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THE FOLLOWING
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QUALITY ORIGINAL (S)
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Town of Barnstable *Permit#�,'D%03a 9l
Expires ti mop the from issue date
• ��� Regulatory Services Fee
Thomas F. Geiler,Director
Building Division
om Perry,CBO, Building Commissioner b 1� � 3 ( L '
200 Main Street,Hyannis,MA 02601 J
.OF IBN www.town.bamstable.ma.us
Office: JGW6yy 4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION. - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/paicel Number I q d '
Property Address e� �� � —lite 6'' �6
,Residential Value of Work 1 D�P r Ce> Minimum fee of$25.00 for'work under$_6000.00
Owner's Name&Address ,
Contractor's Name 6-CC21 Telephone Number Ste' 775—?S2�
HomefImprovement 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 be on file.
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
❑ Replacement Windows/doors/sliders. U-Value ' (maximum.44)
*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.
co y of the Home 13pprovement Contractors License is required.
SIGNATURE:
Q:Fmms:expmtrg
Revise061306
`ys
°ZINE Town of Barnstable
Regulatory Services
snxxsr BM ' Thomas F.Geiler,Director'
S
MAS
16.19. '`�� Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I , �� �., l4A .-�H,••� � ,as Owner of the subject property
hereby authorize � Ac �+— S' �h'G'�`►`'�ss; to act on my behalf,
in all matters relative to work C f thorized by this building permit application for:
(Address of Job)
Signature of LOwnge Date ,
c + J t Pi� s I `tea Nn 5
Print Name
Q:FORM&OWNMERMBSION
Department oflridustiial Accidents
Office.of Investigations'
d 600 Washington Street
Boston,AM ovir..
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builder
s/Contractors/Electricians/Plumers
kpplicant Information Please Print Legibly
1T2>Zle (Business/OrganizatiowIndividual):
Address:
City/State/Zip: Phone#: 4?
►re you an employer? Check the-appropriate box:: Type of project(required):
❑ J 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 cobstraction
❑ I am a sole proprietor or p artner listed on the attached sheet 1 7• ❑ Remodeling
ship and have no employees These sub-contractors have ' 8. ❑ Demolition
working for me in any capacity. workers' comp,insurance: 9, -1 Building addition
[No workers comp.insurance 5• D We area corporation and its
required.] officers have exercised their 10.0 Electrical repairs or.additions.
I am a.homeowner doing all work right of exemption per MGL M❑ Phunbmg repairs or additions '
.Myself.-[No workers' comp.' - c. 152,§1(4), and we have no, 12y Roof repairs
insurance required.] t employees. [No workers 13 [] Other '
camp.Insurance required.]
ny applicant that checks box#1 must alsg fill out the section.below showing their workers'wmpansation policy information:
iomeowners who submitthis affidavit indicating they are doing all,work and then hire outside contractors must submit a new affidavit indicating such.
mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'caarp,policy information. .
im an employer that is providing workers,compensation insurance for my employees. Below is the policy and job site
formation.
wrande•Company Name:
]icy-#or Self-ins.Lie.#: Expiration Date:•
b Site Address: City/State/Zip:
tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
ilure to.secure coverage as required under Section 25A of MGL e. 152 cam:lead to the imposition ofcriminal penalties of a
e up to$1,500f00 and/or one-year imprisonment; as well as civfi penalties in:6e-form of a MYWORK ORDER and a fine.
up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
restigalions of the DIA for insurance coverage verification.
`o hereby ce under th in penalties of perjury that the information provided above is true and correct,
atare:. 'Date:
one#: —� �
Official use only. Do not write in this area,to be completed by city or town offx4aL
City or Town: Permit/License# .
Issuing Authority(circle one)
1.Board of Health !..Building Department 3.City/Town Clerk 4.Electrical 6. Other Inspe1.ctor S.Plumbing Inspector
Contact Person: Phone#: .
Information and- Instructions s`
lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
ursuant statute;an employee is defined as"...every person in the service-of another under any contract ofhire.,
Xpress or implied,oral or written." :
,n employer is defined as:"aa?mdivia al,..Part�aMbip,:association,coiporation or other legal entity,•or any two or more
f the foregoing-engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the'
eceiver or trustee of an individual,partnership,association or other legal entity,employing employees. How.eygx.the
,caner of a dwelling house having not more than three apartments and who resides therein,or.the occupant of the
welling house of another who employs persons to do maintenance, construction or repair woili on such dwelling house
a on the grounds or building appurtenant thereto shall not because of such employment b e deemed to be an employer."
viGL chapter.
§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
•enewal 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."
&.dditionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its-political subdivisions shall
+nter into any contract for the performance of public work until acceptable.*evidence.of compliance with the insurance
-equirements of this chapter have been presented to the contracting authority.
4.pplicants
Please fill out the workers' cont ens ation affidavit completely,by checking the boxes that apply to your situation and,if,
aecessary,supply sub-contractors)name(s),address(es) and phone numbers)along with their certificates) of 1.
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members orpartners; are not required io 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
uired to obtain a workers'
Industrial Accidents: Should y ou have any questions regarding the law or if you are re q
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 suure'to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple p ermMicens a applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"Ilie applicant should write"all locations in - (city or
town)."A copyof 1he:05davit 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-li*censes.•Anew affidavit must be filled out.each
year,where a homeowner or citizen is obtaining'a license or permit not fdated to any business or commercial venture
(i.e. a dog license or pemrit 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 Indust W.Aceidents . . .. .
>. ..offce of Investigations
3' f• 600-Washinocan Street
V -
`E: Boston,MA 02111�
Tel.#617-727-4900 ext 406 or•1-877-MASSAFE
Tax#617-727,7749
evised 5-26-05 www-rn I s,.gov/din
�. Town of Barnstable
Regulatory Services
' Thomas F.Geiler,Director
Building Division
Elbert Ulshoeffer,Building Commissioner
a
367 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
SHED REGISTRATION
120 square feet or less
1 � ���►►�,� ��� . � ��►Ifs
Location of shed(address) Village
Property owner's name Telephone number
L. C. 1CC9,5 LOT 4ys
Size of Shed Map/Parcel*
12 C— 2-0 -\O- IP /
C I og
Signature Date
Hyannis Main Street Waterfront Historic District? N/A
Old King's Highway Historic District Commission jurisdiction? ��
Conservation Commission(signature required) 91A
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
Q-forms-shedmg
t
9
Tom EbSNE
LOT 44 p•00 ° ��` 'PLAtCENfiu l.
10 LOT
47
S6
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LOT
45 LOT
46
LOT -
42
N 6�
LOT
41
CB
RES. ZONE.- "RC" This MORTGAGE INSPECTION PIan is For FL
ank Use Only OQD ZONE. "C"
0 _ ,
REGISTRY OWNER: RL11V_E_M119CY -----------
DEED REF: -CU.J2079__ _BUYER: 11 NIEL NAU�HdI Y_ __
DATE: _VI47 9-6__ _________ PLAN REF: _L_C._ f=A SfL2 __SCALE:1"= 30 _FT.
I HEREBY CERTIFY TOl!77
_
___THAT THE BUILDING t� Of YANKEE SURVEY
N PAU
THIS PLAN IS LOCATED ON THE GROUND AS
SHOWN A y� CONSULT AND THAT ITS POSITION DOES ____ CONFORM ANTS
TO THE ZONING LAW SETBACK REQUIREMENTS OF THE � A.
3 MERITHMM H 40B INDUSTRY ROAD
TOWN OF ---�A&N,TTABLE_____________AND THAT No.32M � MARSTONS MILLS, Ma 02648
IT DOES_NOT_ .LIE WITHIN THE SPECIAL FLOOD HAZA TEL:- 428-0055
AREA AS SHOWN ON THE H.U.D. MAP DATED,6/-9„ -05 —
250001 0015C �'o�at �aasos FAX 420-5553
,9�. THIS PLAN NOT MADE .FROM AN-INSTRUMENT
'A L tmd&T ET- ------ SURVEY NOT TO BE USED FOR FENCES ETC. 24933 MRC
_..-1 o S.4.4
..0 T."4.7..
A .0
0
10 T 46
peaeoagn---'
� es
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Scale °lrr-40 f
.` :.. SITE PLAN
Being lot # 45 as shown on
Land Court Plan # 30545A
Sheet 2. {
This, lot complies with the
setback and sideline require
ments of., the' Town of Barn-
��P�SH or ,ygss9 stable-,building code,. .
Thomas A. cyN Date. '2-27-7$
c .JAMON
No.8931 H
O
/STE'R�
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\� SURv��i
_ .+...+wr...r.�...�fr�ns+.+e+.nraa:MMLMvtrantes.vr�.N>.IwsYlerwY.+.tlIN�mAwrat wrn�.w*M'vi1..,�rwTM.OVa��I+�Mrw1v�..rp
Assessor's map and lot -number SEPTIC
.....................'`�
SYSTEM. MUST BE
INSTALLED IN CQMLiANCE
�.
Sewa a 'Perm.+ number ..,�?...... ..�i ....... ..'...��✓C
ANT1CLE it STATE
WITH
9 ;... SANITANY CODE AND TOWN
�QOFT,NEt��o Y TOWN OF BA'RNSTABLE
µ) Z BARI TdDLE'i _{ It
o19-
b Y��e� 4 E RUI CDING INSPECTOR
4 YP
APPLICATION FOR PERMIT TO .............��Q.J..........4................. � .......... ®�le!.Tio/1J..... ...............
TYPE OF CONSTRUCTION ................Gt.ao.9:......................................................................................................
i
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...aAIFA)...4/..t?.os....................................A; .7_....?�Ao' ....................................................................................
Proposed Use .......................O.CA)............
....................................................................................................I.........................
��...U..� :,^
Zoning District ..:.......... ..........................................................Fire District ...... .err .............................
Name of Owner ........... .. ...Address ....../2........ . lf(1 -Cjit>7.'0;I O;46-
Name of Builder ../` {(�Toi4/......./..V..C�!4�.Y�S.O. ......Address ..... ........... %/5...../N.fY...............
/
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms .................9 fF........................................Foundation .......... �
,o •
..............................:.....................
Exterior CIS(! .......C.E..O.e3. ............... Roofing .45p1 AU. .....................................
........... .... ............ ...................
..Floors U J { Interior ....... y CR .............
..... .
Heating ...........r=.O.RB..C.i'.?.........fz!Q..T.....�1,/!Z....................Plumbing .................... ...........................................
•
Fireplace Approximate Cost
p Qi�l..41 ........... ..�1C:...................................... PP ...... ..G?�..�1.�.Q......................................
Definitive Plan Approved by Planning Board ------------------------------19--------. Area ..... .... ..V........:.... ..............
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
o� QD®
7 1 �1�
}y
• V o s� °'1 0
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3
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding t e above
construction.
yName . ... �. • . .................................
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Whitneyq Mildred
X19
PERMIT REFUSED
_.......-.—�—._—~—..�..,`---,
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--.--.,_-.---..,..—.,—.----.—
Approved ]V
` --------------.--
------------..—..—..---,...--.. '
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Assessor's map and lot number
r
:. .
Sewage Permit number .......:-..... ` �
y�fTHEr��y. TOWN OF BARNSTABLE
Z BARNSTABLE, i
"6 9
o BUILDING INSPECTOR
� upY a• .
APPLICATION FOR PERMIT TO .............!. ! ...........::...................:.'..'....:.................................:...........................
TYPEOF CONSTRUCTION �'�'�^.....................................................................................................................................
.........11:...:..............................19....:.'..
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ...:.?......... ......'.:..:
.............................................................................................................................................................
Proposed Use )�C-=h l ........................................................................................
......................./.,)/ ............................................. ..........
. Zoning District
�...............................................Fire District ......'.......:.::
.......................... ................:............................................
Name of Owner ......... '`.!� rwt= ` .........Address .......................................................?`........ .................
Name of Builder :.::..:.............Address t N�f . 1 . . Ll J - r
....... .............:........... ..............................................................:................:....:
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms �' Foundation . ^ 1e'..
........................ ..............................................................................
Exierior - Roofing '`. .
................................................................................. ..................:....:.............................................................
Floors Interior ......... ....' ."-'�
Heating ......................................... ...........:....:.......................Plumbing ,� ��a .
..................................................................................
ONE Fireplace ..... . .....L............-......... .Approximate Cost }Definitive Plan Approved by Planning Board __________________________ .2 v-
19 ---. Area /. .. .............................
Diagram of Lot and Building with Dimensions Fee .....?. V.).......................
,,mo�tt 1
SUBJECT TO APPROVAL OF BOARD OF HEALTH
V
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.r
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .............................................................
Whitney, Mildred A=190 124
No A1998.9.... Permit for .....addLtion..............
......................to..dwelling.................................
Location ......17..GlAnwoo.d..A.YP.........................
.....................C-enterville.................................
Owner ......Mildred... . Wh.i. etnv............................. .... .. .... . ......
Type of Constructio)( .Nlrzame...........................
k
f ........................................ ................
Plot ............................ Lot
at ...........................
..*.
Marl
Permit Gri. tedd ........................................1978
Date of Jnsp ction ....................................19
Date Complete ......................................19
PERMIT REFUSED
..................................... .................... 19
.......... ............. ........... ..... . .. .... .................
...............................................................................
...............................................................................
Approved ........................................... 19
...............................................................................
................—............................................................
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