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HomeMy WebLinkAbout0042 BRIARCLIFF LANE o � o 0 o Official Website of The Town of Barnstable - Property Lookup Page 1 of 4 Select Language Assessing Division Property Lookup Results - 2017 367 Main Street,Hyannis,MA.02601 «BACK TO SEARCH<< , Print Friendly Owner Information-Map/Block/Lot:148/0861-Use Code:1010. Owner Owner Name as of 111116 JONES;ROBERT SCOTT Map/Block/Lot 'GIS MAPS 42 BRIARCLIFF LN 148/086/ Property Address CENTERVILLE,MA.02632 206 CEDRIC ROAD l � Co-Owner Name ` b ca� Village:Centerville Town Sewer At Address:No �4 Urn GIS Zoning Value:RC ° Assessed Values 2017-Map/Block/Lot:148 1 086/-Use Code:1010 (,C/ 2017 Appraised Value 2017 Assessed ValuePast Comparisons Building $106,200 $106,200 Year Assessed Value P Value: Extra $33,800 $33,800 2016-$263,200 - 3 Features: 2015-$256,500 2014-$256,700 2013-$257,000 Outbuildings:$11,500 $11,500 2012-$255,100 2011 -$254,000 Land Value: $110,700 $110,700 2010-$254,100 l/v� Y " 2017 Totals $262,200 $262,200 2008-$314,600 2007-$313,600 Ulf Tax Information 2017-Map/Block/Lot:148/086/-Use Code:1010 r" Taxes C.O.M.M.FD Tax(Residential) $319.88 Community Preservation Act Tax $75.04 Fiscal Year 2017 TAX RATES HERE own Tax(Residential) $2,501.39 ks f les History=Map/Block/Lot:148 1 086/-Use Code: 1010 I L tory: i ' Y✓ V " " Owner: Sale Date Book/Page: Sale Price: • KQ;k�� JONES,ROBERT SCOTT 2007-06-20 22126/186 $240000 � http:4�.`tbwnofbarnsta le.us/Assessing/propertydisplayscreenl.7.asp?ap=0&searchparce... `ll/5/201704 Official Website of The Town of Barnstable - Property Lookup Page 2 of 4 4. CENGA,JOSEPH A 1992-10-15 8272/32 $1 CENGA,JOSEPH A&CAROLYN M1982-10-15 3578/81 $68000 Photos 148/0861-Use Code:1010 a► f._ � Sketches-Map/Block!Lot:148/0861-Use Code:1010 7 i ll AsBuilt Card N/A Constructions Details,-Map/Block/Lot:148/086/-Use Code:1010 Building Details Land Building value $106,200 Bedrooms 2 Bedrooms USE CODE 1010 A Replacement Cost $137,902 Bathrooms 2 Full-0 Half Lot Size(Acres) 0.47 Model Residential Total Rooms 6 Rooms Appraised $1-10,700 Value 4 Style Ranch Heat Fuel Oil Assessed Value $ 110,700 Grade .-Average Heat Type Hot Water Year Built, 1975 AC Type ' None Effective 23 Interior Floors Hardwood depreciation Stories 1 Story Interior Walls Drywall Living Area sglft 1,390 Exterior Walls Vinyl Siding Gross Area sq/ft 3,130 Roof Gable/Hip Structure Roof Cover Asph/F GIs/Cmp Outbuildings&Extra Features-Map/Block/Lot:148/086/-Use Code:1010 Code Description Units/SQ ft Appraised Value Assessed Value FPL1 Fireplace 1 story 1 $3,400 $3,400 http://www.townof iamstable.us/Assessing/propertydisplayscreen l 7.asp?ap=0&searchparce... 1/5/2017 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 10 F `` yN OF RBARNS4Fpffigation # Health Division ,t • , �, l ; r Datejl�sued Conservation Division Application Fee Planning Dept. Permit Fee �S- Date Definitive Plan Approved by Planning Board ' " .t� TE Historic - OKH _ Preservation / Hyannis Project Street Address "Id. Village Cen�a-Y11\e Owner �tgkr+ VC4, ao ne,5 Address b5 a d OJ pyginfils Telephone 5 n �-4 o 114-o Permit Request PW K- w + I tr ,,�i. 62 s w4h 1-13 celldose, NJ J 1 r a r5 -i 1,.e La-P4 6 rf s; fl . R•r a� i - 4!' DjAiie Q,J bOJ (hen ' WI am, Square feet: 1 st floor: existingro osed 2nd floor: existin Total new p p g-proposede Zoning District Flood Plain Groundwater Overlay Project Valuation4WHO 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 kNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION 1 1I (BUILDER OR HOMEOWNER) 11 _ Name kC[#_SktJ kAne „e ��c. Telephone Number S 6 $ 328 D 3 M Address 7- ) 41, License# S C 1017 T 6 cm Home Improvement Contractor# 3 Email Worker's Compensation # W 01 C 313 6 0l ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Yarp SIGNATURE DATE 8 l i .R FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE f OWNER t DATE OF INSPECTION: FOUNDATION FRAME INSULATION -2 FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts. W 'Department of Industrial Accidents I Congress Street;Suite 100 Boston,MA 02114-20I.7 www.mass gov/dia NVorkers'Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE:PERMI.TTING:AUTHORITY. Applicant Information. Please Print LegibTv Name(Business/Organization/Individual):Cape Save Inc .Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 0266.4- Phone#:508-398-0398 Are you.an employer?Check the appropriate box: Type of project(r"Wu d)s 1:M I am a employer with 20 employees(full and/orpact-tune):* 7. []New construction- 2. I am a sole proprietor or partnership and have no employees working forme in: an capacity. 8: []Remodeling. y p 'ty.[No workers'comp.insurance.requ>red:] - ' 3.1 I am a homeowner doing all work myself. 9., Demolition 4 y [No workers comp.,insurance-required.)t - - 10[]Building addition--' 4.❑I am a homeowner and will be hiring contractors to.conduct all work on my property: l will ensure that all contractors either haveworkers compensation insurance-or are sole 1.1. Electrical repairs or additions proprietors with no employees. 12.0 Plumbingrepairs or additions 5:❑I am a general contractor and I have hired the sub-contractors'listed on the attached sheet. 13 ❑IZOOf'repairs These sub contractors Have employees:and'.have workers'comp.insurance. b.❑We are a corporation.and its officers have exercised:their right 14. Other Insulation of exemption.per MGL:c; - 152,§1(4),and we have>uo employees.[No workers'comp.insurance requireda r•- *Any applicant that checks box#Ii 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'affiidav'Vindicating such. *Contractors thatcheck this box.'must;attaehed 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; 1 am an employer that,is providing workers'compensation insurance for my employees. Below is the policy and job sate information. Tnsurance Company Name:Wesco Insurance.Company Policy#'or Self-ins.Lic.#: C3136274 Expitarion:Date:04109/2016 Job Site Address: 42 Briarcliff Lane " ` :City/State/zip: Centerville Attach a copy of the:workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MOL 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 of this statement may be forwarded to the Office of Investigations:of the DIA for insurance coverage Verification: , I do.hereby certify under:th pains and:penaltie,.s of perjury that the information provided above is:true and correct. Si attire::__ Date: 8/12/2015 Phone#:508-398-0398 Official.use.only.. Do not write in this:area,to be completed by city or town official. •5 City or Town; ^.. .. � � Permit/License Issuing Authority(circle one): << ` 1.Board of Health L Buildin .Department 3.City/Town.Clerk 4.Electrical.;Iigspector 5.Plumbin*Inspectoi 6.Other Contact Person:. Phone#: Ac CERTIFICATE OF LIABILITY p� /�p�/+ >3ATEi , e, YY; �..•�" T i1tlSRar'1.1 i�VE. 3/24/2015 THIS CERTIFICATE IS ISSUED AS A1.MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOM THE CERTIFICATE'HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY`'THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETlMEEN THE ISSUING INSURER(S) AUTHtJRIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER° . IMPORTANT. If the certificate holder Is An ADDITIONAL INSURED,thepoNcy{Les}must 0e endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an a ntlorsement. A statement on thl"s certificate does not confer rights to the certiticate:hoider in li®u oftuch endorsemen §. PRODUCER # NWNIA AME: C011eeI3,CrOW�e]t Risk Stxategildsr Company PHONE {]$1)986-940I7 ` FA (781)969-9A20 AJCrc o 15 Eacella Park Drive 54WAIL .ccrowley@risk-strategieS.com Suite 240_ INSURE S AFFORDING.COVERAGE NAIC 1 02368 INSURERA. leCtIVG Ins INSURED INSURED ... . INSURERS Allm>!"ica FZnailCli3l AZ1l8gCe ' ©212 Cape Says, IAC INSURERCWeSCO Insurance. any 7 D Huntington Ave . INSURERS. � : South Yaeuth 0266,4 -- ... INSURERF: COVERAGES CERTIFICATE NUMgER.CLI532491501 REVLSIQN NUIIM1BER. TICS;IS TO ZERTIfY THAT-TWE.POUCIEs Of'WSURANCE tISTED•BELOW HAVE BEEN ISSUED TO THE'I14SUREd"NA1dIED'I1601rE FbR IHE POLICY"PEKIOD (iVBICATEII. M0TWITH57Afi1DINd ANY REQUIREMENT,TERM OR CONDITION.Of ANY CONTRACTOR OTHER DOCUMENT WITH'RESPECTJO,YiiIiICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE:,AFFORDED BY THE POLICIES OESCRIBED.HEREIN IS SUBJECT TO ALL THE TERMS;. EXCLUSIONS AND CONDITIONS:Of SUCH'POLICIES.LIMITS SHOiMV MAY HAVE BEEN RE1.DUCED BY PAID CLAIMS: 8R TYPE OF INSURANCE am wvo S POLICY NlJs98ER OL ICY EFF .:C'NO/I7D EXP LIMITS GENERAL UABILI Y EACH OCCURRENCE $ l,000,000 X COMMERCIAL GENERAL LIABILITY GE �— PREMISES Ee occurrence $' 100,000 �+ CLAIMS-MADE`Q OCCUR' 1994490 O/16/2014 O/16/2025 MED EXP(Any one person) $' 10,000 PF 2501'dAL,�B AOY iN,.A1.4Y $' 1,0,00,Q00 GENERAL AGGREGATE $ " 2 DOO,ODO GEN'L'AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/ORAG.G $ 2 ,000,000 POLICY X PRO-. X LOC $ AUTO M08A E;LIABILITY Ea cci ent' 1 000. 000 ANY AUTO B BODILY INJURY(Pet parson) $ ; ALL OWNED SCHEDULED 4t79fifi00. 1 BODILY INJURY(Per acadent} $ AUTOS I AUTOSs. /6/201g 1/6/2015 X `HIRED AUTOS X .Not�OV9A�lFD OPERT:Y»DAINAtiE: AUTOS $ . X UMBRELLA LIAR < . X OCCUR EACH OCCURRENCE $ 1 000,.000 EXCES9 LIAB CLAIMS 1ADE AGGREGATE $ 1.,000,000 DED REfEI+fTION ai 39944$U pJi�/aaYa o/36/2035 C WOR►tERSCOMPENSATiQN $ AND EMPLOYERS"uAOttITY ffi Ys Included for X `incsTATLk T_ ANY PROPRIETORIPARTNERIE)ECUTIVE vlro overage OFRMR/EMBER EXCLUDED? N. NIA E L EACH ACC{DENT $ J00 000 (Mandatory in NH} 136�7� /9/ZOI"5 T9/201 b r.• E:I:.'DISEA$E EA EM?.'OY if s,describe under } DESCRIPTION OF OPERATIONSbeto6+ DISEASE-POLICY LIMIT $ 5'00 000 DESCiBPT)ON OF OPERATION$!LOCATIONS!VEHICLES(AttacRACORD 104,Additional Rem ark s'8chedIm" if more spate Ls requirnq Issued as evidenbe of insurance. • Thieiseh. Engineering, Inc. is listed as: additional insureds;as respects; General Liability;as' rquixed.br uorri$t eT> sort#:ract:. ;. CERTIFICATE HOLDER CANCELLATION m>aongC�c ur"EXPIRATIONTHE Da De anc��wra A apels�htoou�?act>.or CELLED sE�oRe as DELIVERED IN Cape Light Compact ACCORDANCE WITH THE'POL.ICY PROVISIONS: Attn: Margaret Soap AUTHORIZEDREPRESEroTATIKE yQQIL ii�i7jY�Ci}t 3195 Main Stroet Barastablt';:DDi fl2E30 chael ChsstianfCLC - ` - - y ACCJRi7 25.(ZDt0/05j Q I988.,2t11-4 ACORO C P43R�4T4#31}. AI#seght�resei�rsd. INS (zotoos).at The ACORD name andlogo aro registered marks pf ACORQ..:: Building Permit Authorization I, Robert and Rita Jones , as owner hereby give my permission to Cape Save, Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Office:508-398-0398 to take all necessary steps to obtain a building permit to perform.work at my property located at 42 Briarcliff Lane Centerville, MA 02632 Signed Date '7/ /� Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 . Home Improvement C6ntractor Registration Registration: 171380 Type: Corporation l Expiration: 3/14/2016 Tr# 249649 CAPE SAVE INC. WILLIAM McCLUSKEY - -�� 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 y ` ` . - --- ---- Update Address and return card.Mark reason for change. SCA 1 t 20M-05/11 Address M Renewal E Employment Lost Card �f�v tlo•ii�ryurculetc�C�rif�l�l�krn"ccJ�' - . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only WE OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: egistration. T171380 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 xpiration 3/14/2016. Corporation Boston,MA 02116 CAPE SAVE INC. 07 WILLIAM McCLUSKEY� 7-D HUNTINGTON AVENUE _ SOUTH YARMOUTH, MA 02664 Undersecretary Not vali tthout signature Massachusetts -Department of Publlc Safety Board of Bui ding.Regulations and`Stan lards ryry �. 4t)111t7 IIt L1U11'Jt��IC1')11111 JIfELIQILY` : RAC License: CSSL-102776 T WHILIAM J MC U 37 NAUSET ROAD West Yarmouth NA J..G,.» /S[�C„>� ►t+ Expiration Commissioner 061=2017 fME Town of Barnstable *Permit 4 OF Tp� Expires 6 monthsJrom issue date Regulatory Services Fee sntwsrABM ► Thomas F.Geiler,Director MASS. 1639. & Building Division !, Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstab le.rti a.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY- Not {valid without Red X-Press Imprint Map/parcel Number Re S)/© � 1 Property Address �-/a QYta✓C 1��� �cn_y[ Ce OIL-eu." Ile &44.4 1 [residential Value of Work ` Minimum fee of$25.00 for work under$6000.00 Owner's Name & Address "-L) e-✓ L7 I --jes, _s - Contractor's Name rtea — ca��✓t /Grr�n�� Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Che k one: I rrt a sole proprietor APR 2 22008 f am the Homeowner �S-rAs ❑ I have Worker's Compensation Insurance'' " -'OwN OF IBAk Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on tile. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) []'ate-side --7*fe u- S 0'z"'e S�•'�t�Z,' [Replacement Windows/doors/sliders. U-Valuevt dye• + (makimum...44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:_ Property Owner must sign Property Owner Letter of Permission. A.copy of=the Home I,mprovement Contractors License is required. SIGNATURE: r _ 1. ... . . . .. Q:Fo rms:b u i l d i n gperm i is/exp res s Revise112807 opt Town of Barnstable ` , "o„ Regulatory Services . BAMSrABM : Thomas F.Geiler,Director 1639. ,�� Building Division rED NIA't A - Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: LAC 2 2 r 204 JOB LOCATION: �i V,,U ��ue �eu2�et tic Oka _aa. number street village "HOMEOWNER": ';?19&t"t .�ByPS -09-'7 Z5-- < Z O'Y. S'C$^ V "6 name home phone# work phone# CURRENT MAILING ADDRESS: R ® Cam co city/to state zip code . The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel 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 insp ' procedures and requirements and that he/she will comply with said procedures and requirer"591s. Signature oTH8meowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for:hire to do such work,that such Homeowner shall act as supervisor. Many homeowners who use this exemption are unaware that they are assuining the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC • 1ME 1 r Town of Barnstable anaxsz"LF4 ' � Regulatory Services ArEo MA'I°i Thomas F.Geiler,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 to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner Date Print Name Q:\WPHLESTORMS\building permit forms EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): �o vc o f Address: City/State/Zip: Phone.#: 5-a Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. 0 I am.a general contractor and I 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. [v]�Remodeling ship and have no employees These sub-contractors have g, E Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.insurance comp.insurance.t ���ed.] _ 5. We are a corporation and its 10.❑Electrical repairs or additions 3.I V1 I am a homeowner doing all work officers have exercised their 11.El Plumbing repairs or additions myself[No workers' comp: right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other cotnp,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. rContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whctha or not those entities have employees. if the subcontractors 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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crirnirial 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 der th p Ins- enalties of perjury that the information provided above is true and correct Signature: Date: Z 2a© Phone#• 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 hiie, express or implied,oral or written." associatio co oration or other legal entity, or any two or more An employer is defined as an individual,partnership, n,corporation g of the foregoing engaged in a joint enterprise, and including the legal representative's 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 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 fok 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 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 onp 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 homeowner or citizen is obtaining a license or permit not related io any business or commercial venture (Le. 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 MassaGhusetts Dgmtment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-490..0 ext 406 or 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass..gov/dia Q` � o P 0 / Assessor's mdp and lot number ..:.......F..............:............ r= SEPTIC SYSTEM MUST, BE ' INSTALLED !N COMPLoA�tCE t. Sewage"'Permit number ........ tl...., .. WITH_ARTICLE II STATE SA#V iTAeRY i CODE AND-TOWN. . . THET��o TOWIN O BARNS AIPLE S BARNMPLZ, • `" y NA86:. RUIL� IN� INSPECTOR o m {r• _4 f,7 ADDITION TO RESIDENCE r� APPLICATION FOR PERMIT TO ...: ..................... ......... ........................................................................ TYPEOF CONSTRUCTION .. G9.d..T-rAMe4...............: ....................................................................................... ,. January ...3....1977......,9........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......Briarcliff Lane Centerville...•..MA•®.__..•.. ......................:................................................... ................................................................... ProposedUse .......esiderice .......................................................................... Zoning District .....Rc ..........................Fire District •..Centerville-Oste.rville .................:.................. ................................................................ Mr® L® Allen Jones•..................Address Briarcliff Ln Nameof Owner .............................................. .................................. .................... Name of Builder rp.........................Address I3I Old Post Rd Centerville......... Name of � ier.....Barr�r Flemmir� l..The..B &IsIL3'...CorP.®................. .............:..................................... Number of Rooms -..........Foundation CraW1 . poured con,C,f. .............. ....................................................... Exierior .Bik h {� .............ROOfng a ................................................... Floors Yard ood8 Interior .....:MA-oarClIng.......................... ✓ ............................ Heating ..................................................................................Plumbing .................................................................................. Fireplace ................Approximate Cost ,F'lmo..ThQ,1,1.s.R.L &...p llml........... .................................................................. Definitive Plan Approved b Planning Board ________________________________19________. Area ....... ... .. . ......................... pP Y 9 Diagram of Lot and Building with Dimensions Fee ............... .. ............. SUBJECT TO APPROVAL'OF BOARD OF HEALTH NICir� Ci`�`Cs"T • j s 0 , N 1 I hereby agree to conform to all the Rules 6nb Regulations ofle regarding the above construction. a F1 mming Name SrTHE`"" RCT;AY' *C10RP.... .. Jones, L. Allen A�2P� �00 tO singleNo .... ermor ..... ... .......... ....... ................................ . Lane i ',:4 Locatio ..... ................................. VV Cenferville CL ............................................................................... L. Allen Jones t, Owner .................................................................. `Z, Type of Construction .........frame ................................. ................................................................................ AL Plot ............................ Lot ................................ Permit Granted ........J.anuary 3, 77 Date of Inspection ........ Date' Completed .... ....... ... .19 0 PERMIT REFUSED ...................................... 19 ........................................................... ............... ................................................................ ................................................................................. ................ ...................................................... Approved ................................................ 19 ............ .................................................................. .................... .......................................................... r.�,,. �. - � -^ ..�.�, a f.:..,.,,�,,.. t t-. r^ a ,� �;,--v Yr3".a�n. -.,.!"4 e. .h+r"3.ti>vr"'+vr �. ,wy^",,,�.'atny'Ysyy.+.�....��.•n..+�,.,,y rt « ^e • ,.. t!' Y.. -.s3...iw<'i.+�.F -.^...,.r 'urv"P•^�17+*^lt` .,•,13�""r'�,,d �i»�^1.t'G Assessor's map and lot'.number .......................................... 7�0, Sewage Permit number .........�!,e.... TOWN OF BARNSTABLE Z 33AMSTADLE, i "6 BUILDING INSPECTOR �Fp Mar Or• _ APPLICATION FOR PERMIT TO .......ADDITION. TO RESIDENCE.............................. k �1C1 C?C� 1Y'tt t11fa k TYPE OF CONSTRUCTION .............•...:;........,........................................................................................................:. ..January...3 19. .77......19..................... .. .......... .. ..... .---TO THE-INSPECTOR OF -BUILDINGS: The undersigned hereby applies for a permit according to the following information: • Location .......Briareli£f Lane Centerville, MA .................................................................................................................................................................. Proposed Use .....RagidQrice Zoning District RG.............................................................Fire District Centerville—Osterville ........... Mr L.. Allen Jones Briarcliff Ln Nameof Owner ......................................................................Address .................................................................................... The Barelacr Corp I3I Old Post Rd Centerville Nameof Builder ............................._.......................................Address .................................................................................... Name of Archi e_ctd�T.....Barry Fle?2 ming/ Th6 BRd resesq. Corp- .......................... .................................. Number of Rooms ..................................................................Foundation Crawl/ poured cone o .......................................... Exterior ..$ ' Ck„Veneer/..W. C...Shin le.s.............Roofing .��v ..Asphalt .I.... ........................................................ Floors YArd :RQOds ..............................................Interior ....ine. B ...oar i.n .......... .. .. ............................................. Heating ..................................................................................Plumbing .................................................................................. Fireplace ..................................................Approximate. Cost .F�ve..Thousand Dollars ................................ ...................................................... Definitive Plan Approved by Planning Board __ ____________________19________. Area ...... !. ...................... Diagram of Lot and Building with Dimensions Fee ' SUBJECT TO APPROVAL OF BOARD OF HEALTH _ I E � d � �, 0 I =.� ��.�5.,�-•,�„�C� �"�y`+ � jC:3�".cam -7�. -:+ice _ _ t f I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �. ar F Himing Name Jones, L. Allen &=208-108 . � l89U4 ^ , NoPermit . family dwelling, ----.. —.------ Lane ! ' Location ..xw�.��-..����c.-�-�-------. . . r Centerville ---------.----..—.---,�------. � � �ll�o Jooeo {�vvner ----.�-----------.--�---. �ro�e ' Type of Construction ---------.----.. ` ' . --..------..---------,------.. - ^ Plot ............................ Lot ................................ . J . Permit Granted— .......... ---'' ' . . , uo/e or Inspection ........................... ........19 uore Completed � PERMIT FUSED ~ _ - . ^ - . - .' ' ..............''. .............. ...---7--' ..................... ............................................................ .................. ~ ' � . . . . '----- ''�'' r . . . . ' � Approved ................................................ 19 > � ' -------'---------------^—'~— ' ' . ` ...............--........ ................................................. | | /