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I °° TOWN OF BARNSTABLE 'F°` % �C Building Permit Application Project Street Address UIV-0 Village ,4-(%1 Owner �1 •�GvylYpQ. �M(�„(� Address Lf— Telephone C[i Permit Request First Floor Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ �6Z9f? 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 Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Cea"I C I=A_C,, Telephone Number -Address `71 Jj A lLcc cv� i� License# lnc ' Home Improvement Contractor# &OS-3 6 Worker's Compensation# Lyej5/S -'1 f o?36-3 y/ NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. G� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Y"yyZ�7y/ SIGNATURE DATE BUILDING PERMIT DENIED FOR TH OLLOWING REASON(S) e • FOR OFFICIAL USE ONLY *. 4 f - t ,Y6 PERMIT NO. ti• DATE ISSUED - MAP/PARCEL NO. �- 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. The Commonwealth of ll/assachusetts Department of Industrial Accidents , t J 1_ Office of/nvestlgat/ons 600 Il<ushington Street Boston.Mace. 02111 L. .�. Workers' Compensation Insurance Affidavit ,ppltcant tniormation-- Please PRINT le�i � name: K,-e,M C 4QAX t eA4 mention: �//y TA R L—S&✓t /✓L giz: C 4(,c 1"14 nhonc# 1 am a homeowner performing all'work myself. I am a sole proprietor and have no one working in any capacity . .:a.:•�•.-.sy-.•.^--••�--ry.F,. �>,.•�.s;-•Ksa.....r..weev.�r,'•'�+.v�-sua�•�....a�*�. --"--.�+r..M..�.-•-.•-.•'T--•r^.__ &jl am an employer providing workers' compensation for my employees working on this job. company name �✓�Lc�Q t/1 C address: MI.- nhonc#• incur-ince co L " A-W.1..� policy# Or—I J S v1 S63 0/ '2 Tam a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: comPInv n•tme• address: phone#• insur•tnce co Police# _ �. - • - _... K:.R[« -:a way -•.�;r^.."�'•C.Y^•i•^'_:RT'.: -.ir.--!^tee••}- -afT. .. .�4-•5.7.?r r..• .i�::: ..+.�s;^svq' :...n.ta-"-: ,riG:T'i�_..'"v` �r •-�� company n•tme• address- city: phone#: insurance co policy# ;. :Attach addur itional sheet if necessar_,y +���=�+�s;�r.:•I�;�:� '�- ��"'•' s-��'^•M."— ruile to secure coverage as required under Section 25A of NIGL 15_can lead to the imposition of criminal penalties of a line up to S1.500.00 andior one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Oliice of investigations of the DIA for coverage verification. I do herehr ccrtijt•t cr pants nttd pet jperjurr that the information provided above is true and correct. Sianature Date 7? i g Print name C F--Ac� Phone#, a official use onh do not write in this area to be compacted by city or town official r � city or town: permitAicense# rilluiiding Department [3Liccnsimg Board. check if immediate response is required ❑Selectmen's Or"ice �licalth Department contact person• phone#; I"IOther !<: A; Wevised;roc rtA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted tom the 1aw", all enipinree is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An emplurcr 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 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 dwellin�i, house of another who employs persons to do maintenance , construction or repair work on such dwelling hous or on the _,rounds or building appurtenant thereto shall not because of such employment be deemed to be an empioyer. 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 lia,, been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits iYtay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tire 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. J , City or,towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas( be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. Tile Office of investivations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. . The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 The Town of Barnstable • aAernsiE. • ' ���' Department of Health Safety and Environmental Services - 1 �,►�'' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: Est.Cost Address of Work:.,-- Owner's Name Ca44�V i/ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEM 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 ap ly for a permit as the agent of the owner. k/� C P PVn C Dad Contractor Name Registration No. OR Date Owner's Name ua= - --Y-a;-�a ..� -- -- "�-'s'— -�-s...z�..,..__ _ _ =tiif.-i.'!+GX,H.aaas..i.C�....• a HOME IMPROVEMENT CONTRACTORS' REGISTRATION + } Board of Building Regulations an&Standards } One Ashburton Place Room'' 1301 :; t'� A. Boston,, Massachusetts ,02108 t T x,� ,;l +{ O VEMENT CONTRACTOR 'r + v H ME IMPRO F Registration' 112536 } Expiration',04/06/991; TYpe. DBA i� ` l e�� gNOME IMPROVEMENT CONTRACTOR igistration 112536 ERASER CONSTRUCTION � � J =a� , ' J;tj`TYpe OK } DEAN C . ERASER % z,�r ' ,{�;�, F:$, �i '' �� " " Expiration 04/06/99, '. ' TARRAGON CIR '� COTUIT MA 02635 ERASER CONSTRUCTION C. FRASER ADMINISiFiMR i.TARRAGON CIR { COTUIT MA 02635