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oF1T Town of Barnstable Permit#
pErpires 6 and front issue date
Regulatory Services Pee
g Y
BnxrrsTnai.E,
MASS.
��� -Thomas F. Geiler,Director
-
Building Division
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 Palid withoutRed X-Press Imprint
Map/parcel Number �� V
Prope Address o"a R' I^Alp 2 in
esidential Value of Work Q Minimum fee of$2S.00 for work under$6000.00
Owner's Name&Address
e � l
Contractor's Name . oP/1/ Telephone Number/ -ID7/ (WO
Home Improvement Contractor License#(if applicable) S
Construction Supervisor's License#(if applicable)
Workman's Compensation Insurance .
Check o
S PERMIT
❑ I a sole proprietor SEP 16
VI
m the Homeowner �a�
ve Worker's Compensation Insuranc "OWN OF BAMS-rABL
Insurance Company Name i]el) U�
Workman's Comp.Policy# T �j
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
- ---- ----❑Re-roof not-stripping- -in . Goin over—. - existin -la ers of too PP g_ _ g g Y --
❑ R -side.
#of doors
Replacement Windows/doors/sliders. U-Value d (maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
P
A copy of the Rome Improvement Contractors License& Construction Supervisors.License is
required.
SIGNATURE:
QAWPFILES\FORMSIbuilding permit forms\EXPRESS.doc
;a The Corn mon wealth of_Massacre:;setts
' Department of Industrial Accidents
�r I' Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractois/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name(Business/Organization/individual): ���� SSp
_ 1
Address:
City/. tate/Zip: OXIV�aE;kc Phone M 90li
Are u an employer?Check the/appropriate box: Type of prof required):
l. I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑N construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling
ship and have no employees . These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.t 9. ❑Building addition
required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions
q ]
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
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 mist 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: I �' 60/9 J ' (1 U% /t/S LU,
Policy#or Self-ins.Lic:#: ? Z5 ✓VA Expiration Dater
Job Site Address: (� City/StatelZip:C 2 , 03
A/t9-C
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator.'Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify der the pains and penalties of perjury that the information provided abo is trug and correct.
Signature: Date: ��` v
Phone#:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: " Permit/License#
Issuing Authority,(circle one):
1.Board of Health 1.Building Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
11-11—,A 1 C Ur 1. IAMILI I Y 1N%`>V 111i-'Ia a /o f20
PRODUCER` THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Hunter Insurance, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
389 Old River Road, P.O. Box 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
,Mayville RT 02$.38--0001
Phone:401-709-9500 Eax:401-769-9502 INSURERS AFFORDING COVERAGE NAIC'Tur
ItISUREO Moan Associates Ina, r -1111�0URERA- national Grange Co 14788
DBA, Gutte-r Helmet
DBA RerleCaal by Andersen of 'RI (NSURER8: Seacon Hutual itiurance Co.
DBA. Gutter Helmet Roofing,
D8A. Moon harks INSURER c T
1137 Park East Drive INSURER D:
Woonsocket RI 02895 -- --
!NSUP.EP,E:
COVERAGES
TrE POLICIES OF INSURANCE LISTED BELO''W HAVE BEEN ISSUED TO THE INSURED NAKED ABOVE FOR THE POLICY PERIOD INDICATED.NOT JVIIHSTANDING
A14Y REQUIP.EMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE NAY BE ISSUED OR
N f PERtAIN,T HE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TMIS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POY EFFECTIVE POLICY EXPIRATION
LTR ItISR TYPE OF INSURANCE POLICY NUMBER DATE tLICRU ) DATE(MNVDD1YY1 ITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
A (X COMMERCIAL GENERAL uABILIrr. IvIPS26619 09/16/09 09/16/10 PREMISES(El a $B00000
CLAIMS Pa-OE FX�OCCUR MED DQa(.Any one person) $ 10 00 0
PERSONAL&ADV INJURY $ 1000000
GENERAL AGGREGATE $2000000
GeIL AGGREGATE LIMIT APPLIES PEP: PRODUCTS-COMP/OP AGG $2000000
POLICY PROT LOC
AUTON-16BIL.E LIABILITY COMBINED SINGLE LIMIT
A I X ANY AUTO B1S26619 09/16/09 09.116110 (Es accident) $1000000
ALL OV}TIED AUTOS BODILY INJURY
SCHEDULED AUTOS (Par person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABI I Y AUTO ONLY-EA ACCIDENT $
ANY AUTO OT HER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMSRELLALIABILITY EACH OCCURRENCE $1000000
A IX OCCUR FcLAIM1SMV+DE CUS26619 09/16/09 09/16/10 AGGREGATE $
DEDUCTIBLE $
IX RETENTION $10 0 0 0 $ r
WORKERS COMPENSATION X TORY LIMITS - . ER'
AND EMPLOYERS'LIABILITY Y I N
B ANY PROPRIETOPJPARTNERrTFECUnvE ❑ 28586 10/01/09 10/01/10 E.L.EACH ACCIDENT $S00000
OFFICER(MEMBER EXCLUDED? —--
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $50 00 00
It yes,SPECIAL
PROVISIONS below E.L.under E.L.DISEASE-POLICY LIMIT $500000
SPECIAL P
( OTHER
I .
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
f
,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
mmvAL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER rW ED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABIL4 Y OF ANY KIND UPON THE INSURER,ITS AGENTS.OR
Renewal By Anderson REPRESENTATIVES.
1137 Parr East Drive AUTHORIZED REPRESENTATIVE
Woonsocket Rz 02895
A CORD 25(2009/01) 019M2W9 ACORD CORPORATION. Afl rightsreserved
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Enginmring Dept.(3rd floor) Map / 7/ Parcel ,J/19 A)s Permit# � 7
` House# p Date Issued ('=l1 �
.Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30.)7 -Z 5�a 4 Fee
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) /. SEPTIC SYST00 F,,'?ZS E
Planning Dept.(1st floor/School Admin. Bidg.) INSTALLED � M�LIANCE
Definitive Plan A prove by Planni Board 19 ENVORON ODE AND
TOW
TOWN OF BA STABLE
Building Permit Application
Project Street Address C
Village C e f l- L/
Owner a -' Address 7 S i
Telephone
T
Permit Request J .p b4 o
First Floor square feet s/Second Floor (IJ ( square feet
Construction Type �A p SS 4,1, P �� ?X T e
Estimated Project Cost $
Zoning,District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure : tf Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No
Basement Type: 14 Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing —� New Half: Existing New
No.o"f Bedrooms: Existing �3 New
Total Room Count(not including baths): Existing-- New First Floor Room Count
Heat Type and Fuel: XGas ❑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
/r Builder Information '! l
Name Q 0 )- `(d ! Telephone Number ` D 9 21 (c�
Address / `P d x ►_ License#
C etl ve-- f/ I,`�Q /Y\�� r d 3 Zr Home Improvement Contractor# D D C D
Worker's Compensation# 3 p-. X r3 O 5
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTI DEBRIS RESULTING FRO THIS PROJECT ILL BE TAKEN TO
SIGNATURE Cal
_ DATE
BUILDING PERMIT DENIE FOR THE FOLLOWING REASON(S)
Y.
FOR OFFICIAL USE'ONLY
a •
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO. aX4
ADDRESS - VILLAGE
OWNER f �
DATE OF INSPECTION: '
FOUNDATION
FRAME .
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL �-
t ' l
PLUMBING: -, ":ROUGH - f FINAL- -
i
GAS: -ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT; "
ASSOCIATION PLAN NO.
The Common wealth of Massach usetts
Departm42
ent of/adustrialAccrdents
OJri►csiJ/oi%es1/ostNis
600`Washign ton Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
AnoUUMI Information•
PODAu /�Lt
localio
phoned
I am a homeowner performing all work myself.
❑ I am a sole proprietor and ha%e no one ��orking in ans capacity r
I am an employer pro\,iding workers' compensation for my employees working on this job.
�. �s ��
com anv name: 1at�
addres
LL h
insurance co if f-t e 4}q Q� t C�t� Policy
I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the following \%orkers' compensation polices:
company n a m : s;f}f;fr
address:
insurance CO policy a
comvRny name:
insurAnce co.
DbOne�'
policy
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a 6a�t ap to SI.S00.00 aad/or
one years'imprisonment as well as civil penalties in,the form of a STOP WORK ORDER and a One of SI09.00 a day against me. 1■aderstand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verificatioa.
I do hereby cerrif)-under th atns and penalties o er a that the information provided above is true and correct
Signature - Date Q-
Print name 6)
�l Phone#
official use only do not write in this area to be completed by city or town official Drd
city or town: _ _ permitAicenst q rlBuildiag DoUcensieg BO check ifimmediate response is requiredOSelectmto'pNealth Depcontact person Phone t/ _ nOtber
. _
rpnld U93 P A
�' j { '•�
The Town of Barnstable
9 1659- `e�' Department of Health Safety and Environmental Services
3
�n ram" Building Division
367 Main Street,Hyannis MA 02601
Office: 508-8624038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
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: Xay cVOC� Estimated Cost r rd
Address of Work: ? �)a,2�Si fit 7'
Owner's Name: 1 lk t4V1 4-AV - b r,
J 92 Date of Application: p L( '-'
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
Job Under$1,000
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 IMPROVEMENT WORK DO NOT HAVE
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.
A//4
Date Registration No.,
fOR
Date Owner's Name
q:forms:Affidav
STANDARD LEGEND
NOTE:not all symbols will appear on a map
° GOLF COURSE FAIRWAY
MAP171 MAP 171 EDGE OF DECIDUOUS TREES
1 ^ � O �� EDGE OF BRUSH
L/ -- ORCHARD OR NURSERY
# 222 # 237 V-P-V--V EDGED CONIFEROUS TREES
MARSH AREA
—---— EDGE OF WATER
DIRT ROAD
DRIVEWAY
�=PARKING LOT
�- —PAVED ROAD
------- DRAINAGE DITCH
MAP 171 -----
PATH/TRAIL
1 ^ _ PARCEL LINE**
171 (J,� ,21 �___-MAPS
# 2 2 7 #1 —PARCEL NUMBER
_ #taco—HOUSE NUMBER
3 `�p�� 2 FOOT CONTOUR LINE
2 - 38 10 FOOT CONTOUR LINE
�\ j/\4.9 SPOT ELEVATION
\ 00o STONE WALL
-X—X- FENCE
a a RETAINING WALL
MAP171 RAIL ROAD TRACK
1 STONE JETTY
o SWIMMING POOL
71 # 211
/ \�l PORCH/DECK
MAPu BUILDING/STRUCTURE
3
DOCK/PIER/JETTY
�� •Q HYDRANT
\ # Z Z e VALVE O MANHOLE
O POST O'' FIAG POLE
T.O- W N O F B A R N S IT A B L E O E 0 6 R A P H I C I N F O R M A T I O N S Y S T E M S U N I T 0 SIGN STORM DRAIN
N PRIMED SME:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES:Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The J1 ames
1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD UTILITY POLE II TOWER
W e 0 20 40 National Map Acaracy Standards at this do not represent actual relationships to physical objects Corporation. Plonimetrics,topography,and vegetation were mapped to meet National Mop Accuracy Standards
=e 1 IN01=40 FEET* enlarged W_
on the map. of o scale of 1"=100'.Parcel lines were digitized from 1999 Town of Barnstable Assessors tax maps. ¢ LIGHT POLE O ELECTRIC BOX
...\sitemaps\Public\m171p19.dgn Aug. 11, 1999 08:26:34
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DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Ez ires: Birthdate:
CS _ _,:,118899 18116 1999 e8�16�1936
8estr�ctted To
fiEORGE Jk AMAIN e
v 31 JOEI RD"
S YARNOUTH, NA 02664
HOME IMPROVEMENT CONTRAC Registration I00105 R
Type - INDIVIDUAL
Expiration 06/09/00
Ell
GEORGE ALLAIN
""Q ,1116 SHEWER Rd. !
ADMMsTRATon!terville MA 02632 i I
yoFTNEro�f TOWN OF BARNSTABLE
i EAUST"LL i
9��OMYa BUILDING INSPECTOR
APPLICATIONFOR PERMIT TO. .............................................................................................................................
TYPE OF CONSTRUCTION �
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ........ ...�/....�..��.. ? ... ... ......... . ., .��" ""'ti
ProposedUse ...................."''.' ......................................................................................................................
ZoningDistrict ......................................... ............................Fire District ........:;:.....................................................................
Nameof Owner .......................................... Address........ _ . ........ . .............. ...............................................
Name of Builder << .......Address
Nameof.Architect ..................................................................Address ................................................:.....................................
Number of Rooms ... !........................................................Foundation ....
Exterior ,.. ,. , I t .............................................Roofing .. -. .........................................
Floors .Interior .....y�-."'��....... ...................................
Heating ,/'"`" �,✓' ...........................Plumbing
Fireplace : .....................................Approximate Cost .......: . . '..V............................
/
Definitive Plan Approved by Plan,,,ar'ing Board -----------____------_-------19________.
Diagram of Lot and Building with Dimensions / p •
J a��
SUBJECT TO,APPROVAL OF BOARD OF HEALTH
ILL- uz,
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ., �..:...,%. ; .................
Small, Alan
o�a otoz� � '
No —.�����.. Panni� for --.—.---�-'�.�---. '
—.--..�...........-...........�..................�..--.---..- .
---- " /
^ Buckskin Path .
-.ion_ --.---_------^-------.—
/
Centerville
^^~—~`--''''''----'—'-------''----'--
Owner Alan �—oa�II
-----'— ----'-------'---'
Type of Construction .......frame........................
,
,
----..~—.—~-,-----..--.—.------'
Plot ............................ Lot .--.#20-----..
/ y�^
Permit Granted --'laJ'..9—.---..—.]9 72
/ .
Date-of Inspection ....................................
` ~v
. x
Date Completed 19 `
« \
' .
PERMIT REFUSED
� —.--.--.—.—..,....-------- 19
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