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FF
,aNE TOWN OF BARNSTABLE Permit No. ..
31055. . .....
�` �e � . ... ...
BUILDING DEPARTMENT
{ ;; I t TOWN OFFICE BUILDING Cash
�'�ecsir HYANNIS,MASS.02601 Bond
CERTIFICATE OF USE AND OCCUPANCY
Issued to Lebel Sollows Truat
Address 55 Braley Jenkins Road '
Y
Centerville, rdass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
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.
October 7, 19...8 7.........
. . .......,.
Building Inspector
f'�
•`�y�••'. TOWN OF BARNSTABLE
BUILDING DEPARTMENT
,u�ua TOWN OFFICE BUILDING
�$ i639' �� HYANNIS, MASS. 02601
�o r�r►.
MEMO TO: Town Clerk
FROM: Building Department
DATE: 7
An Occupancy Permit has been issued for the building authorized by
Building Permit $k ........................................._. ._....................
issued to y ' . _. L � LDS . 2"'*". ....4f r ......... �__ f�i�� �'sJ.�.✓s
Please release the performance bond.
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
Im ^ACC
DATA
TOWN OF BARNSTABLE, MAZO.o; iwzrti.) ul' l uriNG . PERMIT
r1�111 13 9rui;ru + is i
DATE 19 PERMIT
UbIL N T' r �i
APPLICANT ADDRESS
(NO.) (STREET) (CONTR'S LICENSE)
build dwe''113.T1 i .; 1.l1 d '" _. iLI 7_.I '? C?Wf:'J 11T1 NUMBER OF
PERMIT TO (_ STORY_ �•• DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
a
i(''L, �'<'1 9 �) [L-d.!.i?' _ _i)'�:r�.fi: 'l:".!:3.:i t�i'i1Cli :i.;.i ' -. .. ZONING
AT (LOCATION) ° DISTRICT-
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
SUBDIVISION LOT BLOCK LOTSIZE
BUILDING IS TO BE FT, WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
.1. 1'. .
REMARKS: )�JU -")'`�•
- .B0INi)
AREA OR iil+t_I (,).�. :t. 60,OUP?. PERMIT :71..�J
VOLUME ESTIMATED COST FEE
(CUBIC/SQUARE FEET)
Leis l Sollowc-, Tru:_—,
OWNER
ADDRESS v BUILDING DEPT.
BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY,PART THEREOF, EITHER TEMPORARILY OR
PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
P
ROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN
ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND
I. FOUNDATIONS OR FOOTING . MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRu TURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MINAL IN (RE INSPECTION
TO EAT E FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION BEF RE
OCCUPANCY.
PO T THIS CAR® SO IT IS VISIBLE FROM STREET
BUILDI GIN PECTI N APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
OX
3 HEATING NSPECTION APPROVALS ENGINEERING DEPARTMENT
47
OTHER 2 t 6 � Q Q� BOARD OF HEALTH
cl o U
�or �� �
WORK SALL NOT PROCEED UNTIL THE INSPECT- PERMIT 'W!L L BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE
TOR HAS APPROVED THE VARIODUS STAGES OF 'WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. I•.PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION. •
a
e
� -� - <:0
�► G S
a :Z7 oo
0
ooq 00,F-0 - . 00
�-
N
i,s<:f>. o o '
Ace :30- N
_ I
CER�TIRED PLOT PLAN
L0CAT10N: C��7�.4P,Ulle-Z 4�1
F O R
SCALE: DATE: /967
R E F E R EN C E:,B4?—=/•vim
AT�.41Z- 3�-E .�EGciS7'2 y
I CERTIFY TO THE B 6,17 MY KNOWLEDGE AND BELIEF FROM
INFORMATION A QUIRED HATTHE SHOWN ON
THIS PLAN IS L CATED ON THE GROUND AS SHOW -EREON. OF
JOSEPH. G�
DATE F;, FESSIONAL LOA&D SURVEYOR o � N,JfL
MOPIaHA JR.
No. 13660
J. M. MONAHAN, JR. & ASSOCIATES l s
PROFESSIONAL LAND SURVEYORS & ENGINEERS ��OSUR`I`�
TOWNE PLAZA - 900 ROUTE 134 SOUTH DENN.IS, MA. 02660
J.N. 87- 83
Assessor's office .(lst floor): /,+�. � � THE to
Assgssor's map and lot number
Board of Health (3rd floor): . 3ITPrC SYSTEM MU � o�
Sewage Permit number ......... ......r ...... - ��d ��LL ® E 6 ®��L t BAUSTADLE, .
a—6,
Engineering Department (3rd floor): WIT T H TITLE 5 'oo,,�r639 `e��
House number ............................................... e. owar a
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only F
TOWN: -.OF b.-B,ARNSTABLE
BUILDING INSPECTOR
APPLICATION F PERMIT TO CL .� ySE'.............(.. ? SSA.OR ....... .............
TYPE OF CONSTRUCTION ...... 4p S � ...., !(/I..... ................................................................................
f Zp
-.7.. -(. -------------------19 .cam
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
7.. ..9......E 4 ? ......... r.-K-r!�?s........ep.. �e c/..z c,.c
Location ... ... C-- 7�........
Proposed Use ......... .. C�-Lt /� L
Zoning District ................!).A ..............................................Fire District ......................C�......................................................
Name of Owner .......I.CtOS ...Address ..�..3 i.... L�l....�� ...3.z.......A.I ofsw IS
^ it
Nameof Builder ..........&i.....................I ................De. ..Address ...........................................................I.......................
Name of Architect ..../vQ.rE.'�.5..i.,.p..�......�..CS'(. ....... ess ...� ...6.............1.. . ......................................
Number of Rooms ...........
.... . .............................................Foundation ................. FL�� `4�r.........................................
1 •
Exier for ...CZ-ApS...�.�lf�.�,!J.�.�i r('r ..............................Roofing ...... .. ,Rt.- 0<..?.........:........................................
Floors .....................................Interior ........kl..XiJ.NJLr
c- w.�a .;�..... ...................... ....................
Heating1. ............................... ................:.......Plumbirig ... . ....� .�. . WVyl?T............ ... .... . ..... ..................
Fireplace ............. ...?�.......................................................Approximate Cost .......�0 ,...................
............ ...........
Definitive Plan Approved by Planning Board ----l_���L----------19 _. Area ........1/y�.....................
-Diagram of Lot and. Building with Dimensions Fee ................ ............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
"l
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulation of f Barns a e r a din �ve
construction.
Name .. .................... ......... ............ ... .. .............
01_`�z
Construction Supervisor's License ...... ....... ....... .........
t
• Lebel Sollows Trust
No ............... Permit .....l..1/Z story '
i for
�,..............sincle Ifamil dwelling
....... . .......Y..................................... ..
55 BraleyJenkins Road '
Location ........... .
E Centerville _
Owner ..... Lebel ,Sollows Trust
........
T ....0..........`................ T_
Type'of Construction ' frame - '. t - v ,
......`f ......... ..... ..........................
c Plot .............................. Lot ... ....#279 4
p
` Permit Granted ........August..Z...... '....19 87
- Date{of-Inspection ........0.... .2.K-'. P7
Date Com let- k ... A. .. ..19 P ..1a Y
i -
• t
r 1.
• t y
a
1
Assessor's office (1st floor): oFTNE
, >o
Assessor's map and lot number -�"...
Board of Health (3rd floor):
Sewage Permit number .... . �?.... ........ � Z 9l$HSTODLE. i
Engineering Department (3rd floor): �� �� 9°0 16139. `ems
Housenumber ........................................................................
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ........3!; 4..........lILJ S L /. �h�:..............
................................. .0....I. ..... .,..
TYPE OF CONSTRUCTION ......� L.................................................................................
2 `1 19.
gL
...................... .......
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ... /L, �'}7" 2 C/J L C..C
7....... ......�3..�A44K.........� ......�'....... ................... ..................
�c•J CLCrt N
ProposedUse ............................................�'�.........................................................�..a....................................................................
Zoning District �................................................Fire District ...............
Name of Owner �����... C f... f�.S........I.C.S. Address 3 �L� 13Z J4yR /l.G>JI5
'— it
................................. .Name of Builder ..........&1.........................�..................... ..Address ....................... I
. .......................
Name of Architect &6,C Y!.D..�.....,...EF(<c RgAddress ...I` ...�...�?.............. 0� .�.............................
.................... ..
P Foundation
Number -of Rooms ............................................................. ................ ............................................
Exterior ...4w��-RVS...�..�� .�.`�. .(!CS..............................Roofing ....... :SPIG}LT
�w� .. ..............................................Interior ........tJ,� In�r �..-
Floors (� . .................................. .............................
Heating ........................................................Plumbing ...1� .. ...�.c. - Z PT4
Fireplace ..............`/ = .......................................... ...........Approximate Cost ........l�7,p d C7
a.................................................
Definitive Plan Approved by Planning Board ____- ----------- _ . Area ........//
Diagram of Lot and Building with Dimensions Fee .......................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations o the Town of Barnstable��egard�9'T aCp
construction. i
Name / ...
Construction Supervisor's License .?.. ..� 3�
Lebel Sollows Trust A= 171-236
431055 1 1/2 story
No ................. Permit for ....................................
single family dwelling
...............................................................................
55 Braley Jenkins Road
Location ................................................................ '•
1 Centerville... .7...........................................................
Owner Lebel Sollows Trust
..................................................................
Type of Construction frame
........:........................................................................
#279 �
Plot ............................ Lot ................................
Permit Granted .........August 7.............19 87
Date of Inspection ....................................19
Date Completed ......................................19
j
t
- i
i,
Town of Barnstable *Permit# 6 1 —
Expires 6 months from issue date
-PRESS PERMIT Regulatory Services Fee o7�d
.MAR 16 2007 Thomas F.Geller,Director
Building Division
TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number /77 f l 41&
Property Address 6 -130"ql 1 a
Residential Value of Work �� �` y Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name - '� Telephone Number, jo O .19Z 6
Home Improvement Contractor License#(if applicable) /off df Y a
Construction Supervisor's License#(if applicable)
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name A"i .1` al5ZI
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be.on file.
Permit Request(check box)E� ��11rr
e-roof(stripping old shingles) All construction debris will be taken to_ 04-5 �
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property 0 r mus ign Pr per Owner Letter of Permission.
A copy of e Horn Impro em ontractors License is required.
SIGNATURE:
Q:Forms:expmtrg
Revise061306
NOTICE NOTICE
V
TO To
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street,Boston, Massachusetts 02111
617-7274900
As required by Massachusetts General Law,Chapter 152, Sections 21,22 & 30, this will give you
notice that 1(we)have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE, P.O. BOX 4070 BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC 7016215012007 01/10/2007 - 01/10/2008
POLICY NUMBER EFFECTIVE DATES
P O Box 494
Leonard Insurance Agency Inc Osterville,MA 02655 (508)428-6921
NAME OF INSURANCE AGENT ADDRESS PHONE
Mark Herbst 35 Peep Toad Road Centerville, MA 02632
EMPLOYER ADDRESS
01/04/2007
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
DICA.L TREAT-MM- tT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the.insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby n*tified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
T� E POSTED BY EMPLOYER
i
k{h
t
5.
{� h.ARK HERBST
15 Peep Toad Rd.
Centerville MA 026i32
(508) 420-62 x ;
Cell phone 774-238-2938
PROPOSAL SUBMITTED TO. WORK PERFORMED AT:
FrankMcDonald SAME
f SS Brailey Jenkins Road
s °
f3 ` Centerville MA 02632
Y
x 603-556-0155
r.
fd
g We herby propose to furnish the materials and perform the labor necessary for the
i r Completion of the following;
New Roof
N.
Remove I lamer of exisgW shingles
` f Install ice &water at edge
YF InstalllSlb. felt pa er
- ` Install certainteed algae resistant shingles of choice
i Install cobra vent to ridge
Replace all plumbing boots
,. Storm nail all shingles
CertainteedXT 25yr. algae resistant shingles $5 250 00( ) v
k Certainteed Woodscape 30yr. algae resistant shingles 5 575 00(
*Please check and initial choice above Thank You
I Price includes material, labor and dump fees
4 All material is guaranteed to be as specified, and above work to performed in.
i ; f accordance with specifications submitted for above, and completed in a substantial
°a workmanlike manner for the sum of,as specified above&verified w/your initials
Dollars( )with payments as follows;full amount due upon completion
}s * Any alteration(s) from above involving extra costs will be added under:written
z agreement, and beco a an r arge over and above signed estimate/agreement F
tom'. RESPECTFU Y
fit
f '
U 1-
Signature 03-05-07
I 3
ACCEPTANCE OF PROPOSAL ' w
The above prices specification & conditions are satisfactory,we herby accept
You are authorize far do the work anayments will be as specified above. 3
o
Signature(
s l F
Date: 3 fC> L < > r,f
This pr posal ay be withdrawn by said company if not accepted within 30 days
21x�"i ' {f ' °Fr -T,rZ �"jie'e�� 1'�4? a�F� f 5 ` 5 ✓F j'
' #,. H pG t fuej » ' .c `S t
'tz : �Tt's" 'F y 4' k,, r'� 13 ,1?- A* �r I
§'• h r -"". 'i sr a xzu-r'
MR. m, ,
✓� �oara�vaaoasceea�fi o�✓�aaaacr�iva�a ,'
Board aL'Building Regulations and Standards "
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR, before the expiration date. If found return to:
Registration` 126480 Board of Building Regulations and Standards
Expration•: 6/8/2008 One Ashburton Place Rm 1301
Type Individual Boston,Ma.02108
t J
MARK HERBST / r
t
MARK HERBST ^/
35 PEEP TOAD RD. �� =
CENTERVILLE,MA 02632 -i— .- s
Deputy Administrator Not valid without st"nature
r
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
+ d 600 Washington Street '
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual): Rq 114-
Address:
City/State/Zip: Lr, M_LAXPhone.#:
API
o employer?Check the appropriate box: Type of project(required):.
1. am a employer with 4. ❑ I am a general contractor and I
6. []New construction .
employees(full and/or.part-time).* have hired the sub-contractors
l
2.❑ I am a'sole proprietor or partner- isted on the a ttached sheet. 7. El Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
workingfor me in an capacity. employees and have workers'
Y p t3'• �. 9. ❑Building addition
comp.insurance.
[No workers' comp.insurance
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 l 1.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12 [�-R-oofrepairs
insurance required.]t c. 152,§1(4), and we have no
employees. [No workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site
information.
Insurance Company Name:'are iWc���� /
Policy#or Self-ins.Lic.#: /r l!1/C -7 0 1620Z 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 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 insuragiFe coveram verification.
I do hereby certify under a ai and n es of perjury that the information provided above is true and correct.
Signature: Date: r-
Phone#• qC
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
TeGelver nr trustee of an individual.Dartnershim association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicant who has not produced'acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work until-acceptable evidence of compliance with the insurance
requirements of this chapter have been presented'to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that ibis affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit.or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' •
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(City or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,,-
please do not hesitate to give us a call.
The Department's address,telephone-and fax number:
The:Commonwealth of Massachusetts
Department of industrial A.Mcidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. ##617-727-490:0 ext 406 or 1-977-MASSAFB
Revised 11-22-06 Fax#617-727-7749
wwwmass.gov/dia
Engineering Dept. (3rd floor) Map Parcel ermit#
House# Date Issued
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) (p '
Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) � ,44
Plan' n e SE �s �ME,ibc"
Defim _ iliTll �d 19 IN CALL 0 IN
' 91T� LE.
TOWN OF BARNNTA ® ��� � "
n N.REGULATI V ,
Building Permit Application'' s r ; •w
Project Stre Address
Village
Owner �' Address
Telephone
Permit Request
v z,
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes Ll No
Dwelling Type: Single Family Two Family p Multi-Family(#units)
Age of Existing S;ull ,
ld y�� Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No
Basement Type: ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing L2 New Half: Existing New
No.of Bedrooms: Existing_ New
Total Room Count(noZinc ding baths): Existing New First Floor Room Count
Heat Type an7es
p Oil ❑Electric ❑Other
Central Air El No Existing Fireplaces: wood/coal stove Yes
P g �—New Existing ❑
Garage: LJ Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) 7Shed
(size)
one (size)
Q Other(size)
Zoning Board of Appeals Authorization Lj Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review#
,Current Use Proposed Use
Builder Information
Name Telephone Number
Address License#
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 D CONSTRUCTIONEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATUR DATE �9— 2
E
BUILDING PER IED FOR THE FOL OWING REASON(S)
4
w- S � � J 5'' � •�..x .. P r ... J .. [-, -y. k' f� �i # ~r
we
0
• a4 i
4
VE
The Town of Barnstable
Department of Health Safety and Environmental Services
1659. ` Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227 Building Commissioner
Fax: 508-790-6230
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
r
Address of Work•
Owner's Name e
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-
B ' lug not owner-occupied
Owner puffing own permit
Notice is hereby given that: PERMIT OR DEALING
OWNERS PULLING THEIR CABLE HOME IlVIPROVEMENTG WORK D WITH O NOT HAVE
CONTRACTORS F
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner-
Date
Contractor Name Registration No.
�d
nwnPr�c Name
The Commonwealth of ttilassachuseixs
Department of IndustrialAccidents
600 Washington Street
Boston,Mass. OZIII
Workers'Compensation insunuce Affidavit
1TTe' `
WCation•
Cil
0 12honc it "'Co
>tT am a homeowner performino 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 emplovees working on this job.
r&M pan v name .
tit • . . : . . • • I
inurnce co:
i am a sole proprietor,general contractor,or home O owner P P � circle one and have h• •( ) trod the contractors listed v below who have
the following workers' compensation polices:
COMPOny name:
SitXe n�•#: '
1Dsttr9rice co.
. . . •pQlicvl/ ..
tptnnanv name: '
anAurancr:Co.
Failure to secure coverage as required Hader Section 25A of iNGI.152 can lead to the imposition of criminal penalties Of a fine up to SL500.00 andtor
one years'imprisonment as well as civil penalties in the furor of a STOP WORK ORDER and aline Of S100.00 a day against me. t■nderstand that a
copy or this statement Maybe forwarded to the Mce Of Juvcstigatiosll of the DlA for coverage verification.
I do hereby cc r r pains and en ties p ilry That the information provided above is true and earrect.
Signature j � — --
_ _ ate �
!'riot nurtic_1 /l r��N�y � Flicnc# -,I— — t
Lcheck
do not wore in this area to be completed by city or town utficiel
permitAiccuac# Building Department
Qt ieensiul !!nsrd
ate responac is required �$electttnea's Office
C3Hcalth nepartment
phase tt; n0ther
r'
(re i ed 1191 PIA)
s
• TOWN OF BARNSTABLE
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB. LOCATION r
'Number At
Fdet address Section of town
"H0MEOWN=1i (a .. .
Name Home phone Work phone
PRESENT MAILING ADDRESS
City town State Zip cc
The current exemption for "homeowners" was extended to include owner-occ:
dwellings of six units or less and to allow such homeowners to engage an
dividual for hire Who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER:
Person(sj who owns a parcel of land on which he/she resides or intends tc
side, on which there is, or is intended to be, a one to six family dwelli
attached or detached structures accessory to such use and/or farm structu
A person who constructs more than one home in a two-year period shall not
considered a homeowner. Such "homeowner"• shall submit to the Building Of
on a form acceptable to the Building Official, that he/she shall be resno.
for all such work performed under the building permit. . (Section 109.1.1)
The undersigned "homeowner" assumes responsibility for compliance with the
Building Code -and other applicable codesJ. , by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Department zinimum inspection procedures and requirei
and that he/she will compl said pme
ced es and requirements.
HOMEOWNER'S SIGNATURE `, w-
APPROVAL OF BUILDING OFFICIAL
Note: Three family dwellings 35,000 cubic feet, or larger, will be requir
to comply with State Building Code Section 127.0, Construction Control.
HOME OWNER'S EXEMPTION
The code state that: "Any Home Owner performing work for whi4..ja- bu±1
permit is re p provisions of •this sectior.
p required shall be exempt from the ,.
(Section 109. 1.1 - Licensing of Construction Supervisors) ; provided tl
Home Owner engages a person (s) for hire to do ' such work, that such Hon
shall act as supervisor. °
Many Home Owners who use this exemption are unaware that they are assu
the responsibilities of a supervisor (see •Appendix Q, Mules and Regula
for .licensing Construction Supervisors, Section 2.15) . This lack of a
often results in serious problems, particularly when the Home Owner hi
unlicensed persons. In this case our Board cannot proceed against the
inlicensed person as it would with licensed Supervisor. The Home Owne
as supervisor is ultimately responsible. :.r. ...
To ensure that the Home Owner is fully aware of his/her responsi.biliti
communities require, as part of the permit application, that the Home
certify that he/she understands the responsibilities of a supervisor.
last page of this issue is a form currently used by several towns. Yot
care to amend and adopt such a form/certification for use in your comma
per: p� y r}'1e LT(� 1R Y12a Ut2E E t'i'ltl�t?2(,b FtLe no- 270,5�7
'be� t3K,= 5702 PaZC—: 2d2 ScUr-,=
4"o
lz
1 SPEC�l012
lAT 28a l,�T 2�
150.DD
43
loT 28`(
= 2sror�
o
7.
lot 27q O�
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150.00'
LoT 277 2�8
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