HomeMy WebLinkAbout0032 DOLAR DAVIS ROAD LQV�
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V TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map- Parcel D� Application #P o 5�
TQ, �� OFRNSTABl.E . pp
Health Division Date Issued
Conservation Division 4,M17Application Fee. nn
Planning Dept. Permit Fee /��. C)
Date Definitive Plan Approved by Planning Board;�`� f
Historic - OKH _ Preservation / Hyannis
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Project Street Address J,f k"_J Le r%'A /�-
Village
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Owner Y_ rl �-Jr, 1 1 Address 3 L �la��� L� s V? _
Telephone g Z Y o L L
Permit Request / T//- f�A �,Nr .U /� �2- L Ce,4 J(yCc
I'll oo4k l/t,✓fl cc) vd oo r= 6L4 6 y.✓(-�
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuati n oZ o Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: 0 Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing new Half: existing new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size. _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name � ��� t- S 1 Telephone Number(
Address Do f�y.._, I.o License # z
Home Improvement Contractor# ° 4.
7
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Email 1 nc (Yis A- ,C6IVM Worker's Compensation # K S�oZ �l o y
ALL C NSTRUCT N DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO !06 ' IJr j� If
SIGNATURE C\ en DATE
1 I
FOR OFFICIAL USE ONLY r.
^' APPLICATION#
1; DATE ISSUED a
MAP PARCEL NO.
ADDRESS VILLAGE
OWNER
t
DATE OF INSPECTION: F
FOUNDATION
FRAME
INSULATION r I
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
f
i
GAS: ROUGH FINAL
FINAL BUILDING
I` DATE CLOSED OUT
ASSOCIATION PLAN NO.
P
RISE
OWNER AUTHORIZATION FORM
(Owners Name)
owner of the property located at
(Property Address)
�-
(Property Address)
hereby authorim •
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a founding
permit and to perform work on my property.This form Is only veld with a signed contract.
Owners Sig
Date -
RISE Engineering 5 Dupont Avenue. South Yarmouth,MA 02664
The Commonwealth of Massachusetts
Department oflndustriulAccidents
1 Congress Street;Suite 100
Boston,MA 02114-2017
.•' www muss gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Avolicant Information Please Print Legibly
Name(Business/organization/individual): l� 1 ' {� -l; FN J'J 4 e46 &-Q
Address: o S
City/State/Zip: S L'�Lle OAvl'— 9 Phone#:
Ar�=p Ioyer?Check the appropriate box: V�7 1 Type of project(required):
1 ployer with 12—employces(full and/or part-time).' 7. [3 New construction
2.Q I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any amity.[No workers'comp.insurance required.)
3.E]I am a homeowner doing all work myself[No workers'comp.insurance required j t 9. ❑Demolition
4.[:]I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will10 ❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions
proprietors with no employees, 12.Q Plumbing repairs or additions
5.FJ I am a general contractor and I have hired the subcontractors listed on the attached sheet 13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insuranmt 14.MOffier W LWieti\• Z
6.0 We are a corporation mid its officers have exercised their right of exemption per MGL c.
152,§1(4�and we have no employees.[No workers'comp.insurance mquired.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
;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 worlca-s'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information. �^ /�
Insurance Company Name: J �2 T/� f c. O .
Policy#or Self-ins.Lie.#: (f d S V S tea. O O C,) Expiration Date: t� -2 —
Job Site Address: .�2 U �A K_ 1 /Z 2 City/Statetzip: C� ���//� Y✓1
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirationdate).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under th 4 p and penaMes of perjury that the information provided above is true and correct
Si attire: Date: '�
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Phone M S Z� j, — (o (4
Official use only. Do not w)'e in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Autho " (circle one):
1.Board of Health—.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person- Phone#:
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Dice of Ccnm=Affairs and Busies RAP
1Q PgkPlaza-"te 517n
02116
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FlEfR rr INSUTATIONt INC# �� L
.IGB PH RMLLY
P.C. Btu%105
SEEKQ�NK, MA 02771
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Massachusetts Department--of Putaiic:Safet;+ '
Board of Buiiding Regulations and Stand ds G
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t,Il�l�tl UL:14''roI JtjUC7 11111r JT7i'itG1L�
License- CWL-102771 �
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• • Seelnunck;MA:027�1: � '�
Expiratic;v_F
Commissidrier
RETRINS-01 RBLACK1
A� �p CERTIFICATE OF LIABILITY INSURANCE DA'E(MMroD"Y'Y)
8/1112016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THI.S
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 policy(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 endorsemenf(s).
PRODUCER License#1786862 CONT CT
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HUB.International New England PHONE at :(508}678-2750
No
222 Milliken Boulevard EMAa E •(5pg)67 6-1971
Fall River,MA 02722-9946 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAiC 11
INSURER A:selective Insurance Company of South Carolina 19259
INSURED INSURER B:Star Insurance Company 18023
RetroF'd Insulation,Inc. INSURER C;
PO BOX 105. INSURER D:
Seekonk,MA 02771 INSURER E:
INSURER F:
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
AN
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF Y 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.
LTR TYPEOFINSURANCE D D POLICY NUMBER LIMITS LI EFF POLICY P
/YYYY MMtDD/YYYY
A X COMMERCIAL GENERAL LIABILITY
r EACH OCCURRENCE $ 1,060,000
CLAIMS-MADE l-J OCCUR X S2187653 08/1512016 08/1512017
r PREyiMISES(Ea occurrence) $ 100,000
MEDEKP(Any one person) 5,000
PERSONAL&ADV INJURY $ 1,006,600
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 210001000
POLICY RRO-
u JECT LOC PRODUCTS-COMP/OP AGG $ 2,660,006
OTHER $
AUTOMOBILE LIABILITY COMBINEDJEo a SINGLE LIMIT $ 1,000,000
A ANYAUTO 910018200 08/1112016 08/11/2017 BODILY INJURY(Per person) $
ALL O.W4ED X SCHEDULED
AUTOS NO �WN� I BODILY INJURY(Per accident) $
X HIRED AUTOS X AUTOS I R acEand yPAMA - $
X UMBRELLA LiAB OCCUR EACH OCCURRENCE $ 1,000,060
A EXCESS LIAB CLAIMS-MADE E S2187653 _ 08M512016 08/1512017 AGGREGATE $
DED I X RETENTION$ 0
WORKERS COMPENSATION PER OTH $ 1,000,0.00
AHDEMPLOYERS'LIABILITY YIN STATUTE ER
B ANY PROPRIETORIPARTNERIEXECUTIVE WC0845201 08/0212016 08102/2017 EL EACH ACCIDENT $ 1,000,000
OFFICERIMEMBEREXCLUDED? NIA
(Mandatory In
N
if yes, EL DISEASE-EA EMPLOYE $ 1,000,Oob
DESCRIPTION OF OPERATIONS below - E.L DISEASE-POLICY LIMIT $ 1,000,00
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DESCRIPTION OF OPERATIONS 1 LOCATIONSI VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
50 Washington Street ACCORDANCE WITH THE POLICY PROVISIONS.
Westborough,MA 01581
AUTHORIZED REPRESENTATIVE
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
°Fj r Town of Barnstable *Permit#
�{• Fxpires 6 months from issue date
Regulatory Services Fee �245,
'• snxxsrnBc e, L-1
s e� Thomas F. Geiler,Director � l�� 6f ��
prfDha�� -PRESS ldin I Division
Bui g
O C 2OOTom Perry,CBO, Building Commissioner.
200 Main Street,Hyannis,MA 02601
TOWN OF BARNSTABL�www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS ]PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number qJ 2-057
Property Address I�D )cc !�cY 1/LS C(/V1—P 121//�-�
Residential Value of Work 5 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address aW Ll� WOG P I
i H O nT1 G't-D AV AIZ aD=4J b Zl 1 �
Contractor's Name Telephone Number�`�
Home Improvement Contractor License#(if applicable)
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(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Rome Improvement Contractors License&Construction.Supervisors License is
required. � ) D
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 090809
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
f_ 600 Washington Street
Boston, MA 02111
y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):_ —
Address: 1 �--�,fOQ N16-131PAZ
City/State/Zip:P oSt-P,'d pZ,)l (a . Phone #: (o l? 70
Are you an employer? Check the appropriate box:
Type of project(required):
1.❑ 1 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me.in an ca aci employees and have workers'
Y P h'� 9. ❑Building addition
[No workers' comp. insurance comp, insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.VI 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.❑ Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required:]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/dip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the'information provided above is trice and correct.
SiLynature: Date: ' I
Phone#:/2/:2 %-71) 57 9—7
Official itse only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of 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
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-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 or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only.submit 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 questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.tnass.gov/dia
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��HEToy, Town of Barnstable
yT
Regulatory Services
•�snxxnsi Thomas F. Geiler,Director
en�9- 0. 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
If Propedy Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:OWNERPERMISSION
'Y
of��>•�,,
Town of Barnstable
Regulatory Services
• EARN Thomas F. Geiler,Director
asnss.
9q, 0.19. ��� Building Division
ArED ,la Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.nia.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
+� Q Please Print
DATE: /a
JOB LOCATION:��_�
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS: l -I o/1}�/gz94t/J/ ice!'!
ns� Id A D :1-1) b
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection pro.3edures and requirements and that he/she will comply with said procedures and
requirements.
Signatur fHomeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results.in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:\WPFILES\FORMS\homeexempt.DOC
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Assessor's map and lot number .....�'.. .:�..�.. .... - E /�bL- //�/�5
ypi THE TOE
Sp,wage Permit number
�.,,�/ # A L BARN TODLE, i
House number �// 9 NAM
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�........ ! O 39- �0
TOWN OF BARNSTABLE
S
BUILDING - INSPECTOR
APPLICATION FOR PERMIT TO ...... 8'(21.. .... ............�........IF .........................
.. . .... .... .....
TYPE OF CONSTRUCTION � .Y,
................... -��..5 .......19./.>,, l
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ................/y?-r...... �/�,� J .. ..............( �.;
. 7
....... ....... �... -�
ProposedUse ......................... '.. � �./. .. .?.............................................................................................................
Zoning District ..............: (...... ......:............".......................Fire District .... ........:4 ................
�J .. u`J / .............Address i�/9 / lyi . -
Nameof Owner ..... �................................................. ......�..�...........................................�.......................,...
'�/v/�u'
Name of Builder ....................................... ........................Address .......................:...................................'. ,.......................
Name of Architect .,...�f7� ?.��!�`'� . EAddress .........................
.... ......... ................
Number of Rooms ............... .........................................Foundation ......:.....'J ...........6.............�:... -
1 J�
Exterior ...`:��'!,�.� P.!".�................................ ......Roofing ............ ,% /� ��!/ 4
Floors ...:�a. .,Y�( �-'�L..............................................:.........Interior .......��... . �........
Heating ...6/.... "!... .......... Plumbing � �e� -.. .'.! �/>.
.... `.. ..... ...... .
Fireplace � - Approximate.'Cost
Definitive Plan Approved by Planning Board ________________________________19________ Y Area ..........................................
Diagram of Lot and Building with Dimensions Fee .............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
r b�
Al
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Nam ...............................
Construction Supervisor's License
tAte=
....................................
ti
.S L S TRUST A=171-205
No...... Permit for ....1?,..S tQry..........
...."7.895... ....
Single Family Dwelling,,,,,,,,,,,,,
...........................................
location ...LQt...62.9......32...Dalar..Davis• Road
.................Cent. ..V.a 11a................................
Owner .S...L...S.....Trus.t................................
Type of Construction ....... Xrate.......................
.................................................................................
Plot ............................ Lot ...............................
Permit Granted ..-.MaY....17.,...................19 85
Date of Inspection ....................................19
Date Completed ......................................19
TOWN OF BARNSTABLE Permit No. __27_895_
Bu 1ding/Inspector ;` J _-
w6 Cash - —-
F r ,
OCCUPANCY 'PERMIT Bond -_-----X .7 Z�
Issued to S L S Trust Address
Lot 629, 32 Dolar Davis Road, Centerville
Wiring Inspector f Y A! � y ?inspection,date
Plumbing Inspector '� �� Inspection.date
'
-
Gas Inspector Wit) � � �.f�e�"i..�,nn��� Inspection date �0/�c 0,5- ,
xEngineering Department Inspection date v
Board of Health Y�) Inspection date C 85
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
Building Inspector
r ..� °�.e TOWN OF BARNSTABLE
BUILDING DEPARTMENT
TOWN OFFICE BUILDING
rua
��► •639. `� HYANNIS, MASSr02601
MEMO TO: Town Clerk
FROM Building Department
DATE: ' J 1y aly /� g
An Occupancy Permit has been issuedfor the building authorized by
Building-Permit 02 7 /.S
........... . ......... ..
issued to ......... ». ..................
Please release the.performance bond.
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OF oNe
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WI M. M
� WA ICIC
9771 �Q
GISTER�����`
roaAL LAB �-
On the asis of my knowledge, information and FUN0'1 no/v C'67efi'F%CAT1
belief, I certify to The Town of Barnstable, ��- n
The Boston Five Cents Savings Bank and Ticor �Z� 0LAf PXY15 zP
Title Insurance, Co. that as a .r.esult of a - -
survey made on the .ground on /Iz lav5 , I find ZAIT-e�PVIZZZ-�
that:
The structure (s) are located on the site as
shown. IV14 I� 1�9� 15 f49'
The title lines and lines of .occupation of the
site are as shown hereon.
The site is situated in .Flood .Zone
Communi-ty.panel Rio. Date:
Date: IN6
��� 0,1 80/ AA FAL1'Y4UTf/,
William M. ?,larwicic,RLS
(; Assessor's map and lot number ........1171... /�J�L /�//�J/�`v
p%TNETO
.I
Sowdge Permit number ........:............ ...................I............... d
Z
BAS19TABLE, i
House number ............... . �Pllc i6:jrns9
�p' p�^{� .s� �
TOWN OF BA,RNSTA15"EMETITL
BUILDING INSPECT R
/Q
APPLICATION FOR PERMIT TO ........� ..t1..I...�v.�...........L .,
..............�.;... .........................
TYPE OF CONSTRUCTION ..................4lY..1�� .C/.................. . ..........................................................
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit accordin to the following information:
Location ................ ,( U.. ......q
......... .......... �!�..` .... ......�,JJ��
......P
1_.
ProposedUse ....................... ... 1.. .. ...........................................................................................................
Zoning District ..............1i ,_..........................................Fire District ............... ... ...........................
Name of Owner ...... .�........................1............................Address �v�. .� .1. .��%.......
Nameof Builder ...... .... �........................Address ....................................................................................
Name of Architect .�U..d./�1.. .1�.� J` ..... r � ddress ... ..... ......f%.. .. . .. '1.... ... ....
..�y
r/
Number of Rooms ............... ,. .............................................Foundation ...........y•.......... ..
/�/:7/
Exterior .....15- f"Y ................................................Roofing ............. f......�..........(... .
Floors , ...!/��� .............................................Interior ...... �/' �.'/...�'. . ... ................
.7q—.2............................................................Plumbing �U. /l/���
l/ �
Fireplace .............�� .:��..................................................Approximate. Cost ........... ............................................
//ll
Definitive Plan Approved by Planning Board -----------____---------------19--------. Area /1....�l. .. ........
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
ve
1
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .. ... ...........................................
Construction Supervisor's License .....................................O �� f
L S TRUST
No 2.7_$.95_Permit-for 1 i Story
.. Single Family Dwelling
Lot 629 32 Dolar Davis Rd.
Location ......................................... .._ . .. ,
................... ...............................
Owner ...S..L...S.....:Trust
.........................................
/ Y
Type of Construction ........Frame.................................. o
.......:........................................................................
- r
Plot ............................ Lot ................................ r
Permit Granted .....MAY.... :7................ ......19 85 �
Date of Inspection . .................................19
Date Completed .. ... .L .....:.19A�..1
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 1 -7/ -Parcel _2 b 5 Permit# Z.
Health Division Date Issued
Conservation Division t Fee o-S
Tax CollectorP
Treasurer
Planning Dept.
Date Definitive Plan Approved by Planning Board
tC�
Historic-OKH Preservation/Hyannis
Project Street Address PI—V/
village e CK�EI�v
Owner MD�f�'f_ ► A) X/ Cam, Address C/
Telephone �� '� `�� C A4 N5 FA 0--e
Permit Request p
Square feet: 1 st floor:existing --_. ..__- nd floor:existing proposed Total new
Estimated Project Cost —Zoning District Flood Plain Groundwater Overlay
Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House: ❑Yes' ❑ No On Old King's Highway: ❑Yes ❑No
Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new
Total Room Count(not including baths):existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No
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
D AX 6C -T r 4 VA*"-1t-_ BUILDER INFORMATION f
Name T_y A1 0fttA_ "o F-f"C-r- Telephone Number q 2-c7' O
Address �' �� "2 to A-rCJ+ - License if It b �°
H•W'. 1t)a'(-r�'SHome Improvement Contractor# I: b ,
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO r .W A—)
SIGNATURE
3
• FOR OFFICIAL USE ONLY
r,
PEEMIT NO.
I.. � = T - a! • - 'if
DATE ISSUED
MAP/PARCEL NO. ,,•
s .. .� a.-• , <<'? _ {' a f., �' �a.
ADDRESS °I = ^ V3LLAGE
{ OWNER
DATE OF INSPECTION:
FOUNDATION " , •
f, FRAME
INSULATION
't FIREPLACE w
ELECTRICAL: ROUGH -,FINAL--
r `r
PLUMBING: ROUGH ~,FINAL
GAS: ROUGH FINAL,`-'
3 FINAL BUILDING
' - :•
DATE CLOSED OUT
'lo T
ASSOCIATION PLAN NO.
The Town of 13arns a e
Department of Health Safety and Environmental Services >. ..
s6T9 ��0
` Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements. ,
Type of Work: �" Estimated Cost r
Address of Work: ��' D�-1.Ff--l2— 1 _ 01(-C F— kf A-.
Owner's Name:
It-l� I A-)
Q
Date of Application: 2_9 19 1
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law.
E]Job Under S 1,000
Building not owner-occupied
00wner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME HUROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner.
Date Contractor Name Registration No.
OR
Date Owner's Name
q:fomu:Affidav
awl; a v r< x
'✓ � y
�d':'7,p a"�'•.�p - t�eR[!�O�. addAA�sWe�d
wl-
GNOME IMPROVEMENT CONTRACTOf
YPel
JT8_s iQiAS/I�l
�w YeALU1000 NG
90,BERj4f 1t,NQ¢l,LIR
. 6� lRIAR VATCN RD �,: I lf
� OR � V�tMADm!N1TRAT � 0 �, tLEMA' 026i5
A K
_ The Commonwealth of Massachusetts
�- Department of Industrial Accidents
Office offirtresgratfoos
600 Washington Sired
- - Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
name
location: 3`1 �121 �—�'L'-c PAD
city i C-PL y 1 L V C M - phone I
❑ I am a homeowner performing all work myself.
❑ I am a sole rictor and have no one working in any capacity
1 am an employer providing workers' compensation for my employees working on this job.
comaariv name l
address!
L phone
dtvr-
#'
insurance rn. Zvi
❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compensation polices.
tom attvnamt:
....:.. .. :;.
address:
�.
insurance eo
......:. ....
....... ,... ... ......., .. ...... ..... ...... ....-....... .. ............... ::::,.:::
corn attvnamr. . .... •; :::;:::•;'.:;:::
..:;:..;..:.
:..::::::.:......
address:
dtv�
:..;:
. ..;..:•:•:::•.::.�::•iii:i:;?.;v::•::i:v:::;.;.:..:.::•.:.::..::.:::n•.r .:::; :i:$'r:• •i:? :::'.•:
:.....................::•:x..w ........h..................._.:.... :. ....
htsm•Jmce'ro:.
Faitore Cy
if
to secure coverage as required under Section 25A of MGL 152 can had to the imposition of Criminal penalties of a flue up to S1.500.00 and/or
one yeah,imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
Copy odds statement may be forwarded to the Ofilce of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is trru and eorrcet:
PLYD Pt-LX-_ Phone# R'C>-
C
do not write in this area to be completed by city or town otfidal
permitilleense q Budding Depsrt:nent
(]Licensing Board
edWe response is required ❑Sdec<snm's OfIIee
❑Health Department
phone M, ❑Others
(Mined 9/95 P1A)