HomeMy WebLinkAbout0038 GREAT MARSH ROAD ors h c=t
:
o
r .,
' 1
t Application number... .....................................
Fee......... ......3.5................................................
Cis` 7`
. Building Inspectors Initials...... .. .................r
Date Issued.:.... .. �.�...b.......................
Map/Parcel.... .:.1 .. `y. .
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDINGIWINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
I
Address of Project:
` NUMBER STREET VILLAGE
Owner's Name: L> _ Phone Number Y
Email Address: •Cell Phone Number
Project cost$ �� Check one Residential Commercial y
OWNER'S AUTHORIZATION
`As owner of the above property I hereby authorize
to make application for a building permit in accordance with 780 CMR
Owner Signature: Date: / / L Z6 f
TYPE OF WORK
'on L
❑ Siding Windows(no header change)#� Insulation/Weathenzati
Doors(no header change)#. Commercial Doors require an inspector's review
0 Roof(not applying more.than l layer of shingles) „
Construction Debris will;be going to
CONTRACTOR'S INFORMATION
Contractor's name CO
Home Im° vement Contractois Registration if applicable)# � (attach copy)
ro
Construction Supervisor's License# (attach copy)
Email of Contractor G-tA%a Phone number'6$-)7/ 01.4 q/ '
,ALL PROPERTIES THAT HAVE STRUCTURES O ER`75 YEARS OLD OR IF THE SUBJECT PROPERTY-IS IN
A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
VVIIIIINII•Y celUl VI neane�i�uxrw
®� Division of Professional Licensure
Board of Btiilding Regulations and Standards
Const� 1't�tilpg•rvisor
• CS-078000 �' i � E�ires. 02/03/2020
r.
t
SCOTT H QUIETER,
PO BOX 727 % t
WEST HYANNISP/ORTyM .0 2F
Commissioner
74
Office of Consumer Affairs&Business Reg ation
HOME IMPROVEMENT CONTRACTOR
TYPE Individual Registration valid for individual use only
RearsRe°is-- fin Ex iration before the expiration date. If found return to:
13s91 03/22/2021 Office of Consumer Affairs and Business Regulation
SCOTT QUILT '
?,< 1000 Washington Street -Suite 710
-i zi
SCOTT H.QUIL7•ER J,t
247 STRAWBER14'.--Rp'
CENTERVILLE,MA 02632GL.� �.
Undersecretary without signature
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 Legibly
Name (Business/Organization/Individual): ,
Address:
;.. City/State/Zip: hone#: �T
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"
e loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New co traction
2. I am a sole proprietor or partner- listed on the attached sheet. • 7. emodeling
ship and have no employees These sub-contractors' have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
y P ty� 9. ❑Building addition
[No workers'comp.insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑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#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 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/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,ohder the p ins and pena ties of perjury that the information provided ab ve is true and correct
S i ature: Date:
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 bean 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 burn 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 `
OMce of Investigations
600 Washington,Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
1
oFtHET�,, -Town of Barnstable I*Perini
gyres 6 months from is a date
Regulatory Services �ee
MASS Richard V.Scali,Director
'SAY 09 P Building Division
T®��/ 6 t t Paul Roma,Building Commissioner
V V AI A 111V 200 Main Street,Hyannis,MA 02601
' �`� www.town.bamstable.ma.us .
Office: 508-862-4038 _ Fax: 508-790-6230
EXPRESS PERMIT APPLICATION. - RESIDENTIAL-ONLY
r� Not Valid_without Red X-Press Imprint
Map/parcel Number
O:eA4 �e,'
;�Residential
:394 ez,17.4:7A L)
ddress Value of Work$ fly minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �� �'/
Contractor's Name `� C�Y f,/ Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
C�h,�ec °ne:-
[ a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance-
Insurance Company Name u
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-
eplacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
*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 cop Ahe Home Improvement Contractors License&Construction Supervisors License is -
req r
SIGNATURE:
Q:\WPFILES\FORMS\building permit formsTY PRESS.doC
01/25/17
c
O
• A
- � d
L'
0 , c �N
.. y'C 7
> 7 m O
O 0
c� � 'd
O C Q N c0
•-2ti 0 >
m ENr +'
Zm
c'd0Ua
r O Y C
N m A 0
,W d r O 00
crm0 m
i "1 5O v
�a Ca) d
C Z �t:
m O W O LJ
cli
U v
'S
W c
W W C
G. 0
E cc
;
N',
J;.J ZQ
O O N
V Vti (D
I (n fn N C)
I •
iAmf Massachusetts
Board of Buildin Department of Public Safety
g Regulations and Standards
License: CS-078000
Construction Supervisor
SCOTT
PO BOX 7QUILTER k
s
BEST HY27
ANNISPORT MA 02672
r.
I
mmissioner Ex it
p ation:
s ' 02/03/2018
Offl-ce'7 rAvewfiffaftom.
600 Washfize rt►hvCf
tP1V nmasygorldia
WarIt'+ & COnipemSaffiffIILmii-anc ffid xit EID-lde IJC[IniractarSXlwftkums Phombe.rs
'fizaut bffG riafrQ3! - Please Print
.Nam azI
CifgfSfiWtef phone 5D S'. /
Are y'ou an employer?:Qreckthe appropriate bom 6614p3UZ Type of project(requireg-
I.❑ I am a emplapeswith 1 4. ❑I am a general ecafractor and I 6- ❑Nets eonsfroc�Ei�
lagees(fallandforpart-fiime * 1mvehired1hemb-caakradms ,�,_,����
2. I am a sole poprietor arpartaer-. listed en:the attached sheet ?- L7 maaeling.
ship and have,no employees These sub-confractars have g ❑Deawlifian,
wading forme in any rapacity_ employees and have workers'
- 9..❑B.uil adviifion:
Ego .
cam _
4 v4-Cit�E[S CAmp_�t��e .. P materanrr
5. ❑ �41.e are a corporation and its lOr❑Electrical repairs or add ons
retluired I- ,
3. 1 ama homeov«er doing all Mork..- : officers have exerm- ed flair 1L❑Plumbsagrepaim or adcli ions
mys&f[No worker a oomp_ riot of exemption per Mo— �
iir j
c: , §I{4)
nsumnreiegn 6 andwe have no My El Rflofregai�
'employees.Fowozers' 13_❑Other-
co=p_2IIrazance require&]
n• ayap &zi3t&atdmcUboxF-lamst also MoutthesecffonbeIoar�agdeawadredcomp��+��,+,peTicgiafn�msuaa ✓
#Snmem umesTdo submit this affidart inkScstiag they axe doing alFsco¢t and then lose outside caratm amst submit a new affida�t mdicabna sadL'
ICaa'hac�stbzt checf tLds baoc mast a3fache�d as additional sLxef dhouiag theaame of 1be sib-c�ct��d state Whethea arnotfhuse eotitiesha�e
employees.Ifthesub-tam b=e empicyw-%dfieyrmnrpms ide-thea trades'immp.pa q number.
I am arc errip7ayar flint is prctuiducg�varli ets'cortzpertsrdrrt irrsrtratrcevr rays earpfn}�ees Betory is riTdspolicy�caul joFie ,
k ornzatiam _ f
Insurance Company Nratne:
'Poficy�or Self-i�..Li�� }�pit�ioaDafe: •
Job Sit�Address . C�pl5tafel p:
Attach a-loopy of&e waarrker- 'campensatioa:policf deckrafion page(showing the policy mrmber and respiration date)..
Failvre to secure covenge as required under Se4cfiaa 25A of MGI.m 157-can lead to the imposition of criminal pel nigo-C of a -
fine up to$UOD Oa'indror one-yearimpisoz as well as civil penalties i n the farm of a STOP WORK ORDERand a FM
of up-to�Q_DO a clay 26-ainsf the violabr. Be advised Uid a copy of this_statemest saaybe f o.rvarded tam the Office of
I4rvestegxtions ofthe for ms=mce coverage teafcatium
I do Tiem4ry c U trattra irrformatiarrpm-i&dabm�s i s h=qndcarr=t
itmafure: Date_
dme Ph
OBkiat aw arr£y. Do jwt write in 693 area,ter be campfetetd by city aratown ojoi rat F
City or'I'aysn: Pest fAcense
IssuingAntlmrity[Cade one):
L Board of Health Deppxttie at-&'Citylro�m Clerk .4L Electrical ksspee#.ac S.Plumbing Inspecinr
b.Other
Contact Person: Phi#-
orm ation and Instructions .
. Massachusetts setts l7cwl1LdII11..aw 152 r�='an`_plo �'�to�`_'_de "' ��'T for�Ir�pl"J`-""- k
Pm�tD this sfaiufe,an eaployr�is dcfined as¢.every pecsan m ffie sca vicc of another�dez�y contract ofha�
express or jpHecl,oral or' "
or
�T�reT is defined as°`an m�idng paxfnersb�,acrn�on��P�Oa other legal may,or any tWo or mine
AIL of fnreguing aJo '=,and inc�g the jegal�s��of a deceased employer,or$ie
receiver.or trustee of an m didbaL pMt3gblA MOCiHfM or ofb=Iegal enfay,employing employees_ However the
owner of a,dweIlhog house having not more than three aPEdM=ts and who resides therein,or the octet oftbe -
dweIIing house of der who=q&ys persons to do maiatnan.cc,cmstru t;on or repair wo&an such dweIlvng house
thereto shaIlnotbecanse of such�ploymaQtbe dcemedto be an ev4"oyer."
' or on the grounds or bmZd"mg appm�a� •
MGL tPa I52;§25C(�also sfa�s;t3 ieverp sfate'or local Hcensnag agency shaII withhold$e issuance or
chap _ ,
.curse or permit to operate a b'nsmess or to construct buildings is fhe commonwealtfi for atay
reaeveal of a h
applic=iwho has notprodnced acceptable evidence,of cnmprancet�itic athe;,,carahce eove7ragerequa
Additi Ty,M rCI. chapter ISZ,§25CM slates=Nmtb rthe poT�cal snbc$vssions sbalL
Ce the ice.
e ce of � �
enter into any coaiiact for iheperfv�ancC ofpnbIicwnlcn�acceptable, �dea .: comp� _
zCTIi emends of this chapter have beea pres=:trd to the cazd d aothozity_"
APplic=-b _
Please fill oil the worlosas' cpmpeasation affidavit complettly,by��g ire boxes ffi�at aPPlY to your situation and,if'
cmtCa
Of
necessnecessary,�PPIY sob-comracmr(s)�e(s), address(es)sadgfionenDmber(s)aIongwiihtheir cam(s)
sunmce. LimrtndLiabl7rty�pmnes�C)or LmritedLiabilityPartomhips(LIP)wino employees ocher than the
m�
members or p are not d to cry workers'compensafron hjsm=ce- If an LLC or UP does have
Be advisedthatthisa
employees,apolicyisregnhed. $tdayitmaybesabmifi�dfntheDepartmentof In�,cfrial
Accidents for confionation offi smlca coverge -Also be-sure to sign and dafethe affidavit The affidavit should
be retrmned to$e city or fawn that the application for the peon it or license is being rulacslrA not the Department of ;
ExhIstaBI.a ccid=ts. Should you have�Y 4 `ate g the haw or ifyou are rcgmr0dto obtain a worb='
=npensation policL plmse call f m Department at the mznber listed below. Self-fim=d compares should their eninr
s elf-ins=mce license nnmbm on the appzop=ate Imc
City or Town OffEdals _
t
Please be sure that the affidavit is cnmpleh--;aodprmdEdlegibIy- 'IheDepartmeoihas provided a space atlhebotium
tio�hasto Co�ctyamregardmgtheapplicant
' of the affidavid:for you iD fll out in the event the Office of Investig�
Please be sure to fllinthcpeonitllicm=Tn aberwbirhw�beused as azefercace�bcr In addition,an applicant
that must submit multiple peani�Iicense applitations in any given Year,need only submit one affidavit g��
policy fi foraation.(if no�Y)and under`Job Sim A ddess"the apph=A should w�"all locations in (may or-
town)_"A copy of the-affidavit that has been officially stamped or minced by the city or town may be provided to the '
applicant as#oo-fthat a valid affidavit is on file for future pe®ifs or licenses A new affidav>tm�st be fiIled otrt earl
or citizen is n - a license or pe'anitnot relairr7 fo any bn�►r, or commercial vet
year."1h=a home owner btaia g this affidavit
e ado license;or to btsn leaves etc-)said person is NOT req�zed to Iete
(i - gP�
and should am have any questions,
The Office ofInvesfhgaflmswouldlr�to y°umadvance for Your coupe on y
please do not hesifEitC to g* us a call.
The Depmfm enfs address,telephone and fax number: 1
�ott3rafM�ssachnss
DeparEam±of 1austdak AMdents
BMA CdIII
Tel.T 617- -44R0=t 4-06 or I-M--MASAFE
Fax 617 727:7749
B.evised4-24-07 Fg w Wxaas5-&uv
Town of Barnstable
Regulatory Services
Richard V.Scali,Director
i6fq. �
Building Division.
„ Paul Roma,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.maxs
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I Sd n tj , as Owner of the subject property
hereby authorize to act on my beb4
in all matters relative to work authorized by this building permit application for:
(Address of Job) U/GjG
**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.
i
ignatute-of Owner tote of ApWv
p 'cant
V Sa n/
Print Name Print Name
Dat
{
QTORMS:OWNERPERMISSIONPOOLS _-
Town of Barnstable
Regulatory Services :
dFt Richard V.Scall,Director
Building Division
s�►gnarestc, = Paul Roma,Building Commissioner
M+sa.
i639. 200 Main Street, Hyannis,MA 02601
O�Ep
www.town.barnstable.ma.us
Office: 508-862-4038 - Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER-:
name home phone# work phone*
CURRENT MAILING ADDRESS:
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's shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be restionsible-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 i nderstands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
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 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 persons)for hire to do such work,that such Homeowner shall-act as supervisor."
Many homeowners who use this a empiion are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Licensing,Coustraction 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc
06/20/16
'l
kie c sf? r-Permit
_Town of Barnstable # �D��6 4
Expires 6 date
nth
* 'Regulatory Services Fee � 9bb
* snatvsznBr.e,
9 grass.i639• Richard V.Scali,Director It-PRESS �t1lle����� ����O U
`�
ArED MAt A
Building Division
Tom Perry,CBO,Building Commissioner MAY 04 2015
200 Main Street,Hyannis,MA 02601 TOWN OF BA R N STA B L E
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
/esidential Value of Work$ h �3 Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name �� t�0� 1- Telephone Number � � 7/ / 67-
Home Improvement Contractor License#(if applicable) Cp9 t Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Chec 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 oof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ e-side A
Replacement Windows/doors/sliders.U-Value f Y� (maximum.35)#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 py of the Home Improvement Contractors License&Construction Supervisors License is
rc7 ired.
SIGNATURE: i�
Q:\WPFILES\FORMS\building permit form s\EXPRESS.doc
Revised 061313
d/7L �(omvrrxarzc�ecz�C�i a���aaaac�ivaeCYJ�:
Q. Office of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
gistration: 132691 Type:
. piration a/23120;T:7_ Individual
Ir
l
SCOTT QUILTER
SCOTT QUILTER "'--
247STRAWBERRYHICL;,F;D_=
-CENTERVILLE,MA 02632 Undersecretary
individul use only
valid for eturn to..
License, e P rafion tratlodate. if f d Business Regulation ..
before theer Affairs an
Office Of Jaz%- '10
Suite 51
l0parkY►aza2116 -
'Boston,MA�
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License:'°.CS-078000
r:r r.ti
SCOTT H QUELto
PO BOXY 727
West. Iiyannisport !0V2j7
J.•�..�`.� �� �i`�` Expiration
• _GommiSsioner -
02/03/2016
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991it, of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS Licensing information visit: www.Mass.Gov/DPS
r . - .. - _.
i •
Ae caF,z aT�} e of irssrrc r'r eits � •. ESS PERMIT
l epgrWtent of Industrial Accidents
Office oflm tip ons MAY 04 2015
Gov Washingtvrr.Street I O UU N OF BA R N STAB LE
Boston,H4 02-1.1I
wYv-comas&,-vv1dia
Workers' Campensation Insurance Affidavit:Buil-ders/Coiatl-actDrs/El ticians rPhrmbers
Applicant Iufmmat on Please Print LegibIy .
Name,(Busi Be V'Org dual): Sr,011-11 CIPU
Address: L � u
City/State/Zip-
Are Phone# 04(
:ire you an employers`r,7ieck the appropriate box: T}The of,project(required):
1.❑ a empioyer with 4. 0 I am a`genesal contractor and I"
loyees(full anil;orpart:-time).*
have hired the sub-contractors 6- ❑Neu sonstton
2. 1 am a sole . etor of-partner- listed on the attached sheet. - modeling
slip and have no employees These sub-contractors ha,e g_ ❑Demolition.
working forme in any capacity- employees and have workers'
�' c� X 9_ ❑Building addition
[No wcnluafs' comp.insurance comp_ e insuranc
requied-] 5_ ❑ We am a.corporation and its 10-❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers halve exercised their 11.❑Plumbing repairs or additions
self [No workers'c. fight of exemption per MGL
e c_152, 1 4),and we have no 12.❑Roofrepairs
insutancerequirtd.]� � � . '
employees.[No workers' 13.0 6ther
comp.insurance required-]
*Any applicant that checks box#1 mast also fill our the section below showing their WoAens campen.atinn policy inforI adon_
1=onueowners who submit this sM&mit im&cstiag they are,dainz all wcA and then hire outside contractors anise mbuut anew affldaeat indicating sack
contractors thst check ibis bore must stUchad an addisiou,I sheet showiog the name of the sub-contras and state whether or not those entities have
employer. Ifthe subcontractors have employees,theymust,pmvide their aorken'comp.policy number. ;
-fain an employer that is prosriding yrorkers'corig e.?rsatiort hisrrrance for my emplopees Beloit=is tliepol<c.y aridiab site
inaforrnalivn.
Insurance Company Name:
Police 4 or Self--ins.Lic-#: 1rxpiratiotx Date: r
� � F
`.lob Site Address: City/State/zip._ t �
Attach a copy of the workers'compensationpolicy declaration page,(showing the policy number a � expiration date
Failure to secure coverage:as required under Section 25A o€NfGL c 152 can lead to the imposition ofed rimal peQ-f-es o1g
fine up to$1,500-00 and`or one-year imps son t,as well as curl penalties in the form of a STOP WOE K OPDEl&�td a .
of tip to$250.00 a day against the violator. Be advised that a-ctipy ofthis statement may be fomwded to the Office of �
Itrvestcgations.of the DLA.for insurance coverage:verification_ ,M
I do here,by ce it the pains andpena `.s fPet�itrG tliattlte iriforxie�tiaii pt ndrled abos a is'trzr.e ar.td correct
-,
Suture: I1ate:
Phone 12:
Official use oety. Do not ivrite in this area,to be coitipPeted by city or toriai ofczaL
City or Town: PermitfUcense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CiVrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: A: Phone#-.
f
"�
a634- Town of Barnstable
9$ ♦��
Arm�p
Regulatory Services
Richard V.Scali,Director
Building Division
Thomas Perry,CEO `
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
tY
ProP er Owner Must
Complete and Sign This Section
If Using A Builder
I, c_)Sc Y-s�� 1�1 � in ,as Owner of the subject property
hereby authorize �Cc3 ff Ui L+el, to act on my behalf,
in all matters relative to work authorized by this building permit application for: '
�5 C-f mo-* 9A
(Address of Job) �j�3 2-
Signature of Owner Date ,
Print Name '
If Property Owner is-applying for permit,please complete the Homeowners License Exemption Form on the
reverse side..
Q:\VdPFILES\FORMS\building pennit forms\EXPRESS.doC
Revised 061313 0
0
oFtr Town of Barnstable #�
Expires 6 inonths from issue date
r �
Regulatory Services Fee c
a
a BARNSTABLE,
9 MASS,
�$� Thomas F. Geiler, Director
-
BuildingDivision
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstab]e,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 13
i l f- J -° f�. [.-.lw' � � �Ile-
51Residential Value of.Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
(lam �J 'Jj/ t r -le-
Contractor's Name E ✓ �. �
c.r=� Telephone Number. � �"'�•+��'���
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) ` "� � �`
:f� Ct S 41 u m
❑Workman's Compensation Insurance
Cheek o 2 ne: - n APR �
"1 am a sole proprietor
❑ I am the Homeowner TOWN OF BARNSTABL
❑ 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)
EQ/e-roof(stripping old shingles) All construction debris will be taken to3 / ;ry
r--
❑ 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 Home Improvement Contractors License&Construction Supervisors License is
required.
SIGNATURE:
Q:\WPFILES\F0RMS\building permit forms\EXPRESS.doc
Revised 0701.10
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations.
1 it_1 t
;i;;o / 600 Washington Street
Boston MA 02111•'
f r www.mass.gov/dia
Workers' Compensation Insurance.Affidavit:,Build ers/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLyibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: l r t Phone#: f ! 0.: 60711
Are you an employer?Check the appropriate box: Type of project(required):
L ❑ I am a employer with 4._❑ I am a general contractor and I 6. ❑ New construction
mployees(full and/or part-time).* have hired the sub-contractors,
2. 1 am a sole proprietor or partner- listed on the attached sheet. : Q Remodeling
These sub-contractors have 8. ❑ Demolition,ship no employees and have loyees P
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its
officers have exercised their l0.❑ Electrical repairs or additions
i required.]. .
3. I am a homeowner doing all work right of exemption per.MGL 11. lumbing repairs or additions
myself. [No workers'comp. c. 152, §l(4), and we have no 12: Roof repairs a
Y
insurance required.]t employees. [No workers' 13.El Other
comp.insurance required.]
*Any applicant that checks-box W I 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.
lContractors that chock this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer thal is providing workers'compensation insurance for my employees. Below is thepo.cy and job site
+ information:
Insurance Company Name: -
Policy#or Self--ins. Lic.#: Expiration Date: `
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page (showing the 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 painWaidd nalties of p jury that the information provided above is true nit correct
Si ature: Dater 2�
Phone#:~
Official use only. Do not write to this area to be completed
ff l y p ted by city or town official
City or Town: Permit/License#
Issuing Authority(circle one)::
1. Board of.Heii1th'1 Buildingbei partment 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Phone#:
F
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, §2-5C(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 burn 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 ,
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
'THE, Tbo yh of Barri-stable
~ Regulatory Services
CBI E�, Thomas F. Geiler,Director "^Y
o.19
}� 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 OwrierMiust ;w
Complete and Sign This _Section M , ,, . •-' °'
If Using A:Builder
I (>`/� ,s ' I Oil
as�Ownerofthensub'ect property
.Y
c�5 c�� n� � �IY)� !� subject. Perry
r .
hereby authorize ` }�� to act on my behalf,
• r
m all matters relative'to work authorized by this building permit application fora
(Address of Job)
Signature'of Owner Date k r
Print Name 5
If Property Owner is applying for permit please complete. tie k
v}Homeowners License Exemption Form on :the reverse side
Town of Barnstable
Regglatory Services
Thomas F. Geiler, Director
'y s Building Division
rfa µpi''
Tom Perry,Building Commissioner
200 Maid-Strcet,_Ayannis, MA 02601
R�v.toFrn.barnstable.ma.us
Office: 508-862-403 8 Fax. 508-790-6230
HOTS EOW} l:. CENSE EXEMPTTON
Plisse Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name hone phone# work phone#
CURF-NT MAILING ADDRESS:
eityhown state rip 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 HONLEOW?NMR
Persons)who owns a parcel of land on which he/she resides or intends to reside, on which-there is, or is intended to•
bc, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constrgcts 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 Budding Official, that he/she shall be
responsible for all such work Performed under the building permit (Section 109.1.1)
Tl,e 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
minir„nttn inspection procedures and requirements and that he/she.will cornply with said procedures and
requirements.
Signature of Homeowner
Approval of Building.Oficial
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
t State Building Code Section 127.0 Construction Control.
HOMMOWNER'S EXEMP- 6N
The Code states that Any homeowner pcfom ing work for which a building permit is rcquircd shall be exempt from the provisions
of this secdon.(Sccticn l D9.1.1 -I.iccnsibg of canstruction Supervisors);provided that if the homeowner argagcs a pa-son(s)for bin to do such
work,that such Homcowna shaA act as supervisor."
Irfany homeowners who use this exemption an unaware that they arc assumingresponsibilities
the responsities of a supervisor(ser Appendix Q,
Rules&Rcg6lations for I.ica sing Construction Supervisars,Seetioa 2,15) This lack of awarcnao bften 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 horhaowna acting as Supervisor is uhimatc)y responsible.
To ensure that the homeowner is fully aware of his/her icsponnbilitics,many communities require,as part of the permit application.
that the homeowner certify that belshe understands the rcspoasrbilitics 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 it fonn/ccrtification for use in your community.
� .
' milssachusetts Department of Public S,►hti.
`Board of Building Ret-julatio and Standard' 4
Cr nstruction Supervisor License
y` -License: CS 25387
Restfictz(9 to: '00
� c
SEAN FITZGERALD
" 7 GILFORD RD
Fy
HINGHAM MA 02043 '
Expiration: 2t2/2012
at Tr#: 14755
✓sie omen t ✓ a sac�tuaella
' License or.registration valid for individul use only
Oftice of Consumer Affairs&�> :uoB:� before-the expie date. If found return tot
gs Office of Consumer Affairs and Business Regulation
14OME IMPROVEMEAIl'COAT l 10 Park Plaza-Suite 5170
RegistrEion •114335 a
MA 02116
Expiratkb 813012. W 1 'is#`, 1 Boston,
Type: tr► valecat v
lug
FITZ—GERALD
FtAI�D ,cad _� •� rF
$E�41V'f1TZGE
z
7-to1LFORD RD ..� ',
Uudetaccr�tai�! Not valid. outs►gnatu're
- �li�fEal'IA _1' .. .a- i ' .
Bk 2385-5 P:9 17S '38030
07--01--2009 a 1 O 2 29u
Certificate ofAppointment'of Successor'Trustee-
L Selma L.Hughes,a surviving Co-Trustee of 38 Great Marsh Nominee Trust
under Declaration of Trust dated November 27, 1992 and recorded with the Barnstable
County Registry of Deeds at Book 8327,Page 225, do hereby certify that by an
instrument in writing signed by 100%of the Beneficiaries of said Trust, Susan Griffin,of
Plymouth County,Massachusetts,was appointed as successor.Co-Trustee in place of
Robert Hughes who has died.
U Executed as a sealed in this 16'h day of June,2008. .
Selma L.Hughes
COMMONWEALTH OF MASSACHUSETTS
v Barnstable,ss June 16,2009
u
Then personally appeared the above-named Selma L. Hughes; personally known to
a N me,and acknowledged the foregoing instrument to be her free t and deed_,before me
H tw
`
CO
00
-
o Xi erly A.H
00 O
, ao Notary Public
My commission ires:
June 02,2011
43.
b
d
o N"Y nd fs
My oam�i�tai 6pM�s
. .h,ne 2.zatt
BARNSTABLE REGISTRY OF DEEDS
DURABLE POWER OF ATTORNEY
I, Selma L. Hughes, of 38 Great Marsh Road, Centerville, County of
Barnstable and Commonwealth of Massachusetts,.hereby appoint my daughter, .
Susan Griffin,my agent to do the following things for me and on my behalf:
1) Purpose of this Power of Attorney.
I intend this to be a general power of attorney. I shall"specify certain acts
which my agent is authorized to do in my behalf, but this is not intended to limit
the generality of this power. I intend that my agent shall have the power to
exercise or perform any act,power,duty,right,or obligation whatsoever that I now
have, or may hereafter acquire the legal right, power, or capacity to exercise or
perform, in connection with, arising from, or relating to any person, item,
transaction, thing, business, property, real or personal, tangible or intangible, or
matter whatsoever;
2) To Collect,Enforce, and Manage Assets and Claims
To request, ask, demand, sue for, recover, collect, receive, and hold and
possess all such sums of money, debts, dues, commercial paper, checks, drafts,
accounts, deposits, legacies, bequests, devises, notes, interest, and retirement
benefits,insurance benefits and proceeds,securities,any and all documents of title,
claims, personal and real property, intangible and tangible property and property
rights, and demands whatsoever, liquidated or unliquidated, as now are, or shall
hereafter become, owned by, or due, owing, payable or belonging to, me or in
which I have or may hereafter acquire an interest,to have,use, and take all lawful
means and equitable and legal remedies, procedures,and writs in my name for the
collection and recovery thereof, and to adjust, sell, compromise, and agree for
recovery thereof, and to adjust, sell, compromise, and agree for the same, and to .
make execute and deliver for me,on my behalf, and in my name,all endorsements;'
acquittances;releases,receipts,or other sufficient discharges for the same;
3) To Deal With Personal Property.
To lease; purchase,sell, exchange, and acquire, and to agree, bargain, and
contract for the lease,purchase, sale, exchange,and acquisition of,.and to accept,
take,receive,and possess any personal property whatsoever,tangible or.intangible,
or interest thereon,including, but not limited to automobiles, trucks or trailers,.on
e
such terms and conditions, and under such covenants, as my agent shall deem
proper;.
4) To Deal With Real Estate
To maintain, repair, improve, manage, insure, rent, lease, sell, convey,
subject to liens, mortgage, subject to deeds of trust, and hypothecate, and in any
way or manner deal with all or any part of any real or personal property
whatsoever, tangible or intangible, or any interest therein, that I now own or may
hereafter acquire, for me, in my behalf, and in my name and under such terms and
conditions, and under such covenants,as my agent shall deem proper. To sell and
convey any and all land owned by me;
5) To Establish and Amend Trusts
To establish trusts on my behalf,on terms which my agent shall to his or her
belief understand to be my wishes for my estate,and to amend any trust established
by me;
6) To Fund Trusts
To transfer money, securities,and other property to any trust or trusts which
I shall earlier have established;
7) To Execute Disclaimers
To execute disclaimers on my behalf under Section 2518 of the Internal
Revenue Code or any comparable section of any state statute;
8) To Deal With Brokerage Accounts
With respect 'to my brokerage accounts,- to effect purchases and sales
(including short sales), to subscribe for and to trade in stocks, bonds, options,
rights, and wan-ants or othersecurities,domestic or foreign,whether dollar or non
dollar denominated; or limited partnership interests or investments and trust units,
whether or not in`negotiable form, issued or unissued, foreign, exchange,
commodities, and contracts relating to same (including commodity futures)' on
Margin or otherwise for my account and risk; to deliver to my broker securities for
my account and to instruct my broker to deliver securities from my accounts to my
agent or to others,and in such name and form, including his own,as he or she may
direct; to instruct my broker to make payment of moneys from my accounts with
my broker, and to receive and direct payment therefrom payable to him or her or
others;.to sell, assign, endorse and transfer any stocks, bonds, options, rights and
Z
warrants or other securities of any nature, at any time standing in my name and to
execute any documents necessary to effectuate the foregoing;to receive statements
of transactions made for my account(s); to approve and confirm the same,to
receive any and all notices, calls for margin, or other demands with reference to.
my accounts(s); and to make any and all agreements with my broker with reference
thereto for me and in my behalf. The power granted herein shall apply to
brokerage accounts with the following brokers:
including but not limited to:
and any other brokers with whom I may have accounts from time to time.
I authorize:my agent to execute on my behalf any powers of attorney in
whatever form which may be required by.any stock broker with whom I have
deposited any securities;
9) To Deal With Securities.
To buy, sell, trade in, hypothecate, and otherwise manage any securities,
domestic.or foreign, whether dollar or non-dollar denominated, including, but not
limited to, stocks, bonds, and options, which I may own; and to sell all or part of
such securities and purchase other securities;
10) To Make Contracts and Give Releases.
To make, receive, sign, endorse,execute, acknowledge; deliver, and possess
such applications, contracts, agreements, options, covenants, security"agreements,
bills of sale, leases; mortgages,assignments, fire and casualty insurance policies,
bills of lading, warehouse receipts, documents of title, bills, bonds, debentures,
checks, drafts,bills of exchange, letters of credit,notes, stock certificates,proxies,
warrants, commercial paper, receipts, proofs of loss, evidences of debts, releases,
and satisfaction of mortgages, liens, judgments, security.agreements and other"-
debts and obligations and such other instruments in writing of whatever kind and
nature-as may be necessary or.proper in the exercise of the rights and powers
herein granted;
3
11) Bank Accounts.
To deal with any bank accounts or certificates of deposit which I may own,
to withdraw funds from such accounts, to pledge such accounts, and generally to
exercise control over such accounts, and to establish new accounts;
12) Life Insurance Policies:
To deal with life.insurance policies and annuity contracts, to change the
beneficiaries, to assign the policies, to surrender and borrow against the policies
and to exercise,all of the incidents of ownership in any life insurance policies or
annuity contracts I own;
13) Medical Care.
To make decisions as to acceptance or rejection of medical treatment, to
engage and dismiss physicians and other healthcare personnel, to choose where I
shall receive medical treatment and to arrange for my admission to and discharge
from hospitals and other places of treatment, and to do anything in connection with
my health care which I could do personally. If I shall have executed a valid Health
Care Proxy this provision shall be inapplicable;
14) Tax Matters.
To represent me in all tax matters; to prepare, sign, and file federal, state,
and local income, gift and other tax returns of all kinds, including joint returns,
claims for refunds, .requests for extensions of time, petitions to the Tax Court or
other courts regarding tax matters, and any and all other tax-related documents,
including,but not limited to, consents and agreements under Section 2032A of the,
Internal Revenue Code or any successor section thereto and consents to split gifts,
closing agreements and Form 2848, and any other power of attorney required by
the Internal Revenue Service,any state or any local taxing authority with respect to
any tax year between the years 1985 and 2020; to pay taxes due,collect and make
such disposition of refunds as my agent shall deem appropriate,post bonds,receive
confidential information and contest deficiencies determined by the Internal
Revenue Service, any state, or any local taxing authority; to exercise any elections
I may have under federal,state or local tax law; and generally to represent me in all
tax matters and proceedings of all kinds and for all periods between the years 1985
and 2020 before all officers of the Internal Revenue Service and state and local
authorities; to engage, compensate and discharge attorneys, accountants and other
tax and financial advisers and consultants to represent and/or assist me ,in
4
r ,
connection with any and all tax matters involving or in any way related to me or
any property in which I have or may have any interest or responsibility;
15) Safe Deposit Boxes.
To enter any safe deposit box which I may have leased; to add property to
the box or take property from the box, and to surrender possession of the box and
terminate the lease if my agent shall deem it appropriate;
16) Mail Boxes and Mail
To enter any mailbox leased by me; to instruct that mail be forwarded to _
another address selected by.my agent and to surrender any leased mailbox;
17) Power to Do All Necessary Things.
I grant to my agent full power and authority to do, take, and perform all and
every act and thing whatsoever requisite, prior, or necessary to be done, in the
exercise of any of the rights and powers herein granted, as fully to all intents and
purposes as I might or could do if personally present, with full power of
substitution or revocation, hereby ratifying and confirming all that my agent shall.
lawfully do or cause to be done by virtue of this power of attorney and the right
and powers herein granted;
18) Powers Not Intended To Be Limited.
This instrument is to be construed and interpreted as a general power .of
attorney. The enumeration of specific items, rights, acts, or powers herein is not
intended to,nor does it,limit or restrict,and is not to be construed or interpreted as
limiting or restricting,the general powers herein granted to my agent;
19) Choice of Conservator or Guardian.
If it is necessary at any time for,a court to appoint a conservator for my
,estate or a guardian of-my person or estate,I nominate my agent, Susan Griffin,to
serve as such conservator or guardian;
20) Power to Remain In Effect.
This power of attorney is,intended to remain in full effect notwithstanding
any subsequent disability or incapacity on my part;
21) Expiration.
This power of attorney shall not expire or become stale upon the passage of
time but is intended to continue in force until revoked by me;
22) Counterparts and Copies Valid.
I execute this power of attorney in a number of counterparts,each to be valid
as an original. In addition a photocopy of this power of attorney shall be deemed
to be as valid as an original;
23) Other Powers of Attorney Revoked
In executing this power of attorney, I hereby revoke all other powers of
attorney which I have executed earlier, except such as have to do with signature
powers over savings or checking accounts;
24) Protection for Third Party Accepting Power of Attorney.
Any person, firm, or corporation.shall be entirely protected in relying upon
this power of attorney or any action taken by my agent pursuant to this power of
attorney, and I,or my estate in the event of my death, shall hold harmless any such
person, firm, or corporation so relying upon this power of attorney or any action
taken by my agent pursuant to this power of attorney;
25) Designation as Personal Representative Under HIPAA. I grant my
agent the following powers, status, and privilege in order to enable my agent to
obtain all protected information with respect to my health under HIPAA (The
Health Insurance Portability and Accountability Act of 1996.)
I intend that my agent shall be able to obtain all of my health
information, since I anticipate that my named agent shall be obliged to make'
decisions related to my health care,including,but not limited to the payment of
expenses for my care. I declare that I consider all of my health care information.
to be relevant to such activity on the part of my agent. I direct that my agent
shall have such authority to act on my behalf in making decisions related to
health care as shall entitle him or her to receive protected health information
under HIPAA in the status of my'personal representative as that term is used
under HIPAA.
In addition to, and not in limitation of, the foregoing designation of
personal representative,I intend this provision of this durable power of attorney
to be valid authorization for my agent to receive all of the health information
that my agent in his or her sole discretion shall deem relevant. My agent shall
6
not be obliged to state a purpose for the request of such health information, and
his or her request alone shall be presumed to be based upon a valid reason.
I intend that any provider of health care services, including, by way of
illustration and not of limitation,any physician,surgeon,dentist,nurse,physical
therapist, chiropractor, psychologist, hospital, nursing home, or assisted living
facility, shall be entitled to accede to the request by my agent for protected
health care information.
The authority granted under this Article 25 shall expire in five years from,
the date I sign this durable power of attorney.
The reference to"agent"in this paragraph shall apply to the named agent
and any alternate or successor agent.
I understand that I may revoke the grants made in this Article 25 at any
time by revoking this durable power of attorney.
I intend that the grants under this Article 25 are not a precondition for
any treatment, payment, or enrollment under any program or protocol of health
care or payment therefore:
I understand that health care information under this.Article 25 may, once
released to my personal representative or person to whom this authorization runs,
be later released by, such personal representative or person to whom this
authorization runs.
26) To Make Gifts.
To make gifts of my assets to such persons and institutions as shall appear to .
my agent to be consistent with my prior pattern of giving,or as shall be appropriate
to reduce or eliminate Federal or State estate or inheritance taxes on my estate, or
as shall,be appropriate to reduce the exposure of my estate to nursing home
expenses. .This power shall not authorize my agent to make.gifts to himself or
herself. If such power is granted;it will be provided in Paragraph 27;
27) To Make Gifts to Himself or Herself.
I specifically authorize my agent to make gifts to himself or herself, directly
or indirectly;
(To be signed only if this power is granted:)
28) State Law To Govern:
This power of attorney is to be construed according to the laws of the
Commonwealth of Massachusetts.
WITNESS my hand this 11a'day of May,2007.
Selma L. Hughes
COMMONWEALTH OF MASSACHUSETTS
Barnstable, ss. May 11,2007
Then personally appeared the above-named Selma L. Hughes and
acknowledged the foregoing to be her free act and deed,before me,
Kirsten Pierce „
Notary Public
My commission expires �•��, �`
June 01,2012
00 y0A- ��:.0�
z 4s'N Y..
s�CHu"s��
S
•
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
7:1
Application #
Parcel. `Map io
Health Division Date Issu.6d'
Conservation Division App_i atioh Fe Planning',Dept'. m Per it F66 2-1!5
Date Definitive Plan Approved by Planning Board oK
dc
Historic - OKH Preservation Hyannis
Project Street Address
Village
Owner Address D) 0 kltet�A� tee-)4
Telephone
Permit Request 1�e4QVA!QV1
sawlif
Square feet: 1 st floor: existing proposed :2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
LyProject Valuation$7000,(2-0Construction Type
Lot Size e 1 kte Grandfathered: LJ Yes LJ No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family Ll Multi-Family (# units)
Age of Existing Structure -50t11-<,. Historic House: LJ Yes )d No On Old King's Highway: LJ Yes /kINO
Basement Type: 2 Full LJ Crawl Ll Walkout Ll Other
tN3
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft
Number of Baths: Full: existing new Half: existing
Number of Bedrooms: existing new y2
C>
Total Room Count (not including baths): existing new First Floor R M Coin 5-
Heat Type and Fuel: A3 Gas L1 Oil LJ Electric LJ Other
CD
'o
Central Air: Ll Yes Z No Fireplaces: Existing New Existing woo /
. coal s%e: Yes Ll No
Detached garage: LJ existing LJ new size_Pool: LJ existing LJ new size Barn: Ll existing L) new size—
Attached garage:P existing LJ new size —Shed: L3 existing LJ new size Other:
Zoning Board of Appeals Authorization Ll Appeal # Recorded LJ
Commercial Ll Yes LJ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION—
(BUILDER OR HOMEOWNER)
13 31 f�laneCam E5
Telephone Number (,>
,r
Address License#
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Aele-
SIGNATURE DATE
s � .
FOR OFFICIAL USE ONLY
: p APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
r
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME �31I?)sry LX
INSULATION o 3 161
' FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING r6-r �2t °f
i
DATE CLOSED OUT
ASSOCIATION PLAN NO.
i J
I _
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 Legibly
Name(Business/Organization/Individual):
Address• l`PyGl�
--- / C
_City/_S.tate/Zip:�cITzol=✓✓�Ie / 1 �c ��� Phone.#:
Are you an employer? Check the appropriate box: Type of project(required):
4. 0 I am a'general-contractor.and I
1.❑ I am a employer with _._,_._ _ . �- .^6. ❑New construction
employees(full and/or part-tim.e).* have hired the`sub-contractors-; i �*
..2.0 I am a sole proprietor or partner �li sted`oti the'attached-she et. 7..�Remodeling
ship and have no employees The, se Sub-contractors`have� g_ ❑Demolition
employees and have'workers'
working for me in any capacity. $ � �, 9. ❑Building addition
[No workers' comp. insurance comptnsurance
required.]-- 5. ❑ We are a corporation`an� d� it ,'�,, 10.❑ Electrical repairs or additions
officers have exercised their 11. Plumbing repairs or additions
3 I am a homeowner,doing all work ❑ g p
r— —_ right of exemption per MGL
myself,[No workers comp. 12.❑Roof repairs
insurance required]-f-= � c. 152, §1(4),and we have no
�+ employees. o workers' 13.❑Other
comp.insurance required.]
*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.
xContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
lam 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/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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a 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 true and correct
FStm
Date: o2// �� o
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-conti•actor(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 o.r 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 11-22-06
www.mass.gov/dia
�oF VE ray
Town of Barnstable
Regulatory Services
EARN.,Bm . Thomas F.Geiler,Director
mess �► .
� 0 9. Building Division
jOrFn µp't a
Tom Perry,Building Commissioner
200 Mairi.Street, Hyannis,MA_02601
vvww.town.barnstable.ma.us '
Office: 508-862-403 8 Faz: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: r� I Ca I-U O
JOB LOCATION: r&1a- �—
nuumber street village O 2—to J�
"HOMEOWNER!':—a X) Q_U(�� -IS-) `—I`t� �q
name home phone# work phone#
CURRENT MAILING ADDRESS: 6-- re o_4 + I \ct
Lin 1 I C IM C,_ n Z(D 3
eity/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.
DEFUGUON 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 procedures and requirements and that he/she will comply with said procedures and
requirements.
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 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 msponsrbilities 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:forms:homeexempt
s► Ta,,� Town of Barnstable
Regulatory Services .
• uxivsresi.E. •
NAM $, Thomas F.Geiler,Director
�Eo.Jg6 16�� Building Division
Tom Perry,Building Commissioner
a 200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner M t
Co lete and Sign Thi Section
f Usin ABui er
I, AL , as Owner of the subject.property
hereby authorize YZ �� S ` to act on my behalf,
in all matters relative to work autho ' d by this bug ' permit application for.
(Address of Job)
Signature of Owner Date
'3(L-1 ry
Print Name
If Property Owner is applying for permit please c e.
Homeowners License Exemption Form on averse side.
Q:FO RM S:0 W N ERP ERM IS S ION
I � -
I
i
,- ._ � -
.__�. ._ ..l_ _�_. _ _� . �s . .� _ .. .____s,._.._ ,_._��,.-.______._�_� �..F__._..__.��____.__.____ ..,__.�_. _.,,_ _T_ ....__ ___ __
1
1
' � I -i---
� � 1 �
• 1 � , � I � I
i t 1 �
.w . ..A .4 �---�i-.- �.... ..L. i !- ,� � l� ti L ,i.�a.._ P � I I i 1 i +..� I i �....,..'�...,.._ �......._
_� � 1�; i i L��1 �. { ..���� �..�J��-_.tom...�n�����-+ �. ' t ��1 �-_ .� .����
1 —! +- , dam. �.._ F 1 � r � f � ( 1 f � ' i ....J..
I 1 � 1 ; j 1 + + �-- 1-
I..e..�-_-�._s_._..
• � � � 1 � 1
w.�— i
r 1
1 �
f
j-
Y !
1 �� 1
_ I
I
,
I
1I I
,
I
I I
ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR
ONE- AND TWO-FAMILY DETACHED RESIDENTIAL:CONSTRUCTION (780 CMR 61,00)
Applicant Name: Selzn4V Site Address: ,a
Town: P�✓�
Applicant Phone: 7`15 —� :7� ` ��� y�h er,f
A
Applicant Signature: i e-, ��, Date of Application: Q�/ir/�oo 1
NEW CONSTRUCTION: choose ONE of the following two options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE-AND TWO-FAMILY BUILDINGS`
MAXIMUM MINIMUM _
Ceiling or Slab
❑ _Option 1: Basement
Fenestration exposed Wall Floor Perimeter
Wall AFUE HSPF SG1R
U-factor floors R-Value R-Value R-Value R-Value
R-Value and Depth
National Appliance Energy
R-10, Conservation Act(NAECA)of
35 R-38 R-19 R-19 R-10 4 ft. 1987 as amended,minimums or
renter as a licable
Note: This form is not required if you choose either of the two versions of REScheck as.listed below.
❑ Option 2: �. REScheck Version 41.2 or later variant software analysis must be completed
(780 CMR 6107.3.2).
REScheck:Web which can be accessed at http.,//www.energ co des.goy/reschecly
ADDITIONS-OR ALTERATIONS TO::EXISTING.BUILDI GS'OVER 5 YEA.RS OLD*
*Buildings under 5 years old must use option#1 or#2 in New Construction section above.
Complete the following formula to determine the % of glazing:
(a) Gross.Wall & Ceiling Area equals Formula:. (100. x b = a)
SF 100 x % of glazing
(b)_Glazing area equals. SF b a
If glazing is <.40%o us(ethe chart below. If.glazin is> 40.`0/o proceed to "SUNROOM" section
780 CMR TABLE 6101:3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING.
LOW-RISE RESIDENTIAL BUILDINGS
MAXIMUM MINIMUM
Slab Perim
Wall Floor Ba
Ceiling and eter
Fenestration sement Wall
ue
U-factor Exposed floors R-Value R-value R-Value. R-Value
R-Val and Depth:
39 R-3 7 a R-13 R-19 R-10 R-10,4 feet
R-30 ceiling insulation maybe used in.place of R-37 if the insulation achieves the full R-.value over the entire ceiling
area(Le,not compressed over exterior walls, and including any access openings).
SUNROOM An addition or alteration to an-existing building/dwelling unit where the total
glazing area.of said addition exceeds 40% of the combined gross wall and ceiling area of the
addition:
Note:. OWner to fill out Consumer Information Form (found in Appendix 120.P)
l b SEPTIC SYSTEM MUST BE
Assessor's map and lot'number
••••>•••••••••••••••••:•-•••••� ' - INSTALLED IN COMPLIANCE
WITH ARTICLE II STATE
SANITARY CODE AND TOWN
,Sewage Permit number ......4cut.-AA f-U. e°L ............. REGU Th9/(y��S
yo�THEr°�y TOWN OF BARNSTABLE
Q ;
i BARNSTABLE. i
"AM BUILDING INSPECTOR
CFO MPY a'
APPLICATION FOR PERMIT TO . +'4. :49.1 .� s�.�...Crl �!1,� .....pe-It-act
TYPEOF CONSTRUCTION .... r .....................................................................................................
............................... .............19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
�$ �r-- .: crain��9'l ffn.....I :�.......0 6.. ..........
Location .................... .. ....
ProposedUse ........... Gs ................................:...............................................................................................
Zoning District ......... ` �.(.1��.....
f.4.. ...............................................Fire District ..
Name of Owner
L-, �
.............I ! ':e ...�... � -5 ...................................................... ...........................
f A
. .`.......` - J ...............Address' �C(�l!` f/4 t.. �i..
Name of Builder ...... ...... ...... ........... .... ........ .......... . ..............
Name of Architect ,..`..................................Address "�—
................ .. ... ......................................................
Number of Rooms .............!E P. P....................................Foundation .09.uta\1 o
Exterior ...........�����..u- .!.. �/.......................................Roofing ..�. ,S.0 .... .� ...~. .V.. .. .f ....��/ /a,�,�
J
Floors V ...............................Interior P
Heating .............. 0-.V\..................................................Plumbing ........ ......................................................
Fireplace p�.... ..........Approximate Cost ......... ov
P
Definitive Plan Approved by Planning Board ________________________________19________. Area � �.�
Diagram of Lot and Building with Dimensions
Fee .............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
ID
0
Lo -
I hereby agree to conform to all the Rules and Regulations of the win Barnstabl rding the above
construction. (�
e�
Name ....................................................................
French,, L. Theron
18467 add porch
No -----.. Permi� f�" .......
to dwelling `. =
------------------.-------..
38 Great Marsh Road
Location --.--------_----------
Cenlarvi]Lle .
--------.--.----~----------.
L. Theron French
Owner ----------------------
frame
Type of Construction --------------
--------------------~-----'
' - ^
Plot .-----__.. ��
— ----------..
�
� ~ ^
June 17'- ' 76 `
Permit Granted ------------..]P
Date of Inspection `lV' '�----'
Dote Completed . '
'�� --�.�--l� ^ '
- �
. .
�
| ^
PERMIT REFUSED
.
� *-----.--^----------.'...—. l�
� -
� '--------'~'------'--_�------'
_~~----,...------.—.--�-------
--
-----------.-------.,�.------
-- . . .
____,_____.____,,,.____._____,
Approved .........................................-- lQ
--
^ .
'
� --'_----------~.—...---.---~— . . ~
� -----------.-------,—.—.~.~..
' ^_
,
`
./ r.,-.. ti..r. .x ~.. r l:+• 1 ..y.Yi.�...... ..+' r a,. �,.F- y. 6r:� e .. _, _ r
Assessor's map and lot number - '
Sewage Permit number .....Xt!s'?:��.. �.�'G ��'
T"Er TOWN OF BARNSTABLE
Z BA"MULE, i
° 0 Ya,•�° D-UILDING" , INSPECTOR
A
Conrtruct ,a' Screened Porch
APPLICATION FOR PERMIT TO .... : :......................... ....:............................................
TYPE OF CONSTRUCTION ..... r. E'rame..............................................................................................
................................................19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
38 Gr a'trMarsh RoadGiCente'ryille,,(Mass:�026�32 \ z C7r3 '?1
Location ,........ .............I.................. ......... ......... ................................ . ..........................
Proposed Use
Re de'nce
.................. . ... .... ...............................................................................................................................
... � 1 rrostervilile Centery ileI
Zoning District .... .....•..........................................................Fire District .... ........................
Name of Owner .K ,..... n French �rY(rv..Address ........................................................ �., .... . ...............
Name of Builder ( Carl A1. rd5@r "" Address Ma in St Ba•rksta`ble
.!:,:.. ....... ........ .... ................................ ......... ...............
. a i
UlA. -------
Nameof Architect ....................::.............................................Address ....................................................................................
...............Foundation Coricrete�Posts
��y
Number of Rooms ..............tc�.. .Qrie ..............._...-...................::................................
Screen 1
Exterior ..... 7r"'fn;.....:1.....................................Roofing AlsXnit:e St ucto Grazed.. ......... ..�... ......... ,
wood �
.4
Floors .............. AA. />.6.. ..................................................Interior ... 1.A.......................................................................
None, >1 `!Nonef G _
h•
Heating ...........................:Plumbing ........... ................3...................................
Fireplace ..................:......:.. .....................................................Approximate Cost ......$..i8:00.:!�Q. .. ..................................
! i-4Ie I i f
Definitive Plan Approved by Planning Board --------------------------------19--------. Area -10.:!...by...1.0................
e
Diagram of Lot and Building with Dimensions Fee ..
........... .. ................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
•r
A {�
t
o
I hereby agree to conform to all the Rules and Regulations of the n of Barnstableeregarding the above
construction. r
Name ..�P................................ ... ........ �,.. f.......................
French, L. Theron A=210~~163 '
add porch
18467 to
~
single family d_-~-_ /Ro
' .
38 Great
Location ----..--.^----.^.-MarshCent ��� . '
_^ ^
........-....----
L. Thw
O"w.u* frame
. `
Type of Construction
^
.
. . `
..-.----------'
.
^
`-
AL
17
Permit Granted wu.
----- .
76
~~'~ of Inspection
Date Completed
�
. - .
- `
ER
'
................................. l�
�
.-------. .. .--------- �
/ /. /�� 04W
-.--.f:�^.... --�------------.
. . . , .
.-.-.--------..~-....-...------.
.. . . . `
.--------.-~---------...-....-
'
Approved ................................................ lA
-
'
----------------------~.--..
`
----------^^---------^----'-