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0836 BUMPS RIVER ROAD
I i r I 1 k6 �J, M l r i i Town of Barnstable Regulatory Services pFSHE Tp� o Richard V. Scali,Director Building Division. BARNSTABLE, MAS& Paul Roma,Building Commissioner. 200 Main Street,Hyannis,MA 02601 www.town.barnstable ma.us Office: 508-862-403 8 Fax:. 508-790-6230 Approved: Fee: Permit#: 44,V6 HOME OCCUPATION REGISTRATION Date:tVA, Name: l 5� 3 l C.I-�(_'�^S U'l� Phone#: 5 U�-1 2 8-7- Z- ff ' t Address: M P 5 I V(E P_ Village: C-f—k fiF K V l Lt- Name of Business: T (�E R M�4[b S 'Z)A�-F_ Type of Business: ST1-A F LE-- Map/Lot� O g INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as.of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,.glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. , • Any need for parking generated by such-use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation • If the.Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No p son shall be 4�loyehe Customary Home Occupation who is not a'permanent resident of the dwe g unit. I,.the unders'gne ve read an e abo a restrictions for my home occupation I am repste ' g.. Applicant �-' Date: 2- Homeoc.doc Rev.06 0116 YOU WISH TO OPEN A BUSINESS? For Your Information: . Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. ' Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis`, MA 02601. (Town Hall) and get the Business Certificate that is required by law. E. DATE: a Fill in please: APPLICANT'S YOUR NAME/S: L i S A 1 GK r R BUSINESS YOUR HOME ADDRESS: €3 C, PC.QMPS RIVER RQ &Z8 7(o221 �` E V�IT ti'` t L_L_ ,, Nt C92 3 4 NLk TELEPHONE # Home Telephone Number 5 Q 5-2�3 �F-:•i•+' . r;;t n;�•r!;; E I N #: E-MA I L: fV W @ �C 0 NAME OF CORPORATION: TItI— M'ERMAX6:5 SAL-G NAME OF NEW BUSINESS TYPE OF BUSINESS E5TATE. SALF IS THIS A HOME OCCUPATION? , YES NO M OZc a22 / ADDRESS OF BUSINESS. . F3tQMP5 RIVER RD J CFiJTERVIU.0 MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth ' Rd. & Main Street) to make sure you have the appropriate permits and licenses..required to legally operate your business in this town. 1. BUILDING CDMMISSIONER' FFIC '" � - . MUST COMPLY WITH HOME OCCUPATK) This individual has b en ' r e f an r uiremerits that pertain to this type of busi ess. RULES AND REGULATIONS. FAILURE TO COMPLY MAY AESULT'IN FINES. ^Authorizecl Signature CO MENTS: 2. BOARD OF HEALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. CT' Authorized Signature** . COMMENTS: . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # W t Health Division Date Issued Conservation Division Application Fee Planning Dept. r�✓(� Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation%�H,y�a0nis-<(/y �(�c � T l' Project Street Address G 17dnn 9 e", �, ,,, �. Village Owner (. Address Telephone 5 77Y S7� Permit Request ,.J..., �f Ce 1,, Jhi Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ('G5. Construction Type Lot.Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Le' Two Family ❑ Multi-Family(#.units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 0 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 Telephone Number ]PO Box 52 Address License # West Dennis, MA 02670 Cell (508) 280-6964 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER - DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 'j FINAL BUILDING a DATE CLOSED OUT ASSOCIATION PLAN NO. C 7 r ti Town of Barnstable 4 Regulatory Services Richard V.Scali,Director i639. Building Division Tom Perry,Building Commissioner 200 Main Stieet,llyw nis.�14A 02601 �ti�w.towa.barnst�bl c_ma,ns Office: 508-862AO'>S Fax: 509-790-6230 Property Owner Must Complete-and:Sign.This Section. ,If Us n,Fl&A Builder I, a.s Caner of the.suti•ect propeny ltcrebyauti3orize _�/_� 'C�} to act;on'.mybel alf, in all matters relative to work authorized by this building permit application for. ,rs., �.; -- � erg roc '' ' 6 Z637, {Address of :ob} "`Pool fences and alarms are.the responsibility of'the.appl cant,.Pools are not-to be filled or utilized before:fence is•instaUcd and all firral inspections are performed.and accepted- signature of ; er Signature of Applicant ,4'-,r P r Name Print Nam, Daie Q:tortnss:o�i�t��sttl�sstoNPcxais: Pw '/' CAW" Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2017 Tr# 264961 MICHAEL MCCARTHY MICHAEL MCCARTHY P.O. BOX 52 WEST DENNIS, MA 02670 �:° __ r,.;=s ,,••�, s• , f: Update Address and return card.Mark reason for change. scn i :.5 zoM-osm Address ❑ Renewal F-j Employment F- Lost Card -------- �e�a7iL-r�wazareaCC�a�C%�tiadac�ioae� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. if found return to: Registration: ; .169393 Type: Office of Consumer Affairs and Business Regulation Expiration 68 1201-7 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 MICHAEL MCCARY TH Y MICHAEL MCCARTHY ' 6 RANGLEY LN. SOUTH DENNIS,MA 02660 Undersecretary Not lid with t signature r Massachusetts Department of Public Safety `y Board of Building Regulations and Standards License: CS-058633 1 Construction.Supervisor t MICHAEL J MCCARTHYt `j P.O.BOX 52 VoN, WEST bENNIS MA 026s7 ;i �} , a NO ro-' • Expiration: Commissioner 04/10/2018 The Commonwealth of Massachusetts Department oflnfltistrialAccidents I Congress Street,Sitite 100 Boston,MA 02114-2017 wwm mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers. TORE FILED WITH THE PERMITTING AUTHORITY: Applicant Information Please Print Le ibly Name (Business/Organization/Individual): Mike McCarthy Construction OX Address:_ west De>mnis, MA 02670 C Cell 08)#280-6964 ity/State/Zip: _ ? 169393 Are you an employer?Check the appropriate box: i Type of project(required): 1.2I am a employer with �1 employees(full and/or part-lime).F 7. New construction 2.❑I am a sole proprietor or partnership and have no cmployccs working forme in $• Remodeling any capacity.[No workcrs'comp.insurance required.] 3.O I am a homeowner doing all work myself.fNo workers'comp.insurancerequircd.]t 9. ❑Demolition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my properly. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.r]Electrical repairs or additions proprietors with no cmployccs. . 12.❑Plumbing repairs or additions 5.Q 1 am a general contractor and i have hired the sub-contractors listed on The attached sheet. These sub-contractors have employees and have workers'comp.Insurance., 1 3.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.�Olher .VAC.i 1,,_,,t 152,§1(4),and we have no employees.[No workers'comp.insurance required.) 'Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy;lnfonnaiion. t Homeowners who submit this affidavit indicating they are doing all work and Then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. If the sub-contractors have cmployccs,they must provide their workcrs'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: A Policy#or Self-ins.Lie.M V V✓L— 7c,-- -�G n(, % Expiration Date- )]1s- 1( 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 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under t a• s enalties of perjury that the information provided above is true and correct Signature: Date: Phone#: lsc, -C f C r Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: r - i DATE(MM/DD/yyyy) fA R" CERTIFICATE OF LIABILITY INSURANCE12/07/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:>If the certificate holder is an ADDITIONAL INSURED,the poiicy(ies)must be..endorsed. If SUBROGATION IS WAIVED,subject to, the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 01962-001 NONTACT Bryden&Sullivan Ins Agcy of Dennis Inc AIC.No.Ext: (508)396-6060 . /i.No.: (508)394-2267 PO Box 1497 R ES$: So Dennis,MA 02660 INSURERAFFORDING COVERAGE NAIC M -INSURER A, A.I.M.Mutual Insurance Company 33758 INSURED INSURER B: Michael McCarthy Construction Inc INSURER C: P O Box 52 -INSURER D: West Dennis, MA 02670 -INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER MM/D[NYYYY �j�jj �jy LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMMI ESS(Ea occurrence) P RE $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ OLICY E OC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ c ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY accident) c de DAMAGE $ AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS MADE AGGREGATE $ DED I I RETENTION $ $ '/"r8e P�cF�t?4�s�Clsn"�j% X ?dS� IAn 1 s °�' q�ypR�p���To�/pqR7NER/��ECUTIVE YIN E.L.EACH ACCIDENT $ 1,000,000.00 A OFFICER/MEMBEREXCIUDED? F—Y] NIA VWC-100-6017666-2015A 12/15/2015 12/15/2016 ((Mandatory In OFneN�nH)) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 D99sCRIP I ION 9PERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION Cape_L.ight.Compact PO BOX 427 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable,MA 02630 THE EXPIRATION DATE THEREOF; NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PRO)IISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD Town of Barnstable Building �PostThis,Card�So That rt-,is Vis�ble�From the Streets Approved�Plans Mustbe Retained on;Job and this„Gard�Must�be,Kept ° �" -`�ficate.of ccu anc� �s':Re u�r:.ed� such"8ildm `-shall Notbe Occu ied�until=a�F�nalsln ectlo'n has been�made� � Permit Where a Cert O Permit No. B-16-1797 Applicant Name: Map/Lot: 167-008 Date Issued: 07/19/2016 Current Use: , y Zoning District: SPLIT Permit Type: Shed-Residential-200 sf and under Expiration Date:, 01/19/2017 Contractor Name: Location: 836BUMPS RIVER ROAD,CENTERVILLE Est Protect Cost: `$0.00 Contractor License: Owner on Record: NICKERSON,SAMUEL&LISA&LAUTHER;BERN ICE Permit Fee -: $35.00 Address: 836 BUMPS RIVER RD Fee=Pa)d g''$35.00 CENTERVILLE, MA 02632 ,' Date. � � 7/19/2016 , Description: installl a 10x16 shed Project Review Req : installl a 10x16 shed F �`3 x i _ r Building Official This permit shall be deemed abandoned and invalid unless the work authorized by�this permit is commenced within sa months after issuance. All work authorized by this permit shall conform to the approved application and the approved constru"ctioiWocuments for which this permit has been granted. All construction,alterations and changes of use of any building and comp'lianc`ew ithfthe_local zomngb laws and codes. This permit shall be displayed in a location clearly visible from access street}or road and shall be maintained openbile#inspection for the entire duration of the work until the completion of the same. g ; The Certificate of Occupancy will not be issued until all applicable signatures,by theme Building and Fire Officials are prov dedt n this permit. Minimum of Five Call Inspections Required for All Construction Work `1.Foundation or Footing ju 2.Sheathing Inspection „' # 3.All Fireplaces must be inspected at the throat level before firest fluining is installed T e l 4.Wiring&Plumbing Inspections to be completed prior to Frame InspectFon;` z S.Prior to Covering Structural Members(Frame Inspection) t 6.Insulation s � ' 7.Final Inspection before Occupancy , ...�._ x a_.., Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT xi -71,911(, Town of Barnstable Regulatory Services Richard V.-Scali,Director '"'MASS. '�' Building Division •�A�� Paul Roma,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 . : 508-790-623 PERMIT# — FEE: $35.00 a -n SHED REGISTRATION 10 RESIDENTIAL ONLY w 200 square feet or less -M Location of shed(address) Village Property yowners name Telephone number 1 7 - Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) c% , Sign off hours forConservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEETHE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN forms-shedre REV:06/20h 6 I N ; DL,/EU_/A/G 50 �1•�;�' f� i n I certify that this property is., v P _ located in Flood Hazard Zone C (out- side the 500 year flood) as identified j by the Department of Housing and Urban Development (HUD) . JL ✓� �� CERTI FI ED PLOT PLAN Date y25 —`'T y LO CATION SCALE• /"=3c .... DATE Reg `�1 ar `L1bUv r PLAN REFERENCE , `?... . .. EC S1G I certify to Bank of America,'FSB and Its title ins.co. I CERTIFY THAT THE that there are no visible encroachmen . ` SHOWN,ONTHIS PLAN IS LOCATED ON THE GROUND Or easements except as `shown and that this AS SHOWN HEREON AND THAT IT CONFORMS TO THE plan was prepared .under my immediate SETBACK REOUIREMENTS OF THE TOWN OF ` . (�9Tlt/S7t'JOZ— WHEN CONSTRUCTED. supervision. a DATEj! S,,q,Nicresv Iq OTf1&7_5 -,P9777-10,V 7ZS REGISTERED LAND"SURVEY R 3 (� S of Z�{� Town of Barnstable *Permit#— 318W, �( a Expires 6 mondis from issue date °�' � ° Regulatory Services Fee %f � � r 1 'I Richard V.Scali,Interim Director Building Division Tom Perry,CBO Building Commissioner r , 200 Main Street,Hyannis,MA 02601 , www.town.bai-nstable.ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY f Not Valid without Red X-Press Imprint Map/parcel Number_ V Property Address 5 (/� �U lL r c T� l F .Residential Value of Work$ 1, C 0 Q., cTc�! Minimum fee of$35.00 for work under$6000.00 �— tT� Owner's Name&Address �� [�� L ��C /;�/�S Oi✓ 6,,�.-V71 1111rF f Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑workman's Compensation Insurance,'... Check one: , ❑ I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name �- 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) ❑ Re-side v� » ® Replacement in oors/sliders.U=Value (maximum.35)#of windows #of doors: , F ❑ 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.• ***Note. " Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required: . SIGNATURE: T:\KEVIN D\Building Changes\EXPRESS PEP-MinEXPRESS.doc Revised 061313` » The Commonwealth of Massachusetts Deparbnent of Imbisbial Accidents . QBce of lnveshgations 600 Washington Sheet 43oston,ALA 02111 ftimmass govIdin Workers' Compensation Insurance Affidavit Budden/ContractDrstEkTt6cLwastPlumbers Applicant Information Please Print I&M Name(Bus�ess/Organi�tionit �}i� /l//CY�G1,�so`J . .. . Address: Qty/State/Zip: �G1 v /�e D 639 Phone#_ d 9--1-/2 I1-0 ` '(y 16 Are you an employer?Check the appropriate box: Type Of project(regtrued): 1.El I am a employer with 4- ❑ I am a:general contractor and I 6 employees(full..and/or part-time)s have hired the sub-contractors ❑New construction 2.0 I am a.sole proprietor or partner listed oa the attached sit 7- ❑Remodeling and have no employees These sub-conmors.have Pp 9y Ul 8_ ❑Demolition wodring for me in any capacity- employees and have wodc� ' I s 9. ❑Bailing addition . [No workers'comp.insurance comp i.nurance- d.] 5_.❑ We area corporation and its. 10-❑Rlectrical.repairs or addthons 3.M11 am a officers have exercised fir homeowner doing all work 11. ❑Plumbing repairs or addchons x myself [N •crop- right.of 'on MGL o workers_ of',exemption P� 12:❑Roofrepairs insurance required.]F c.152,§I(4),and we have no. employees 13-(-[No workers' Other M �✓ � comp.msvrance required:] .. °Ally applicant that checks box#1 maul also fill out the section below sbowint dheu waik essation policy in�ttuati� t Homeowners who submit dus affidavit indicating they are doing all arch and men lane outside contractors must subffiit a new"affidavit indicating and L { +Contractors @rat cbeck this box must attached an additional sheet mowing the name of the sus-contractors and state whetim or notthese end have empin}VES. Uthe sub-conttactats have emplo}ees,dwy rmast provide tlusir warkets'comp.policy number- I am an employer that I prerputh g�wvrtrers'compensation insurance for my etriptoyees: BeIory is the policy and job site information, . Insuritace Company Name: Policy#or Self-ins.Lic.#: . . . . /�''. Expiration Date: Job Site Address: Cityf$tate/Tp: Attach a copy of the workers'compensation policy declaration. a wing. po_'cynumber and expiration date). Failure m P.ge.(sho the h. .'" . secure.coverage as required under Section,25A of MOL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-gear imprisoument;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. pqr»s. psr�. . f p�ury that;tlie infgimidcon provided shone is bus and correct I do hereby c erhfyunder the and attics o Sitmatlue: �� ��� Date Phone#: b g 12 4 6.. . . . . . . . . . . . O,f isial use only. Do not write in this area,to be completed by city or town stffl i L City or Town: Perm tucense# . Issuing Authority(circle one)..` . . • l:Board of Health I Building Department.-3.Ptyrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other . Contact Person: Phone#: ' Town.of Barnstable Regulatory Services of Richard V.Scali,Interim Director ,Building Division sAxrtseeatE.KAM ` Tom Perry,Building Commissioner + 1639• m� 200 Main Street Hyannis,M a, A 02601 �b b www.town.barnstable.ma.us- Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION' Please Print Z pj DATE: 3 Z ate�/I JOB LOCATION: number street/ - e village' "HOMEOWNER": name / home phone# work phone /# _ CURRENT MAILING ADDRESS: 93 cv 4(//�7�✓� /ar2 G3 t•vsr#13 e�� i>r, .e ®gG3.2.. city/torn 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 buildinitipermit (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 inspection procedures and requi s and that he/she will comply with said procedures and requirements. , 'Signature of Ho er 4 Approval of Building Official y 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 1.09.1.1 -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 assuming the responsibilities of a supervisor-, a. (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. ¢ . T:\KEVIN D\Building Changes\EXPRESS PERMIT\EXPRESS.doc Revised 061313, flies of Zs ji K Town of Barnstable *Perms y� Expires 6 mon h rom issue date �l Regulatory Services Fee 3 s 039. • lARN8rA9L6, f u"m• Richard V.Scali,Interim Director " 7tllld Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-7.90-6230 EXPRESS PERMIT APPLICATION - RESIDENTLL ONLY ®� ® Not Valid without Red X-Press Imprint Map/parcel Number _7 Property Address fflit S Residential Value of Work$ o� �® ®- Minimum fee of$35.00 for work under$6000.00 Owner's Name&AddressSmug] Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) l Zr' Email- Construction Supervisor's License#(if applicable) . 0 /y 007 Workman's Compensation Insurance APR 1 7 2014 Check one: ❑ I am a sole proprietor ❑ I am the Homeowner . _ I have Worker's Compensation Insurance -TOWN ARNS--TA13L Insurance Company Name Co 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) f ❑ Re-side Replacement Windows/doors/sliders.U-Value �® (maximum.35)#of window (:D #.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. ***Note: Property er sign Property Owner Letter of Permission. A copy of R Improvement Contractors.License&c Construction,Supervisors License is required. . SIGNATURE: TAKEVIN Muilding ChangesTMlt6S PaffdXPRESS.doc Revised 061313 f ROME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: PLEASE READ THIS CONTRA("r THD At-Home Services,Inc. d/b/a The Home Depot At-Home Services 908 Boston Turnpike Unit 1,Shrewsbury,MA 1545 Toll Free 8779033768;Fax 8009863610 Branch Name: Boston South Date:3/29/2014 ME Lic#C 02439 RI Cont.Lic#16427 CT Lic#HIC.0565522 MA Home Improvement Branch No: 31 Contractor Reg.#126893 Federal ID# 75-2698460 Installation Address: 836 bumps river road Centerville Ma 02632 City State Zip Purchaser(s): Work Phone: Home Phone: Cell Phone: Sam nickerson 508-775-5767 Home Address: (If different from Installation Address) City State Zip E-mail Address (to receive project communications and Home Depot updates): Marketing emails will not be sent from The Home Depot. Proiect Information: Undersigned("Customer"),the owners of the property located at the above installation address,agrees to buy,and THD At-Home Services,Inc.("The Home Depot")agrees to furnish,deliver and arrange for the installation("Installati on")of all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into this Contract by this reference,along with any applicable State Supplement and Payment Summary attached hereto and any Change Orders (collectively,"Contract"): Job#:(Internal Reference) Products: Spec Sheet(s): Project Amount Windows $1,230.99 Minimum 25% Deposit of Contract Amount due upon execution of this contract Total Contract Amount $1,230.99 Customer agrees that,immediately upon completion of the work for each Product,Customer will execute a Completion Certificate(one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable,each Customer under this Contract agrees to be jointly and severally obligated and liable hereunder. Payment Summary: The Payment Summary# ,included as part of this Contract,sets forth the total Contract amount and payments required for the deposits and final payments by Product(as applicable). GENERAL TERMS AND CONDITIONS Responsibilities: The Home Depot:will provide the Products identified above,make arrangements to have the Authorized Service Provider perform the Installation services in a professional and workmanlike manner,and arrange proper insurances. Unless otherwise expressly provided for herein,Authorized Service Provider will obtain required permits and provide permit numbers. Customer:will identify any property lines,easements,covenants,underground or overhead utility lines,pre-existing physical or 0130-14 SFC _ Page 1 of 9 r Basement Hopper Assessed Width=31 Assessed Height= 13 Basement No Window/Door Wraps Pricing Includes: Window or Door Wraps '�y s } `x,�n..,fi��.%��>.��,,.�P,-.���t��x. v�..�.. ,? ;.._��� .'�w �.��sa..�i��,�.��i�a;m �m��r,..�,7»,�x•.1,,�� ,u»,,� ���n+��`�� ?z�����s �Pa'�<r��'�� Ta�� �" %TOTAL CO CT�AM�ONT ^,�$1�-230 99�`' ���;"�xi���� u �� ����_ � ��� ; t��7����w��,�� ����;������g� �. ��� � � • - a s 4Fc t,C b`�f,}n"3'xaw. .,x�. w+te ;, s 2s..�-� ,<x",ui'',..�. r �q�G�s,�m7 mwW�fiA;.:.�F:f;'i.�d.a:v;,,:'�t,t,�'�irm."��"��+;�`>fls}`.�a!�4 o-�4' •"�4E.�u�.P, %u°� '`":��'�':�;F'%���f��,���,�liu�� 9c, Y, San) nickorson (Mar 29. 2014, 10:26 AM) 0130-14SFC 'Page 7 of 9 �. rw, ash. pan e t of •pia� Kegmations and Sta L- ice � CS-070077 _,SET 4CDUARTY", "", FA i t � )d WAR Hi A asm ri wi` NiJr��Yr+v w1 ��,.iYw��yla(��C",2 '.�/' May 11, 2013 Barnstable Building Dept. The fo•I'Iowing is a list of our approved sub-c®ntrators for The Horse Depot: Ericsson Torres - CSSL # 100546 HIC # 163528 Michael-Viola a CSSL#•099403 HIC # 140993 Vincent Smith - CS # 106837 HIC # 165927 Timothy Thomas — CS # 51899 HIC # 152121 Ronaldo Solano.—CSSL # 101027 HIC #152206 Joseph Duarte - CS # 70077 HIC # 132349 a` Douglas Szyna) — CSSL # 103950 HIC # 146142 Brian Laroche CSSL # 100478 HIC # 152612 Joseph McKeon —CSSL# 98863 HIC # 132614 If you have any questions please contact !Mike Bedard our permit coordinator at 508-962-6942 or myself at 617-438-9017: .S- erel 4 uss one Bra Installation Manager THD At-Home Services,Inc: 908 Boston Turnpike• Unit 1 •Shrewsbury,MA 01545 Phone:774-275-2139•Fax:508-845-6076&Toll Free:800-657-5182 • e Department of Industrial Accidents Office of Investigations 600 Washington Street t Boston,MA 02111 — �� awww.mass.gov/dirt ...Workers'.Compensation Insurance Affidavit: Builders/Gong°actors(Electricians/Plumbelrs A licant Information / Please Print Legibly NaMe (Business/Organization/Individual): ,c) 1 -- Address: 6e__!5 le A_R_ kQ AP f r v � City/State/Zip: Alk4 � � 303 �.3 Rhone#: d75 �� w- Are you an employer? heck the appropriat�e x: Type of project(required): 4. a general contactor ad I 1.[ I am a employer- 6. New construction employees(full and/or.part-time). have hued the sub-contractors - listed on the attached sheet." 7. []Remodeling 2.❑ I am a sole proprietor or partner- ship.and have no employees These sub-contractors have g, C]Demolition workingfor mein an capacity. employees and have workers' y P ty 9. ❑Building addition [No workers'comp. insurance comp.msurance.x 5. corporation and its 10.❑Electrical repairs or additions required:] ,. [� We are a 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.[] hoof repairs insurance required.]t c. 152, §1(4)1 and we have no employees: [No workers' 13.�Other l comp,. re wired. YnIelit mP q .. � 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy in ornmtion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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 nurnber.� - I am an employer that is providing ivorkers'compensation insurance fop my employees'. Below is the policy and job site information. % Insurance Company Name: / y `✓f?il-e- �/v_,5- l_® .; Policy#or Self-ins.Lic.M W G 0 q to !' Expiration Date: 3 Job Site Address: gP/P2QS / (UG1 . City/State/Zip: t� i�XU!' �� !/► 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 \l of up to$250.00 a'day against th tolator. Be advised that a copy of this statement maybe forwarded to,the Office of investigations of the DIA f r' ance covera e verification. I do hereby certify under a ins an penalti rjury that the information provided abo a"is t e and correce Signature: Date: �6 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): n . 1.Board of health 2.Building Department 3.City/Town Clerk �4.Electrical Inspector 5.Plumbing Inspector . 6.Other Contact Person: Phone 9: _: Office of CoI IMPROVEMENTME NCTOR egistration : 132349 Expiration : 1111 /20 15let 5� { R emodeling Duarte ` I I s , Wareham , ma 02571 t; 4cce o o�m�ier an usnmess a ation 10 Park Plaza - Suite 5170 Boston, N*sachusetts 02116 14ome lmprme�= ontractor Registration ReOsrtratlon 126893 Typa: . Supplement Card y E Oon: 6=014 The Hom6 De not At-Home Se ' ' ANDREW SWEET 2690 CUMBERLAND PARKWAY L- . ATLANTA GA 30339 ` . `i, -�---- Update Addrew mad return card.Mark reawn for cbaW Addremn (] Roowwal ❑ Rmpleymeat [] Lost Card CPA-CAI`0, 444"��10 RIO ,,,,,,vv Unite oT �nilfi� o`�s Lie or regbtraden vmdW for ladtvldul user only • ME w4ovm r cour wow �r before the explraNam date. Mend return te: Moe of Consumer A.ffaln and Sudnew Repletion '�:• 10 Perk Plans-SWte 5190 Supplement CardBestei4 MA 02116WDOPE.v4 6 21 =01 A ► ,tom►�t7.�V t, • �Ja�EmtilCrltYry dareL1°11V _. �� t � � � .,�,:, Town of Barnstable Regulatory Services oFUKE Toy, Richard V. Scali,Interim Director ~� Building Division 9 S& Thomas Perry, CBO, Building Commissioner �Ar i639' e,1` 200 Main Street, Hyannis, MA 02601 ED MA'S www.town.barnstabie.maxs Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: My name is -��_.��?� /J�/`` r%C����©�✓ I am the side of the property located at: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: �/J 9 Name &relationship to owner: Name &relationship to owner: The Family Apartment will be the primary year-round residence for above-idsntifi f family members. In the event that the listed relatives vacate said apartment;; ill immeiatel notes the Building Commissioner in writing. I understand that no subletting-Pr subleasing of Zz-1_d Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the- uilding (10 F Commissioner listing the names and relationship of occupants in said Family Apartment.I also understand that I am required to comply with all conditions imposed by the Z A SpeciAPermn andlor the Town of Barnstable Zoning Ordinances Section 240-47.1 Family partments:) I agrje to notify the Building Commissioner immediately in the event of the sale of this properly, 6 j. co rn If there is no longer a Family Apartment at this location,please explain: _ The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to der the pains and penalties of perjury this day of /�, 2014. ignature, Phone Number Print Name q:forms/famaffid.doc rev 11/08/11 - Town of Barnstable Regulatory Services ox Thomas F. Geiler,Director Building Division. TOW41 . F BAR M'STABL '"R''' LF� ' Thomas Perry, CBO,Building CommisMAMs' 6,`� 200 Main Street, Hyannis, MA 02641 o ff 2 6 9 www.town.barnstable.ma.us Office: 508-862-4038 DIVISIONax. 5�5-790-6230. Town of Barnstable. Family Apartment Affidavit I, being on oath, depose and state as follows: My name is- m �'��C-���1 �✓ T am t sident of the property,located at: F 3 �qr r/c�ti The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: 669_e o7/CC e— Z/9U1-11F)2 M0 rle. I,t,, Ll _ Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) . Other Sworn to under the pains and penalties of perjury this a�L day of C h� 2013. SigiraturV Phone Number Print Name q:forms/famaffid.do c rev 11/08/12 i Town of Barnstable Regulatory Services of Thomas F. Geiler,Director Building Division ` Thomas Perry, CBO,Building Commissioner;,, Ar 1639. s��� 200 Main Street, Hyannis, MAX`02661 E t www.town.ba rnstable.ma.us Office: 508-862-4038 r ` �, ; Fax: 508-790-6230 s IO Town of Barnstable Family Apartment Affidavit' I, being on oath, depose and state as follows: My name is ��✓nve //�• Aloe- I am the wn eside f the property located at: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: C F/Zo ✓�'�t �•uL11w' Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately note the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(Appeal No. ) Other Sworn to under,the pains and penalties of perjury this ��, , day of D l 7'0° .2012. —c ^O . Signature. Phone Number Print Name _�vcZ�, q:forms/famaffid.doc rev 11/08/11 z Town of Barnstable Regulatory Services �t Thomas F. Geiler, Director TOWN OF Fp_f; tj txYs Building Division '• IARNSTABLF " Thomas Perry, CBO Building Commissioner Q11 ° 5 i639' 200 Main Street, Hyannis, MA 02601 EO MA'S www.town.barnstable.ma.us Office: 508-862-4038 CI l Fax .508-790-6230 Town of Barnstable, Family Apartment Affidavit I, being on oath, depose and st e as f lows: My name is I am the 4 'resident of the property located at: !p ti The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name & relationship to owner: Name & relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, 1 will immediately notify the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. 1 understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to complywith all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. 1 agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and penalsies of perjury this day of 2011. F-y o76 Sign ture Phone Number ' Print Name na v Town of Barnstable Regulatory Services pF1HE T°y, Thomas F.Geiler,Director Building Division ll:l► '�` ' L 1 BLARNSTAB Tom Perry, Building Commission; 1,.I 19 i; : 200 9 1639. ,0NASS. � Main Street,Hyannis,MA 0260`1 ' VA* www.town.barnstable.ma.us Office: 508-862-4038 DIViSTO Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: My name i � `Je �/T �`// QJI am the owner/resident of the property located at: � The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: / C Name & relationship to owner: G (1_WA/ Name & relationship to owner: The Family.Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the Building Commissioner in writing. 1 understand that no subletting or subleasing of said Family Apartment is permitted. I understand.that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to notify the Building Commissioner immediately in the event of the sale of'this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and penalties ofperjury this day of 2010. •z 0 - 0 Signature ZPhone Number Print Name Q/bl dg/forms/famaffi d Rev:12/08 Town of Barnstable Regulatory Services FiHE TQ Thomas F. Geiler,Director Building Division 34l 10F l3ARNSI'LE. BARNSTABLE, ' Tom Perry, Building Commissioner v� 6 9. �e� 200 Main Street,Hyannis, MA 02601 Z� � .IA 5 APB 4 b AlF p �A www.town.barnstable.ma.us DIV 514 Office: 508-862-4038 Fax: .508-790-6230 Town of Barnstable Family Apartment Affidavit I,.being on oath, depose and state as follows: MY •I am the owner/resident of the property located at: lip3 C, S P . The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name & relationship to owner: (/Jel-lvw q- // 24f'0/ Name & relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately, ' notify the Building Commissioner in writing. 1 understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also. understand that I am required to comply with all conditions.imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to notify the Building Commissioner immediately in the event of the sale of'this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and penalties of perjury this g day of � 2009. F Signature Phone Number Print Nam'G /v'� �c ers0-L� Q/bldg/forms/famaffid Rev:12/08 Town of Barnstable Regulatory Services FIHE rqy, Thomas F.Geiler,Director tia Building Division * RUMSTABLE, ' Tom Perry, Building Commissioner MASS. g A 1639• 200 Main Street,Hyannis,MA 02601 Tfv �A www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: _ My name ice, yi J`C��//� /id� O�t/ I am the owner/resident of the property located at: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: T j . Name &'relationship'to owner: ��-- !%v��._..� Name &relationship tol owner: ' he Fami y-Apartment will be the primary year-round residence for the above'* ntified family members. ]Fn the event that the listed relatives vacate said apartment, 1 will immediately note the Building Commissioner in writing. I understand that no subletting or subleasing of. said Fd`.dy Apartment is permitted. 1 understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that 1 am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and pe alties of perjury this day of i' 2008. C -O Signature Phone Number Print Name- r+�/y���� �J�Q�L Q/bl dg/forms/famaffid Rev:1/03 Town of Barnstable Regulatory Services 0 pFZHE TO Thomas F.Geiler,Director 4 Building Division snxivsrna , Tom Perry, Building Commissioner s 11 , d [fit s�: fj 9 Mnss. g �p 163g6 A�0 200 Main Street,Hyannis,MA 02601 `�FEB . rFCMA'� www.town.barnstable.ma.us 20 PM 2: 26 Office: 508-862-4038 l Sf d+F 5-H-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: MY name is, _ � ` �-" � c` �t�` !�2� I am the owner/resident of the ;i property located at: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name & relationship to owner: Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. 1 understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and penalties of perjury this T day of 2007. Sig ` __Phone Number - - Print Name y I �Zl°`fC�54�a Q/bldg/forms/famaffid Rev:I/03 Town of Barnstable Regulatory Services �t►+e rok, Thomas F.Geiler,Director Building Division s�� * anxxsTnarE, : Tom Perry, Building Commissioner , 4(} } MA & an "'' i639. 10� 200 Main Street,Hyannis,MA 02601 � 1 ArEv �a www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows:--- My name i ,'' I am the owner/resident of the propertylocated at: Map and Parcel Number The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: A � � f Name &relationship to owner: �G���?/li'7G/ /fi��rZ ,L� �-�L/� Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately note the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. 1 also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains a5no penalties of perjury this day of ��°/ . 2006. _2�,.. Signature c/ �. _ _ Phone Number Print Name �1e,-c� ,/y G 1� �.`jl,2,1i) Q/bldg/forms/famaffid Rev:1/03 � o A Town of Barnstable Regulatory Services �pFTHE To�yti Thomas F. Geiler,Director .I0 WU OF BAR STABL€ P Building Division Tom Perry, Building Commissione2006 hAR -8 P' 3 9 039• 200 Main Street,Hyannis,MA 02601 ATFo �a www.town.barnstable.ma.us PIV$JON Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I,being on oath, depose and state as follows name i� "IF--e., nt of the _ .._ property located at: Map and Parcel Number The following members of-my family.will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship-to-owner: - 0 lC Name & relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately note the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. 1 also understand that I am required to comply with all conditions imposed by the ZBA in the Appeal No. identified above. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other Sworn to under the pains and penalties of perjury this day of J��- �, 2005. 70 Signature Phone Number Print Nam�� � Q/bldg/forms/famaffid . Rev:1/0 3 0(� 'Town of Barnstable Regulatory Services pQt TO�� Thomas F.Geiler,DirecWWN OF BARNSTABLE Building Division �p snuvsrnat E Tom Perry, Building Comnj§n{�nn's'i�t,�*i+R 22 PM 1' 4 1 Mass. � 200 Main Street,Hyannis,MA 02601 ." -..DIVISION Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I,being on oath, depose and state as follows: My name isGf<G�50�� I am the owner/resident of the 12 property located at: 3 G `��S Lj 1,_11 Map and Parcel Number The ZBA granted me a Special Permit/Variance on y-7 1995 r 13� Date 19 5 Appeal No. The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: AK 2WC-15 Name &relationship to owner: - The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the Building Commissioner in writing.I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA in the Appeal No. identified above. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(Appeal No. ) Other r:t=nsajialties perjury this day of R 2004Sworn to de Si)y atu Phone Number Print Name 05 0 Q/bldg/forms/famaffid Rev:1/03 Town of Barnstable a C /6 Regulatory Services OF THE Kok, Thomas F.Geiler,Director 'TQ V41 0, SAR ;STABLE O Building Division * BAMSTAeLE, = Tom Perry, Building CommissioneP03 FEB "3 PM : 2 9 MASS. 1639. 200 Main Street,Hyannis,MA 02601 �AtED MA'1 A Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: My name is SG ` v� L-�� I am the owner/resident of the located at: property -- Map and Parcel Number IL 7 0 The ZBA ranted me a Special Permit/Variance on I D 2C) S I -1 J D g P Date Appeal No. The decision of the Zoning Board of ,pp•als has been recorded with the Registry of Deeds in Barnstable County: Book s W.yage Rr. The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: '��� Name &relationship to,owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that 1 am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA in the Appeal No. identified above. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program (Appeal No. ) Other lign nder the p 'n aan pe altitoferjury this day of, qo,_k 3. � -4�-(Y7(O'/ Phone Number Print Name _t`_� v 1 �- f4 ' Q/bldg/forms/famaffid } Rev:1/03 Town of Barnstable )'0 Regulatory Services pF� Tqy Thomas F.Geiler,Director ' Building Division TOWN OF BARNS TABLE G 9&UMSTABM� Peter F.DiMatteo, Building Commiss'01692MAR _7 AM 8: 42 161 200 Main Street,Hyannis,MA 02601 ArEO�,1 A Office: 508-862-4038 _ Fax 5AIR-790-6230 r 1VISION Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: My name is U<;c I am the owner/resident of the property located at: Map and Parcel Number The ZBA granted me a Special Permit/Variance on Date Appeal No. The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: pp� Name &relationship to owner: C�--i'�(1 fl Sa% Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notify the-Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that 1 am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA in the Appeal No. identified above. I agree to notify the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location, please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(,Appeal No. ) Other Sy"under e p ' and enalties of perjury this 25 day of Ft 2002. xr ti;� Signature Phone Number L)'_C_Z>CA �08 r420-��6G� Print Name Q/bldg/forms/famaffid Rev:010702 COMMONWEALTH OF MASSACHUSETTS BARNSTABLE AFFIDAVIT f U� - I, 5DMU.J a, 6Sg L °ram'"1 , being on oath, depose and state as follows: 1.) I reside at 2.) I am the o of the proRexty locate shown on Barnstable Assessors' maps as MAP C7 PARCEL 3.) I Do Do not have a Family Apartment at this location. 4.) On 199�, the Zoning Board of Appeals, on Appeal No. 1 ranted me a Special Permit/Variance to maintain a Family Apartment at the above address. 5.) I understand that the Family Apartment may only be occupied by members of my family who are persons related to me by blood or by marriage. 6.The following members of my family will be the sole occupants of the Family Apartment at the above address: a) NAME &e- niCe �ou4Noer Relationship to owner: MQ,�hft' - b) NAME Relationship to owner: 7.) The Family Apartment will be the primary year round residence for the above-identified family members. 8.) In the event that the above-listed relative(s) vacate said apartment, I will immediately notify the Building Commissioner in writing. 9.) I understand that no subletting or subleasing of said Family Apartment is permitted. 10.) I understand that I am required to annually file an Affidavit with the Building Commissioner listing the names and relationship of my family members occupying said Family Apartment. 11.) I understand that I am required to comply with all conditions imposed by the Board of Appeals in Appeal No. r aq 5 135 I2.) I agree to immediately notify the building Commissioner in the event of the sale of the above- listed property. 26oa Sworn to under the pain and allies of perjury this day of G , 199- Signatu Print Name I L N LSA k�R� COMMONWEALTH OF MASSACHr L ' VED BARNSTABLE I AVIT t�--�L rs a n 5 1!go 99 ---- --z 1,L------------------- being of th, depose and state as follows: OF�6 ILDI A NSTAB DIV. 1.) I reside at. C�3 U B I"PI Ri VI_� ------ 2.) I am the owner of the property locate at_ 3In— m S_R1 V'PX R8=------L6/v% 1_(�_A --------------------- shown on Barnstable Assessors' maps as MAP--- __PARCEL_ ______—__ �_ 3.) 1 Do-__ ____Do not -----have a Family Apartment at this location. 4.) On_-__ �_ ------- 1997 A' the Zoning Board of Appeals, on Appeal No. Y-4 granted me a Special Permit/Vanance to maintain a Family Apartment at the above address. 5.) 1 understand that the Family Apartment may only be occupied by members of my family who are persons related to me by blood or by marriage. 6.The following members of my family will be the sole occupants of the Family Apartment at the above address: a) NAME---�P.��L�C�-�-J--- --��=—��r----- " Relationship to owner:_—_ ,1_2 La 1' b) NAME--------------- Relationship to owner:_-=-_--__—_-- 7.) The Family Apartment will be the primary year round residence for the above-identified family members. 8.) In the event that the above-listed relatives) vacate said apartment, I will immediately notify the Building Commissioner in writing. . 9.) 1 understand that no subletting or subleasing of said Family Apartment is permitted. 10.) I understand that I am required to annually fiie an Affidavit with the Building`Commissioner listing the names and relationship of my family members occupying said Family Apartment. 11.) 1 understand that I am required to comply with all conditions imposed by the Board of Appeals in Appeal No. _- =g = - --------------------- ---------- 12.) 1 agree to immediately notify the Building Commissioner in the event of the sale of the above- listed property Sworn to;under;the pains and:perialties of perjury this I U_--day--of �_ 1991_ gnat ---- --- ----=--=------------- Print Naive 1 COMMONWEALTH OF MASSACHUSETTS BARNSTABLE ( AFFIDAVIT I, _L i 5 C�—I� t e=1—c_r S U r-1----------------------- being on oath, depose and state as follows: 1.) I reside at == 11Y1ps_ L�er_Rd _ 1 �1 �_�YV 11 1c, MA •02(o3Z 2.) I am the owner of theperty located 31 (� CCY.Rd at__Sv__� s -C-cx�k6 V�-1 1,e, . MA 02(_o32-------- shown on Barnstabld Assessors' maps as MAP__i(e: __ __PARCEL_— 3.) I Do— _v —__Do not ___—_—__have a Family Apartment at this location. 4.) On �0 _25 ---------- 199 the Zoning Board of Appeals, on Appeal No. 1`19�r J3 granted me a Special Permit/Variance to maintain a Family Apartment at the above address. 5.) I understand that the Family Apartment may only be occupied by members of my family who are persons related to me by blood or by marriage. 6. The following members of my family will be the sole occupants of the Family Apartment at the above address: a) NAME---- Y1 C ---Gt -- -�r------------- 7'QGy{�_,, ------------ Relationship to owner:—_----HC-1 Y, b) NAME------------- ------------------------- ��=`f EB—2$— ------ Relationship to owner:___ _______________l' /h 7.) The Family Apartment will be the primary year round residence for the above_ideri� 'pie' family members. 8.) In the"event that tl'e above=listednrelative(s),vacate said apartment, I will immediatelyYnotify the Building Commissioner in writing. 9.) I understand t11at fio subletting br subleasing of said Family Apartment is permitted. 10.) I understand that�I am required to annually file an Affidavit with the Building Commissioner listing the names and relationship of my family members occupying said Family Apartment. 11.) I understand'thatf I am required to comply with all conditions imposed by the Board of Appeals in Appeal°No. 12.),I agree fo immediately notify the building Commissioner in'the event of the sale of the above- listed property: Sworn.to under the pains and enalties of perjury this q___day of_F ______, 1992 t Sign le j I ----------------------------------- / rent ame L 1 S G The Town of Barnstable °.� Department of Health Safety and Environmental Services BARNSrnBM IV Building Division v 16.19. � 367 Main Street, Hyannis MA 02601 FD MA'S A Office: 508-790-6227 Ralph M. Crossen Fax: 508-790-6230 Building Commission February 18, 1998 The Lauther/Nickerson Residence 836 Bumps River Road Centerville, MA 02632 Re: Family Apartment located at the above address Dear Ms. Lauther or Mr./Ms. Nickerson, A letter was sent to you on December 30, 1997 requesting information regarding your Family Apartment. The affidavit has not been received as of this date. It is required under Section 3-1.1 (3) (D) (1) of the Town of Barnstable Zoning Ordinance that it be submitted annually for the duration of such occupancy. Please indicate the status of the family apartment on the enclosed affidavit and return to this office by March 1, 1998 in order to comply with the conditions of approval. _ Thank k you in advance Ralph Crossen Building Commissioner °FINE A The Town of Barnstable Department of Health Safety and Environmental Services ■AMSTABM Building Division &� KAS& �� 367 Main Street, Hyannis MA 02601 ArFD MA'S A . Office: 508-790-6227 Ralph M. Crossen Fax: 508-790-6230 Building Commissione December 30, 1997 The Lauther/Nickerson Residence 836 Bumps River Road Centerville, MA 02632 Re: Family Apartment located at the above address Dear Ms. Lauther or Mr./Ms. Nickerson, Our records indicate you have not filed an affidavit regarding the above referenced family apartment for quite some time. It is required under Section 3-1.1 (3) (D) (1) of the Town of Barnstable Zoning Ordinance that an affidavit be submitted annually for the duration of such occupancy. Please indicate the status of the family apartment on the enclosed affidavit return to this office by January 30, 1998. Unclosed is an affidavit for your convenience. Thank you in advance, 4ew aa_a� Ralph Crossen Building Commissioner 1 Town of Barnstable Zoning Board of Appeals Decision and Notice Appeal No. 1996-138 Lauther&Nickerson Special Permit-Family Apartment Summary Granted with Conditions Applicant: Bernice Lauther, Lisa and Sam Nickerson Property Address: 836 Bumps River Road, Centerville, MA Assessor's Map/Parcel 167/8 Area 0.49 Acres Zoning: RD-1 Residential D-1 Zoning District. Groundwater Overlay: AP Aquifer Protection District Appeal No: 1995438 Bernice Lauther, Lisa and Sam Nickerson are appealing to the Zoning Board of Appeals for a Special Permit in accordance with Section 3-1.4(3) (E)Family Apartment as per Section 3-1.1 (3) (D). Background Information: The locus of this appeal is on Bumps River Road in Centerville. The surrounding neighborhood is residential in nature with one large lot of 8.18 acres located across the street. The Applicants dwelling is located in a Residential D Zoning District which allows family apartments as a Conditional Use providing it complies with Section 3-1.1 (3) (D). The Applicant is requesting to construct a family apartment for.the mother/mother-in-law who is somewhat disabled and in need of assistance on a regular basis. The proposed family apartment addition of 840 sq. ft is attached to the principal dwelling of 1936 sq. ft. according to the Assessors records. Procedural Summary: This appeal was filed at the Town Clerk's Office and at the Office of the Zoning Board of Appeals on September 28, 995. A public hearing was before the Zoning Board of Appeals was duly advertised and notices sent to all abutters in accordance with MGL Chapter 40A. The hearing was opened on October 25, 1995, at which time the Board found to grant the appeal with conditions. Board members hearing this appeal were Ron Jansson, Emmett Glynn, Gene Burman, Robert Thorne, and Chairman Gail Nightingale. Tom Morse, the Builder, represented the petitioners. The proposed family apartment is to be 840 sq.ft. (24 x 28; 1 1/2 story) and the main house is 1936 sq. ft. (25 x 44; 2 story). Mrs. Lauther is one of the owners in addition to being the" in-law". The proposed apartment is to be constructed within the required setback, and in compliance with all provisions of Section 3-1.1(3)(D)- Family Apartments-of the Zoning Ordinance. No one spoke in favor nor in opposition. Finding of Facts: Based upon the testimony given during the public hearing on this appeal, the Board unanimously found the following findings of fact: 1. The property at issue is located at 836 Bumps River Road, Centerville in an RD-1 Residential D-1 Zoning District and AP Aquifer Protection District. 2. The property currently consists of a principal dwelling that is 1936 sq.ft. 3. The petitioner is seeking a Special Permit which is allowed under Section 3-1.1(3)(D), and based upon the testimony given, the petitioners do comply with the provisions of this section. 4. In granting the relief, it would not be in derogation of the spirit and intent of the Zoning j Ordinance nor would it be detrimental to the neighborhood. Zoning Board of Appeals-Decision and Notice Appeal No. 1995-138 Lauther&Nickerson Decision: Based upon the positive findings a motion was duly made and seconded to grant a Special Permit in accordance with Section 3-1.4 (3) (E) Family Apartment as per Section 3-1.1 (3) (D).with the following conditions: 1. The petitioner shall at all times must comply with the provisions of Section 3-1.1(3)(D). Failure to do so shall result in a show-cause hearing before the Board on revoking of the Special Permit. 2. Scaled plans of the proposal must be submitted to the Building Commissioner. 3. Prior to occupancy, affidavits listing the names and family relationship among the parties seeking approval have been signed and shall be signed annually thereafter for the duration of the occupancy and the Special Permit. 4. The petitioner must comply with all Title V Regulations and Health Department Regulations. 5. Sixty (60)days from the date the family member vacates the apartment, kitchen facilities must be removed and the Building Commissioner shall inspect the premises. Also, the premises must be restored as nearly as possible to a single family dwelling. 6. The Building Commissioner shall have the right to further inspect the premises upon which the apartment has been vacated at least three times per year for three years. 7. This Special Permit is not transferable and is only issued to the Applicant. The Vote was as follows: AYE: Ron Jansson, Emmett Glynn, Gene Burman, Robert Thorne, and Chairman Gail Nightingale NAY: None Order: Special Permit Number 1995-138 for a Family Apartment has been granted with conditions. This decision must be recorded at the Registry of Deeds for it to be in effect. The relief authorized by this decision must be exercised in one year. Appeals of this decision, if any, shall be made to the Barnstable Superior Court pursuant to MGL Chapter 40A, Section 17, within twenty (20)days after the date of the filing of this decision in the office of the Town Clerk. , 1995 Gail Nightingale, Chairman Date Signed Linda Leppanen, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20)days have elapsed since the Zoning Board of Appeals filed this decision and that no appeal of the decision has been filed in the office of the Town Clerk. Signed and sealed this day of 1995 under the pains and penalties of perjury. Linda Leppanen, Town Clerk 2 QUERY PROPERTY: QUERY END QUERY PROPERTY PENTAMATION----------------------------------------------------------- 12/30/97 PARCEL ID 167 008 GEO ID 9267 LOT/BLOCK DBA PROPERTY ADDRESS OWNER NICKERSON 836 BUMPS RIVER ROAD SAMUEL A& LISA & LAUTHER BERNICE H CENTERVILLE 836 BUMPS RIVER RD CENTERVILLE MA 02632 PHONE DISTRICT CO DEVELOPMENT STATUS C ASSESSOR' S CODE CAPACITY (NOTES) ZONING DIST/ZOC SPLIT SEWER SYSTEM FLOOD PLN/ELEV. WATER SYSTEM OKH? # BEDROOMS ZBA DECISION FAMILY APT LOT SIZE 21344 .4 OPER/MGR NAME WET LANDS MULT ADDRESS USE 101 PROTECT DIST (N) EXT / (P) REVIOUS / NO (T) ES / PER (M) ITS / (V) IOLATIONS / (G) EOBASE / (E) XIT QUERY PERMITS : QUERY END QUERY PERMITS PENTAMATION----------------------------------------------------------- 12/30/97 PERMIT NUMBER 10669 PARCEL ID 167 008 836 BUMPS RIVER ROAD PERMIT TYPE BELEC WIRING PERMIT DESCRIPTION MOTHER INLAW APT AND SER CHG CONTRACTOR PERMIT FEE 30 . 00 VARIANCE STATUS C COMPLETED CONSTRUCTION TYPE 753 GROUP TYPE APPLICATION 09/29/1995 EXPIRATION VALUATION 2500 . 00 DATE ISSUED 09/29/1995 COMPLETED 12/19/1995 DEPARTMENT-----STATUS---DATE-----DEPARTMENT-----STATUS---DATE---- (N) EXT/ (P) REVIOUS/ (C) ONTRACTORS/ PR (0) PERTY/ (I) NSPECTIONS/ (H) ISTORY/ (F) EES/ (A) RCHITECTS/ (V) IOLATION/ (E) XIT 1"Board Assessor's Office'(1st floor) Map rot w0 ermit#Conservation Office(4th floor) ;\ ate Issued of Health(3rd floor)(8:30-9:30/1:00-2:00) S^ E5o Engineering Dept. (3rd floor) House#1 _ ��� i la in De t. 1 �or Sc o 1 Admin. Bld ������ fi ' 1v P App o ed by Pla Board , 19 / y :AND OV TOWN OF-BARNSTABLE r® "�� Buildin Permit Application Project Street Address �' .}; \, Village CGu-t6 kc)" L(. .Owner!Am 1���ACAS&6 Address km 6 Telephone F Rer;itRequest w d _,-..�1LV Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) ?0 square feet Estimated Project Cost $ Zoning District Flood Plain Water Proted-bon Lot Size Grandfathered? Zoning Board of Appeals Authorization Recorded Current Use -5 & 64,0,)14Cq 't, jJ Pro osed Use ,�` P I�i1 4-lU-CAW Sod-6- Construction Type .Ui col &A `c> Commercial t,1 C Residential ` Dwelling Type: Single Family fl . Two Family Multi-Family Age of Existing Structure S Basement Type: Finished Historic House Unfinished Old King's Highway ` Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor i4 Heat Type and Fuel U Irl L. Central Air Fireplaces Garage: Detached. Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name Telephone Number t�' A-;; -J Address !JJJO L"�- License# ": ►G(-F /g Home Improvement Contractor# Worker's Compensation# �J,a\('7) 1 LT Lclaa r f NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 9S BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) C/ TOR OFFICIAL USE ONLY PERMIT NO. 10649 _ DATE ISSUED 0 9/2 8/9 5 MAP/PARCEL NO. 16 7 -0 08 t t � t 836 Bumps River Road Cehterville ' ADDRESS VILLAGE t t y Phillip & Marie Souza OWNER , DATE OF INSPECTION: FOUNDATION Vv� M_v FRAME = INSULATION FIREPLA�1K: - ELECTRICAL: ROUGH •FINAL PLUMBING: R(3UGIT;,' FINAL GAS: FINAL + FINAL BUILDING DATE CLOSE6'0 ff, ' ,-� ASSOCIATION-PIN �.. . � �1e �omzmanu�ea�.l�t o�✓�aaoac/zuae/ta ° L OEPARINENT OF PUBLIC SAFETY C4NSTRUC.tI.IN SPPERVISOR LICENSElug Mbar rEzpires: ` Rest[;ct� 1u 00 � , w. __.-TH9lNtS R MORSE IAKESHORE OR ,�' SANDYICH, HA 02563 ' � IA 14, � �V- 0, TOa r, T � DMtiN15T � sr }. a.n wi fr �p, 25Q The Town of Barnstabl.e � Serest «� Department of Health Safety and Environmental . Building Derision 367 Main Sloes,liyaanis MA 02601 RalpfC 1 508-790.62Z7 r r HWU Fad 508-775-3344 . For affice use aaiy _ Permit nc- Date AFFIDAVIT HOME Il WR0VEM=CONTRACTORLAW SUPPLE51[mT0 PERNIITAPPUCOWN MGL a 142A requires that the"reconstruction,aitemtio=reaovatim maft� impmvemau, mum-4 demolition, or won of an addition to W PIc'°� , Qom° building containing at least one but not more than foar dwdllag err to to skit residcaoe or building be done by registemci anwacmm with certain cooepfliotts,along wr cum Type of Work: c �,Cast y"0, Address of Waric Owner.Name: Date cf Permit Appii=ion: I h=br versify that: Rcgistr cn is not required for the following Tc=m(s)- Wet aodudedby►law, ' Job cadet SL000 nitdiag to aarQe wa ugied Chv=pailiagownPew . Native is hereby On'm that: CONTIU OWNERS pULI.MG TMR OWN PE*Or OR DFJUMG V= DO NOT ACCESS TT R APPLICABLE HOME M tOVDA01T WaM ARBI' IATION PROGRAM OR GUARANTY FUND UNDER MGL C. 14ZA SIG-M UNDER PENALTIES OF PE Y 1 b=cby apply for a permit as the ageat of the Owner. R /0 Date cm MZ= OR 17:02 'C8177277122 �^ Cp/}ZJYIOIZU/P.QLtiL O ffla.16=11,adedd earr�3t� to t, / . U4,A,#j% &MA O2f!1 ,�rnes.l.CampbEU .. CGl171lfiSSiOAeI Workers' Compensation Insurance JW&vit with a principal place of business at: 06 N A , ( do hereby certify under the pains and penalties of perjury, that: an mployer provid'mg workens compensation coverage for my employees w4 this job. insamanae rnpatty Policy �itmtber I am a sole proprietor and have no one woridug for me in any capacity. O I am a`sole proprietor, general aomraaor or homeowner (drele one) and have"bit contractors ilsced below who have the following workers' ccMeasanon policies: Contractor Ins=nce CompaaY/Policy Contractor h mance Comp=wIPoiiCf Contraaor Insurance Company/policy O .� [ atn a homeowner performing aff the work myself. I wzeu_ana:L.0 a C07f of d:is srsvmm vai be fwr:•arded w d•.e OMm of Immdpdons of dw OIA for c7mate verw=ion and drat w enge s m=i and andZSA of MGL 152 cart kid m the lrnpCWdon a pcnaidw one of a ft Of up to S 1,: yex:s' imprisonr..ant as 01-9-uf1 pstnaid tri .ei a STOP W , a Me o�200.00 a daY opinst mG Signed this ofP7 , 19 LicenseeRerminee Building �epatmtenL Lioeming Board Selectmen Office L,fa7tfth nPtf�7E8t I T - _ UQ I 1 � � ELE VAT bAI -•a Le //v'=rp• REf+R fLEVArfcm 6lDR :Tc ki Auce SF Yd➢• /$S/ - ____j1CAl�w1.._. 'F4 SNAR ,j .uA lO � Snll u;eiJ 77X��.7y I I I i I 1 axN 41o4f —\ �Lt axw RPSTEty _ I FUT AR\A ax to wr e w - —� — R106C W,.tX7 RAiT Ecj R3Q cw5• i_ i t/L-ct -�S/MKT Leaf - Af pHA T cax GLAp eod•R_o FFo�+T 1 ;I/ I .DrV S♦IOE f W�C 3 slafg � I �'I i aaxV 7oP PcAiCS .. - $"T.T.tJ. I �I y1rD sc. axd NE.+DE<Gj jH v7TfaS FRo.�'T �.. dx-c - C _ — RH SrLc IJyv l.,.cTro�J FAyC/A-f SOFFIT r -Lx ID Df+H YVS E /L'O(. 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N \ DEGK �- n � i; �RISrNG i a0 s 1� I certify that this .proper-=ty-is___ located in Flood Hazard Zone C (out- side the 500 year flood) as identified by the Department of Housing and Urban Development (HUD) . Date Jay zs CERTI FI ED PLOT PLAN LOCATION 49eP?'/ i SCALE /.�_3al.... DATE t., Reg ! ar L �v r PLAN REFERENCE ��`-�!��. , �. . . ... -y C St o /�5 S! 1�✓� ON .�Ij. ... . . . . . I certify to Bank of America,�FSB and its title ins.Co. that there are no visible encroachments I CERTIFY THAT. THE td'/ST1!t�G Z�L�✓EY-L✓^� or easements except as shown and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND plan was prepared under my. immediate AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REOUIREMENTS OF THE TOWN OF supervision. , . . L�T�N•S?1°J�� ,WHEN CONSTRUCTED.. DATE oTfS REGISTERED LAND SURVEY R i Town of Barnstable Regulatory Services Thomas F.Geller,Director BABNSTABLE 9 MASS. $ Building Division i6S9• pTFD MP�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,Na 02601 Office: 508-862-4038 Fax: 508-790-6230 .� FEE: $ �r` �O© PERMIT# G SHED REGISTRATION 120 square feet or less A"Er Location of shed(address) Village. Property owner's name Telephone number Size of Shed Map/Pa cel# Signature Date Hyannis Main Street Waterfront Historic District? Ala Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature required) 3 da PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:121901 2 -75 c' 5 co d � �I 1 ' .�fir s3 • � � \ a-ocAk-FOO N OF PMOPE.R- Y- LANES AAAAY NOY BE AACC RALYE STANDARDLEGE,ND NOTE:not all symbols will appear on a map GOLF COURSE FAIRWAY EDGE OF DECIDUOUS TREES EDGE OF BRUSH r i ORCHARD OR NURSERY V'YT-9 EDGE OF CONIFEROUS TREES r MARSH AREA _ —--•— EDGE OF WATER DIRT ROAD `V� wf�� DRIVEWAY PARKING LOT J Y IQ ,pl PAVED ROAD r i — — DRAINAGE DITCH - - - - PATH/TRAIL PARCEL LINE 7 MAPr,a --MAP# 21 -e PARCEL NUMBER #Ie60 a� � �� ----_-_ � _---__ E—HOUSE NUMBER 2 FOOT CONTOUR LINE —IN3 10 FOOT CONTOUR LINE l Elevation based on NGVD29 x /\4.9 SPOT ELEVATION x # 822. ------- STONE WALL o -X—X- FENCE RETAINING WALL RAIL ROAD TRACK © STONE JETTY (� SWIMMING POOL • � PORCH/DECK ❑ BUILDING/STRUCTURE 4F- DOCK/PIER �.� HYDRANT 6 VALVE ® MANHOLE O POST O" FLAG POLE T O W N O F B A R N S T A B L E 6 E 0 6 R A P H 1 C I N F O R M A T 1 O N S Y S T E M S U N 1 .T 0 SIGN ® STORM DRAIN N PRINTED SCALE: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 James ❑ TOWER - 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 o UTILITY POLE w a 0 G 20 1 40 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and vegetation were mapped to meet National Map Accuracy Standards s I INCH=40 FEET* enlarged scale. on the map. at a scale of 1"=100'. Parcel lines were digitized from FY2003 Town of Barnstable Assessors tax maps. 4 LIGHT POLE O ELECTRIC BOX oFtKE r Town of Barnstable *Permit#,53 t® Expires 6 months from issue date CAB , : Regulatory Services Fee o2.5 MASS, v� 16g9. � Thomas F.Geiler,Director A'EDN1°`A Building Division Elbert C Ulshoeffer,Jr. Building Commissioner 367 Main Street, Hyannis,MA 02601w 'PRESS PERMIT Office: 508-862-4038 MAY 2 9 2001 ALI Fax: 508-790-6230 `EXPRESS PERMIT APPLICATION TOWN OF BARNSTAB ff i Not Valid without Red X-Press Imprint Map/parcel Number. Property Address i 3lp lq m ps 9 ye'g— e2 Residential OR ❑ Commercial t ueo.f Work � il Va ����� b Owner's Name&Address SN lie-L. l Y«4 sue/ Contractor's Name 61U 66e6 !& TV Telephone Number .5b2 3 9 y0 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) OWorkman's Compensation Insurance Check one: I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 1CA.N � o�`7Zt. Workman's Comp.Policy# WC g 3 9 6 01;�-9 Permit Request(check box) Re-roof(stripping old shingles) Re-roof(not stripping. Going over existing layers of roof) Re-side Replacement Windows. U-Value O a 37 (maximum.44) Other(specify) ` *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. Signature expmtrg o- 1.......• �.....a_ -'.- :. •-•'e..:.: :. ,._ ... ...:s -.-.. ... .. .-..-.. _ .7 .v. }.: d 7 f �. ✓/zea7�7Fwizurectl�i 0�'✓1cz�/N.aetla Board of Building Regulations and Sfandar ds HOME IMPROVEMENT CQN-TRACTOR Registratidr% 126893 � Expiration: dg%03/2002: TYPe Supp,ament Gard = Home GPpct At HornF Sbrvis$ -v c: T MIKE BEUFir'tr. PK�d1iYas��. 32C�0 COBB`GALLERIA 't ALTANTA,GA 30339 Admen s•rator c• 1 '4 e f .� r � '.t �,'�. *: r:: era -F -,. •.z. is MAR-12-01 12:27 FROM- T-495 P.02/02 F-380 TM CERTIFICATE OF LIAE JLITY INSURANCE o3/09/2001 Sfluc R Ear-jai# q27 THIS CERTIFICATE 18 ISSUED A8 A MATTER OF INFORMATION SHEPARD&8COTT CORP. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR 352 SEVENTH AVENUE-SUITE 805 I ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. NEW YORK,NEW YORK 10001 INSURERS AFFORDING COVERAGE INSU;i F ADMIRAL INSURANCE COMPANY RMA HOME SERVICES, INC. INSURER a, TRAVELERS INDEMNITY OF ILLINOIS 3200 COBS GALLERIA PARKWAY INsuRERc: CONTINENTAL CASUALTY INSURANCE CO.w ATLANTA, GEORGIA 30339 I INSURERD: AMERICAN INTERNATIONAL GROUP INSURER E: 3VERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO T �INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY Rd l CLAIMS. TYPE OF INSURANCE POLICY NUMBER--R n LIC Y POIJC N LIMITS GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 l X coMMERaALCENERALUAB1uTY A01AG10097 2/28/01 2/28102 FIRE DAMAGE(My onenw) 50,000 CLAIMS MADE [X OCCUR MED EXP(Any ono person) s EXCLUDED PERSONAL SADVIhUURY a 1,000,000 GENERALAGGREGATE s 2.000,000 GEN'L AGGREGATE LIMIT APPLIES PER- PRODUCTS-COMPloP AGO s 11000,000 X POLICYO AUTOMOBILE LIABILITYY81033000703-TIL 2/28/01 2/28102 COMBINED SINGLE LIMIT s $1,000,000 ANY AUTO (Ea aoclder� i ALLOWNE13AUTOS BODILY INJURY y SCHEDULED AUTOS' HIREDAUTOS 5WILYINJURY $ NONlJWNEDAUTOS„ .. (Peroccidonll PIWPERTY DAMAGE s (Per ralda�tl aARA0ELIA ury AUTO ONLY-EA ACCIDENT s EA ACC 5 ANY AUTO AUTO OWYYN AGG S EX¢EMSLWBILITY EACHOCCURRENCE S 10,000,000 C :xl OCCUR CLAIMS MADE CUP 247893247 - 2128101• 2128102 AUGREGATE s 10,000,000 DEDUCTIBLE I a X RETENTION s 10,000 I s WORKERS COMPENSATION AND WC 9386027,WO 9386028,: 3/10/01 3/10102 X euMlTs ER D EMPLOYERS'LIABILIT:Y.:., WC9386029 E.L.EACH ACCIDENT s 500,000 E.L.DISEASE-EA EMPLOYEE s 500,000 E.L.DISEASE-POLICY LIMIT i 500,000 OTHER DESCRIPTION OF OPERATIONSiLOCATIONSIVENCLE&T-=LU510N3 ADDED N ENDOR9(EbIENTISPEQAL PROVIS(ON9 i i CERTIFICATE HOLDER X rZ.ITIl0XAL INSURED:INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBEDPOLICIES BE CANCELLED opog=THE EXPIRATION. i DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEfT,BUT FAILME TO DO SO SHALL `O�� O� INSURANCE' — " REPitEBENTATIL(E>g,impoag No �N OR LIABILITY OP ANY KIND UPON THE IN6M&R ITS AGENTS OR AUTHORIZED REPRESENTATIVE OF INDEPENDENT INSURANCE AGUNCY Annbrl 9O o i1/G7� .�APAD11 AnpOP1Ow Tin►I�f100 ; I Town of Barnstable CF'THE 1p� o Building Department Services Brian Florence, CBO BM N8TABLE, v MASS" BuildingCommissioner �- �gg `��+ �. C6A s63q. ♦� a <� a 4s#�13.7f Tens s 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us fill g t .f<_I 114 PH 3* '3 6 Office: 508-862-403.8 Fax: 508-790-6230 � ^ rm Town of Barnstable Family Apartmen't.Affidavit I,being on oath, depose and state as.follows: My name is �'�rr,ve�l ��C./�1 ��®G� I am the owne side f the property located at: I IV1515 1-4- f a, 2_. The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: Ae' (,Z1V1ee_ �- Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notiIfy the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand*that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(Appeal No. Other Sworn to under the pains and penalties of perjury this / day of 2019. Signature Phone Number Print Name q:forms/famafd.doc rev 11/08/13 Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 39. TOIN OF BARNSTABLE �Fo 01 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us 2018 ,JAB( 18 PH ( 56 T Office: 508-862-4038 Fax: 508-790-6230 DT t t Town o arras a e Family pa men i avit I, being on oath, depose and state as follows: My name is I am the weer/resident o the property located at: 3 ( 9L,-1 s�w�<c•IZ J C�;✓, �tJ`l L/O Zrz®-;7 G 3: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: ,/i ✓'�Lil/GC �/�l/��'I c'/Z— , ��z✓ Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notes the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable Zoning Ordinances Section 240-471 Family Apartments. I agree to note the Building Commissioner immediately in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(.Appeal No. ) Other Sworn to under the pains and penalties of perjury this day of J�_am 2018. Signature Phone Number Print Name q:forms/famaffid.doc rev 11/22/2017 Town of Barnstable - -- Regulatory Services Richard V. Scali,Director TOWIN .Of BARNSTABLE Building Division RAJOWMMPaul Roma,Building CommissionerL'!117 ; R -3 t i g: 51 61 200 Main Street, Hyannis,MA 02601 www.town.ba rnstable.ma.us Office: 508-862-4038 Tit€SIMFax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I,being on oath, depose and state as follows: My name is ye-( Ad �G I so�,/ I am the o res' of the _. property-located at: The following members'of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: A�_W/ Name&relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately notes the Building Commissioner in.writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that;l am required to file an Afdavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment. I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit andlor the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Apartments. I agree to notes the Building Commissioner immediately in the event of the sale of this property. If tbsere is-no longer a-Family Apartment at t1-ds location,please explain: The apartment has been dismantled. The apartment has been transferred to the Amnesty Program(Appeal No. ) Other Sworn to under the ams and penalties of perjury this day of 2017. Signature Phone Number Print Name cJl/3'�7v�� / N/G/ P43n5 D q:forms/famaffid.doc rev 11/08/12 Town of Barnstable Regulatory Services oFIKE jW�, Richard V. Scali,Director Building Division r a ,,BMM Thomas Perry, CBO,Building Commissioner 1639. `0d ArEo a 200 Main Street, Hyannis,MA 02601 — , wwwaown.barnstable.ma.us Office: 508-862-4038 F 508-790v6230� Town of Barnstable Family Apartment Affida4t a I,being on oath, depose and state as follows: My name is �e�(/I`; �f�� o�✓ I am the owner/resident of the property located at: — �ryJ/J5v�w The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. 'In the event that the listed relatives vacate said apartment,-I will immediately notes the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family Apartment.I also understand that I am required to comply with all conditions imposed by the ZBA Special Permit and/or the Town of Barnstable.Zoning Ordinances Section 240-47.1 Family Apartments. I agree to note the Building Commissioner immediately,in the event of the sale of this property. If there is no longer a Family Apartment at this location,please explain: T hE apdr-anent has b.. uismantied. The apartment has been transferred to the Amnesty Program(Appeal No. _ ) Other Sworn to under the airs d pen ties of perjury this �i� day of 2016. J 0— 2 Signature:. Phone Number Print Name q:forms/fam affi d.d o c rev 11/08/12 Town of Barnstable pFI E rod, Regulatory Services Richard V. Scali,Director rt BARNWABLE. : Building Division Thomas Perry, CBO, Building Commissioner ED hAp`l 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Town of Barnstable Family Apartment Affidavit I, being on oath, depose and state as follows: My name is ��/� � 4 I am th owner sident of the property located at: The following members of my family will be the sole occupants of the Family Apartment at the aforementioned address: Name &relationship to owner: �'x...�/ /%IC17E: ��/L Name &relationship to owner: The Family Apartment will be the primary year-round residence for the above-identified family members. In the event that the listed relatives vacate said apartment, I will immediately' notes the Building Commissioner in writing. I understand that no subletting or subleasing of said Family Apartment is permitted. I understand that I am required to file an Affidavit annually with the Building Commissioner listing the names and relationship of occupants in said Family A ,ment. I also understand that I am required to comply with all conditions imposed by the ZBA�I ecial Permit Zz and/or the Town of Barnstable Zoning Ordinances Section 240-47.1 Family Ap'o, ents. I agree to note the Building Commissioner immediately in the event of the sale of this �perty. == 9 If there is no longer a Family Apartment at this location, please explain: _ The apartment has been dismantled. CIO The apartment has been transferred to the Amnesty Program(Appeal No. Other " Sworn to under the pains an pena}ties of perjury this day of 2015. L 0 Signature Phone Number Print Name q:forms/famaffi d.doc rev 11/08/11 �i j al