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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Al
Map �� Parcel // 9 - Permit# h 37 02 7-1
Health Division Date�lssA ` V_<23_ 5 F
nn
Conservation Division - Fee
Tax Collector
Treasured` 00 A� o Q
Planning Dept.
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis k
Project Street'Address
,Village
Owner fd /.0,&,4/ Address
Telephone
Permit Request cS
Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new
Estimated Project Cost Zoning District Flood Plain - Groundwater Overlay
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
Ditached 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 O Yes ❑No If yes, site plan review#
Current,Use Proposed Use '
'BUILDER INFORMATION
Name < Zc Telephone Number -7 7 -7-2
Address License#
Home Improvement Contractor# l n
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO -�'iZ, �
SIGNATURE DATE �'O �'
FOR OFFICIAL USE ONLY
.PERMIT,NO. T '
DATE ISSUED, j 7 ►
Y
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTIO 4
FOUNDATION
FRAME
INSULATION
FIREPLACE ? -
ELECTRICAL: ROUGH 'FINAL -
PLUMBING: ROUGH - d •FINAL
GAS: ` ROUGH FINAL
FINAL BUILDING _
DATE CLOSED OUT
ASSOCIATION-PLAN NO.
O
The Town of Barnstable
KAM �m Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
Permit no.
Date t ��
G
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: Er,/Z-l � '�'� Estimated Cost
Address of Work: ' `
Owner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job Under S1,000
Building not owner-occupied
[-]Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING 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 fora ermit as the agent of the owner.
Date Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affidav
1
_.-. Tl:e Commonweafth of Massachusetts
Department of Industrial Accidents
(JAI __y ; 1 Ofllct atlm►estl�adoos
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance davit ,
e:
location-
City phone it
❑ I am a homeowner performing all work myself.
❑ I am a sole aromictor and have no one working in any ca achy
I am an employer providing workers' compensation for my employees woddrig on this job.
eounnanv name• fa'/ �� �G C
address: 6�
cites �� /� /v l�r phone#t 7 7
insurance rn. T� / e < niicv t! Ve- `e G �'
❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the conaactors listed below who
have
the following workers' compensation polices:
comoanV name•
oddresse •K
dtr. Acme*
.. .<.:,. . ...... Its+#
Insornnce ce
------------------
• .. .. Kiv ...
con anv name-
address•
dtv- phone M. :....
nsursnce t O: a.:.:..... ?.t••..... ,:: o#d... IIt:V i!' .,�;.:....:.;.,„w;^^..
Failure to scents coverage as required under Section M of MGL ls2 can lead to the imposition o(c inmui pendtln ata am up to s1 ouo and/or
we yearn'impstwument as well as drat penalties in the fora of a STOP WORK ORDER and a Qne of s100.00 a day against am I understand that a
'copy of this statement may be forwarded to the Ounce of Inrtsti;atiotts of the DIA for eoeerav•eritt ulm
I'do hereby t nti der e p Perjury that the information provided above is true,and
Sigpattue Date -
7
Print name s ;7�
oludal use only do not write in this am to be completed by city or town oMcId
dt►or town: pereeftscen"p Mtdldlas De
p
DLieansias Board
OInCV
❑chmkiflamtedlate response is required ❑S esittnm's ruan
I�Seaith Depaetmmt
contact person: phone#-. ❑Other
Cmv ua 9/95 PIAI
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 cm= -
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
cue foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the recwn'er .
uvstee 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
.,.i.�"a%^awwmiggm„Pvvrvmc to do maintenance construction or repair work on such dwelling house or on the grounds o:
a:......... ..........r...;.,r---�--- --
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 insumnce requirements of this chapter have been presented to the CDIIL�CLITiQ
authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to yoursrtnatiam and
suppivinS company names, address and phone numbers along with a certificate of insurance as all affidavits maybe
,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 Departneat at the m=b. er listed below.
i ,
/ /I ".
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 art in the event the Office of has to contact you regarding the applicant. Pl=c
be sure to fill is the permit1licease number which will be used as a reference mrnber. The affidavits may be returned io
the Department by mail or FAX unless other arraagemeats have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should von have any questions•
please is not hesitate to give us a call.
'the Depn,.r= at's address,telephone and fax number.
The Commonwealth Of Massachusetts
Department of Industrial Accidents
Office of imtesd0adons
600 Washington Street
Boston,Ma. 02111
fai If: (617) 727-7749
phone #: (617)•727-4900 eat 406, 409 or 375
�\ U9
. CC��i_(�✓liliCt'v�'I�:Cio;%CtuF'Ltcl � ^�
11ME�;IMpRO:VEMEN��x C.ONTf�ACTORS REGISTR,AT10N /
_ o`ard'" of Building'`Regulat` Ens and 'Standards '
One Ashburton Place Room 1301
Bos,i�to W
s'V h: :R ..
4on T g .-.. s.. Val
Xy'
H ME IMPROVEMENT, C,ON�y,TR':
t'.. .:.�"5 fin. •,,:.H. .:e.- v..]'. v ,. J. r .:'.:.rl e1 ."k{e 2.s-txat':iot�e1,08.g1;� x ir:,a .o:n
;; P t Q. 2 00
•-.•+y.F :may . ..,....., „< _:. .. }. ,a; •. �ieT.-E.,�&. , ..x v^: �n :�.._ .'` .• i
v ;'C..t .,; .. a -- fi-7. a ,e a ..a. -
�.• �,�. *l {,fit.., '� .:yp't4 . - ` �✓ ,//
F 'd T f t 1.. v' "Vu �y, .h� 2- L r1, M .T46�;7ICfJbi'iN.sKu�''I.C.N t' .!iY.�.afflCrt'uoe�,wp r
.0>r '.43.v+,:,,..�ne:c:'r`r a-4 "'*r.-
HONE�Ir:r RO�._ME►IT EONT4ACTOR
� � '
:, ,ra .. :-: r � xf �� •' - r ReAistr'ation lOby18
� � .& a 1 INDIJ.IGUAL
THE.ODORE=L HITCHCOCK; Expiration O8/21/0.0.
-
;t4 W BARNSTABLE MA 02668 ' j THEODORE L. HITCHCOCK
PO 60% 211/ 55 LISA LN -h
I.AARNSTABLE MA 026b8
ADMINISTRATOR
w " Q1 N
i
T"E�°�� TOWN OF BARNSTABLE
i BARISTABLL i
9� Q aYa�e� BUILDING INSPECTOR
APPLICATIONFOR PERMIT TO ...... .. ...............................................................................................................
TYPE OF CONSTRUCTION
..... .......,..........................19.7
TO THE INSPECTOR OF BUILDINGS:
a
The undersigned hereby applies fora ermit according to the following information:
3
v _- ��
Location ...... ..... .............. ...��... . ........................... ... —................................... . . . . .....................
ProposedUse ..... . ... ... ........... . ...........................................................................................................................
ZoningDistrict ................................... ...................................Fire District ....../;............. ......................................................
Nameof Owner ......................t..;..: ................Address ....................................................................................
Name of Builder ..................................Address ................................
Nameof Architect ..................................................................Address ........... ...............................,.........................
Numberof Rooms .......6....................................................Foundation ................... ...........................................
Exterior ,...... . ................:' ............Roofing ........ ............................................................
Floors �- ...................Interior ......r................................................................... ....................................................
Heating ......!........................... '.........................................Plumbing ....... ... -.e`- ....................................
Fireplace ........ ...................................Approximate Cost .... ".' .. ....
..�. .........................
Definitive Plan Approved by Pldnning Board ________________________________19--------. �6 V �� �,•
Diagram of Lot and Building with Dimensions
SUBJECT TO APPROVAL OF BOARD OF HEALTH o
LU
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Nam ........................:.........se Cl".................................
Soaal]'v &Iazz `
-
'
one story
No —. Permit for ....................................
single family dwelling
............. ' .......'`'~--'—^^—'—'-'—'—^'—^`--- `
LocatO�
1�zcicakin Path
----`— ~—'---''—''-----'---'—'----'-
Centerville
--------'---'--''---'-----'---''
�Ian Soa�]'
Owner -------------'--------'--'
Type of Construction .......frame........................ '
_~--..,^,—._..--.—.-.~—.---..-----
�
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Plot ............................ Lot --..:.���
...................
�
'
may 9 72 �
Permit Granted --.........—.-------lg �
�
Date of Inspection ............................ 19 _
Date Completed ~�,� 19
�
PERMIT REFUSED
'
.---.—.---..—.--.—.-------. lg �
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----.---.......-------.----,.—.—.. '
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^^^'—^'^'----^—^^^^`^`—^''—^—'-```--'--'
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Approved ............................................... 19
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