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1127 CRAIGVILLE BEACH ROAD
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" , �, -, -� 2"',", � � � � � � � � , , , , , �,, ;n, � lo��� 1:� , � � , � , *i�� ���- ;,, c z����' , ,� , � - :�, ,;',��1��,� �,� ,� 4,��`,, " Molotov AM A; & z R j I nt � - :,�,*,"',"",�.:', , �,'," V - , ,-���,� �-';�� Town of Barnstable Building a� " ;: ��:,', .".=`r: ,,�.,P✓ �z' r,, � f ,°Ft � ,,`" ,� ,�., t' ,, �.a r�. ,,,.� g ,,F;'� <d,.� i,� a :. �» Post;This Card SoT,hat it�s Ulsible FromaheStreet, A rouetl.PlansMust;beRetainedson,Job and th�s�Card"Must.be Ke t MRf1tTI'A611', '. :" t�..w arn� Posted Until Final InspectionHas=Been Mader r ° Where a Ce"rtificate of Oecu anc,xis Re" aired such Buildm shall Not be Occu red until a Final In`s ect`ion has been made Permit .�,��„,x ._.. Permit No. B-18-1802 Applicant Name: Darren Shepard Approvals` Date Issued: 06/08/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/08/2018 Foundation: Location: 1127 CRAIGVILLE BEACH ROAD,CENTERVILLE Map/Lot 206-049 Zoning District: CBDLBSB Sheathing: ZZ Y =s a - � Owner on Record: Kennedy, Douglas Contractor'Name 4 DARREN E SHEPARD Framing: 1 Contractor'Lce .Address: 1127 Craigville Beach Rd. i y nseCS 085746 2 Centerville, MA 02632 `� '� Est Project Cost: $7,300.00 Chimney: Description: Strip and re-roof ti ` Permit Fee: $37,23 Insulation: Project Review Req: Fee Paid $37.23 Dated 6/8/2018 Final: - Plumbing/Gas s Rough Plumbing: rBuilding Official Final Plumbing: ,. '.M 1 This permit shall be deemed abandoned and invalid unless the work autedbimitim within si th4aferssuance.nz ti Rough Gas: All work authorized b this permit shall conform to the approved a lcat�on ante a Y ppp pproved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by lawsJ t codes. Final Gas: This permit shall be displayed in a location clearly visible from access nd shall be maintained open for publiclinspect,on for the entire duration of the work until the completion of the same. a p Electrical 114 � � ��`� The Certificate of Occupancy will not be issued until all applicable sign atur I es bey the i3U1 g and,,Fie Officials are',provided on this^permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Z 11�11 °� ,,.-- Roug h: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage,Final: 7.Final Inspection before Occupancy ' Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "'Aersons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT vY Town of Barnstable RECEtEPT KASS 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit c) Application No: TB-18-1802 Date Recieved: 6/6/2018 Job Location: 1127 CRAIGVILLE BEACH ROAD,CENTERVILLE I C" o Permit For: Building-Siding/Windows/Roof/Doors Contractor's Name: DARREN E SHEPARD State Lic. No: CS-085746 ? ) r— Address: Attleboro Falls, MA 02763 Applicant Phone: (774) 696-2732 v m (Home)Owner's Name: Kennedy,Douglas Phone: (617)438-9903 (Home)Owner's Address: 1127 Craigville Beach Rd. , Centerville,MA 02632 Work Description: Strip and re-roof Total Value Of Work To Be Performed: $7,300.00 Structure Size: 0.00 0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor;subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,or or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Darren Shepard 6/6/2018 (774)696-2732 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $7,300.00 Date Paid Amount Paid Check#or CC# i Pay Type Total Permit Fee: ,_ $37.23 6/6/2018 $37.23 XXXX-XXXX_XXXX_ Credit Card 1567 ........... ............................ .......:........ ............... Total Permit Fee Paid: $37.23 Town of Barnstable Building • Post�Thls Card�So,Thai�rt rs.Vrsrble�Fromthe�Street .A rovedl,Plans�IVlust be�Retarned on;Job and�this Card,Must be�Ke t ;, /, w.p M Posted UntII Final Inspection HasBeen Made, ` 461 Permit alloy'` Where aECertlficate of Occu a'nc ,Is.Re ulred such Buildln shall Not,'be Oceu ued,until a�Final;;lns ecUoo has�been made.,.. . Permit NO. B-18-736 Applicant Name: Doug Kennedy Approvals Date issued: 04/06/2018 Current Use: Structure Permit Type: Building-Restore to Single Family Expiration Date: 10/06/2018 Foundation: Location: 1127 CRAIGVILLE BEACH ROAD,CENTERVILLE Map/Lot 206 049 Zoning District: CBDLBSB Sheathing: Owner on Record: BRYSON, DOROTHY P ontractorName Framing: 1 Address: 11 ACORN DR Contractor'Llcense 2 AUBURNDALE, MA 02166 ? Est Project Cost: $2Ile ,000.00 Chimney: Description: I am purchasing the property on 15Mar18. The property currently Permit Fee: $85.00 x Insulation: has an illegal apartment,the intention of thisgperrn Isto�remove F.ee'Pal $85.00 the kitchen. This permit is for the demolition'of the exlstlrg area F � - 4/6/2018 Final 0 G 03 jQ Date consisting of removal of refrigerator and interIor.sheetrock walls E _ ^ , and drop ceiling. At the completion of demolition the room:wlll�be ,.: painted and used as a recreation room. f s r' Plumbing/Gas Please note the sink will be removed by a licensed plumber;: Rough Plumbing: separate permit to be opened. . . . . .: ' EE Building Official Final Plumbing: Project Review Req: RESTORE TO SINGLE FAMILY Rough Gas: i s This permit shall be deemed abandoned and invalid unless the work authorizedy L b permit is commenced within six months,after issuance. Final Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for`which;.this permit has been granted. All construction,alterations and changes of use of any building and structures shall b0 n compliance with the local zomnglby laws and codes. Electrical This permit shall be displayed in a location clearly visible from access street or road aril shall beirnaintained open for puhlic inspection for the entire duration of the work until the completion of the same. Service: s 3, ..s Rough: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials_are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Final: 1.Foundation or Footing 2.Sheathing Inspection Low Voltage Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Health 7.Final Inspection before Occupancy Final: 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. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: o� Town of Barnstable Pos ard So�That rt isVisibleF rom�the�Street'�,Approved,Plans�Must be;,Retamed on Job�and th�s�Card Must be Kept , ,,.. Building y jx aA1tNs68�3[¢AB I�t�. he-a�e�ai wz.C ? ''w Permit UCttTh " =dM" tePos W1 Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT �� q ,. .. w " E gc J Anderson, Robin From: Douglas.Kennedy@sanofi.com Sent: Wednesday, March 14, 2018 11:37 AM To: Anderson, Robin Subject: FW: B&B Excavation Attachments: Kennedy.pdf Good morning, Robin attached please find the memo from B&B excavation. As I mentioned on the phone they are under contract to install the approved septic at the property. They are sub-contracting the associated plumbing for the septic as well as the removal of the sink in the apartment. Could you let me know what the next steps are in order to approve the property for the smoke certification? MY walkthrough is scheduled for 313M today. Is there'an official memo? Thankyou From: B & B OFFICE [mailto:office@bandbexcavation.net] Sent: Wednesday, March 14, 2018 11:24 AM To: Kennedy, Doug/US; nicole.kennedy96@yahoo.com Subject: [EXTERNAL] B&B Excavation Hello Please see the attached. Let me know if this is what you are looking for. Thank you Meghan Barr B&B Excavation 508-477-0653 Exc$vation 14 Teaberry Lane Forestdale,MA 02644 (508)477-0653 March 14,2018 Mr.Douglas Kennedy 1127 Craigville Beach Road Centerville,MA Please be advised that the sink,in the apartment at.1127 Craigville E each Road,Centerville,MA will be removed within the next(14)days as agreed. Feel free to call if you have ariy questions.Thank you Respectfully Submitted, Robert Gilfoy B&B Ezcavation,lnc. Anderson, Robin �'��'(� To: Mike Grossman (mgrossman@commfiredistrict.com) Subject: FW: Building and Plumbing Permits Attachments: image001 Jpg FYI: Regarding 1127 Craigville Beach Rd 0�p6in Robin C.Anderson Zoning Enforcement Officer 200 Main Street Hyannis,MA 026oi 5o8-862-4027 From: Douglas.Kennedy@sanofi.com [mailto:Douglas.Kennedy@sanofi.com] Sent: Wednesday, March 07, 2018 9:25 PM To: Anderson, Robin Subject: Re: Building and Plumbing Permits Thank you Robin for the detailed explanation as well as your time`today. My intentions are to bring the Home back to the state in which it is on file with the town. Thanks again On Mar 7, 2018, at 4:33 PM, Anderson, Robin<Robin.Andersongtown.barnstable.ma.us> wrote: <image001.JP9> Hi Mr. Kennedy, As a follow-up to our discussion, you may apply on-line as a home owner for the required Restore to Single-family building permit. This permit will not be issued to you until you pass papers on the property. You should submit a copy of the P&S agreement as well as a sketch of the entire house in its existing condition and as proposed (with no apartment/kitchen in the subject area). Label all of the spaces accordingly in the before and after version. You may contract with a plumber to remove the kitchen sink at any time but preferably prior to the closing. The plumber will obtain that permit and as long as he has access to the property and with the blessing of(former/current) owner, he may proceed. If not removed before the closing, please provide me with the plumber's name and the date he is scheduled to perform the necessary work. I trust that Debi was able to advise you regarding the on-line permitting process but in fhe event you have trouble please feel free to call our main line (508-862-4038) and a permit tech will assist you Thank you for keeping me informed and best of luck with the closing! 0�9btz Robin C.Anderson Zoning Enforcement Officer 200 Main Street Hyannis,MA 026oi 1 f Official Website of The Town of Barnstable - Property Lookup Page 1 of 4 Select Language!V j Assessing Division Property Lookup Results - 2017 367 Main Street,Hyannis,M.A.02601 <<BACK TO SEARCH<< ��IPrint Friendly — = Owner Information-MaplBlock/Lot-206/0491-Use Code: 1010 Owner < �. t Owner Name as of 1/1/16 BRYSON,DOROTHY P Map/Block/Lot GAS NAPS I, 11 ACORN DR 206/049/ V Property Address Q� p y AUBURNDALE,MA.02166 P 1127 CRAIGVILLE BEACH ROAD Co-Owner Name jVillage:Centerville n I Town Sewer At Address: No (�r GIS Zoning Value:CBDLBSB ,C Assessed Values 2017-Map/Block/Lot 206 1 0491-Use Code:1010 (co 2017 Appraised Value 2017 Assessed Val uePast Comparisons Building $50,100. $50,100 Year Assessed Value 1 Value: Extra $18,300 $18,300 2016-$348,200 Features: 2015 $331,600 I 2014-$331,600 dJ" 2013-$331,600 Outbuildings:$300 $300 2012-$329,900 D� 2011 -$342,000 �V Land Value: $259,600 $259,600 2010 $346,600 L27 . /- 2009-$403,800 2017 Totals $328,300 $328,300 2008-$422,400 (� 2007-$422,400 1 ` Tax Information 2017-Map/Block/Lot: 206/049/-Use Code: 1010 Taxes I C.O.M.M.FD Tax(Residential) $400.53 Community Preservation Act Tax $93.96 Fiscal Year 2017 TAX RATES HERE Town Tax(Residential) $3,131.98 - $3,626.47 Sales History-Map/Block/Lot:206/0491-Use Code: 1010 History;__.__�._.._,. I Owner: Sale Date Book/Page: Sale Price: BRYSON,DOROTHY P 1984-05-24 #D336056 $0 http;//www.townofbarnstable.us/Assessing/propertydisplayscreen17.asp?a... 11/29/2017 Official Website of The Town of Barnstable - Property Lookup Page 2 of 4 �I BBRYYSSON,,�R'O'B'ERT J&DOROTHY P1977-06-17 C70880 $0 Photo? s 206 1 049/-.Use Code: 1010�� Sketches-Map/Block/Lot:206/049/-Use Code: 1010 12 AS ash EP t x a g AsBuilt Card N/A PConstructions Details-Map/Block/Lot:206 1 0491-Use Code: 1010 Building Details Land Building value $50,100 Bedrooms 2 Bedrooms USE CODE 1010 Replacement Cost $77,025, Bathrooms 2,Full-0 Half Lot Size 0.14 ff (Acres) l Model Residential Total Rooms 6 Rooms Appraised $259,600 Value Style Ranch Heat Fuel Propane Assessed $ Value 259,600 Grade Average Heat Type Floor Furnace Minus Year Built 1950 AC Type None Effective 35 Interior HardwoodCarpet depreciation Floors ' Stories 1 Story Interior Walls Drywall Living Area sq/ft 720 Exterior Wood Shingle Walls GrossArea sq/ft 1,286 Roof Gable/Hip Structure . t Roof Cover Asph/F GIs/Cmp Outbuildings&Extra Features~-Map/Block/Lot:206/049/-Use Code: 1010 Code Description Units/SQ ft Appraised Value Assessed Value http://www.townofbarnstable.us/Assessing/propertydisplaysereen 17.asp?a... 11/29/2017 f Official Website of The Town of Barnstable - Property Lookup Page 3 of 4 FEP Enclosed porch- 506 $15,400 $15,400 roof,ceiling FPL1 Fireplace 1 story 1 $2.900 $2,900 PAT1 Patio-Average 60 $300 $300 j Sketch Legend Property Sketch Legend B214 Barn-any 2nd story area FPC Open Porch Concrete Floor REF Reference Only BAS First Floor,Living Area FTS Third.Story Living Area(Finished) SOL Solarium BMT Basement Area(Unfinished)FUS Second Story Living Area SPE Pool Enclosure (Finished) " BRN Barn GAR Garage TQS Three Quarters Story(Finished) CAN Canopy GAZ Gazebo UAT Attic Area(Unfinished) CLP Loading Platform GRN Greenhouse UHS Half Story(Unfinished) FAT Attic Area(Finished) GXT Garage Extension Front UST Utility Area(Unfinished) FCP . Carport KEN Kennel UTQ Three Quarters Story _ I ' (Unfinished) FEP Enclosed Porch MZ1 Mezzanine,Unfinished UUA Unfinished Utility Attic FHS Half Story(Finished) PRG Per UUS Full Upper 2nd Story (Unfinished) < FOP Open or Screened in Porch PRT Portico WDK Wood Deck PTO Patio ''Print Friendly . Contact Director Edward F.O'Neil MAA P 508-862-4022 IF 508-862-4722 8:30a.m.to 4:30p.m. 367 Main Street Hyannis,MA.02601 Public Records Ann Quirk Public Records Request P 508-862-4022 367 Main Street Hyannis,MA.02601 http://www.townofbarnstable.us/Assessing/propertydisplayscreen 17.asp?a... 11/29/2017 Official Website of The Town of Barnstable - Property Lookup Page 4 of 4 Helpful Links to Downloads Abatements SALES LISTINGS Barnstable FD Residential C.O.M.M FD Residential Commercial-Industrial- Mixed Use Cotuit FD Residential Hyannis FD Residential Townwide Condominium W.Barnstable FD Residential Exemptions Parcel Consolidation Questions about values FY17 Combined Tax Rates Town Land Use Codes Helpful Maps All Town Maps Flood Insurance Maps Property Maps FY17 Tax Mates Owned and Operated by The Town of Barnstable-Information Technology Home Departments&Services Boards&Committees I Residents&Visitors I Doing Business Town: Calendar Phone Directory I Employment Email Town Hall http://www.townofbarnstab.1e.us/Assessing/propertydisplayscreen 17.asp?a... 11/29/2017 Town of Barnstable *Permit# b a��`� � Expires 6 months from issue date Regulatory Services Fee_ cta a. PERMIT Thomas F.Geiler,Director � Division Building 1 APR 2 � NOT � -�� a6 c? Tom Perry,CBO, Building Commissioner ©�l2y�d? OF BARNsTABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERAUT APPLICATION .- RESIDENTIAL ONLY (�� /� Not Valid without Red X-Press Imprint V l p/parcel Numberb(o ( �q perry Address _ Residential Value of Wor / d ,Minimum fee of$25.00 for work under$6000.00 JK wner's Name&Address ontractor's Name Telephone Number ome Improvement Contractor License#(if applicable) :anstr���sor's-Liuonse`#(�-appiicabie) ]Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance ssurance Company Name Vorkman's Comp.Policy# ,opy of Insurance Compliance Certificate must be on file. ,ermit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side Co'1-�l des) . Replacement Windows/doors/sliders. U-Value (maxunum.44) "Where required: issuance of this permit does not exernpt compliance with other town departmentregulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property.Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. ,IGNATURE: I:Fomis:expmtrg .evise061306 I he C.•ommonweault-ol Massachusetts Department of Industrial Accidents Office of Investigations• ' ? ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia ' Workers' Compensation hasurance Affidavit: Builders/Contractors/El6ctricians/Plumbers Applicant Information Please Print LetZitaiv Name (Business/organizati diyidual): D Address: i i acA rzW i v e City/State/Zip ��t�,:,-��� �'j/�-c,*Ylf, Phonet G l 7 —a 4Lf — o q 3 i— Are you an employer? Check the'appropriate box: -Type of project(required):. 1.❑ I am a employer with 4• ❑ I am a general contractor and I employees (full and/or part-time). have hired the sub-contractors 6. ❑New construction . 2.❑ I am.a•sole proprietor or partner- listed on the'attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' S,..❑Building addition [No workers' comp.insurance comp,insurance.$' required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3 I am a homeowner doing.all work officers have exercised their 11.ElPlumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t c. 152, §1(4), and we have no 12.❑Roof repairs employees. [No workers', 13:❑ Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensatian policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees: If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is.the policy and job site information. Insurance Company Name: Policy#•or Self ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page'(showing the polity 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 tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a line of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Off ce of Investigations of the I)IA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and.correct. Si afore: Date: 2- Phone 4 4—a93@ Official use only,.Do not write in this area, to be completed by city or town offrciaL City or Town: Permit/License# I: Issuing Authority(circle one); �I :1.Board of Health 2,Building Department 3. City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Inform ati®n and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer, or the TP('.elVer nr trust_ee-of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling-house having not more than three apartments and who resides therein;or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." IvMGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal.of a license or permit to'operate a business or to construct buildings in the commonwealth for any applicant-who has not produced;acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until-acceptable evidence.of compliance with the in-mr nce requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other.than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or.license is being requested,not the Department of Industrial Accidents;- Should you have any questions regarding the law.oi-if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate-line. City or Town Officials. Please.be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy,information(if necessary)and under"Job Site Address"the applicant should write"all•locations'in (city-or town)."A copy of the affidavit that has.been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questio.�-,- please do not hesitate to give us a call. The Departinent's address,telephone-and fax number; e Commouwealth dMassaehuwtts Dgpa_ tmed of WQstrial Mdents Office of Investigations • &�4�ashi�tgt� Street Boston,NIA€12.111 Tel.4 617-727-490.0 ext 406 or 1-M-NIASSAFB Fax# 617-727-7749 Revised 11-22-06 wvw.Mass:gav1dia - oFIKE Town of Barnstable. � do Regulatory Services �B '$ Thomas F.Geiler,Director Building]Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to.work authorized by this building permit application for: . (Address of Job) Signature of Owner Date Print Name Q:FORMS:OwNERPERMIS S ION