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0009 EVSUN DRIVE
Al 4 tool SAM urn 711 :ototl�,low TAY WN oil. PAT 0 VAN n�, n� q l" �C_ W a I tool WIN! AN 4 list Ah" TV! A go init� AWAY -COW loci a IQ; SON army A, tag 212 Q Tnav"VIVOIF tons, VQ . WI A A atom, W 0; ayp,l� '51 in Woo cm W4, q v", 1� --0", i., "U, ON Mo WOW -73 4 —.114 poll V to Bo no moo, A Quys, 5-vi,�t k, Xe N X,V 06, N,��A`Dt,' X� WAN14 van -,"W"P f_gw - , I 1�":` , , , V7 OIL :0W WMAMI AM ;3A "."1""'44 i hu *0 7"A'p fx gy rw 4R vi, Ing wl y, 1, �1�1 KiK` .NO WA Al 4 "s MUTT v T MZI 74 k"T Ex p�l Yr jiz; IR, n6k" 3 pAp v x ASK AND WA "n ,�,Wk Ave WMA REP 4li� xli, va,_ V,z Ax 41 "M N via 1M Was INYVAS70" NEW w "!2T, WOO as 9 m EST! 1 Nk �,"q Mlp�;__,,rdl��414� g"_j. L will 4 5,V, A-A-M", ld 14 AR� "MIN "WE W f, clk oft AOL 574 Mir -W-- v Aviv" . too, its `v KOV K K, Town of Barnstable Permit, � k Regulatory E.11 Fi es 6 monthsfrom issue date ES, BARNWABLE, MAM Richard V.'Scali,DirectorP0 1)j �'639 A�`� AUG J5 Building DIV�sn��� 9 Z016 Paul Roma,Building Co i sioneOF�/1 b p t 200 Main Street,Hyannis,MA 02601 r]'11 S�A B�F www.town.barnstable.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 Property Address ❑ Residential" Value of-Work$ Minimum fee of$35.00 for work under$6000.00 Owner.'s Name'&Address 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 1 ❑ Replacement Windows/doors/sliders.U-Value. (maximum.32)#of windows #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 Owner must sign Property Owner Letter of Permission. A coy of the ome ImprovementContractors License&Construction Supervisors License is 5q red. \ S G ATURE:J \ QAWHILESTORMS\building permit forms\EXPRESS.doc 06/20/16 ?he t;ommoyn Health gfMassrzditxsettr Department afradzzsbialAccidads O}face afb"W569atirrns. 600 WasIdizem Street Beastzrn,MA 02111 -- kvrvtumass gor1dia Workers' Compensat anImm-once Affidavit:S•trid r-JCantractars)E ectricianrdP'lmnbers AppEcant IIIfor atku Please Pain e n N �:A ts"A citwst-& V O Yll�BflU rr Q ���. Are yOII an employer?wee kthe appropriate bay Type of praject.(requireelj: I.❑ I am a employer" with 4 ❑I. ❑ 6.am a general confractar and I tructim employees aidfor par"me j* have biredthe sub-co�actos l�e4v cons 2.❑ I am a sole propzieton orpartner- listed on the attached sheet. I- ❑Remodeling. slop and have no employees These sob-cant<actars have g ❑Demolition " waaifing far me in any capacity- employees and lMre Workers' 9."❑B.nilEng additic'n [No Worlmrs,comp.insurance comp.*nsuma l ree r. F6md] ' 5..❑ We are a cmporafiim amd its 10-❑Electrical repairs ar addfions 3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or addifians mpseLf[No wodmrs'damp- rightof exemption per Zi GL :❑12 Rflofrepairs innzancerequired-]t c.152, §1(4),aadwe have mo employee.[To worms' 13.❑ Other camp insurance required-] *Any applic=ff=t cbedsbos#1 mast also fiIIootthe smiionbdow showing flmk v adcere ca®peasatinapeHcynrF3oaal mL I meDaraers�aSubmittbi��da[7EID�9t Y HIE�m�81FW�fiII,ilweblgIeO•ilt9+d£r0'IIbSfi+*r�Stmffin3it anew afcY32IDdir�nvsad , fC.aatractas ffist d-dr ilds box LffiSt sffmrh sn aMitirmal sheet shonjng tha ra of the Sub�SMd 5tHte Vhether GF nvt those enjitieshrm employees.Tftbesub-cRn�1laveemP1gyw-%tfiepamstpm &tles wodm&camp.poRUnumber- .Tam air employer that-is prm iidircg warketsr comperlsidan hLutrartwfor my empin}wes Setoty is Aepviicy imd job site hzfbmathm Insurance CompanyName: 'Po-licy 4k or Self-ins.jue-;k ExpirationDate: i Job Mfe Address_ CitplStawz{ p. Attach a-copy of the workers'compensationpolicy declaration wage(showing the policy number and expiration date). Failnm to secure coverage as required.under Section 25A of MW—a 15 can lead to the imposition of criminal penalties Of a fine up to$UOD OU indlar orie-yearimpfiso as well as rim penalties is 9re fay of a STOP WORK ORDERand a f of up to$250-00 a day Againi t:the violator. Be adsaserd that a copy of this shkment iaay be forwarded to flee Office of Iuve gafiorts offhe DIA for insutance CAMraffe,venfrcatiam- I do ifer,ffiry s and talus°, thatthe irffonna€Lm>•prm.-bW abmw is hue and correct --.4'ivsta'fnir: anal use add. Da not write in this area,to be evinpteted by dip or town agffi'L Cky or.awn: PermitUcense f Issuing Autherity(dreTe erne): L Board of Health y Bw1iring Departnent 3.cAytrown.Clerk 4.Fechrical Iuspector S.Phunling Inspector *Other Contact Person: Phi#- laformation and lastruefions , Masm mft Creue;al Laws ffiEptrr 152 rmFd=all employers'fn Fa M&worms'compensation.for ih M employees. . PMMM3UttD this sfStU:e,an EZTL yM is defined as 1`_.cvezypersanin the service of E.oflierunder any conb:act ofhfir, express or implied,oral or written." Air f7np&yer is defined as"an mdrnidval,per,association,corporation or of m Iegal eutiiy,or any two or more of fiareg'omg=gaged fa&joint a t=p±.se,andincbdmgthe Iegatreprmeofatives ofa deceased employed,or fiie rwtivm or tmstee of an mdividnal,per,association or ofhealegal entity,employing cmployees. However fhe owner of a.dwelling house havfngnotmo¢e than three apaztmwt;and who resides therein,or the occ paint oftbe - dw Ilm7 g house of aw1her who employs persons to do mamte�=,caastra't on or repair wodc on such dwelling house or on the grounds or bmldmg aPPnrf�zf ih ereto shall not because of such employment be deemed to b,an employer." MOIL chapter 152,§25C(e7 also status iiat`°every sty or local licensing agency shah withhold fhe issaance or renewal of a license or permit to operate a busm.ess or to construct bufidmgs im the commonwealth for any applicant-who has notprodnced acceptable evidence of compfiao.ce wit$tim insurance_coveXrage required." Adclitionally,M(M chapter 152,§25CC7)sites-Ne%j rrthe.cammpnwealthnor gy ofitspolitticaI snbEvisions shall - into any contract for the performance ofpnblic work u�I acceptable ev an ide ce of compliance with mesor inaace•. re;T3iL euiets of this chapter have Been presemted to the contacting alitiioiiy." App4c=Is Please fill ovt'fine Wo1J=,compensation affidavit completely,by chmking the bones That apply to yors sitnaiion aud,if sol� ntractar(s)name(s), ad&ms-s(es)andphonenzbcr(s) alongwiththeir=f:dacatE(s) of necessary,supply s with no Io ees other than the insurance_ Limitsd Liability Companies(LLC)or I,imitedLiab�itp�l'artnership (LIP) � Y members or pmtam-s,are not regtmed to cant'worbme compensation msuran e. If an LLC or LT P does hate employees,apoIicyisrmpRrd. Beadiised that this affidaykmaybesabmitindtufheDeparimentof Industrial Accidents for con£nmation Of ms'm-,==coverage Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for thin pewit or license is being requested,not the Department of ; 1 A_=dents. MMM you have airy quest Ons regarding tho law or ifyou aie regoaed to obtain a workers' compensation policy,please call the Deparfine t at the number listed below. Self_ft=rd companies should mtm thair self-;n�nra��ce Iic®se n�ber on i$e apprap line. City or Town Officials Please be sure that the affidavit is complete and primed Iegmly_ The Department has provided a space at the bottom of the affidavit for you to fIl out in the event the Office ofInvestigations has to contact you g the applicant Please be m=to fill in the pedmii/license mmmber vA ch wiiIl be used as a mfumum number. In addition,an applicant that must submit mu14Ie pennWhceuse applications m any given year,need only submit one affidavit indicating cusent policy information Cif necessary)and under`Uob Site Address"the applicant should write"all locations in (may Or_ town)-"A copy of tile-affidavit that has beear officially stamped or ma130d by the city or town may be provided to the applicant as proofthat a valid affidavit is on file for f ltm pemits or licenses A new affidavitmitst be filled out each year.Where a home owner or citizen is obtaining a license or penal not related 1 D any bn c;T,cs_c or mmmercial. (i-e_ a dog license or pemnit to bum leaves etc.)said person is NOT xcquircd too complete this affidavit The Office of Tnvesfigalims would Ike to i-hznk-you m a&ance for your cocpera ion and should you have any gvestions, please do not hesitate to give us a calL The Dc rtmenf's address,telephone and fax rsember: 'N -ffiE Of Masmch . Depart�amt offla� Amidenta - n Bostou.,MA Q I I I Fax#617` 27 7749 Kevisea 4-24-07 � _ _gPv a WE Town of Barnstable Regulatory Services ILMINSMAEMZ� Richard V.Scan,Director qua Building Division, Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us j 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 pertnit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final . inspections are performed and accepted. Signature-of Owner Signature of Applicant .. Print Name ^ Print Name , Date QYORMS:OWNERPERNOSIONMOLS 1y Town of Barnstable Regulatory Services dFt Richard V.Scali,Director Building Division * m . ' Paul Roma,Building Commissioner �KAM �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ^ Please Print ` JOB LOCATION: C_ y�J U V V h fl ' V� �y V�-_V 1 LU number street village "HOMEOWNER": 15 c .' 9L - -M 5 name come phone` v work phone# CURRENT MAILING ADDRESS: 9 ^— v T4 \ city wn 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. eTjAeeqeMj ' mer"certifies that he/she understands the Town of Barnstable Building Department minimum inspection and that he/she will comply with said procedures and requirements. Si ature of omeowner 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFTLES\FORMS\building permit forms\EXPRESS.doc 06/20/16 f Town of Barnstable RegJatory Services do Richard V.ScaIi,Director' * * Building Division 4.4 f - r � f v ASS $ Tam Perry,Building Commissioner , ''TEo Mai 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 • Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date Name: 0 t\1 Phone#:_ Address: F vs U Ali lage: C P-A V\ _ Name of Business: Ro tiR(Y\ V" b c\fie_ 1 rM ro\i e M O-,A+ Type of Business: &W_ IN'r ENT: 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-I.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 conta,'n;ng 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 trick 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 person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I,the undersigned,have read and ee with the above restrictions for my home occupation I am registering. Applicant_ --- — Date: /$�'— tAssessor's offioe ,(1st floor); / �y 'P IC SYSTEM MUST Brl-� oFTWE>o� Assessor's map and lot number . ..............�'••a.......L�•.....✓ ` {w�LiA� i �s, Board of'Health (3rd floor): -' STALLED IN CO d ILSewage Permit number ::.... J\-. 6(,...�.. ....:.............. WITH TITLE 5 Z_2AU9TA LE, i Engineering Department (3rd floor): ENVIRONMENTAL CODE...A..�..�.... A'`'¢o' rABs � 39- House number . .. .............................. ....... .. ... TOWN REGULATIONS °"rFo�aY 6�0 APPLICATIONS PROCESSED 8:30.-9:30 A.M. and 1:00-2:00 P.M. only TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO A11):...�/ ......ry ..........:.................................................... TYPEOF CONSTRUCTION ..... .47................................................................................ ............ 0 19 .1.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location � 5 �.................�r v/��.4 / ....................................... ProposedUse ....,,/e .1.����................................................................................................................................ ZoningDistrict .....................................................................:..Fi.re District .............................................................................. Name of Owner n ....�/.��'�� ..�,/. .Of1.��2: ............Address ./..�.../.�7...i�,��...... ... .�..�.lL/..��'�..... Name of Builder c'!/.:/..zz/ ........Address Nameof Architect ............ .....................................................Address .................................................................................... Number of Rooms ........../....................................................Foundation Exterior .......W.X.0..r�f1V. .e_a ...........................Roofing ....el—ilpN'' 47 ................................................. Floors ......�,�/� 4a..................................................Interior ...../•if1..Q000V-Jhkk ..v ....................... Heating .........../✓ �4................................ ......Plumbing ......eery . ..... Fireplace ....... ......................Approximate Cost ....... ...... 40 Definitive Plan Approved by Planning Board ________________________________19_______ . Area .../ .. �.................. ' Diagram of Lot and Building with Dimension% ® �! O Fee ......... ........ ........................... SUBJEC TO APPROVAL OF BOARD OF HEALTH -®r �V.A�'nJ IUD • 300 t � � OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby tgree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above constriuction. f Name .. !� .r- ............................................ Construction Supervisor's License .. ..�.......... ARREN, CHARLES 30. 600 - ADD SUNROOM No .............. Permit for .................................... Single Family Dwelling ............................................................. Location ....9 Evson Road ................................. . Centervilile .....................................................................I......... Owner I ......Charles Warren .. .. ...................................................... Type of Construction Frame .......................................... .................... ...................................................... Plot ........ .................... Lot ................... .......... Permit Granted ..... ..........:.-19 87 Date of Inspec-tion ....................................19 Date Completed ........ ................7-*I—*—*I..I9i()7 17 N,Assessor's offioe (1st floor): f /�� ocq/ pz THEt� Assessor's map and lot number �.......-1..&.a......�� Q � L, Board of Health (3rd floor): fO *Sewage Permit number ....... �a................... 2 BAHIISTMAOADLE, Engineering Department (3rd floor): moo 39, \ems House number ............................. . ........ ...... !1....t��,.�;...• oraYA" 1, APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only . TOWN OF BARNSTABLE - BUILDING INSPECTOR APPLICATION .FOR PERMIT TO ..... x/.f:.... ' NJ ............................................................... .... .TYPE OF CONSTRUCTION ......C!u.�-��... .�M.................................................................................. ' 0...... 7 ......... TO THE INSPECTOR OF"BUILDINGS: The undersigned hereby applies for a permit according to the following information: F Location .............r ..................e.....� ...../.........v� ........................................................... ProposedUse .....,�2 � ..... ../ ............................................................................................................................... ..................Fire District ...........................................Zoning District ,,,,,,,,,,,,,,,,,,,,,,,,,;,,,,,,,,, ........�..........................................., Name of Owner ....�' -1 ..� / �` "'`'.........Address ../...z- T/... -� . ..... . ................................... ry Name of Builder ... ... ....................Address ./ ... vR� � �.. Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ..........�/......................................................Foundation Exterior ......W. ..0...... ...........................Roofing .....Ilf-If LT................................................ Floors .......04.,e 1,W00 .................................................Interior .....!�4,., h� r.. .... -<..................... �l// Heating. g .. ...o0..... .. i Fireplace ........ 11.4. ..........................................................Approximate Cost .,�r� ®a® .... f................................................... f Definitive Plan Approved by Planning Board _____--________________------- -------- . Area ... ©...��...................... \ Od Diagram of Lot and Building with Dimensions Fee .............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH ®r l N I� 309 � 1 l 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 ...0.13.Li.CO.I......... WARREN, CHARLES A= 68—€�' Cl8l No ..30,600,.. permit for ....ADD........NROOM . ngle,,,fam ... Dwelling ......... Location 5.Q.I .Road............................... ................C.ex3:G.e r.v.i.l.1 e.................................. Owner .....Charles. Warren ..................................... Type of Construction ...ZFame.......................... ............................................................................... ; Plot ............................ Lot ................................ Permit Granted .....April.. 2,..:...........19 87 Date of Inspection ....................................19 Date Completed 19 r r a Assessor's map and lot number ... !: . '?.:....:. v ' �F THE TO Sewage Permit number ef�";>..I......~.: ................. Z MARNSTABLE, i House number _ ` ......, 9 MAM ........... ................:........ O t63q It 101 Mix TOWN) OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO j /t,US TYPE OF CONSTRUCTION ........1.k..4 fP....��1?'Y'.: ` ................r�. ................................... �1: ...................................... .......... .... ?.r .I. ................19 ` .TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... I�.,........gT...r� �............... ProposedUse e ................................................................................................................ Zoning District ............�.;.•'.....................................................Fire District ......C�i�1�P..fZt11/�� ................................................... � -r Name of Owner ���� CyzOce��leY�- )A.,.YI?Vn11:�. 1�Address ....�t. .....�i,n1C?....:...�:.........: ja„ r� !.�C............. _ f Name of Builder' ...•::..5 A rn .........................................Address ................ .A ....................................................... Name of Architect .....:S-PrM.-C.........................................Address ................ rn. ................................................... Number of Rooms �rA.........................................................Foundation ...... ........................................................................ Exterior W QC�Q S A )<P ,,.�.c ?de .......Roofing As.. ..6 �, Floors r7,4og f7� Interior Heating ..1................................................................Plumbing .................................................................................. + Fireplace ........�-:, ...............................:........ ... ................Approximate Cost ......j(�t.....a 0 �...................................... Definitive Plan Approved by Planning Board _______---- _ _________19________. Area ..*... `. a.. ............... Diagram of Lot and Building with Dimensions Fee / '.�� .l.................... .. .. ................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 00 o° rq CIO �ua OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS `° Ilo )hereby' agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �` f 1 �7 l.0�,.,e t� `ice. .r Name .... _ .... .......... Cl/ Construction Supervisor's License G�. Z CROWDER, DALE & JAMUN COMPANY A=68-081 No .2$2..�7...... Permit for ....1 Story.............. Single Family Dwelling .... ti Location Lot 3, 9 Evs®n...Drive. ........................... ........ . Centerville ............................................................................... Owner Dal. ... .. e Crowder, & Jamun. ...Company. ....... . ...................... .. ........ . . ....... Type of Construction Frame ...................................... ............................................................................... Plot ............................ Lot ................................ Permit Granted July 85 ...............29..................... 19 Date of Inspection ....................................19 Date Completed ......................................19 ;,.;.+,i - .:,.3:-.�,u.�.;>-J:.K�:.#.,i•" .- .�.te5,.�r',::.: .«....:e.x:.;c:.,... A Jr. - ,','h7_s".'Z�a `�y,("r*-=t3.:;:.r^r...w'�-" .:�-f--".-aw-.�^zz:- ;�.r�•w,rr,� o•it TOWN .OF BARNSTABLE Permit No. 28257 Building'Inspector cash e..n ------------ — - _ '►+c my► OCCUPANCY 'PERMIT Bond _X Issued to Dale Crowder & Jamun Co. Address Lot 3, 9 Evsun Drive. Centerville Wiring Inspector � � Inspection dateiO.� ----- Plumbing Inspector-/,/ Inspection date. �= Gas,Inspector '`G p � F' Inspection date 2,4.6r-7-- txEngineering Depame � J is:•?r/✓ � � ..>,.r1D O ction date I�rt [� Board of Healtb` .�� ,i, }Inspection date 2�r �` i S . 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 :.. �.,: y f--. t r i. '�— . ._. . .:m.::- .I . I I .: �*. ;.., ,e�.,� i . .� I..:,. I.. I I ,.,::�-.,,I .�:�.. �, ..':��,:', ,-����:::::;;;." � - 1. . r r . . 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ENZEML FORM � � Bond No. 1 FIREM AN'S FUND INSURANCE COMPANY FIREMAN1S THE AMERICAN INSURANCE COMPANY FUNSNATJONAL SURETY CORPORATION ASSOCIATED INDEMNITY CORPORATION AMERICAN AMERICAN AUTOMOBILE INSURANCE COMPANY INSURANCE YAC O M P A N I ES HOME OFFICE: SAN FRANCISCO.CALIFORNIA KNOW ALL MEN BY THESE PRESENTS, " That we, Mari o P." Geminianili 570 Kelley Blvd, No. Attleboro, MA 02760 (hereinafter called Principal), as Principal, and The American Insurance Companya corporation organized and doing business under and by virtue of the laws of the State of NJ and duly licensed for the purpose of making, guaranteeing or be- coring sole surety upcn bonds or undertakings required or authorized by the laws of the State of T4P-GCa('h1JSPttS (hereinafter called Surety) as Surety, are held and firmly bound unto TEMSMB OF THE TOW OF BARHSTABLB, MASSACHUSEM hereinafter called Obligee) in the just and full sum of onP' "9-1ir�t�ganrl anri nn/inn--------------------------Dollars ($1000.00------ ) lawful money of the United States of America,for the payment of which, well and truly to be made, we hereby bind ourselves and our and each of out successors and assigns, jointly and severally, firmly by these presents. THE CONDITIONS OF THIS OBLIGATION ARE SUCH THAT, WHEREAS, the Principal Is desirous of obtaining a permit under Article 29 of the Bylaw of the Tam of Barnstable .to build a structure on Lot 3, Euson Drive, Centerville, MA 02632 RM THERMU, if the said Principal shall faithfully observe anal keep each and all of the agreements, stipulations, conditions, specifications and provisions by the said Principal to be kept and performed, contained in said permit issued to the said Principal, according to the full extent and spirit of said permit and the ordinances of the said Obligee now relating, or that may relate thereto and shall indemnify and save harmless the said Obligee from all liabilities, loss and expense whatsoever which the said Oblige& easy incur and suffer arising out of the issuance of such permit, and shall make no default therein; then this obligation shall be null and void; otherwise it shall be and retrain in full forca and effect. IN WITNESS WHEREOF, said Principal and said Surety have caused these Presents to be duly signed and sealed this �5th day of June 19 84 Mario P. Geminiani Principal" The American Insurance Company Surety L. Edith Richardson Atiorney-,-Fact 3604E 1-2-69 THE AMERICAN INSURANCE COMPANY KNOW ALL MEN' BY THESE PRFSENTS:That THE AMERICAN INSURANCE COMPANY. a Corporation duly organized and existing under the `taws of the State of New Jersey. and having its principal office in the City and County of San Francisco. California.has made. constituted and (' appointed. and does by these presents make. constitute and ap2�ootnt CHARLES N. . ROBINSON, RAYMOND J. TRAVERS, PATRICIA A. JONES, L. EDITH RICHARDSON, STEVEN J. DANIELSON and SUSAN B . MADORE HYANNIS, MA J)ointly or severally its true and lawful Attorney(s)-in-Fact. with full power and"authority hereby conferred in its name.place and stead. to execute.seal.acknowledge and deliver any and all bonds. undertakings. recognizances or other written obligations in the nature thereof NOT TO EXCEED F I VE HUNDRED THOUSAND AND NO/100 DOLLARS ($500,000.00) and to bind the Corporation thereby as fully and to the same extent as if such bonds were signed by the President. sealed with the corporate seal of the Corporation and duly attested by its Secretary. hereby ratifying and confirming all that the said .4tiorneos►-in-Fact may do in the premises. This power of attorney is granted pursuant to Article Vlll. Section 30 and 31 of By-laws of THE AMERICAN INSURANCE COMPANY nou in full force and effect_ "Article VIII,Appointment and Authority Assistant secretaries,and Attorney-in-Fact and Agents to accept Legal Process and.lake Appearances. Section 30, Appointment. The Chairman of the Board of Directors, the President, any Vice-President or any other person authorized by the Board of Directors, the Chairman of the Board of Directors, the President or any Vice-President, may, from time to time, appoint Resident Assistant Secretaries and Attorneys-in-Fact to represent and act for and on behalf of the Corporation and Agents to accept legal process and make appearances for and on behalf of the Corporation. Section 31, Authority. The Authority of such Resident Assistant Secretaries, Attorneys-in-Fact, and Agents shall be as prescribed in the instrument. evidencing their appointment, and any such appointment and all authority granted thereby may be revoked at any time by the Board of Directors or by :,ny person empowered to make such appointment." This power of attorney is signed and sealed under and by the authority of the following Resolution adopted by the Board of Directors of THE AMERICAN INSURANCE COMPANY at a meeting duly called and held on the 28th day of September. 1965. and said Resolution has not been amended or repealed: ""RESOLVED.that the signature of any Vice-President. Assistant Secretary.and Resident Assistant Secretary of this Corporation. and the seal of this Corporation may be affixed or printed on any power of attorney. on any revocation of any power of anorney. or on am certificate relating thereto. by facsimile.and am power of attorney.any revocation of any power of attorney.or certificate bearing such facsimile signature or facsimile seal shall he valid and binding upon the Corporation.' IN WITNESS WHEREOF. THE AMERICAN INSURANCE COMPANY has caused these presents to he signed by its Vice-President. and its corporate seal to be hereunto affixed this 4 th day of April 19 83 THE AMERIC.N INSURANCE COMPANY S 41 By �,ce-Pre%,orm STATE OF CALIFORNIA. ss. ' CITY AND COUNTY OF SAN'FRANCISCO On this 4 t h day of April 19 83 before me personally came Richard Williams to me known, who, being by me duly sworn, did depose and say: that he is Vice-President of THE AMERICAN INSURANCE COMPANY. the Cor- poration described in and which executed the above instrument; that he knows the seal of said Corporation: that the seal affised to the said instrument is such corporate seal;that it was so affixed by order of the Board of Directors of said Corporation and that he signed his name thereto b% like order. IN WITNESS WHEREOF.I have hereunto set my hand and affixed in,. official seal.the day and year herein first ahus a written. isuuuuamur,.ussuut�snusumrronnnnsotnl� OFFICIAL SEAL SUSIE K. GILBERT 1 NOTARY PUBLIC - CAI -GRNIA s CTTY i COIAtrY DF SAN R lfCISCO My Commission Expires Nov. 17, 1984 CERTIFICATE STATE OF CALIFORNIA. l CITY AND COUN'TY OF SAN FRANCISCO i ss 1. the undersigned, Resident Assistant Secretary of THE AMERICAN INSURANCE COMPANY, a NEW JERSEY Corporation. DO HEREBY CER- TIFY that the foregoing and attached POWER OF ATTORNEY remains in full force and has not been revoked: and furthermore that Arn:le VIll. Sec- tions 30 and 31 of the Ely-laws of the Corporation,and the Resolution of the Board of Directors,set forth in the Power of Anorney,are nos% in iorce. Sianed and seaicd at the City and County of San Francisco.Dated the 25th day of June . 1 y 8.4 Z. y`• Rrstornt A%%i%iar.:5nrnan -C_ 360711-TA-5-81 tQ'�eelT2�' r. �OAS/G�IJ �,4T.4 Shee7`_1�o f' c i f CAM/LY 3 B�O.200rt%j5 Aj� cilz, (�.ce.r•ce:. o�szg3. ��4Cy`�/6�n USE<3--��L�oG✓O!F�7JSo,�S •r SioEwQrrG L./�.esrEA .6�yy;s/,�- z 2�a G.�o• o r•. 7 1,ivy* qsX: -Ali O�T/a•/Lr �.�O ,��,ter.---.� � � .. 14 16 _LrL 7�I1� 1 t. lYti Qv v� • •• .. N � � .1J d 1 r . � _t, t• 1_O S.�/OWiv�E,2�O.V Ca�IP.L•YS Lt//r,�".'y�`%�". `�`tsr�;7� ryE .5'/OE�/iVE �Q/UO. SEl�iQC� �O� •' LVi LIA�f �0.� ; ...2EQU�.�c�E.(/�.5 `D.c'.Tf/.Ej?�W,(% �•` :C�. 1�1r� ,t } N Y E IZA ? , Ytv 0,47�-. TcE� ' • •... .eEGrS?�,2E'� l�vo,.SU,��/EY0,2S 7a cc✓l��77/G r�0 6e ' P�rcb/aio/?�c'atc L zip r D-D G ro/ TOP FNO. /a 8 I Loa .;, •o►!c. %e"5 /oO p 91 /N✓�/c�/, : c4� 51 1/60 sEorrc 9 IZ/.VV /,v✓ T,a,ci,� .444 A eQGhvD. :. ;ill. ".�TL•WEs: p 72 k!QrE�ELG✓ Z•3 /Vo..SC.4.L�:.°.. Assessor's map and lot number ... .. .............. ..................... THE 01 Sewafg"e Permit number ...............as.......—5 60 (C:�, ....................... SEPTIC SyST-1-.,;1-'1 I 33AMSTABLE.NSTALLED IN C01 PAS& House number .............. ......................... .......P� WITH TITLE 5 1639- COD- Z, w�'-4 TOW k,OF -BARN§1X Als BUILDING INSPECTOR . APPLICATION FOR PERMIT TO ..... N69.S-E............................. .... ..............9 ..... .. .... . . .................................... ........................................................................................ CONSTRUCTION ........5(k ...... TYPE OF ................... /k................ 9E�5 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... .....CtNh.)&VA..(1,e........ ....................................................... ProposedUse ...R ................................................................................................................................................................ Zoning District .... Fire District ...... N........................................... Name of Owner C... .. .. .............[dress .....6.c;.L....Vf.6a... ...... GA)1.Vt.X Nameof Builder .............�.e. .........................................Address .................�.a.yy).-p................................................... ......... ..... ..... -M.t.................................................. Name of Architect ......SC�C.M.-.0 .........................................Address ..................9..I.N. ....... Numberof Rooms .....6.....................................I...................Foundation .......M...X .33............................................. Exterior ............W. .......... .......Roofing ......... ...................................................... Floors ............. ............... Rk................Interior ....... .0-ary.........................................I................ Heating ....... ................................................................Plumbing .................................................................................. Fireplace ........... ............................; ....... ................Approximate Cost .......(P-41 ..................... ..........6...... Vo I Definitive Plan Approved by Planning Board ------- *-------------19-------- - Area ..... ................. Diagram of Lot and Building with Dimensions Fee .........i........ ................. SUBJECT TO APPROVAL OF BOARD OF HEALTH 416. 00 A 0 %U 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 ....... ........ .1__CR—VPDER, DALE & JAMUN COMPANy No ... Permit for ....1!...S.t.q.ry............... —Single Family Dwelling ............................................................................... Location ...L9�t•A ...... ............... ..................Cen.t.erv.i.l.le..................................... Owner ... Dale & Ja n Co- mi)anv . .................... ................. Type of Construction .....Frame....... ............................................................................... Plot ............................ Lot ............................... July- 29, 85 Permit Gran+ed ....... ................................19 Date of Inspection ................. ................... 09 Date -Completed ........................................19 i Op71HE roy, Town of Barnstable Regulatory Services * BARNSTABLE, y MASS. Thomas F.Geiler,Director lfo►9+" Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 July 10, 2008 Rildo Lima 9 Evsun Dr Centerville, Ma. 02632 RE: 9 Evsun Dr., Centerville Map: 168 Parcel: 081 Dear Mr. Lima: This letter is in response to an application submitted to do work at the above referenced address. Unfortunately, the application can not be approved at this time because the work shown encroaches in the required setbacks. A variance issued by the Zoning Board of Appeals would be required to perform the construction as shown. If this office can be of any further assistance please do not hesitate to call. I may be reached at (508) 862-4034. Sincerely, 44� ey L. Lauzon Local Inspector Q:zoning5 1 c.�20r s a F s�7�B�-tcs i DECKS ❑ f located in OKH or Hyannis Historic District- Certificate of Appropriateness is needed Map/parcel number Sign-offs from:. [� Health onservation Tax Collector Treasurer l Owner's name & address eck Dimensions Estimated Cost omplete dwelling information for the Assessor's dept. Applicant's telephone number Signature Plot Plan Two sets of plans with cross section' Workman's Comp. form. Copy of Insurance Compliance Certificate must be on file.- Construction Super's License.AND Home Improvement Specialist's License OR Homeowner's License Exemption form. Check expiration date on license(s) ❑ Application fee ❑ Permit fee Property Owner must sign Property Owner Letter of Permission. q-forrns:permits l rev.010208 J oF11HE>q� Town of Barnstable ti Regulatory Services sAaNSTA1uZZ y MASS. Thomas F.Geiler,Director �p i639. ♦� 'Foy" 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 Check One: ❑Shed ❑Deck ❑Pool ❑Porch ❑Gazebo FOR ALL APPLICATIONS: ❑Determine map and parcel number and enter it on application. (This information maybe obtained from the Engineering or Building Dept.) ❑Completed Building Permit Application Approval/sign-offs are required and can be obtained at 200 Main Street: ❑Historic District Commission ❑Old King's Highway Historic District(North of Route 6) ❑Hyannis Main St. Waterfront Historic District(see map for boundaries) ❑Historic Preservation(if applicable) ❑Health Department Hours are: 8:00-9:30 AM or 3:30—4:30 PM ❑Conservation Commission Hours are: 8:00-9:30 AM or 3:30—4:30 PM ❑Tax Collector ❑Treasurer ❑Homeowner License Exemption Form (if homeowner is acting as general contractoribuilder for project) or Copy of Construction Supervisor's License must be submitted (except for in-ground pools) ❑Worker's Compensation Insurance Affidavit must be submitted. Copy of Insurance Compliance Certificate must be on file. ❑Copy of Home Improvement Contractor's License (residential only if applicable) ❑ Property Owner must sign Property Owner Letter of Permission. ❑ A NON-REFUNDABLE Application fee is due upon receipt of application number ❑ Permit fee. SHEDS/DECKS/OPEN PORCHES/GAZEBOS: ❑�C P1o`t Planyor_mo.r-tga-ge-suF_yeyprequired to verify zoning compliance. Placement of proposed structure must be sketched in and the distance from property lines indicated. The location of the septic system should also be shown. ❑Two (2) sets of plans (8 1/2" x 11" or 8 1/2"x 14) showing cross section and framing schedule. ❑Prefab sheds require factory brochures & specifications. ❑Prefab sheds require a copy of the Home Improvement Specialist's License unless the homeowner is applying for the permit in their own name._ POOLS(250 sq. ft.and over or 2' deep or deeper require a building permit) ❑Plot Plan or mortgage survey showing the proposed location of pool and the distance from property lines. Plans must also show location of backwash pits if applicable. p ❑Construction Drawings or Factory Brochure & specifications. ❑ Show placement of fence, list description of fence and materials used. Q:bldg/wpfiles/forms:shed-deck Rev:112807 PERMIT PAYMENT RECEIPT TOWN OF BARNSTABLE BUILDING DEPARTMENT 200 MAIN STREET HYANNIS, MA 02601 DATE: 06/19/08 TIME: 08:16 ----------------- -------- PERMIT $ PAID 50.00 AMT TENDERED: 50.00 AMT APPLIED: 50.00 CHANGE: .00 APPLICATION NUMBER: 200803289 PAYMENT METH: CASH PAYMENT REF: id } TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map � . Parcel Application # Health'Division Date Issued Conservation Division Application Feeax Planning Dept. : Permit Fee Date Definitive Plan Approved by Planning Board o S " 1 e Nc 8AG Historic:- OKH Preservation/Hyannis �Pr ject Street-Ad dr ess—, u Village--�'( Q.QL� �CZ N c\S i��� �Owne \1L-\tKA Address `` `t t c:--Telep o e (06 67 -1 �Permit-Request i Square feet: 1 st floor: existing proposed 2nd floor: existing _ proposed Total new Zoning District Flood Plain Groundwater Overlay P-ro�ject-Valuation. 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 r ❑ 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: _ r� zi Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# : Current Use Proposed Use co .. w r- APPLICANT INFORMATION (BUILDER-OR HOMEO_W-NER) Nam"'e i U�►'� Telephone Number \ R 6 Addresses �► �, License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE q: DATE �I FOR OFFICIAL USE ONLY Y. t t APPLICATION# z DATE ISSUED MAP/PARCEL NO. 1 j ADDRESS VILLAGE OWNER i DATE OF INSPECTION: FOUNDATION FRAME f` - INSULATION FIREPLACE q - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ` FINAL BUILDING i - DATE CLOSED OUT ASSOCIATION PLAN NO. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map I Parcel Application # C� y Health''Division Date Issued Conservation Division Application Fee / O 4 Planning Dept. Permit Fee. Date Definitive Plan Approved by Planning BoardNc af-'rc►� �K Historic - OKH _ Preservation / Hyannis � L Project Street Address Village Owner n 1�`--� ��._��1 Address t 1A � V 5<1 WV : D— Telephone Permit Request C`X "� to. t,\k 1n lzy Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new � Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type 0 Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family 0 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 f 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 D new 'size _Shed: ❑ existing ❑ new size _ Other: a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ C Commercial ❑Yes ❑ No If yes, site plan review# + ` Current Use Proposed Use APPLICANT INFORMATION u! t (BUILDER OR HOMEOWNER) ` Name \ \ S 6 eN - O �� Telephone Number O 1 6 Address. C v 5Q 1�s License'# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO A SIGNATURE DATE i FOR OFFICIAL USE ONLY R 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 FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl �NaIIIe"(Bus Organization/Individual): 6A-'ddress: tx� ,eCiry/State pPhone 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 6. ❑New construction, employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- 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' 9 ❑Building addition [No workers'comp..-insurance comp•insurance.$ required] 05. ❑ We are a corporation and its 10.❑Electrical repairs or additions Q 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.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'conversation 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. tcontmctors that check this box must attached an additional sheet showing the name of the sub-contrxctors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Iam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: . Policy#or Self-ins.Lic.M Expiration Date: 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 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 nd penalties of perjury that the information provided above is true and correct. i _ . �S afore•-�-=e: � Dater "° Phone# Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority_(circle one): 1.Board of Health 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,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." 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-contractors)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 than you in advance for your cooperation and should you have any questions, ` please do not hesitate t6 give us a call The Department's address,telephone-and fax number: The C6mmonwealth of Massachusetts Department of Wustrlal Accidents Office of Investigations _ 600 Washington Street Boston,MA 02111 Tel. #617-727-490.0 ext 4.06 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia oFIHEt Town of Barnstable Regulatory Services vMAsS. Thomas F.Geiler,Director i639. �0 .. r6�6. 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 Se tion If Using A Builde as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorize y this building permit application for: (A dress of Job) Signature of Owner Date Print Name . If Property Owne is applying for permit please complete the Homeowners License Exemption Form on the reverse side. POP PWZT)WWPRPRRMIRRI(N Town of Barnstable mop THe rph� y� o� Regulatory Services BARNSTABLE Thomas F. Geiler,Director. p MASS. �* 019. A�� Building Division TfD � Tom Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 wvt'w.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 9 \j number street q. 1 village "HOMEOWNER': ���9]� �L � .2�'3 c� 1 -fSE6 oo� 1 name p— home phone# {� work phone# CURRENT MAILING ADDRESS: 96 4= U �� t\\ `city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and V 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 Persons)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 procedures and requirements and that he/she will comply with said procedures and r ' ements.. Signature of Homeowner 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 st2tes 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 personas it would Wiith 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/eertification for use in your community. v s' 1 dop M � L 3 LL 10 COIG /� Z���\tV� ,� ��'�i\'C�ram. C.1� �"�►�'a cs j ,�: Z�si i�i�C - F-T J Iry a ,4r as- `"ne01 �, �� e ID 1-0 Its 1 _ � s"t _ L / 2 lip Mw, W • .77 r 9l•7 . 77 <LeFe :7 ' \ T / k . � .714 ioo o ProP.eoA SS n 1ni � a28 • .�ar.�sfa•6/e ��i���rvil/��/�as5 ���r �, r , 4 � r ARTIN r SON CD �� ` E / f,Z m: a. .77 Le4e�� If ���O GX/ST SnoTELC1/... I ioo-0 Proms Co127 v0 i _ • zo, MiN �F.voo ,r�. Ile) e) ` ! • • r t,,�t n°� I•r;.t, ASARTIN. c ks ,o f234I7 .?