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0325 GREAT MARSH ROAD
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TY Y i FC e • 06130 S_� Town of Barnstable *Permit# Regulatory Services ��6 hsfr sue Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma.us Office: 508-8624638 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY Not[valid without Red X-Press Imprint Map/parcel Number Z/0 045' II L --Property Address 6, ,.+ /I c t`s ��il (10 1- i A ® 25 ((residential Value of Work$ 5,C0. 00 1 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address s c A,,s4 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) mp�❑Workman's Compensation Insurance l Check one: �Iam a sole proprietor am the Homeowner A�� ❑ I.have Worker's Compensation Insurance J'Qpki Insurance Company Name V O 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) Fe-side Replacement Window door/sliders.U-Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand 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 copy of the me Im r tractors License&Construction Supervisors License is SIGNA _U - Q:\WPFILES\FORMS\building permit forms\FMRESS.doc Revised 060513 The Cumamnocafth ofHassuchusefts Departnrr nt ref fndmoffal Accidents OKWe COMMagadons ' 600 kPaskhVton Street Boston,MA 02111 wwm masx gorrdia Workers'Compensafian Insurance Affidavit:BluIders/Contractors/Becirici2nsXlumbers APPHcantInfarmation - Please Print Legibly Name t t CitylStatrjzip: ✓I'� 2 �Phfls�e# yam Am you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with. 4. ❑Ism a dal contractor and 1 6- ❑New cons ruction . employees(fall andlorpartAime}* have hared the sub-contrwiors. 2-❑ I am a sole pmpFietor or partner- listed on the attached sheet 7_ ❑Remodeling ship and have no employees These sub-oontracters have 8- ❑Demolition woricingfo��r me in any capacity_ employees and have wod:ers' 4. ❑Building addition L'a workus'comp_LUSUY7ii C comp.insurance., ] 5. ❑ We are a corporation and its 10-0 metrical repairs or additions. -3. I am a homeowner doing all work officers hn m exercised their 1€-0 Plumbing repairs or additions —myself myself[No work='comp. right of exemption per MGL 12..❑hoof repairs insurance required.]i a 152,§1(4} and we hnre no- employees-[No Workers' 13.N Other i-S e �t rim comp-insurance require&] �1Yny app]vamt that checks box#1 mast also fMour the sectionbelow showing then wodezC compensadoapvficyinffirmatiam. Homeowners vrho sabaut this a$idavi�iadusting they asE doing alIuu�c and lien bite t>ut9de comhactars oxmst submit a new affidxrk mehcatmg such_ t®cmrs that check this boot must imched as addidausl sheer showmb the name of the sutr-rnmframoa sad btate whether tarot tbose endues ham employees. Iftbe mobtontmcturs hate emplayees,they mist provide t Ar workers'comp.policy number. I am an employer that isprotiirg workers'compensation insurance for my employees. Below is the panty aa.d job srfe,. informat&n. Insmmce CompanyName: Policy;9 or Self-ins-Ile-#: Expiation Bate: Job Sifm Address: Cityl5tatelzip: Attach a copy of the wGrkers'compensation policy declaration page(showing the policy number and ezpi nation date). R&ure to suite coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a` tine up to$1,500.0D and/or one-year imprisonment,as well as civil penalties in the fvms of a STOP WORK ORDIR and a fine cf up to$250-00 a day against the violator- Be advised that:a copy of this statement maybe forwarded to the Office of luvestigations of the DIA€or insurance coverage vadEcattion- I do hereby cetti ��idpnnxwq n ofpedzuy that the information presided 9bove" true and correct Dane_ Off' &I use only: Do not write in this area,tar be campleted by city or town officiaL City or Town: Pena itUceuse# Issuing Authority(circle one? 1.Board of Health 2.Binding Department 3.Cifyfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pu suantto 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildnigs in the commonwealth for any applicant Who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152 11;§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and;if necessary,supply sub-contractor(s)name(s),address(es)and phone numbers)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 toverage. .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 lime. 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 permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hike 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. 1 i R The Co=amealth of Massachvsdts. Depaxttnennt of 1udustrial Accidents- Office of kvestigatxons 600 washfivon St=t Boston,IAA 02111 Ta#617�-727-4M at 406 or 1477 MASS AFE Fax#617-727-7749 Revised 4-24-07 w govldia l THE Town of Barnstable °-^ Regulatory Services MRNSMSIt' : - Thomas F.Geiler,Director Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 2 Please Print DATE. 70B LOCATION: .�L"�t�'L 1t�9 t dCff` —--_�_ ���yVJ ✓1%G- II n street--- "HOMEOWNER": / kill 0 5•�•4� name /it home phon'eA t work phone# CURRENT MAILING ADDRESS: Ct Ile- city/town _ i_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 Persons)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or of 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 buildkg_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 and d 'ho certifies that he understands the Town of Barnstable Building Department minimum inspection ed en that he/she will omply with said procedures and requirements. '`Signature of Homcown Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code, Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1.-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)'for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. C:\Users\decollrlc\AppData\LocaAM=soft\wmdows\Temporuy Internet Files\ContentOutlook\QRE6ZUBNIEXPRFSS.doc Revised 053012 Town of Barnstable Regulatory Services t Rl{�1VC1`�Ri.Y._ • .� g Thomas F.Geiler,Director s639. Ea,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 w Property Owner Mu` w Complete and Sign Thi Section 1 If Us' A B er r. as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work autho ' ed by s building this b errant n gP (Address-of job) Pool fences alarms are the responsibi]x of the applicant:' Pools are not to be fill d or utilized before fence is installed and all final inspections ar performed and accepted. Signature o Owner ' Signature of Applicant Print 4ame Print Name Date Q:FORMS:OW MERMLSSIONPOOL-S 6/2012 Bk 25975 Ps51 320 01-03-2012 MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 01-03-2012 8 03:42cm Ct24: 1532 Doc*: 320 Fee: $458.28 Cons: $1341000.00 BARNSTABLE COUNTY EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS QUITCLAIM DEED Date: 01-03-2012 S 03:42am CLI-04 1532 DocT: 320 Fee: $361.80 Cons: 3134YOGO.0o 1, PAUL R.STARKEL, an unmarried person, of 6311 Falcon Drive,Englewood, Florida, 34224 for consideration paid of ONE HUNDRED AND THIRTY-FOUR THOUSAND AND 00/100 ($134,000.00)DOLLARS r 325_ r-ea-t Marsh Road Grant to KRISTOPHER W.DUMAS,an unmarried person, 1rCerite ville Massachusetts, 02632 with QUITCLAIM COVENANTS The land with the buildings thereon situated in Barnstable(Centerville), Barnstable County, Massachusetts, more particularly described as follows: NORTHERLY by Great,Marsh Road EASTERLY by Camp Opeechee Road SOUTHERLY and.WESTERLY - by land formerly of Ferdinand G. Kelly and formerly of Sylvia R. Crocker Meaning and intending to convey and hereby conveying Parcel 5 on Town of Barnstable Assessor's Map 210, being the same premises described in a deed recorded in the Barnstable County Registry of Deeds in Deed Book 1024, Page 579 to which reference is made, Subject to all other rights,reservations, restrictions and easements of record insofar as the same are in force and applicable. Being the same premises as described in the deed from Michael E.Dumas and Patricia A. Dumas dated.May 26, 2011,recorded at the Barnstable Registry of Deeds in Book 25477, Page 43, Property Address: 325 Gfeat Marsh Road,Centerville,MA / . Bk 25975 Pg 52 #320 WITNESS my hand and seal this gl 6-'t day of December 2011. PAUL R. STARKEL STATE OF FLORIDA (' L4eQ County December ,2011 Then personally appeared the above named Paul R. Starkel,and proved to me through satisfactory evidence of identification,which was a o o,- Oq_t ijeKs Llly e to be the person whose name is signed on the preceding or attached document, and -4183ea-OG-t"AF-190-0 acknowledged to me that he signed it voluntarily for its stated purpose. (seal) �b'k `= MY COMMISSION AK no76e647 Nota Public- %.,os • EXPIRES March 17,2012:•'- �' 407;-914,63 FFQftN0W Sedka.wm My Commission"expires: 3 7-d bis BARNSTABLE REGISTRY OF DEEDS a-1 - II I -,L BUILDING t - Certificate of Appropriateness :d; do not accept application package-. one call or in writing). ' 1 . for project: at the Registry of Deeds ns f r /� ���� �� �� P��� 11e �gl�b� �%-�a �/�� . .a fi6od zone Pt flSed U-s,e GONDi7MMUM i zon SPLT-ISPLITZ NE I fl� memo � firiQd zone ;. b-Addrs [ Text ; $( Plan ReView p pen ftems . VA am n s = ' Find Related OVF I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town T .t MA. Date:j �� Permit# Building Location:;6d Owners Name: Type of Occupancy: Commercial j J Educational xJ, Industrial Institutional ( Residential r--., New: ! :j Alteration:l j Renovation:,L Replacement:! Plans Submitted: Yes No FIXTURES z z (n O W z U) U) U (n Cl) vy } rn Z I¢— Y Q rn Q UQ Lu Z ? F Z U) 2 tY d W cn W Z cn `� a) O 2: X M Q rW ❑ Q W W O0 W z W Z U n. u. ¢ Y = 3 O �O I- x z Q u_ a Y ¢ = w w w a s ° a o a d °o ° ° Q a a a F- AIR ¢ M M 0 ❑ u. U x `4 _1 J W cxn U)i 1- 5 O SUB BSMT. BASEMENT 15TFLOOR 2 u FLOOR 3 FLOOR 4 FLOOR 51HFLOOR 6 IHFLOOR 7 H FLOOR 81HFLOOR Check One Only Certificate# Installing Company Name: ( { Corporation I... l Address: City/Town � ,r �T State: MA F-' Partnership Business Tel: �� �} � Fax: �� - -�^�� firm/Company Name of Licensed Plumber:{ .. �' ��- �9 INSURANCE COVERAGE: I have a current liabilitV insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes�X]No,, If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity j Bond Li tY P Y._ YP Y OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my . Knowledge and that ail plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent.provision of the Massachusetts State Plumbing Code.and Chapter 142 of the General Laws. ByL...,,m,..w Type of Licensq: }� Title t Signat a of Licen a lumber Plumber. �- - City/Town! , MasterLicense Number: APPROVED OFFICE USONLY)�Y Journeyman l...w TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z( 0— Parcel d Application # Health Division Date Issued ' Z Q r Conservation Division Application R- , Planning Dept. Permit Feb 3 Date Definitive Plan Approved by Planning Board ak w?'4/l1 Historic - OKH _ Preservation / Hyannis rl�oiect-Street Address, 2 5 L� cc-6-(A / �-Q�► �Uillage� ( n,AJZ_.� ^ Address r �l dd --- GTelephone - �� It �P-errni#:Request ' t"/r a"� Square feet: 1 st floor: existi �rosed- 2nd floor: existing proposed Total new -K Zoning District Flood Plain Groundwater Overlay Pro ect Valuation* 0 Construction i -- Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No i Barn: ❑ xi tin ❑ new size Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ a e s g Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ - Commercial ❑Yes ❑ No If yes, site plan review# '` Current Use Proposed Use T_ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) 'r Name�- l %G�./a lJ��� Telephone-Numberd u2 Addr_ess License # y try III.- - Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM �THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE— Z f FOR OFFICIAL USE ONLY r APPLICATION# ,r DATEISSUED MAP/,PARCEL NO. t F ADDRESS VILLAGE i OWNER f - i r DATE OF INSPECTION: k' FOUNDATION i h i FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL s GAS: ROUGH FINAL F. FINAL BUILDING c-�ec-�^c �� nN ��2A, x r .. DATE CLOSED.OUT P ASSOCIATION PLAN NO. 7 i Y IA 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 Leaibly Name (Busin(--ss/Organization/Tndividual): Address-..- �Ge U d/RB City/Sta e/Zip: . C �. j �l/t. Phone #: r- .??/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling These sub-contractors have r ship and have no employees 8. Q Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp. insurance. $ 9. 0 Building addition equired.) 5. We are a corporation and its 10:❑ Electrical repairs or additions �.�Iham a homeowner doing all work officers have exercised their 11.0 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.❑ 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 cntities have employees. If the sub-conti actors 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' compensatiea 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 11,500.00 and/or one-year imprisonment,as well as civil penalties in the forma of a STOP WORK ORDER and a fine of up to 3250.00 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 coveragt,yerifcation. I do hereby certify under he pains nd penalties ofperjury that the information provided above is true and correct afuie �- Date: Phone#: L�yt e only. Do not write in this area, to be completed by'city or Ln wn: Permit/Lice hority(circle one):Health 2. Building Department 3. City/Town Clerk 4. pect&r 5. Plumbing Inspector rson: Ph 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 m 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-contractor(s)name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships (LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation.of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the'periivt 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 611 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 infomration(if-ftecessary) 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: T c Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Teh #.617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia I : , Town of BarnstabrIe THE Regulatory Services t Thomas F. Geiler,Director pq, ,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 wwwaown'.barnstable.ma:us Office: 508-.862-4038 Fax:, 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE:__ NZZ JOB QCA�T_ION 3 Z� _ fp(� / nS�l IW� —�'✓t+l.0 MG number street village "HOf MEOWNER_" r C/'( ( t N".4AL name home phone# work phone#.:, C—URREN-T—'M-M[ NG ADDRESS: — :G�r 'city/town t 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 ordetached structures accessory to such use and/or farm structures. A person who constructs more thari 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 100.1.1) 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 inspecti ro ures a d requirements and that he/she will comply witlr,said procedures and requiremen Signature of Homeowner r Approval of Building Official ' Note: Three-family dwellings containing 35,000 cubic feet or larger will be requimd-to comply with the ' State Building Code Section 1'27.0,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.-Liccrising-pf construction Supervisors);provided that if the homeowncr engages a person(s)forhire w do such ' work,that such Homeowner shall act as supervisor. Many homeowners who use this exemption are unaware that they arc assuming the responsibilides of a supervisor(see Appendix-Q, . Rules&Regulations for Licensing Cons truction.Supervisors,Section 2.15) This lack of awarencss often results in serious problems,particularly when the homeowncr hires unlicensed persons.,In[his case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowncr acting as Supervisor is nitimatcly 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 hc/shc.understands the.responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such'a form/certification for use in your community. Q:forms:homeex empt of THE r E E E BARNSTABLE, E 1659L. Town of Barnstable Y 63 q ��� Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry, CRO Building Commissioner 200 Main Street, Hyannis,MA 02601 e www.town.barnstable.ma.us Office: 508-962-4038 Fax: 508-790-6230 Property Owner Mu Complete and Sign T 's Section If Using A ilder 1, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work autho zed by this.boil g permit application for: (Address of job) Signature of Owner Dat Print Name !f Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. c-- C:\Users\deeollik\AppData\Local\Microsoft\Windows\Temporzry Internet Files\Content.OutlOOk\DDV87Aa.Z\EXPR-ESS.doc Revised 072110 • �- r�-�°�✓� 3 Z�'�' C�ram-ri''L��� �, _ p ,v Fwn 7c-prQl t kp NA �>4 l` 'i' 0 . � � � ��� � , � � ,m. .- - � o�� ��G� � � � � , �, . , Page 1 of 1 Anderson, Robin From: Grossman, Michael [mgrossman@commfiredistrict.com] Sent: Tuesday, April 26, 2011 1:20 PM To: Anderson, Robin Subject: 325 Great Marsh Road Centerville Hi Robin, I received a follow up call from the real estate agent Heather Miller providing me with contact information for the property owner Mike Dumas 508-771-6836. She stated he could meet you at the property if you wanted to set up a time. Mike Michael G. Grossman, Fire Prevention Officer Centerville-Osterville-Marstons Mills Dept. of Fire-Rescue & Emergency Services (508) 790-2375 ext. 1/Fax: (508) 790-2385 �,.�►� yl7,77 III e/f 2511. 1 it cX3 a," i+,tc.� 4/26/2011 f °PYRE�qh, Town of Barnstable Regulatory Services BM NSTABLE• ' Thomas F.Geiler,Director iOTFON►o�°i Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 August 29, 2007 Michael Dumas 554 Old Stage Rd. Centerville, MA 02632 RE: 325 Great Marsh Rd., Centerville Map : 210 Parcel : 005 Dear Mr. Dumas: This letter shall serve as notice that the above referenced property is currently in violation of the Zoning Ordinance of the Town of Barnstable Section 7(F)(1). As you may recall, permit#55287 was issued on August 20, 2001 to relocate a shed. No inspections were recorded by this office until a site inspection by myself just this past week. It was observed that plumbing and electricity were added to the shed without the benefit of permits. You must obtain all the necessary permits(plumbing,electric,building) along with the required inspections or remove all unpermitted work. This must happen by September 29, 2007 or you may be subject to criminal prosecution. I may be reached at(508) 862- 4034 with any questions you may have. Thank you for your attention and anticipated cooperation in this matter. By Order, �0f�-- e L. Lauzon Local Inspector Q:zoning5 NOTE INFORMATION BASED ON ASSESSORS MAP AND DEED DESCRIPTION AN INSTRUMENT SURVEY AND A PLAN FOR RECORDING SHOULD BE PREPAPRED. BUILDINGS ARE-PRE-EXISTING AND NONCONFORMING. GREA T HA RSH R OA vll R 240..00' " GA 14f 73 1 SSE. 15s 124 f o, SNED AS LOT 6 AS 'LOT 5 00, AS LOT 4 RES. ZONE RC" Tn1S. -MORTGAGE INSPECTION Bank 'Use only, FLOOD ZONE.- "C" THE DISTANCES AND MEASUREMENTS ON THIS_PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY. TOWN: —CEN REGISTRY OWNER:. ESTATE OF ROBERT JKARINEN DEED REF: 2479 BUYER: �IlICHAEL F .& PCIA A. DUMB DATE 12310 PLAN REF: NO PLAN N (�F SCALE:1 50 _FT. I, HEREBY _CERTIFY TO FIRST TRUST FINANCIAL_______ \` YANKEE SURVEY lll. _________________ THAT'.THE BUILDING rr t'A .4 \ SHOWN ON THIS PLAN IS LOCATED ON THE GROUND Af3 d` CONSULTANTS SHOWN AND THAT ITS POSITION'•.-DOES, CONFORM 2.FR+ THEW TO THE ZONING LAW SETBACK REQUIREMENTS \ ,.Q EMENTS `OF THE TOWN OF BARNSTABLE_____ ___ AND:.THAT N,"•�7F�S �p�P INDUSTRY ROAD. IT DOES_ NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD % ��s: MARSTONS'MILLS, MA.' 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED 81985 _ Suq ��,, TEL:' 428-0055 Co unit - anel 250001 0005 C FAX: 420-5553 ___ z -THIS PLAN NOT MADE FROM AN INSTRUMENT SURVEY. 28489 °CB P JLL A MERITHE7,PLS NOT TO BE USED FOR FENCES BUILDING PERMITS ETC. TOWN OF 1IARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 00S Permit# Health Division �d l .( �, � � Date Issued Conservation Division Fee Tax Collector � SEn �`STEM (v y Treasurer 1N181n�LLED 114 CO PLIT'z �' __L WITH TITLE:- Planning Dept. 0?4W �i6� E,HVQ 0,N tEMIT?L C�� Date Definitive Plan Approved by Planning Board Historic-OKH 3 Preservation/Hyannis Project Street Address Village �en:�-eC L) e— nn Owner ��fi'�G,��� �A'�/�C'�i•� ��� Address - �S zy 7Z Z Telephone- 7 7/ Permit Request /�7 K5� 11 Square feet: 1st floor: existing Q 8 proposed 2nd floor: existing proposed Total new .Valuation 1060• Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family O Two Family ❑ Multi-Family(#units) Age of Existing Structure 4 r' /9V9 Historic House: 0 Yes 3lo On Old King's Highway: ❑Yes a No Basement Type: of ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new 22,- Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: CAI Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes L No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 3'No Detached garage:2 'existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded El Commercial ❑Yes ONo If yes, site plan review# `Current Use`_T r - Proposed Use- BUILDER INFORMATION Name Telephone Number 7 7/ --- 626 Address _ (5 9") License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE c - y FOR OFFICIAL USE ONLY s PERMIT_ NO. t ` DATE ISSUED17 MAP/PARCEL NO. - ADDRESS _ �/ VILLAGE OWNER DATE OF INSPECTION: FOUNDATION s FRAME � y INSULATION' FIREPLACE 'i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL x GAS: ROUGH FINAL ' ► FINAL BUILDING y DATE CLOSED OUT ASSOCIATION PLAN NO. 'i, t F THE .�.� The Town of Barnstable w RAMS[ABI.E, 9� MASS, �m� Regulatory Services ArEO 1,9. Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner 367 Main Street,Hyannis MA 0260.1 - Office: 568-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 3z number / street village HOMEOWNER,>: _U� name home phone# work phone# CURRENT MAILING ADDRESS: Ifs dam• 0 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,Qrovided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or . farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and require 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 responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMPTN JLN The Commonwealth of Massachusetts -- - -- Department of Industrial Accidents --- -= �: == office 011nestioatioos T _ 600 Washington Street v G Boston,Mass. 02111 Workers' Co m ensation Insurance Affidavit name: ✓ wlwl.�I S Iomtion 3Z� Gree�� ,r1 cifil �� �t/i/`fie - 6 ZG L phone#�Z'L '2-' ❑ I am a homeowner performing all work myself. ❑ I am a sole rietor and have no one workii in anv ca acity I am an em layer prtrviding workers' compensation for my employees working„on this job. cttw ohane . .. insurance:ca:< - alley# 555, ❑ I am a sole proprietor,general contracto or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: cofn an .name. ........................ ..................................... ...................::>.... ..................... .............. ::<> »::>:>::......;::> : :;:.;:..;:::: ::.:.::.:...:.:.:::::.:::..::::..::::::. ::..:::.:::.:...: :::::.::lion:...::......................................:::.:::::..::.;;.::;;.:;.;..;:.:::.;;:;.;:.:;.;:.:._:....::.::::::: CV :<>.... `: X. c snv>aata ,.:. address. ;.: :::>::.<:>:::::::> one#. ....... ......... nntrancty co< . :::<>;::.:;;:.......;;::: alley# ::.,.:..:.... _ ga& to seem a coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,600.00 and/or one yeah'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification. 1 do hereby certify p ' penalties of perjury that the information provided above is true co ed Signs Date Print name Phone# official use only do not write in this area to be completed by city or town o®dal city or town. permit/license# ❑Banding Department ❑Licensing Board ❑check if immediate response is requited ❑Selectmen's Office ❑Health Department contact person: Phone#; ❑Other Umsed 9195 PJA) Y Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", 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 pe rsons 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. r local licensing agency section 25 also states that every state o g shall withhold the issuance or renewal MGL chapter 152 sects • construct buildings' ess or to g of a license or permit to operate a business in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 r please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits maybe Industrial Accidents for confirmation of insurance coverage. Also b submitted to the Department of e 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 e not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if you being requested, eP are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns 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. The affidavits may be rearmed io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 Inyesdosuoos 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 PERMIT TO MOVE BUILDING APPLICATION#(fapplicable) FEE ASSESSORS MAP& PAGE NO.OF CURRENT LOCATION MAP&LOT NO. WHERE MOVED TO THE TOWN MANAGER OF BARNSTABLE The undersigned respectfully requests written permission to move a building over the.public ways in the Town of Barnstable under the provisions of General Laws(Ter. Ed.),Chapter 85, Section 18. The building (multiple move, see reverse) shall be moved:FROM: TO: ,0$?i+��/// � ROUTE: BUILDING SIZE: Height(loaded) /Y% Length _ Width Weight (See reverse for additional buildings) / DATE OF MOVE: F— TIME OF MOVE: /� TO PM ALTERNAT DATE(S) APPLICAN DATE ADDRESS PHONE OWNER ATE ADD PHON E The department heads listed below do hereby approve the granting of the a ove: j TREE WARDEN DATE S ERINTEND OF P.W. DATE CHIEF OF POLICE DATE C MONWE LTH RIC DATE EW ENGLAND TWHONE DATE B ILDING C MMISSIONER DATt &OLD KINGS HIGH AY(if applicable) DA E C—ABLEVISION IVAJE HIE OF FIRXPIPXIRTME14T 6ATE 1 OWNER OF R D AY(private) DATE LICENSING DIVISION(collect fee) An original certificate of insurance shall be provided to the Town Manager's office regarding workmen's compensation, public liability,automobile liability and any other applicable insurance including subcontractors. The name of the insuring agent will also be supplied upon request. The Town shall determine the specific insurance limits through consultation with the Administrative Services Director. On building moves over 18 feet loaded height where there are additional time requirements for the raising and lowering of wires(utility company assistance)the applicant shall be responsible for notifying a daily newspaper as well as at least two on- Cape radio/TV stations to properly apprise the public of the impending moving activity(i.e date/s of move,hours of move and roads affected). . 'L The Town of Barnstable • utuvsrr BLL 9 MAM g Regulatory Services r: `bp 1639. •`0 Thomas F. Geiler, Director, TED MA'S Building Division Peter F. DiMatteo, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: //" —/D &,_7 �(.�1J -� Estimated Cost` off Address of Work: C/IcAt Z-- Owner's Name: /�'c�G<'���// Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied ©Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTOR OR ALICABLE HOME IMPROVEMENT WORK DO NOT ARBITRATIONc. ACCESS TO ATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name q:forms:A ffida v:re v-070601 FTHE 1ph, Town of Barnstable Office of Community and Economic Development BARNSTABLE, * 367 Main Street,Hyannis,Massachusetts 02601 9 MASS 0� (508)862-4683 Fax(508)862-4725 Qj 039. 1 AlfO f�M't A October 24,2001 Jane Wallis Gumble,Director Department of Housing and Community Development One Congress Street loth Floor Boston,MA 02114 RE: Notice of Town of Barnstable's Accessory Unit Affordable Housing Program Comprehensive Permits Dear Ms. Gumble: In accordance with CMR 760 Section 3 1.10 requiring notification to your office of upcoming possible Chapter 40B Comprehensive Permits,I am notifying you that we are processing the following applications for site approval letters. The applicants are: 1. .Michael and Patricia Dumas,325 Great Marsh Road,Centerville—,anew accessory unit;and 2. Mark and Jolene Bis sett,496 Santuit-Newtown Road,Marton Mills — a single-family accessory unit. These applications are being made under the adopted General Ordinances of the Town of Barnstable,Article LXV- Pre-existing&Unpermitted Dwellings.This program is an attempt to provide safe,desirable and affordable housing throughout the town. Respectfully Submitted, Paulette Theresa-McAuliffe, ` Housing Coordinator cc: Toni Hall,DHCD Gail Nightingale,Hearing Officer Kevin Shea,Office of Community&Economic Development Town Manager's Office Town Attorneys Office Public Health z 1-Building Department Barnstable Housing Authority File:Q/CommDev/DHCDOCT.DOC . 1 45\ Town of Barnstable *Permit#Ro ( 1{ k` ^ Expires 6 montlrsjronr issue date/�1 ��/ V Regulatory Services Fee ems- C K Thomas F..Geiler,Director X-P PERMI T � e�1 S' r�'1C., Building Division Tom Perry,CBO, Building Commissioner AUG 16 2007 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us TOWN OF SARNSTAY�E Office: 508-862-4038 Fax: 508-790-62 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �114167� Not Valid without Red X-Press Imprint 60\1 Map/parcel Number Z 0 COS— Property Address El-Residential Value of Work �a• Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address f"��C"d g � ��� /Z) �� Contractor's Name C� C � 1c�', ephone Number, � "-34(g Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Q'ram the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) / S Re-roof(stripping old shingles) All construction debris will be taken to f f�1� �G� ZfiW j ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e,Historic,Conservation,etc. ***Note: Property Owner must sign Pr erty w r Letter of Permission. A copy of the e Imp ent Con act s License is required. SIGNATURE: Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts k Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 , www.mass.gov/dia Workers" Compensation Insurance_Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual):. Address: / % C)k 7 Z 2— City/State/Zip: ��� / •Phone.#: �� 3 2� - 19 Are you an employer? Check the appropriate boa: -Type of project(required):. 1.❑ I am a employer with 4. I am a general contractor and I . employees(full and/orpart;time). + have hired the su.b-contractors 6. ❑New construction . 2.❑ I am a•sole proprietor or partner- listed on the-attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance. 9. 0 Building addition$ �Xquired.] 5. F] We are a corporation and its lo.❑Electrical repairs or additions 3.L1 I am a homeowner doing all work officers have exercised their 11.[_1 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] , ''Any applicant that checks box#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. 4Contractors that check this box must attached an additional sheet sbowing 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 isihe policy and Job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: lob 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$250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the Office of Investigations of the MA for insurance coverage verification. I do hereby certify under 4thQe airs an pen es of perjury that the information provided above is true and correct: Sienature: Date: Phone#: Official use only. Do not write in this area,'to be completed by city or town official City.or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other • Contact Person: Phone#: aoF 'may Town of Barnstable. Regulatory Services aai.E,$ Thomas F.Geiler,Director �bAT �b1` Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable..ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign. This Section If Using A Builder A& C.��1/ ,as Owner of the subject property- hereby authorize to act on my behalf, in all matters relative to work authorized bythis biu7ding permit application for: , (Address of Job) Signature of er Date Print Name QT0RMS:OwNERPERMIM5I0N GREA T MARS TOWN WAY - 1969� �oA L.O. PB 228. PG 29 37.53 eLOG S 850 12'10-E 256.40' � e •325 ti� �tT � DECK 82.573 S.F. 1 . 89 AC. 10' BLUESTONE — �O 49 ca gs Ile to do AZ 0 ' V C� v • H p8 03 Og 14 Cli THE LOCATION OF THE ORIGINAL BUILDINGS SHOWN HEREON EITHER WAS /N COMPLIANCE WITH THE LOCAL APPLICABLE ZONING BYLAW j IN EFFECT WHEN CONSTRUCTED (WITH'RESPECT 1 TO HOR/ZONAL 0I MENS/ONAL REQUIREMENTS ONLY) OR EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER TITLE VI CHAPTER 40A SECTION 7. 1K wa ; THE DWELL/NGS DEP/CTED ON TH/S PLOT 'PLAN .PLAN WAS LOCATED ON THE GROUND IN BY SURVEY ON SEPT. 26. 2007 AND �!`7�2�©� EXISTS AS SHOWN AS OF THE DATE BARIVSFABLE. MA . OF LOCATION. SCALE: .I -40' SEPT, '27. 2007 THIS PLAN IS FOR PLOT. PLAN EAGLE SURVEYING , INC PURPOSES ONLY AND NOT FOR RECORDING. DEED DESCRIPTIONS 923 Route 8A Yorrmuthport, NA. 02675 OR ESTABLISHING PROPERTY LINES. (508) 382-8132 (508) 432-5333 THIS PLAN /S VOID IF NOT STAMPED AND SIGNED /N RED 0 20 40 80 PROJECT NO. 07-091