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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
_ -14
Map Parcel Application o2o
Healthbivision '° I Date Issued
Conservation Division Application Fee
Permit Fee 670 ,
Planning Dept.
Date Definitive Plan Approved by Planning Board ;
Historic- OKH Preservation/Hyannis
Project Street Address
Village
Owner w lie Addressii6q
Telephone �rcS HISS
Permit Request r
Square feet: 1 st floor: existing proposed _�2nd floor: existing proposed _Total new _
Zoning District Flood Plain Groundwater Overlay
8
Project Valuation 060 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 t No On Old Kin 'S Hi hwa :'�[ Ye 4Ao
9 9 c� � g Y g Y
Basement Type: Full ❑ Crawl ❑Walkout ❑ Other $_;
Basement Finished Area(sq.ft.) Basement Unfinished Area (sgrft)y
Number of Baths: Full: existing_ new Half: existing new.
TTTT Ln
Number of Bedrooms: existing D new �o
Total Room Count (not including baths): existing new First Floor Room Count-
Heat Type and Fuel: , Gas ❑Oil ❑ Electric ❑ Other
Central Air: 414es ❑ 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: &4xisting ❑ 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 S'Q _
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Telephone Number
Address PCAr_1fym,I Dr License #____�I
vi a, m� Home Improvement Contractor# ( U
Worker's Compensation # hW C_7D_:)�C t
r-
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE �—
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL N0. :-
r '
ADDRESS VILLAGE
OWNER
r
DATE OF INSPECTION: ,
FOUNDATION
FRAME y 112
'INSULATION,
»FIREPLACE .
ELECTRICAL: ROUGH FINAL ,
PLUMBING: ROUGH FINAL `
7
fr , GAS:.- ROUGH FINAL
DATE CLOSED OUT.
ASSOCIATION PLAN NO.
{
The Commonwealth of Massachusetts
Department of Industrial Accidem's
D,Bice of Investigations
600 Washington Street
Boston, MA 02111 q.
www.mass govMa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician.s/Plumbers
Applicant Information Please Priest Legibly
Name Pusiness/Organization/Individual):
a
Address: C t v
City/Stawzip: d Phone
Are you an employer? Check the appropriate bog:
4. I am a Type of project(required): ..
12.
.�I am a employer with— ❑ general`contra.ctor and I •,
employees(foil and/or par€-time).* have hired the sub-contractors 6 ❑New construction
❑ I am a sole proprietor or part ter listed on the attached sheet. 7.`[modeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me.in any capacity. Lmployees and have workers'
[No workers'comp,insurance comp.insurance•t. g ❑Btuldm g addition .
required_] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 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 I2
in.c,rrance required.]t c. 152, §1(4), and we have no 0 Roof repairs,
employees. [No workers' 110 Other,
comp.mmzance.required]
*Any applicant that checks box#1 must also fM out the section below showing their workers'compensation policy information.
t homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.xContracmrs drat check this box mast attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If fhe sub-contractors have employees,they must provide then workers'comp.policy Cr.
I am an employer that isproviding workers'compensation insurance for my employees Below is
information. the policy and job life
1'
Insurance Company Name:
Policy#or Self-ins.Lc.# D 1�A1 r� 6 ���SS r o��� Expiration Date: '7 l_
Job Site Address: City/State/Zip: Ve I"
Attach a copy of the workers' compensation policy declaration page(showing'the policy number and expiration date).
Fatqure to secure coverage as required under Section 25A of MGL c. 152 can lead-to the b4osition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the four of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. 'Be advised that a copy of this'statement may be forwarded to the Office of
Investigations of the DIA for inenra ce coverage verification.
I do hereby ce ' under the airs andpenulkes ofperjwy that the information provided abaNe is true and correct
Si o - Date: l a
Phone* n f? If)a
Official use only. Do not write in this areg to be completed by city or town 00iciaL
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health Z.Building Department 3. City/Town Clerk 4,Electrical Inspector S.Plumbing Inspector
6. Other
Contact Person: Phone#:
DA1°E tMNL'C C'YYY'T
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�a ',s_653 K -3 H!'S CE IS;f A !$ f$8L*ED A AHATTER 0 lNFORS69+ICAT
PRocucEF ii..^,a: 18-651-.?QG ®NLI� ANO CANS-ERS Nib RSQHTS u IN T~4E CERTSflCATE
Eastc_n 7nsura,nCe CraLp L L C -:cI r.�r:tea'_ Li H+aLS3E#l. T}it8 CERTiFSDd►TE DOES N0' ANEENS) EXTE�lD OR
.
23{ nest Certral Street ALTER THE C®yERAQS: AFF ROS:D 5 THE PD �CIES BE ��,
i`lati.CIC RMA, -7F,� AOC
iN,t,IRS;RS AFFCR'D4NCi COY6R�E___°_________
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19:, perciva'- Drive
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IN8LHEAF'
COVERAGES
U n r C� C:B'FA:_^ R CTHBF. �r r Jy WITS agSPV T TO VAIL'21 I-XIS
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RTIFI�ATE D'A�' BE :SS'UE: OR MAY BERTAI.;� :8= Eg
TlE TERHlS, EXCLC£ICI1S Rti'C CO.yD-TiCNS CF STJC,F POLICIES. dAG TCLTCTS YEFFIMiT$ PSRC+7NkF-a- O'$�___rEDUCEa UMA SAIL CLs+L17.'.
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cd A AIfi iRAJ7F f i 1R I rVIWNAL&ADV NUnY
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` QEN'L AROREOATE UNdT APPLEb6 PEA i
1 POLICY i P L�
j j CCLIgi =VwGLELIMIT -
AUTOfM MLE LIABILr"!
"-11 A'dYAUTO L
I ALLOVltvEDAUTCS I `IPa p�aen;
l 9CHEDLILEDAUTOS -
y---j BcDIY IN RJf?Y $
I 91 F1@D AUTOS I PLV ACLm+E;' _
NON-OWNED.AJTOS (I �-
1 PROPERTY DMIAGE
� �--i, I I � IIPa�atxddlrR}
! - AUTOCN:Y-EAA:C!CENT S
GARAGEUARU°r{ Fd,ACG 18
l j OTHER THAN
ANYAUTO ^-T—
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A fl
` EACH OCCURRENCE $ _--
j_@XGE RELIJ.UASILRY AGGREGATE13
OCCUR CLAIMSMADE
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WORKERS COWENSA
EMPLOYEPr LIANUT I E 1.1 ACNAer_r�r.�.
I a!N PROPRReTOWFART"FL' IVS ( j E.L.DISEASE-FA EMPLOYEE _
OFFICr;RAAEl�EREXCLUDE E.L.DISEASE•POLICY LI T
4 AL
OTHER i
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Vi= LNi'iiAti:Olt .Q t3i� 3� JAYS tnPi'iTE' crQ^ICE TO T?3
Tow.^. 0i SarnBtabi E CFuiIFT_CFT$ HC.7LR. Y:'SED TO Tim LEf'C, EJT FF.iLaRE 20 �
,67 Vain S:eet $0 31i4LL ::{POSE �ZO CBLIG8MU C.? i IF.fsL:+ITY C" ANY ZINC
F ya-,uii5 VA 026C'- upoy rAE IN�TJRTi�r I75 AGENTS OP F.EcF.BSE:d:hT,I�lES.
AJTHOR386>«PRES@NTATiYC J:Nnwr ",� ,.y::vY
ION 199E
®ACOFWD�RPA�
aco�D ut�aci�os>
R:
*=' Nlassachusetts- Department of Public Safety'
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 49879 ,
4 "
STEVEN L MELLOR 7, � .
199 PERCI VAL DR
i
.. 026687e. r
W BA RNSTABLE M A -.
Expiration: 5/22/2012
('uunuissiuncr Tr#: 169.27
Office of Consumer Affairs&B smess Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration A-117610 Type: Office of Consumer Affairs and Business Regulation
Expiration 4b/25/2012 Individual i 10 Park Plaza.-Suite 5170
Boston,MA 02116
ST EN L.MELLORF G
a i
I
STEVEN MELLOR:,� � i
199 PERCIVAL DR � ,L
W BARNSTABLE, MXI2668' Undersecretary Not valid without signature
o'ET Town of Barnstable
Regulatory Services
KAML g Thomas F.Geiler,Director r
16;q. 10
Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601 .
www.town.barnstable.maxs
Office: 508-862-4038 Fax:.508 790 6230._. - -.
i
Property Owner Must
Complete and Sign This Section
If Using.A.Builder
c
as Ownet of the subject.property
heteb authorize
-- ----y to act on thy behal�
in all matters relative to work authorized by this building permit
1140
410
(Addre 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.
Signature of et
. Signature of Applicant
NA W WEB fi� �11a
Print Naive Print Name
3 A-7 AOld.
Date
Q:FORMS:OWNERPERMISSIONPOOLS
THE Town of Barnstable
Regulatory Services
• �axrtsrnar.E 'Thomas F.Geiler,Director
1639• p.�� Building Division
lED MA'1
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state ` n 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. % ` ' ' ' ' f ` ,
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to
be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to`the Building Official,that he/she shall be
responsible for all such work performed under the building permit (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws, rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said 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.
y . 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 knlicensed 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 fortn/certification for use in your community.
Q:forms:homeexempt
di
OFIKE rqy, Town of Barnstable *Permit# ?C) v 7
Expires 6 mo hs rom it, date
Regulatory Services Fee
s �
• s
w BAMSt•ABLE,
16 9 ���' _ Thomas F.Geiler,Director
��rED MAY A Building Division X`P ° SS PERMIT
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bastable.ma.us TOWN OF 3ARNSTA-i
Office: 508-862-4038 rn Fax: 508-790- Z
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
'-7 Not Valid without Red X-Press Imprint .
Map/parcel Number ! d l 0 L o-r
Property Address 46ZI ;5AV L-A-tJk::-
NKesidential Value of Work DO 0 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address W A-t'�lL t:... I+IEJ 12 'J-IZ— A-7.!L'� fJ A-P v 7
L
Contractor's Name
�hFE'12LS f+7Z�lM1� Telephone Number ( � �J `q7�
Home Improvement Contractor License#(if applicable) 4' 0 2S f
Construction Supervisor's License#(if applicable) d4
Vorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ kam the Homeowner
have Worker's Compensation Insurance
Insurance Company Name AW? CAV ZiJA-Gm -31Jsu2&WC
Workman's Comp. Policy# &ZZ 03 - 1347)Pk JY— 6 —/V
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
2/Re-roof(stripping old shingles) All construction debris will be taken to t3A'fYu5TAIL , Ttft4;h;P_
❑ Re-roof(not stripping. Going over existing layers of roof)
erA-n o)j
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License& Constructi n Supervisors License is
/required.
SIGNATURE: C. WAZILj
f�
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 070110
r
r
sHErti Town of Barnstable 4
,. ;Regulatory Services
uaxsrAsr.� , .
MABI g Thomas F. Geiler,Director'
Building Division
Tom'Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.b arnstab l e.rna,us
Office: 508-862-4038 Fax:n:508-790-6230
Property Owrier Must
Complete and Sign This Section
-x Usina.A.Builder
as Owner of the subject property
hereby authorize -S 6J (i-tr0'V-4/3 to act on my behalf,
in.all nutters relative to work authorized by this budding permit application for:
(Address of Job)
Signature of Owner
Date.
r
Opt c.T 1+i�y�y :
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on'the reverse side.
Q:FORMS:OWNERPERMISSION
t
Town of Barnstable
o Regulatory Services
y
ri�xxsn�sr E Thomas F.Geiler,Director
MA3£ -
t659 ..erg a Building Division
Tom Perry,Building Commissioner
200 Mairi•Street,_Hyannis,MA.02601
www.town.barnstable-ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOKEOVdNER LICENSE EXEMTTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
cityhowo state zip code
The current exemption for"homeowners"was extended to include owner-ocff'ied d vellin4 of iz units or Iess and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor_ i , , s (fi
I1tTI.
DEF nON OF HOMEOWNER . l
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to-
be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a bomeo-vmer. Such
"homeowner"shall submit to the Building Official on.a form acceptable to the Building-Official, that he/she shall be
res>aonstble for all such work performed under the buildine permr it I (Section 4109.1�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`Departmrlat
minimum.inspection procedures and requirements and that he/she will comply wit ,s#id pror.edn4es and �'•'
requirements. 1 t
t ,
Signature of Homeowner Y
Approval of Building Official w`
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 perfomvng 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 rxcmption 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 bftm results in scious 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 fuIly aware of his/her responsibilities,many communities rr-quire,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Superrisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a fart /ccrtification for use in your community.
Q:formts:homeexcmpt
The Commonwealth-of Massachusetts
l ,; Department of Industrial Accidents
^U.L 1 Office of Investigations a
600 Washington Street
Boston,MA 02111
c www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information LC1 * AWL%(F DG"?./II 6� Please Print LeZibly
Name (Business/Organization/Individual)
Address:
City/State/Zip: cmjtwl"� A4 A 0 WPhone #: -7 ° 71
Are y n employer?Check the appropriate box: Type of project(required):
1. I am a employer,with ?/. 4. ❑ 1 am a general cdntractor and 1 6. ❑New construction
employees(full and/or.part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance, g, ❑ Building addition
[No workers' comp. insurance 5. `] We are a corporation and its
officers have exercised their. 10.❑ Electrical repairs or additions
required.]
3.❑ lam a homeowner doing all work right of exemption per MGL 1].❑ P bing repair's or additions
myself. [No workers' comp. c. 152,'§1(4),and we have no .12. Roof repairs
insurance required.]I, employees. [No workers'
13.❑ Other=
comp.insurance required.]
*Any applicant that checks box#I 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 hire outside contractors must subm it a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the.sub-contractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name: 1404 'u c". MUMV �w6e , 6z •
Policy#or Self-ins.:Lic:#: p ZZ VW` `Jr3�����-0'l� Expiration Date:
Job Site Address: `T(®l Ii � City/State/Zip:: UVII"44Cif. 14A
r
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 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 rjury that the information provided above is tr a and correct.
Signafore: �• Date:
Phone#:
74 0 _ 1/71
r
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 in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,Aeslitpasb otltignti h' eemployees.mPI in However the
. Y owner of a dwelling house havin not more than three a artments and wh . e
,.. -.._._.. . p p_ o. sides therein or the occupant o
r 7 >. r f the
., P
dwelling houses,bf�ano tier' Y1 �eMploys peiso rs to`:d'o_ma t6nance Eonstaidion or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employrpent be deemed to_be,ap employer."
MGL chapter 152 j25C(6)also states that"every state or-16ga1 licensing.agency.shall withhold the issuance or
renewal da licetis or percp[t"o-op6ate°e business or to consfr�lct°bdildiags in�W6Eam`-Mou eaatt 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 cornplia'uice 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 thi 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. $e 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
.w.
a c •.K�y„w�,�„�t 4,�,h.yq` �•i ..i{.'`'a nAti .
Please be sure that e'affidavit is complete and printed'legibly. '�'he"Department has provided a space at the bottom
of the affidavit for-you to fill out in the event the Office of Invest ga,konsbhas.ao eoflt�qt you'r�gaizding the applicant.
Please be sure to'fill'ift tlie`permitllicense number which will be used as a reference number. In addition,an applicant
r 't.
th tnpst subm t mu�lti�l�e;�ermit/license applications in any given year,need`oily�b�7tsotie,',affidav�itiildicating current
policy information(irnecessary) 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 future 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 burn 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 _9d fax number:
The Commonwealth of Massachus,4tts'
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727--4900 ext 406 or 1-977-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass..gov/dia
V VHV
ZURICH WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (GZZUB-4391 P88-0-10)
NEW-10
INSURER: AMERICAN ZURICH INSURANCE COMPANY_
NCCI CO CODE: 80012
1.
INSURED: PRODUCER:
WHITCOMB REMODELING INC WILLIAM PALUMBO INS
PO BOX 501 . 125 ROUTE 6A
W HYANNISPORT MA 02672 SANDWICH MA 02563
Insured Is A CORPORATION
Other work places and Identification numbers are shown In the schedule(s) attached.
2. The policy period is from 09-14-10 to 09-14-1 1 12:01 A.M. at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in
item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease; $ 500000 Policy Limit
Bodily Injury.by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06A
o�
D. This policy Includes these endorsements and schedules:
op SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
o�
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 10-01 -10 MA ST ASSIGN: MA
OFFICE: ZURICH-ORLAN 809
PRODUCER: WILLIAM PALUMBO INS 77TSM
004307
The Official Website of the Executive Office of Public Safety and Security(FOPS)
Mass.Gov Home
Public Safety
Department of Public Safety Licensee Complaints
License Type Construction Supervisor
License# 83184
Restriction 00
Name Charles A Whitcomb Jr
City,State,Zip .Hyannis,MA,02601
Expiration Date 4/28/2012
Status Current
No complaints found for this Licensee.
Back To Search
p /�aaaac�uaeltb
I•;
fie tr�o�itirrw� e tf[atton valid for indivi�ul use only
Lase:fly ,
_. Office af,Con§umer Affairs&Business Regulation
beforethe expiration date.. If found return to:
HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
atwn. =140251 iic Plaza'=:Smfe
Rego Tr# 290356 Pon,MA 02116 51
10 70
i,... Bost
ration 4 2512011
1
T p ', tv aE
CHARLES WHITPMBJR
R J.
CHARLES W NtTC
707 MA HST Not�ralid without signature
h1 MMS,-MA'02601
lJadersecrefary
1
Assessor's map and lot number ..................................... / �oF THE Toy 11
Sewage Permit number
Z BABBSTLBLE, i
House number ...................:...:.... rG. y............................... 9� MA86
039• e�0
'Fp Up(A,�
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .,.. 'Z ..'J� l?...,..................
�- .......................................
TYPE OF CONSTRUCTION .......... ........... �fi,5 T'v �' I. ..........................................................................................
....................................19..
TO THE INSPECTOR OF BUILDINGS: "
The undersigned hereby applies for a permit according to the following information:ig
Location :_ !Rc1 ' ......... .4 tea........ N���. c /l�, —/<.1 .� '........:............
ProposedUse . ... :Ir!c .��....'..liA- r/ /1 ........................................................................................ ....... ........
Fire District �......-........ /.........
Zoning District ..1.�'LS/.�;..;,7.f,.�.::.............a:�..� � , ...................... .:...�!,rv'>...,. �:........ ..
Name of Owner .:5�,!.,�!/,/4. -... /, ll„/.,A....r ffAC..!'�Address �+JiF/...:.C .....117,E �/�...... ....
f...
Nameof Builder ....................................................................Address ....................................................................................
.Name of Architect ........................................:.........................Address ....................................................................................
Number of Rooms ....r�..........................................................Foundation ..C•riR..f !.9.........
CoNc
...................................
Exterior .!7 .. �f /C e X�L !
(/<i^X......................... .............................................Roofing .,......•.�......................................................................
Floors . .Interior ...r: /l�c�-`y�'n cam ,
lHeating ......4'7...rc........ .........%.........Plumbing ... .................................' r ..............................
Fireplace ..C).........................................................................Approximate Cost ...R0. C?'� wr- V(/
/........ ..............................
.........
'�- . . .. f'
Definitive Plan Approved by Planning Board ___ --- - -_____19 . Area ......................
Diagram of Lot and Building with Dimensions Fee ......... ......................
SUBJECT TO APPROVAL OF BOARD,OF HEALTH
ti rd
\ \\\
t ,
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstableregarding the above,
construction. - �✓'�'l/� y�2�.�c.� L �-�"'
Name ... .. ................
Zf/�
SILVIA &
..........a... . ...SI..L..V...I.....A.. ASSOC
S S O,C...
T E..
.SI.V..,.
INC.
RC. A=186-44
24177 One Story................. Permit for .......... .. ..................
Sinjle Famil Dwelling
Location 46 BA a.ne..........
.................Cent ville.... ............................
Owner S.i.1.. ...a & Sil ' a Associates
.................... ..............................
.... ...........
("la L
Type of Co 'truction ......Elam.......................
................... ............................ ...............................
Plot ......... ................. Lot ...............................
Permit Gra ted ..............Jure...2.9.........19 82
It ......
Date of Ins ection ................. ..................19
Date Compl ted ................... ..................19
PERMIT REFUSE
......................... ........................... .......... 19
......................... 1P0................ .......................
............................ ........................... ......................
.............................. .......................... .....................
............................. ...... ..... ............. .....................
Approved .............. ......................... ....... 19
......................................................... ...................
...............................................................................
Assessor's map and lot number .......................................... �QFTHEto
Sewage Permit number ...
SEPTIC
SYSTEM MUS
' Z Y�71d 9TADLE, i
House number ". ` INSTALLED IN COMPLI
�i-�G................................. p 039. \e0
WITH TITLE 5 o M 'i
TOWN OF BARNS s " L osEsN
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...�Cl `�,f TR,CI�C�r+.... 'lfSl�/f .....
-1.:.. M.r..... .......................................
TYPE OF CONSTRUCTION ..........L.G1.Q.7>O. .4titiJT/PfJi.// a ✓ ..............I........................
......... ........ ...... .....................
.... .`..............................19..?1:
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location t' .?........ .........�4.,fee.. ....... /V7 /21�/LL ............................................................
ProposedUse ....S1,,.V7. ......... ., �/�?X/ ....................................................................................................
Zoning District .A:sl. -r^4.........�.......1. i Se� .. .
..... ........ ...........Fire District .. ....... ....-' ..... ................
/ !/r!g;r'- /....41�/�. /94-J'. Address
Name of Owner .,,�..� .. . . .... . .L . . .. .. . .P. ... rj!✓ ..��1..�/'�.tnT.�........,�'/...,....... . i���. .......
1
Nameof Builder ....................................................................Address .........................................................1.........................
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms ....� Foundation f /�P� ..............................'............................................................ ..........................
Exterior ../`.'.......................................Roofing /. ` f......... ..................................................
Floors .H1.q ....................................iI..............Interior .......Q............................................
Heating 44c,��.....j`10.7...��!QA:!s....6. �.,1 ....Plumbing ...�U ?�eP.*.&..........d.t.. L...:...........................
Fireplace ...&.).,.........................................................................Approximate Cost ...,550 OZ�' [JO'...............................
Definitive Plan Approved by Planning Board _�2G —-----------19_ z'. Area ... .. s
Diagram of Lot and Building with Dimensions Fee Y?-6
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ..... . ...... .....""�� ... ................
SILVIA & SILVIA ASSOCIATE, IN,-
24177 One Story
� 1
q No ................. Permit for ....................................
Single Family Dwelling
r........................................................... ...
Lot #7 464 Bay Lan
Location ........................................................ .... ..
Centerville r
...............................................................................
Owner .....Silvia & Silvia Associates, Inc.
............................................................
Type of Construction Frame..................
Plot ......................... . Lot ................................ - -
June 29, 82
Permit Granted ........................................19
Date of Inspection ....................................19
Date Completed ....aG.' '. .......19
PERMIT REFUSED ;
................................................................ 19
...............................................................................
_ V
. ... ....................................................
Approved ................................................ 19
..........................._...................................................
.................... ..........................................................
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LOGATZ-_G Wl71—AtV-1 T"Cr V:-Lc)OQ PLAIQ
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Building Inspector cash
OCCUPANCY PERMIT Bond
Issued to ,Ilvla Oc b1i Assoc. Address
,64 Raty La?ze, Cent(-rville
Wiring Inspector Inspection date
Plumbing Inspector Inspection date
Gas Inspector Inspection date
Engineering Department Inspection date
Board 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 MASSACHUSETTS STATE
BUILDING CODE.
2�.. . j
Building Inspector
e
1 U'-,) GA28AGC- C>21 Qr->r--Z
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Designed For I PPny 4 Ae�k o PL This is an original design and must not be released or copied unless applicable EquipmenKITCkNDESIGNS t
r: �
//,,'' fee or deposit has been paid or order placed. and-
AND
Address:`T�� 13Ca y ��ham' I The Purchaser understands that an order has been placed and anychanges in
measurements pliances M T be approved by K 8 D _ iignns)Unlimited. Specifications
TOM F. LE ROM C.K.D. City. C P�jA-t- State: ZiP: GaIC-3 Approved By.L Date: Range
Certified Kitchen Designer Principal _ _ C.K.
866 Main Street,Osterville, Massachusetts 02655 Designed By: T r�✓Y'1 {— -e��t5�r�'►� Scale: �0�� All measurement are tf Ish mesa ementf unlesc therwlse noted. Cook Top
Ph:508-428-3999 Fax:508-420-3640
Cook Top
Wall Oven
Microwave
Hood
`.� � O n S►'Y1141
r ° Compactor
�- !fin '+-> � 1"�,Via.�,"kr -1+.'4r �a. .�+.. .:am":ys v.�.r`,r tv''•,,.,�5 �^'F��. - �.•: � w . __
♦ Sk" � �G7� � _
t(% O �v C �i$v I, ��a r. �` Dishwasher
d . Se '.'1 f 9 � 1� 'fib s2w4t✓ Refrig
v
";
Wine Storage
Ice Maker
G lam } t Sink
v As
qtj � G Sink
f _ _ Soffit
�i I" Warming Drawer
M —t /I7 ; bl I Glass
I
Base Cab Toe Space
Flooring Material
tD-
3:
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Hood Venting
Appliance Panels
Y
—)-1 7/8 ? Under Cab Lights
Casi ngs
j *?14 Fla
Counts Tops
g . Faucet
..• ®acksplash
.............. M—
.JZ i i'e. i L�J�•••�'v s er
y
tiling Hyt.
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