'��:,����,,,,'��,��i�,;,�',,�',�,�"7�� , " 191I.Ngu��,,� it � _1� � , . ',�_ 1 L.Iv,'�` � k a xi,,� ,�,,!'SAM,'t "i, It .o... U�/C yL SAG 9l� �l��l Assessor and lot number .... .... .. .... ...... THeT �- SEPTIC SySTEm hAUST BE Sewagb Permit number .8 1c -7.1.................................... INS'TALLED IN COMPI LANCE .. WITH TITLE 5 t 33aEB9TODLE, Hou 6 number . . ....................................... .......:...... l� ENVIRE�I�MENTALo C( ply �t� �p g�§.qi� 0�1 d® pO i6�9 `ems T�� �tE�IJLATIONS ypY a TOWN :OF -BARNSTABLE SUBJECT TO APPROVAL r�APNNSTABLE C0iNSEMJAT:' i BUILDING INSPECTOR -,33, ' J APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION ...............1N00D....�2R;/'2�... ... .................................................................... S :..Z.y........19..`��. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..............1-.071.1.............f3f y.... 4n ...........�...... TC(�Y.F.[ 4t............................................................ Proposed Use ......... S/n/6L F..A.M. L`/......1��!✓E[-l-F.!!���................................ ZoningDistrict .......(�1�....�..................................................:...Fire District ...........4................................................................ Name of Owner r « ..P ?-.�T�. .� //p�/✓/.11��S1..l�1:... (Z.,.�. . 4 ..... ....... .... ............. .....Address Name of Builder L'n/�E 1Lct.....0O2t0..................Address Gl✓.:../.y.,.q.ld...4' .j...0 T�...... . d• Bo 9G /�l�Mo Pot' Name of Architect ..�Q���.�.F�. �/.C�✓....................Address � � �.........(. Number of Rooms .............(F.................................................Foundation .10.. F.Tc �!, !'I.W1.9.4:G......................... C� R Exterior .......C��� �... .........................................................Roofing. ........R�.........p...�............................................ Floors ...... ......................::Interior ............HL................C.l4-............................................. Fie'ati�g'�' „?GAS... 4. .: �.:WATC .......... ..................Plumbing ...P��.: 1�. 1: .. .��'�. ...wi :. ...... .. Fireplace 0 00 0 O .................. p ..:.....B2/,G./C-................:.......................................�App�oximate .Cost .........��..}........... 'i'1� Definitive Plan Approved by Planning Board ________________________________19________. Area j..................:......:.......... Diagram of Lot and Building with Dimensions Fee ..........b..6.SUBJECT TO APPROVAL OF BOARD OF HEALTH-- 0 j- I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Allau . .. ... ...:oL.!.. ................... KF2 I`TI, PHILLP _ 23��9 One Story ;° o J� Permit for ........................ . 4 Location ..LQ.t..13 .....2.6...ZA ?..,Lga............ C.eat�arvi-Up............... , ......... `Owner .P 1IP. .FJar.exi.ti............................ �I r Type `o`f Construction -Frame............................ ................................................................................ , IL Plot ............................ Lot...... ...................... Permit Granted .........November 2.5.; 1.9 81 } fi Date of Inspection/g:''.!K:—V"..................19 - Date Completed ,�.. " PERMIT REFUSED ......... _�.. ................ ................... 19 .... ........................ ' ......................................' t . ..... ........ ..... .............................................. {; *' Approved .....:.......................................... 19 ..... .. ..... ........................................ ............... 9 // .............. .. ......... .................................... _ / ti a_ 9 Y }t a 40�- bAT f✓ cMZTIF-,j T14A7.�T14 -- F0UND�-POt4 5110%OW Rr=Fc2E�.IGE Z GcaMPLVS -WIT,14 t"S SID'E.Ll L-p T I Al.lt� 5Li` t?'ACIG VC-QUiQEMcuTS C)F- TNF' -I b lvv Q o>,= ra j GU Y G o k_E'T T I I °t_l q DATE IC5-�C.-�ti REGIStCtZ�.D "wo 5ueva'(Ov_S ThtIS 0L.AW 1-5 JOT BA.l;E'E,7 . .g" AN oSTEQvt�� o Ma�S. t..l,(+`t•',Lti�_1J, SU�vcY ¢ T:a� U�CS[-�.Tri SI•IG"•►Jl.a APPLIC.'t�.I..IT` C+�H�':•r.rtL�c1�..��::. Co�.;F'. + TOWN OF BARNSTABLE -.--------_- - .7�y0 Permit No. __._______-__- Building Inspector { .�n,�c Cash 00'r'639 \� OCCUPANCY PERMIT Bond 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 '' ?.�' - — Pnront l 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. .....................................................1 19...... ...................................................................................................... .--- Building Inspector f O//< Assessor's map and lot number ....�:` �`.'.. ..; � .,� 9 Y ?H E'TO�♦ Sewage,-,Permit number ..�n.I.S.W...........................:....... 1 d Z BAH39TAKE, i HOute number ..-5� .! ?....................................................... y Mnea l Op 1639. �00� YPy a' TOWN - OF BARNSTABLE BUILDING INSPECTOR �a5� APPLICATION FOR PERMIT TO ........................�:........ . ......DX 4.&X/�IE............................................... TYPE OF CONSTRUCTION WDD D �l�`I M ........................................... .......................................................................................... .......................... y........19.. �. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .............. .a. .................8 .�!...z./�r{v ..........,.......C . ,C Lt .......:........:... Proposed Use ...........IIV(O—LAE .....AFLN.iKA........��(: L�.. /. ...............................................................I........................... Zoning District ....... ....".' ..................................Fire District ...........�.. C�.......`.................................... Name of Owner ...6-!.! .. ... ..11f7/jE .�............................Address ..:?�/ /G'2iV nI GSl.1?�\�` ! .......... Name of Builder ..f.t= %. n�✓tLL.......... f2f� ���1 l�/ . ,4�/a/n� �' C�N� :.................Address ............................................ ...1..:.......................: Name of Architect .. � L.! l .Gr?���:!✓ ...Address c t�'0 96 YA9� L)oc�t7PG2`............... .................... ..................................... .................. Number of Rooms ...............C. ....Q ....................... /?..................................................Foundation /........................1....... !:"..... Exterior ....... ................. ...Roofing Floors ...... ....t... !. .....!..J.�C:..........................Interior 8LKt E.r /Z0. ......................:: Heating .... �1.C.... ..[ti'f1T .��_........................... Plumbing ...f Y�,Gtfr1.>" : �" ..r A/� (?....:SU%��� �........... Fireplace /1/C,/C.........................................................Approximate Cost ...... /CO`.��. ..:. '.G1............................. Definitive Plan Approved by Planning Board --------------------_-----------19________. Area 0 C S.: . l Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH oL m � LnIC I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. . 1� ......... .-.....11...n/../............................... PARENTI, PHILIP (!A_:L�6-36-1 q(, 3 (1 i 23659 One Story No ...............:::-Permit for .................................... x ....Single. . . . ...Family. . ....Dwelling. . . .:.... . .. .. .... .. .. ....... .... ....... .... .. . Location ....Lot #1. ......86 Bay Lane .. .. ...................................... Centerville ............................................................................... Owner ...Philip Parenti Type of Construction Frame ................................................................................ Plot ............................ Lot ................................ E ' E November 25 81 Permit Granted ...................................�...19 F 6 i Date of Inspection Date Completed ..............::......................19 PERMIT EFUSED .................................... 19 ............................................................................... ............ .. ....................�.�. �........................... :.......... ..o. ........ ................. Approved ................................................ 19 ...................................................................... ............................................................................... t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r Map Parcel Application # ( l �Lf Health Division Date Issued ' Conservation Division Application Fee Planning Dept. Permit Fee 7 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address Village F_-tv-rig C_ V i_.c,.C- Owner l<ra-Tz Address /vim Telephone 's ?C;6 Permit Request iVsn e__ A tig/i/n 4'_/ v P IL� F20w7- a C-nrr oE 4Q 92ej o rV 77- 'PA en m Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 6E00 Construction Type Lot Size 0 z, i Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family, 3' Two Family ❑ Multi-Family (# units) Age.cff Existing Structure z 7s Vie E Historic House: ❑Yes IINo On Old King's Highway: ❑Yes C *o Baser vnt 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 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 ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: /t��n»�iC•aK �Z mP Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ ^v O Commercial ❑Yes No If yes, site plan review# 4 Current Use S Proposed Use m 0 _ APPLICANT INFORMATION av m (BUILDER OR HOMEOWNER) Name ►5 1;/u/1)6`fN [ .ors a-i CL_ Telephone Number .5 n F 3 y t/9- Address License# C S 0 7/y ' , Home Improvement Contractor# �/Z Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO i7Y '19-ON-P• SIGNATURE DATE 3 l f l' �! �i L: t• F FOR OFFICIAL USE ONLY APPLICATION# a DATEISSUED MAP/PARCEL NO. w } r ADDRESS VILLAGE OWNER t4 Y DATE OF INSPECTION: ;;FOUNDATION FRAME INSULATION.' 4 FIREPLACE f ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ROUGH FINAL FINAL BUILDING r DATE CLOSED OUT a ASSOCIATION PLAN NO. �7 The Commonwealth ofAfassachusetts •� Department of Industrial Acciderift . 005ce of lnvesdgations 600 Washington Street I Boston, MA 02111 wwl.massgov/din Workers' Compensation Insurance Affidavit:.Builders/ContractorsXlectricians/Plumbers Applicant InformationPlease Print Legibly NaMC (Business/Org-anization/tndividol): l���r�n✓ 7'7./ l o�J s[�( Address: City/State/Zip: 9requimd.] an employer? Ch the appropriate bog: m a emaployerwith" 4. 0Iam a general contractor and I [7. pe ofproject(required):ployees(fuiIl and/or part-time).* " have hired the sub-contractors ❑New construcfian m a sole proprietor or partner- listed on the attached,sheet []Remodeling p and have no employees These sub-contractors have ❑Demolition rking for me.in any capacity, employees and have workers'workers'comp, insurance camp,insurance,$ 0 Building addition 5. [] We are a corporation,and its Q Electrical repass or.additions 3.0 I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL insurance required]t c. 152, §1(4), and we have no 12.0 Roof repairs employees. [No workers' 13-[ Otherlfii9 / c P fZ A�1J P comp.insurance required.]. *Any applicant that checks box#1�mst also fmm out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors mast submit a new afnd"it indicating such $Contractors that check this box mast attached an additional sheet showing the name of the sub conhactors and state whether or not those entities have employee If the sob contractor have ernploYees,they most provide their workers'c off ember. °mP•policy m I am an employer that isproviding workers compensation insurance for my ern information. ployees Below is the pokey and job site Insurance Company Name: Policy#or Self-ins.Lic.# Expiration Date:' Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500:00 and/or one-year imprisonment,as well as civil penalties in the foun 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 Iuvestigafions of the DIA for insurance coverage verification. I do hereby certify under the pains and enaldes o erjury that the information provided above is true and correct Si true: Date: 311 Phone# 73 (E Dffccial use only. Do not write in this area,to be completed by city or town oj}icial City or Town: Permit/f�icense# Issuing Authorify(circle one): ' I:Board of Health 2.Bnilding Department 3.CRY/Town Clerk 4.Electrical Inspector 5.Plnmb>ag Inspector, 6. Other Contact Person: Phone#: -------------- 1 �IKETown of Barnstable Regulatory Services * s�xxsrws�, • Moves. g Thomas F.Geiler,Director 019. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: .508-862-4038 -..Fax:--508-790-6 230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject ptopertp hereby authorize K9 nJ,JE Coto`c L� to act on my behalf in all matters relative to work autb.otized by this-building permit R)AN 1 4100- (21 r: Te 17-U / (Address of job) Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. a S ature of App�c f Print Name Print Name 3 �h �Z Dat Q:FORMS:O WNERPMMISSIONPOOLS THE 1r1._ Town of Barnstable Y Regulatory Services • &42NSTMM : Thomas F.Geiler,Director MAS& 16g9. .� Building Division ArED MA't� TomTerry,Building Commissioner 'r 200 IV. in Street, Hyannis,MA 02601; .town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEO ER LICENSE EXEMPTION Please Print/f DATE: j� JOB LOCATION: % number s eet village "HOMEOWNER": ✓` name f horn one# work phone# CURRENT MAILING ADDRESS: city/town \ state zip code The current exemption for"homeowners",was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. /' \ ' DEFINITION OF HOMEOWNER Person(s)who owns a parcel 0 and 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 l09.1.1) 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 minimurn inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building 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. Q:forms:homeexempt Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supertisor }q k Office ofConsumerA airs ifsiness. egu,g;_on License: CS-010714 Lri;*� HOME IMPROVEMENT CONTRACTOR rs .3 � a Registration:� ,1 .12880 Type: N piration 2KENNETH F C& GULL< / 92013 DBA 21 GEORGEI- 'OW1ING E BASS RIVE$'MA 026'64 <UILDING&iRIEM©DELING F- r KENNETH CO) y sJ— ♦ 2.1 GEORGETOWMLANDING= Expiration raj Commissioner S.YARMOUTH MA 02604 11/10/2013 `_- Undersecretary y i a lid for ind'ividul use only ' registration va Y ense or .before the expiration date. If found return to: Office of Consumer Affairs and Business'Regulatioii 10 Park Plaza-Suite 5170 Boston;MA 02116 i I- Not valid w o si ature . } 20sv'S— ao�_ A o 61S E i o! c- I , fie.a ✓����1 w� "---',`,�, €— ! a - ' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , '- m / IL DATA >` t i Y� I _K , 8Cv 3A� k w r1i e- r �Yl a a Z _ .'i - � '.4 e o ,. _ ""'�?L.;e.t _'6,'7•�!'Y<� �<__,_ ,���� ??."`tie �*-,.i `a%' _.L -s,�1..}CC��- 3 Wit,.. Town of Barnstable Regulatory Services �1HE Thomas F.Geiler,Director Building Division snaxsTnaLe, « Tom Perry,Building Commissioner v� 1639. �0�' 200 Main Street,Hyannis,MA 02601 plFO A Office: 508-862-4038 Fax: 508-790-6230 December 4, 2012 K.C. Building& Remodeling Attn: Kenneth Cowgill 21 Georgetown Landing South Yarmouth, Ma. 02664 RE: 86 Bay Lane, Centerville, Map: 186 Parcel: 036 001 Dear Mr. Cowgill: This letter is to follow up on the status of permit application number 201201544. A permit issued was for a temporary.ramp to be removed by November 1, 2012. Please contact this office immediately to explain why the scope of the permit has been exceeded and to resolve the issue. Respectfully, Local Inspector Jeffrey.lauzongtown.barnstable.ma.us (508) 862-4034 —Engineering Dep . (3rd floor) Map /k�� Parcel 43 4 46 Permit# House# 26 DJ3 Date Issued r)-(8:15 - 9:30/1:00-4:30) Fee oor)(8:30-9:30/1:00-2:00) err School Admin. Bldg.) INE Planning Board 19 _ - BARNSTABLE. °rft 19- TOWN OF BARNSTABLE Building Permit Application Project Street Address /V fzF Village ✓t c.L - Owner 3-0(4 rJ /} -r L Address S14 , Telephone 771 Y 3 �— Permit Request o e First Floor square feet Second Floor square feet Construction Type 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 ICJ 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 Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes No If yes, site plan review# - Current Use Proposed Use Builder Information Name e E COW C-i L-c_.. Telephone Number 35 e( (e �/ l Address 2- 1 c'-E®RC-1r''T0EJki X nwb . License# n / �7/y S , Lb9- Home Improvement Contractor# / f Z_eF&d 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 LIq 2 In o'yr 7-14 '7'`L igrNf FiF (L SIGNATURE DATEL,92 BUILDING PERMIT ENI FOR E FO WING REASON(S) j tic"`l e 4 r. FOR OFFICIAL USE ONLY t y rt` PERMIT NO. rz' � 62 DATE ISSUED MAP/PARCEL N9. ADDRESS VILLAGE OWNER ! DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL „ PLUMBING: ROUGH FINAL + ; GAS: ROUGH FINAL " FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. - f. The Town of Barnstable • EMMABLE, • 9� &619. Department of Health Safety and Environmental Services Building Division .367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only k t 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: 61 e®, Est.Cost �', Z.®© _ Address of Work: (o U ti w ✓ Owner's Name s H 0 J<' Y4 T z/ 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 oft a owner: 'gLA 0 /,?-? - Z &eo Ddie gontract&Name Registration No. OR Date Owner's Name The Commonwealth of Massucliusettti' - a.i Department of Industrial Accidents y � r . r�. Office o/lnveS&92 VflS 6110 ►Vu.vhitr­ton Street Boston, Ma.u. 02111 Workers' Compensation Insurance Affidavit �pnIiatnt information: Please PRINT F.-jlf( �_ _.__..__... . fS_...._...._. name• � dr F ( OcvU 6 -t �,�. ocati n: b nl r (2atti ti�L(L ✓L city e n! t V B L nhone# I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity _ ,. .".e.��-+r--.s-•..�..........-:r.+.�..Tl.s vrr..i+wS�tiT^++�*!�'.lA'!+e.;..Xt!www7+.+!.!+Rim:..�..,r.+�.Rw.n+.�........Y..".w���."'w". .�.w�r,.-�....__... CI I am an emplover providing workers' compensation for my employees working on this job. comn:trn• name: address: city: phone#• . insurance co. polio # I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the followin_ workers' compensation polices: comnanv name: address• city: phone#: insurance ro. noliev# company name: address: tin: phone#• insurance co nolic}•# _ Attach additional sheet if Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a line up to S1.500.00 andiur une wears' imprisonment:is well as civil pcnaitics in the form of a STOP AVORI:ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement ma} be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certify tinder the parr•and penal 'es of perjure•that the information provided above is true and correct. Si_nature Datc T 1.2 Print name o -,j t�tr L"` Phone# —3!y 6 91,5' ' official use only do not twrite in this area to be completed by city or town official city or town: permit/license# riBuilding Department r Licensing Board check if immediate response is required Selectmen's Office t 011calth Department contact person: phone#: MOthcr Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for tile'. -law- an etnploree is defined as every person in the service of :uu)ther_urtder any employees. As quoted from the 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 the foregoingenzaucd 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_ hou. 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 h.: been presented to the contracting authority. Applicants Please fill in the \vorkers' 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 tiie city or town that the application for the permit or license is being requested. not tiie 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 Investibations has to contact you regarding the applicant. Plea be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned v 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 question. please do not hesitate to give us a call. TIT .-....�.,�...--r- r•va�..-�+ _. ...- .� .. .—+.wv-.+-r-.. _ _ -���.....n -.r..-.+�+.�,..w...+v.........�rv'a1.r. _ .. — - .. a'.-. ..:s' The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents _.. Office of Investigations 600 «'ashington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 f x I • t ,t 0lf IMPROVEMECONTRaCT F � tEa, ype IHDIVIDUfI° < KCBUII�DIN6: EMODEJ,INfi . ....:_....._.:. KENNETHj I16ILL fi ANDIN6, °s ADMwIS7anmR' 'YARNQUiNM�` 266 r ¢�.r�,` a�€' , <•.. Via ; a }OARTHHNT OF PUBLIC°SAFETY 1 ' ,; 4ON,STR'JG"�O'�_a(1P8P,VISOR i�ICE�tSB ' �LlEtt HXpILPS: Bi*tldate Restt;ctE ; 00 5', / RHNNSTH F COWGiLL GEORGETOWN LANDING ' BASS RIVER, NA 02664 } � � As" is m6 and lot number �.��,. �. . , Sewpge Permit number 4, !. ....... .......................... ' ypF THE T� •` _; TOWN OF BAR Ell NSTABLE i BABBSTADLL • �^' 90 rb 9• �e 'a ; BUILDING , INSPECTOR '£�YPY Or• f, a TION.-FOR PERMIT ........ .................... � .....................APPLICA . ...... ' TYPE OF CONSTRUCTION :::'.....:.:..... . ........ .....=V ...........19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit actor 'ng to the fall o ing information: Location .............elf.............. ...... . ... '..... .. .......................................... ProposedUse ..................:...........:.......................................................................................................................... Zoning District .................�..-/............................. ..Fire District Nameof Owner 4,M ..� Fe ......f.... :....Address ........................................................................................... .. ..N • Nameof Builder .......................Address .................................................................................... Nameof. Architect .............................................................:....Address .................................................................................... Number of Rooms ..................................................................Foundation .....:.... Exterior ....................................................................................Roofing ...........................................................................:........ Floors ......................................................................................Interior .................................................................................... Heating ...................................................................................Plumbing ....................:..................:.......................................... Fireplace ..................................................................................Approximate Cost .................................................................... Definitive Plan Approved by Planning Board ________________________________19--------. Area .......................................... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 4 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable.regarding the above construction. Name/ .L_ ✓�� William R. Funk Jr. ..... Permit for ....A1119 Sh.............. .......... ....... Ch•!. : x�. ... r. ! Location ,. >................................. I n ...........................:........C en t erm i l,................... Owner ...Wjj1.iam..&....F.unk..Jr........................ Type of Construction .............:............................ ........................;**"*,*""*****"""*"",**'I....................... S l t -• M 186 36 Plot ......................... .. Lot ................................. , r Permit Granted :t.19 " - ,Date of Inspection Date Completed .`.....:"19 t PERMIT REFUSED ::......................:. 19 ' ...................... ... .. ......... ............................................................................... Approved ................................................ 19 ............................................................................... J , S V 1J r�, ,J • { a 7-1 PH N 977 v �It`L.' 9a. I • {