HomeMy WebLinkAbout0015 BREZNER LANE 46
Town of Barnstable Permit#
� Expires 6 months from issue date_
pp Regulatory Services FeeMAMS& PR
/D@�oESS $? . {Q®+�
At ���' Richard V. Scali,Director ',
IT
EDMA A '.
Building Division 'FEB 1 b 2016
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis;MA 02601
www.town.bamstable.ma.us TOWN OF BARNSTABLE
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDE_ NTIAL ONLY
® I I n Not Valid without Red X-Press Imprint _
Map/parcel Number
2- f� r
Properly Address kF /�
❑Residential Value of Work C) 004 Minimum fee of$35.00 for work under$6000.00
� Id�l��/Y p �/ nn :
Owner's Name&Address P��� c U l MA M&
im hoe-
Contractor's Name �iN 1 �,�./ ll n Telephone Number ✓wY
Home Improvement Contractor License#(if applicable) /D Email: VOklry A VWhOn UASkCVL'h2 A
Construction Supervisor's License#(if applicable) C S V �T✓`U 7`
❑Workman's.Compensation Insurance
7 k one:
am a sole proprietor t
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name -
Workman's Comp. Policy# -
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
'® a-side
[VReplacement Windows/doors/sliders.U-Value' t 3 0 (maximum.32)#of window
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Noted Property Owner must sign Property Owner Letter of Permission.'
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required -
SIGNATURE: �Wz
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC
Revised 040215
f
The Commonwealth of-Vas-sachusetts
�•� Deparanew o,f Industrial Accidertls
r` 600 Was hirtgton Street .
Baston,MA 02111
4 ?i<'Ytrft Inamgm1dla
WGrkers' calmpensat an Insurance Affidavit Buuilderm/Contractars/EIectricianslPlumbers
Applicant Inf6rmatEan Please Print LegibIY
Address_ PI
cityrsta& ; �' s f 7— /�: D)_63-5__ Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer v41th. 4. ❑I am a general contractor and I
employees(full andlor part-time)-* have hired the sub-contractors6. New construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. FZRemodeling
ship.and have no employees These sub-cozrtractors have
�P �P°� $_ ❑Demolition
wvorldng for me in any capacity- employees and have workers'
i . ❑Building addition
[NOEliorlfler°.s' Comp_fzactt7anre comp. nsurance-1 9
required-] 5- ❑ We are a corporation and its 10❑Electrical repairs or additions
3.
officers have exercised their El am.a homeowner doing all work 11.❑Plumbing repairs or'additions
£ o workers' right of exemption per MGL
insurance equire&]t c.152, §1(4)�and we have rto 12_❑Roofrepairs
employees-(No worims' 13.0 Other
comp-insurance required_]
'Any appbamtthat checks boa R amst also fill out the section below showing their workere compeusatiouponcy in5nnation.
I Homeowners Who subnnt this af5datdt indkzun j tky are doing all'wa&and,dun hire autside coattsctors amct submit anew affidavit indicating-such_
ICanuactors that check this boa mast attached atr additional sheet showing the name of the sub-contrac as and state whether or not those entities ham
employees.If the sub-contiactves have employe %&eymusr pm made their workers'ramp.policy number.
I am an eutp �vr that is pr4nidingitorkers"congwLvirgaiiinmiranceforinycHrPLaileel. 3e103v is fhe pa£icy and job site,
ircforrnafian. ..
Insurance Company Name.-
Policy 44 or Self-ins.Lic.4: Expiration Bate:
Job Site Address: Citylstawzip: n ,
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 OD andlor one-yearimpriso—mi as we11 as cM1 penalties.in the fonts of a STOP WORK ORDER and a fine
of up to$250.00 a day against the-violator. Be adtased that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
I do hereby cerfrfk,antler the pairis and penabYes ofpeg'aty that true information prouicEedlabar [[is true attd ctrrrect
Simlature: aNk VW Date �/�U
e
Phone J'�V`L/� / l
official use aril}. Do not write in this area,to be camp£eted by city artoirn ofj`adat
City or Tawn.: PermitEicense;W
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citjlrown Clerk 4.Electrical Inspector 3.Pluunbmg Inspector
6.Other
Contact Person: Phone#-
information and Instruefions
Massachusetts CGeheral Laws chapter 152 regizffes all employers tD provide workers'compensation far their employees.
P -tD this statute,an.eaplayee is defined as -.every Person in the'service of another under airy contmd of hire,
express or implied,oral or written_"
An
Moyer is defined as"an individual,partnership,association,corporation or other Legal entity,or any two or more
of the engaged gaged is a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or t=nstee 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 -
dwPl�house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or bmldmg appurtenantthereto shallnotbecause of such employment be deemed to be an employer."
MGL chapter 152,§25C(S)also sues 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 c6mpliance with the insurance.coverage required."
Additionally,M(-chapter 152, §25C(7)states"Neither the co*nin aaweakth nor any of its political subdivisions shall
enter inn any contract for the perf=aace of public w013.c umhl acceptable evidence of compliance;with the ins�ce.-
r eats of this chapter have been presented to the contacting auf-hority."
Applicants
PIease fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s), addresses)and phone n=ber(s)along with their cerlificate(s) of
hivurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not regtm ed to cauy workers' compensation insmance. If an LLC or LLP does have
employees, a policy is regained. Be 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 retrumed 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 obtam a workers'
compensation policy,please call the Departmei±at the number listed below. Self-insured companies should enter their
self-msura ce license n=ber on the appropriate line.
City or Town Officials .
f -
Please be store that the affidavit is complete and primed legrbly_ The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigation has to confact you regarding the applicant_
Please be stare to fill in the pen litlIicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permitJlicensa applications in any given year,need only submit one affidavit indicating cu=t
p olicy hif6 ation Cif necessary)and under"Job Site Address"the applicant should write"all locations in (sty or
town)-"A copy of the-affidavit that has been officially s imped or mar}ced by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for furore permits or Iirenst& 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 rBvaired to complete this affidavit
T11e Office of Investigations would lake 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 C:G.=MMWeaja of Massaahusi--tta
Depar nmt of I&Imtdal Amidentt%
Qfoe of jIIVe&tigatio?=
C04,wtQll Sft-Q;f--t
Boston,MA O1 I I I
`f(1.4 617 727-4g00 cx- 06 or 1-a77=IAS F
Fax##617-727-774-9
lZeviseri424 t)7 .m ggvldia
Massachusetts De
Board of B Partment of Public S uilding Regulatio afety
License: CS-047667 ns and Standards
Construction Supervisor
PHILLIP
M VOLLME�
PO BOX 64 -
COTUIT MA 026j5 -
Commissioner Expiration:
f 09/01/2017
Construction Supervisor
Restricted to:
Unrestricted-Buildings of any use group which contain
less than 35,000 cubic feet(991 cubic meters)of enclosed
space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
DPS Licensing information visit: VVM.MASS.GOV/DPS
yccuealC/o�C�/��cc�achcraet .� License or registration valid for individul use only
irs&Business Regulation /I ,
CONTRACTOR . before the expiration date. If found return to*
1 Type: Off ce of Consumer Affairs and Business Regulation
i, individual 10 Park Plaza-Suite 5170
Boston,MA 02116
Undersecretary I Not valid without signature
ok�
t ;
BARN rnei e. •
Town of Barnstable
Regulatory Services
Richard V.Scali,Director
Building Division.
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize C) to act on my behalf,
in all matters relative to work authorized by this building permit application for:
_
Z5 re zl;Llr Zgaf,
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side. -
C:\Users\Decollik\AppData\I ocal\Microsoft\Windows\Temporary Intemet Files\Content.Outlook\2PIOIDHR\EXPRESS.doc
Revised 040215
t.
' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �D Parcel Tr,9'N OF BARNSTABLE Application0c)
Health Division t� 4t ;,_,g 4 Date Issued
I L. d e
Conservation Division Application
Planning Dept. u s Permit Fee;,
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address S— pp� n D tz. c �
Village
Owner KI---c �-. �s r-.� �- t Address
Telephone
Permit Request �Jc`��.�r.Z Iz,.. a- �` ��ll �`,4 1.� ,ki,;
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing —new
Total Room Count (not including baths): existing new First Floor Room Count
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:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name Mire McCarthy Construction Telephone Number
PO Box 52
Address West Dennis, MA 02670 License #
Cell (508) 280-6964
ST.-58633 HIC-169393 Home Improvement Contractor#
Email Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
k,qr,%"_J i-- P�1.,
SIGNATURE DATE
zy
a
r
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
4
MAP/PARCEL NO.
r
ADDRESS VILLAGE
` OWNER
DATE OF INSPECTION:
't FOUNDATION
R
x
FRAME
INSULATION
4
FIREPLACE
56 ELECTRICAL: ROUGH FINAL
F
Y
e
PLUMBING: ROUGH FINAL
F
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
a � ..any�.-.. `• - ..
Town ofarnstabe
. �t�gi�la�oiry Sece"s,
BIJA
M
' Richara,v Scat,Dire#or .
i6"3
µid t' BY17�t7u1g�iVLS1®Ht.
' Tom Perry,Bwlltng CammEc�oner
200 Mam Skeet Hyannis;MA 02fi01
' www town.barnstabie.ma.us; ,:
Office: 508-862-4038`' 1�ax508790-6230
Pmprerty Owner Must.
Co xplete=a dr=Sxgn.This Se'cU'gn,'
If Us -ABu�de�r '{
J, s .l Ae1L"A'�S•a"' 'itb'rf.i s ii
erpf tieyaubJe;ct-pro`perry;'
' i. ?' 5. t/,�` Ai.�� � .° ' �W Mtn 4i�•3& 7.�'�*'+''t 4s
"'`�ioacio��� 'behalf
is alI warners".tplafive to.wo autho",p 'bythu buili�ag.permu a Plir for. i.
(Address ofjo,yyb'��¢¢;{{Y—i
. aa -
�``Poolefences.aad alarms aie rlxe respans�l%d�t of'the applicant Pools H
<are not'to lie- iJled'ar utilized liefoie fence is'iastalledand all viral'
nspecaos`a pezfarmed.and accepte d
Kar�Matt(a(Ju 3..b15) -
Ssgz�auue of- Owner. of'Applicant;
4 Print'Name, +PnntNamef �Y.
Q.F RM 6WMPPWWSSIONroOcs '40.;
r _
r
�r
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen•isor
License: CS-058633
MICHAEL J MCCAR
PO BOX 52
W DENNIS MA 8267 1
Expiration
Commissioner 04/10/2016
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 169393
Type: Individual
Expiratio /2017 Tr# 264961
71,7
MICHAEL MCCARTHY
MICHAEL MCCARTHY. i r --
P.O. BOX 52 re
WEST DENNIS, MA 02670Update Ad ess and returnr change.
jD Address Renewal [ Employment 1 Lost Card
20M-05/11
0
The Commonwealth of Massacillisetts
_ Department of Industrial..Accidents
_ a I Congress Street,Suite 100
Boston,MA"02114-2017
www.mass govIf is
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pl)imbers.
TO BE FILED 11MI ME PERMITTING AUTHORITY.
Applicant informationconstir lease Print Le ibl
Name(Business/Organization/Individual): Mike Mc a y
SOB x5*2
Address: West Dennis, MA 02670
Cell -
City/State/Zip: f'QT -5$1�3#: HIC-169393
Are yoq an employer?Check theapropriate box:
1. i am a employer with employees(full Lrl'QY/ Type of project(required):
and/or
7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.) g• ❑Remodeling
3. i am a homeowner doing all work myself. 9. ❑Demolition
❑ g y [No workers'comp.insurance required.)t
4.❑i am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
5.❑1 am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 12.[]Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.igsumnceJ 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.00(her
152,§1(4),and we have no employees.[No workers'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 hn 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.
lam an employer tliat is providing)Porkers'cotnpe►isation insurance for my employees. Below is Cite policy and fob site
information. p� M
Insurance Company Name:
Policy#or Self-ins.Lie.#: V t�I(;,—)a�— Gi 7C�6 - )`( fj'' Expiration Date: ).:�
Job Site Address: }S 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy cif this statement may be forwarded to the Office of Investigations of the DiA for insurance
coverage verification.
do hereby certify tin tl at s and alties rj try that the:inJormntion provider!above is trite and correct.
Si nature: Date:
Phone#:
FC117e only. Do not)vrite in this area,to be completer!by city or Io)Pn official.
n: Permit/License#
hority(circle one):
Health 2.Building Department 3.City/Town Clerlt 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMPAGE
A.I.M. Mutual Insurance Company
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800)876-2765 NCCI N0 26158
POLICY NO. I VWC-100-6017656-20146
PRIOR NO. VWC-100-6017656-2014A
ITEM
1. The Insured: Michael McCarthy Construction Inc
DBA:
Mailing address: P 0 Box 52 FEIN:**-***3862
West Dennis, MA 02670
Legal Entity Type: Corporation
Other workplaces not shown above: See Location.
2. The policy period is from 12/15/2014 to 12/15/2015 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states 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 liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 500,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 0712979
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $550 Total Estimated Annual Premium $29,332
GOV GOV Deposit Premium $7,748
STATE CLASS
MA 5479 State Assessments/Surcharges
$28,601.00 x 5.8000% $1,659
This policy,including all endorsements,is hereby countersigned b
9 Y 12/15/2014
Authorized Signature Date
Service Office: Bryden &Sullivan Ins Agcy of Dennis Inc
54 Third Avenue PO Box 1497
Burlington MA 01803 So Dennis, MA 02660 /
WC 00 00.01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance, V�
used with its nermiccinn. `,
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map �,1;® Parcel I Application #
Health Division Date Issued
`�6.' l0AZ
Conservation Division Application Fee
Planning Dept. Permit Fee I&
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address j S �Q7�ll la n
Village Ce_n�e.w e.Owner PAU �,64 C-eA Address (A 4 RSSMoce Q%- 94jem P A
Telephone L� �5 cq -q H ._-7 IS3
Permit Request Ve-tl(licNe
(Se- W 1VJGw 5 k i (-
Square feet: 1 st floor: existing 10 04 proposed 0 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation '000 Construction Type
Lot Size U ASS Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(# units)
Age of Existing Structure P-7 1 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: O Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) 0 Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing J- new Half: existing new
Number of Bedrooms: G( existing —new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: Ii[Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existin od/coa[_�tove ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ i : ❑ exis,Oig Utnew size_
Attached garage: A existing ❑ new size _Shed: ❑ existing ❑ new size _ r:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name / ° AC k \�l�11�� Telephone Number �0:6J 7 76-aC(q a
Address Q rJx lD License # es C)*be 7Z
rd k Home Improvement Contractor# M
Email `John--e,tGlndsOAco/,S�wcA kbA���Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
1113-rh 1� 1� OJT S �S
SIGNATURE �1/`' V DATE
T FOR OFFICIAL USE ONLY
W
APPLICATION# `
a
,x
t DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME C& U bA5 4-4
INSULATION �S
FIREPLACE
t ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL ;,
o
FINAL BUILDING o '
� f
DATE CLOSED OUT `
ASSOCIATION PLAN NO.
The Cori monsFtealth of-gassachusefts
Deparftmmt of1Ydksft id Acc_zde7rts
- Oface of invesagadons
600 Washington meet
Boston,M54 02111
wm masmgmldia
Workers' CompensationInsm-ance affidavit:$ua.IderslCoutractorsMectricianslPlumbers
Applicant Infarmation I `1 Please Print Legibly
/��1
Name(Ilosmeasld�ganizationFfndividua!): / G,(k yC1 l\WC,�
Address: � 6 . &X
Cxtyfstate p: Ldp� Mk G Phone 47 S off-77 C —a9 C1 a-
Are you an employer?Check the appropriate box: Type of project(required):
4-. I atliY ai contractor and I YI?`e PQ' 1 (� '�=
1_❑ I am a employer with 6- ❑New construction
employees(full and/or part-#ime}* have hied the sub-conhactom
2.KI am a sole proprietor or partner- listed on the attached sheet 7. [XRemodeling
ship and have no employers These sub-contractors have g_ ❑Demolition
w for me many capacity. employees and have wormers'
od�ng y I 9_ ❑Building addition
[No workers'comp.insurance comp-insuranm-
required-1
5..❑ We are a corporation and its 10.E]Electrical repairs or additions
3-❑ I am a homeowner doing all worm officers have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'comp- riot of exemption per MGL 12_0 Roof repairs
152, ,
insurance requred.]T e. §1(4 and we have no� 13_.❑Other �
employees-[No workers'
comp-insurance required-]'
*Any Whom-t that checks boa-1 toast also fill out the section below shovdag ibeu woders'compensation policy infMnzti�
T l[ameowners who submit thus affidavit indicstieg they are doing ali am*and then hue outside contractars must submit anew afdavit mdirsung Bach_
tractors that check this box mmt attached as additiaml sheet shocking the nme of the soli-odors and state whether ornot thane emities hzve
emplayees. Ifthe sub-contractors have empIoyees,the}must provide their warkers'comp.policy number-
-Taman employer that is protddiag it�orkers'comlrersatfon fnstirance for my enrplrryees Beioty is thepa&y aced job site
infotmatfon_
Insurance Company Name:
Polo y,{#to Self rns_I a Expiration Date:
Job Site Address: City/5tatelzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required puler Section 25A of MGL c. 152 can lead to the imposition ofrriminal penalties of a.
fine up to$1,500.00 and/or one-year impriso ument,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 vzriflcatum
I do hereby ire ra t epons nd enal es ofper,�ury that the fnforruation prat�ided above' tnu apdLccorrect
Sitniature: rG�2� Bate:
Phone
Qftial use only. E?a not w1iie in skis area,to be coutp7eted by cio or town officiaL
City or Town: Permit/License 9
Issuing Anthority(circle one):
1.Board of Health 2.Budding 1)"artment 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Iuspector
6.Other
Contact Person: Phone#-
6,
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,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 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 Iocal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth.,`.or oily
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 this affidavit may be submitted to the Department of Industrial
Accidents for confirmation ofinsurance 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 Departanent 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. Sell insured companies sa.ould 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 add_tion,an applicant
that must submit multiple permit/Ecense 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 Qf Industrial Accidents
office of kwstigations
640 Washington Street
Boston,lam.02111
Tel.#617-727-4900 ext 406 or 1-977-MASWB
Revised 4-24-07 Fax#617-727-7 749
w .mas&gov1dia
IKE
* ILAEOMAJ3M
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division w
Thomas Perry,CBO.
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.ba rnstable.ma.us
Office: 508-862-4038 , Fax: 508-790-6230
Property.Owner Must
Complete and Sign This Section
If:Using A Builder '
as Owner of the subject property
' A "
lierebp authorize /l `•-✓D �/l/fi to act on my behalf,
m all matters relative to work authorized by this building permit application for-
re Z,04eX, z
5 (Address of Job).
Signature of Owner Date
Print Narne
if Property Owner is applying for permit,please•complete the Homeowners License Exemption Form on the
reverse side.
• t, ..
y •
C:\USeis\decollik\AppData\LocalUNi-- ft\Windows\TemporaryIntemet Files\Content ou[look\QRE6ZUBN\EXPRESS.doc_
'Revised 053012 '
WBoard
tilssachusetts - Department of PublicS�fety
of Building Regulations.anclStarndardI
Construction Supen isor
License: CS-047667
PMILIPItI Vt� Lt 12 . "
S "OB0X64 '� r
COT UIT NIA 92 a �
�J I
Commissioner' Expiration
09/01 ]v.
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sllasn,yaesseW ayl10 u'oliipa luaianu a ssassod o}ainllej
aaeds posolow
o(£uU.166) jaaj:oigna 00.0`S£uUgj'ssaj ureJuoa
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�`•. `Office.of Consumer Affairs Business Regulation. . License or registration valid for individul use only
—; HOME IMPROVEMENT CONTRACTOR
before.the expiration date. If found return to:
i }registration 109558 Type: Office of Consumer Affairs and Business Regulation
c ,Expiration 9/21/2016 Individual
10 Park Plaza-Suite.5170
- Boston,MA 02116
MARK VOLLMER.:
MARK VOLLMER.
.1455 SANTUIT NEWTOWN RD
COTUIT, MA.02635 Undersecretary - Not valid without signature
r `}
f
Y.
of Town of Barnstable *Permit 5 0
6JWVn&rJ6M ranks dam
Regulatory Services 610
Thomas F.celery 1&eetor
' Building Division
Tom Perry, 13t0din.g Commissioner X-PRtSS PERMIT
200 Main S'treet,.Hyarmis,MA 02501
ice: Sob-862-40�8 FEB 2 3 2006 (2)
r'aa: sob 790-6230 - TOWN OF ! NST LE
EXPRESS PERMIT APPLICATION - RESIDENTIAL,ONLY
Not VaW wUftut Rs4X-PresslaeprW
►FparwI Number Q/6
=tyAddress S Zr e Znor-r- CA" C e,n
Zesideatiat Vsfiie of Wont 3 0 U Minimum fee of$25.04 for work Hader$6000.00
,ces Na=&Address -?O u l 'V�i N CAA"t 1 Ce
. 1a9 lRoss rnofe lz�c►'ye iVlC Qer" W /Ci , S _
(tractor's-Jonas . C Kee a K ZL� -Ipn�- ... elephone Numiber
ne Improvement contractor License#(if applicable) 13.3 kr(
etructiox Supervisor's License#(if applicable)
Workmen's Compensation Insurance .
Check one:
El I am a sole proprietor
❑ I matbe Hoameowner
,® I have Worker's Compensation Insurance ,
raace Company Name L t t 6 er T . . 4
d=ws comp.Policy# (•UC a " 3 S-3( �1)G a-G�S
iy of Insurance Compliance Certileate must be on file.
nit Request(check box) /
Sgaw Cda r
r �
ails-soof(str44=9 old shingles) All c0nshuc6n debris will be taken to Dm l 10 3 per4x / 4 G E'er
❑Re-roof(not stripping. Going over existing layers of roof)
D Re-sidi
D Replacement'Viadows. U Value (m d==.44Y-
'Whore required: Issuance of this p=dt dots not awVt compliance with other tovm department regWations,i.w asistm ia,Casemtimr,ete-
***Notc Property Owner must sign Property Owner Letter of Permission.
Home Iurprovemxkt Contractors License is required.
torture zL
rms:expmbrg
st053004 -
FEB-23-2006 09:10 FROM:ASTRAZENECA 610 408 0975 TO:15082555107 P:1/1
FeU ::':S W0 at;;.01 Mark Nicke,son 5(M-255-�5107 P.1
f
Town of Barnstable
regulatory Services
NUM
=�wiwur,�.c. - Titntntis Y°'.Gelloc,Director
' Building Division
Toth perry, Building Commissioner
200 Main Stmet, Hyaomis,MA 02601
www-townbarnd+bh-WR-us
Ui ,uc: 508-862 ?8 Fax. 505-790-0230
Property Owner Must
Complete and Sign This Section
if Using ABuilder
1.__L l -� �,d e "1Q (j,-'• ,as Owmr of the subiL prrmperty
beseby authorize �,�G,c�c�! o� __to act ott to y behalf,
in al) ,,,L% rs relative to work authorized by this bundimg pemdt applicat on for.
(Addmss of Job- _
A _ a^ J3
Date
sibtl nme of Owner
YrnAt N'Une
C) <
SUb' 2S�' 5 Ja7
QkUE.M�Y)H'Nl:lif'ERMiS$!ON .
i
of
Page No
• .Aa es 1
NNICKE N HOME IMPROVEMENT; INC.
x i25245
P 5- Box 2476
HYANNIS, MA 0260E
i
(508) 790=5880 Fax (508) 255-510T
PHONE r�ATE
Paul Dvnattia ``
l SI'huf-c `1 �v
e A E fr •... t4Ps
I d ;) `�o
CA \j Irk.�
15 Bezner Lane
��355 Centerville
aoe NUMBER: �s�ss PHCTPIE
f'
UM *XV
Strip shingles off entire roof
Inspect all returns and flashing
Renail all loose sheathing
Install 8" white aluminum drip edge on all lower edges
Install-36" of ice&water shield on all lower edges, around all openings and in all valleys
Install black underlayment felt paper on remaining stripped areas
Install new flanges around vent pipes
Install 25 year 3 tab Seal King algae resistant shingles on entire roof
All trash and debris will be removed and disposed of properly
All labor,materials and debris removal $
Pe,w e R It..,oo
OPTIO To install 30 year Woodscape series algae resistant architectural shingles add to abov
To instal150 ear Independence roof shingles add$ ► 'o a
a Install ride vent at roo nee c�'or$ -'per lineal foot (kQMC j-� ve... .% a,�
Repair rotted wood at$' ;`per man hour plus the cost of materials
PLEASE INDICATE URNED PROPOSAL .
Only items specified above are included in this proposal 1 � P � �
Rotted wood repair is not included
Materials guaranteed by manufacturers,workmanship guaranteed for.10.years by Nickerson Home.Improvement.Inc.
WE PROPOSE hereby to furbish material and tabor —complete in accordance with the above specifications,for the sum of:
and00/100�E1�1�rS dollars($ , ).
rayment to oe made as follow-s:
l .f 0)deposit upon signing,progress payments upon request,balance upon completion
6(6- 466 (- �7 s
All material is guaranteed to be as specified. All work to be completed in a professional
manner according to stanclard practices. Any alteration or deviation from above specifica- Authorized
tions involving extra costs will be executed only upon written orders, and will become an Signature
extra charge over and above the estimate. All agreements contingent upon strikes,accidents or
delays beyond our control. Owner to carry fire,tomado,.and other necessary insurance.Our Note:This proposal may be
workers are fully covered by Worker's Compensation Insurance. withdrawn by us if not accepted within 2n days.
J
ACCEPTANCE OF PROPOSAL.—The above prices,specifications ��'�\l t
and conditions are satisfactory and are hereby accepted. You are authorized Signature `� a+�
to do the work as specified. Payment will be made as outlined above.
/ Signature
Date of Acceptance: ( t O t0
' e
:c.. ✓fe -Vry»vrreao2cc�eallf. a��l aJaclt..J'& '
Board of Building Regulations and Standards License or registration valid for individul use only
V j HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 133851 Board of Building Regulations and Standards
Expiration: 8/17/2007 One Ashburton Place Rm 1301
Type: Private Corporation Boston,Ma.02108
NICKERSON HOME IMPROVEMENT
MARK NICKERSON
12 COMMERE DRIVE. b
ORLEANS,MA 02653 Administrator Not valid without signature
Engineering Dept: (3rd floor) Map Parcel _ Permit# ��
House# [ Date Issued
..,.Board of Health(3rd floor)(8:15 -�30/1:00-4:30) Z Fee
/Conservation Office(4th floor)(8:30-9:30/1:00-2:00)
Planning Dept.(1st floor/School Admin. Bldg.) IKE rq
Definitive Plan Approved by Planning Board 19 M �;
BARN"ASU. `
MAM
TOWN OF BARNSTABL
Building Permit Application ,
Project St Address
Village CWTWN
Owner Address
Telephone
q ' � e, ov 'DB_e�- �1J ss%,A
Permit Re uest ±� �11J �
First Floor µ' ,, ��`` square feet Second Floor square feet
Construction Type DECK _jl L� JJ
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family IU/ 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
k 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 LOMA&D ly N Telephone Number -a W s
Address License# a45 n : -_
Home Improvement Contractor# 1Z'i 7 3
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 D�rlS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
BUILDING PERMIT DENIED FOR THE FOLL WIN REASON(S)
> FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUEDa
MAP/PARCEL NO. i
ADDRESS a. i VILLAGE` ,
OWNER
DATE OF INSPECTION: - t
FOUNDATION r e
FRAME, t ti N
-INSULATION
{' + - .., a ...+ • - ` _ Y n ,` - .i
FIREPLACE . " 'A
ELECTRICAL: ROUGH ' FINAL ' ( -
PLUMBING. ROUGH' FINAL' _ s
GAS: ,ROUGH . FINAL A _
FINAL BUILDING
DATE CLOSED OUT,
•ASSOCIATION PLAN NO. e 3 '
' The Town of Barnstable
Department of Health Safety'and Environmental Services
De1"96partment BuiIding Division ,
367 Main Strew,Hyannis HA 02601
Ralph
Crossen
Office: 508-790-=7
Building Con
Fax: 508.790-6230 unissioz:
For office use only
i
Permit no.
Date AFFIDAVIT,
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL a 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 orb i,It lding be done by registered contractors, with
certain exceptions,along with other requirements. J s�
t/Type of 'work: '
ax, . �� �ti ��x�� t.cost �
/Address of Work:
u a '
/w is Name
Date of Permit Application: a
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
_Job under SI.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 IMPROVFZAENT WORK DO NOT ITRA17ON PROGRAM OR G �
ACCESS TO THE GUARANTY FUND UNDER MGL c 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby a ply for a.permit as th gear of the o
Date Contractor Name
Registration No.
OR
Date Owners Name
The Commonwealth of Massachusetts
Zi-
�� Department of Industrial Accidents
office 0115 restig0ONS
600 Washington Street
Boston Mass. 02111
Workers' Compensation Insurance Affidavit
Lame: l� �t`At�. %JA IV
location:
ci 4 \ Gam .MA
hone# U- S-6 0 3
❑ am homeowner performing all work myself
am a sole r rietor and have no one working in any ca�acity
❑ I am an employer providing workers' compensation for my employees working on this job.
companv name:
address:
city phone#: -
insurance co. Rolicv#
❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices:
comoanv name• -
address: ::.. .::.:. ..
city: phone#: :.:. .
. , :::>
Insurance cm olicv#
:iw:ii::ii:
/////// /
. ..
company name:
address:
city-. phone#: <>;:
insurance co: ;. .. . - oiicv#
Failure to secure coverage as required under Section 25A of:11GL 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flue of$100.00 a day against ma I understand that a
copy of this statement may be forwarded to the ONIIce of Investigations of the DIA for coverage verincatlon.
I do hereby cent der the p d penalties of perjury that the information provided above u rum and correct
Signature Da t JaqJS f -
Print name Phone#
Echeckff
weo not write in this area to be completed by city or town otIIcial
town: permit/license# ❑Building Department
❑Licensing Board
response is required ❑Selectmen's Office❑Health Department phone#; ❑Other
(levered 9/95 PJA)
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any corgi;
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 receive.-
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 work on such dwelling house or on grounds c:
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 renew
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha
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 have 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 along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is
being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law"or if you
are required to obtain a workers' compensation policy,please call the Department at the number listed below.
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. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io
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 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 Imlesdgwons
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 eat. 406, 409 or 375
f
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In DEPARTMENT OF PUBLIC SAW
COMSTRUCTI 11 OII SUPERVISOR LICENSE
r Nu®ber Expires:
` ?
— — Resulted Jo "; 88
R0NALD R N ONTAQUILA
_ 192 SANDY'VALLEY RD
NARSTONS NILLS, NA 11648 �`N•,
0 IMPROVEMENT CONTRACTOR
�t R�gistra,Cioo��I14073 ��*raw g'
. Type PRIVATE CORPORATION ?°
'Expiratioe
` LR MAP OPE R IES,_INC
Spa V1.EYD u>'
rf}
noMINIs�RaTOR r XARSTQ ILLS A�ti016 8
°*THE r TOWN OF BAR
NSTABLE
89SH9T"L&.i
'6 9* BUILDING IN PECTOR
am '
APPLICATION FOR PERMIT TO ..... .l..OP... lrU.2��1..`11
TYPE OF CONSTRUCTION ..i',<C'.Q�.,.zz.
.............. .�...�� 19.7Q.
�...............
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ... �...?!— ............ .. ... ./{ ........44-1lL.�..�......................................................................
j f
ProposedUse ........ ..�. ............................................................................................................................... ;
Zoning District ........................................................................ ............
Fire District �1..!„��U„/.[�� -- L��•Ul`/�,,,
64U ,l
Name of Owner ..�?.��.�.:�:.... ................1.1:V.��.........Address ...�...�!'1.�:4��6.2...5.�1.....�%1;f.,��Qcll..Iln�,,5S'
Name of Builder .....Address ...�V..III.I..�'Y�r ,lG' G�..✓���:..,!ll�ePC/ "'//f.�
Nameof Architect ............ /..........................�I/....................Address .........................../ .....................................................
Number of Rooms ........ ........................................................Foundation ../V..
.
f <.yam /� �j 1
Exterior .:.. k4/./...'i.....C.•.:. .<9.2....,.5,�•%L1/ �iS........Roofiing .......T./, /���./.l.r�. .......................................
Floors ......elf.a:Q.1,0. .O..C��.......................................Interior ......./ ...��......, L`.�'l/: ��......................
Heating ...4-7,4-...�....^-�...[7.Q .40A.T'e..<..................PIumbing ....... C1�A� "`- O / -... `.....
. . ........ ..... ............
Fireplace ........../....................................................................Approximate Cost
f............... ......................................
Difinitive Plan Approved by Planning Board ________________________________19--------.
Diagram of Lot and Building with Dimensions
THE PROPOSED METHOD OF
SANITARY WATER SUPPLY, SEWAGE DISP OS-AL
J �
S AND DRAINAGE IS HERLDY AI `fiuVE,D
TOWN OF BARNS TABLE,
ROA/U s� F HEALTH
-.-�jr
3LM3-c
Nly W3 S.tS 77
,-Lao jsn b-LSN�(Gjv
I
�377t/.CSNI Q�SN3�Jb�d
R� z /uL- /e 4,ql,e--
I hereby agree to conform to all the Rules and Regulations of the Town f Barnstable regarding the above
construction. k _•
Name ..................................................................................
Tominsky, Joseph
DECK 197
12855 one story
permit for ,, ,
No ........... .........................
single family dwelling .
...............................................................................
l 5 Brezner Lane
Location ................................................................
Centerville
Owner ............Joseph Tominsky
....................... .........................
Type of Construction frame p;
................................................................................ 9
Plot ............................ Lot, ........... 52...............
`F o
Permit Granted ......February..2...........19 70 0 �,
Date of Inspection ... '—
Date Completed ..... ..........19 n G o
I
PERMIT REFUSED. �0 \ �
................................................................ 19
............................................................................... i ► b
.................................................. ........................
...............................................
�] I
Approved .............................-.t............ 19
...............................................................................
...............................................................................