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(3rd floor) Map 5— Parcel Permit# _ - �House# / Date Issued - L Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) g Conservation Office(4th floor)(8:30- 9:30/1:00 2:00) -/ P/ Planning Dept. (1st floor/School Admin. Bldg.) INS"02ILLED LIANCE Definitive Plan Approved b Planning Board - 19 wI ENVIRON a E AND 3 TOWN OF BARNSTABLE TOWN orals Building Permit Application Project Street Address Village'^71 �C/TL7C -t Owner /�/G.'��fQ . /�O/JOG�fS65 Address 16'0.61 ZA-1 y�6Zw Telephone .SD, 71 0 ' Permit Request 44--A46,ce 5X/6 ✓/.yU, tilhK7,71Z J662WAAl }�v� First Floor v2ly 0 square feet Second Floor square feet Construction Type Estimated Project Cost $ leg,Dd o Zoning District Flood Plain C Water Protection Lot Size r 8 0 Grandfathered ❑Yes ❑No Dwelling Type: Single Family Ur"' Two Family ❑ Multi-Family(#units) Age of Existing Structure J o /k et4 Historic House ❑Yes QoKo� On Old King's Highway ❑Yes Ck o Basement Type: ❑Full [16rawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing 3! 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 J� 1 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ,'Attached(size) 22 L Ir" ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name IST6 0A-1 1677- Telephone Number I Address U • 13-0X -V,0,JZ/ License# 0 6-0 40�t5-7 �D✓ZJY T, til 02,4e 3 3 Home Improvement Contractor# /U 9�i o (R Worker's Compensation# (it/G /22.7 NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �2- 4: Ehv SIGNATURE DATE BUILDING ERMIT DEN T?. 4 1 OWING REASON(S) - FOR OFFICIAL USE ONLY < is - - .' , - _ �• , • PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE ; 1' OWNER DATE OF INSPECTION: - + - :' = `• FOUNDATION FRAME INSULATION +�' _ q B FIREPLACE + t ELECTRICAL: ROUGH ' ` 7 FINAL , PLUMBING: ROU H t FINAL "t ; GAS: ` ROUH FINAL _ r + f + FINAL BUILDING* E 1 DATE CLOSED OUT--- ASSOCIATION PL'A-1 N&.l + . a way. —11 VIA - ;r r ' �' f ; i.•:,! a �I Inc, f:,. ;¢ �� i C, to ; 1 .1, i 1 l �. �� .' x ( ��i � rsx �+d'.i 8�'y uv.AG�, f�, hwa � R.a. S.u: ^• `4g*.:y�'�as �M�� vex f Barns table The Towla ® . CES •• •� I g� Department of Health Safely and Environmental Seri' � e� Building Division 367 Main Shtcs,Hymmis MA 02601 Rziph Office: 508-7,90-6227 Buiidiaz C. Fax: 508-7 90-6Z 0 For office use oniv Permit no. Date AFFIDAVIT HOME MOROVEII'iENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION �, sir, ma erni==4 MCL c. 142A requires that the reconstruction, alterations, renovation, Maion to any pre-esistir.= conversion, improvement, removal+ demolition,est one bnconstruction rt otmoref an than four dweiIing units or tt owner occupied building containing contractors, wii:: structures which ire adjacent to such residence or building be done by registered certain exceptions.along with other requirements 67414,1-AA& EX<d'T/A.1.4- A"T&z j Type of Worst- ZabAVOK4 '34rH Est. Cost Address of Worst: /Lf lGt��t`G.rL /�C9�OG✓f/CG� Owner's Name / Date of Permit Appitc ation- I hereby certify that: Re"istrrtion is not required for the following rr-=on(s): Work excluded by law _Job under 51,000. Building not owner-occupied Owner puffing own permit Notice is hereby given that: OWNERS PULLING 'IZiEIR OWN PERMIT OR DEALING WITH UNREGISZEA-D CONTRACTORS FOR ,,pPLICAB� HOM GRAM OR G�zJR�FUND UNDER MGZ.O I4Z.� � = WORK Do ACCESS TO THE:ARBITRATION PR SIGNED UNDER PENALTIES OF PEFIJURY I hereby apply fora permit as the agent of the Owner. �c Co �/�/� P06,�ewlatrac Regis= ion *ia- Dare Thc• Cuntnron wealth of Massac h usetts DepartmeW of luchutrial Accidents l t OI/iceo//nyestlgal/ons 690 11 a. Litz-fors Street ,44` Boston. A1a.,vs. 02111 Workers' Compensation Insurance Affidavit �pplirint ititorniatian• - Please PRINT name �G �df72C per! locition• city. nhonc 1 am a homeowner performing all work myself. [1 I am a sole proprietor and have no one working in any capacity — �v_.�............_.,-..inn.•+.-��1nc s•.'+r.w^'llr! .:../•r' .w�...w+. ... ..aw��.. ww..�•�....Y'�...... nw..+r..•w. ..ww.._-....-_....... I am an employer providing workers' compensation for my employees working on this job. cnnm•tnv n•imc• address cite �r9J/L�i �� UZCI JJ �thnne#• insur-ince cn ` C ynoiicv# Ale 27 -7-!' [I I am a sole proprietor. general contractor, or homeow�nery(cricle one) and have hired the contractors listed below who have the following workers compensation polices: comn:=m• n-itne: address: city ,nhonc#- in,mrnnce cn Holier # •i.._ Vim•-^ '^T.�Y..•;....,.. _� _ _fir...—.�::��t��T"f!�ww:y.�r, •—:TT�• ....ti .�....-..._ compiny nntne: - address: rin nhonc#• insur•tnce co noiic�•# Attach additional sheet if necessary' ::Y '=;��..,�:. xa:� ._- =----- :�'� =.=.r."_ '�y.e:.�==ie.•r+:=:�-.,x. Failure to secure covernac as required under Section ZSA of AIGL 152 can Iead to the imposition of criminal penalties of a tine up to s1.500.00 andiur one cars' imprisonment as well as cis it pcnattics in the form of a STOP NVORK ORDER and a fine of 5100.00 a da}•against me. 1 understand that a COP) of this statement ma% be forwarded to the 011ice of Ini•estigations of the DIA for coverage%,crifrcation. I do hereht•cerrifi r rlr the writs rd pe aloes of perjun•that the information provided above is true and correct. Si^_nature /'�/':� Date Print name / Phone# '7 4- 7 �� '' offici. _s• t not ss•rite in this area to be cum Ieted b�•cin•or town official r" ni use unl dt P ' cin•.or to»n: permit/license# rIBuilding Department L Licensing Board t check if immediate response is required C3Seiectmen's Mee F �.' C31lc21th Department contact person: phone#: r,Utlter E4 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employees. As quoted from the "law" an emploree is defined as every person in the service of another under an• contract of hire, express or implied. oral or written. An eniplorer is defined as an individual. partnership, association. corporation or other legal entity, or any t%V0 or mor the fore�goin�g emga�ged 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 tll� 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 ho: or oil the `_rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe: MGL chapter 152 section 25 also states that every state or local licensing agency sliall withhold the issuance or rencival of a license or permit to operate a business or to construct buildints in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the in 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 h been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit compietely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 7'lte 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 requires to obtain a workers' compensation police. please call the Department at the number listed below. . City or •towns Please be sore that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o: the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple: be sure to fill in the permit/iicense number which will be used as a reference number. The affidavits may be returned ; the Department by mail or FAX unless other arrangements have been made. The Office of Investi=ations would like to thank you in advance for you cooperation and should you have any question please do not hesitate to give us a call. �...y.., �. _ ...__.�...:.... ...--......q...-�... -.»ter.... ..-....�.-rrwww��aa-w+�wry ....: w�.+..w.. /.'7r"^r^'w-.�•ws+���... 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 fax #: (617) 727-7749 phone 4: (6I7) 727-4900 ext. 406, 409 or 375 r -- —___—_— �_--- 51jE.� r--- -- ------ -- I k I tJt�a! or� � � OEA HL ca acuv.�� I �."/1��." _'� 1 1- I I'x.I-I I I 1'��__•nab �'WI&,5 4r 1 I MAT =,c� exls IIJy i I � , - — \ --—LAF- - - tifit � Cl _ sxl t t 1 t-�� 1 _ —NATcN At•l,��M�xFFQ ,. 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MAr1 1� - I v�l -rlerJ od7Dl IcrJ \ � � t21�H �It7E EI,EVD� 10�1 '� �j d>sl atpr�•I,T s���s --� �LDD�_�L.�.I�) E p,F�,WgA �U t r Mau+To ExISr) �" ,, H aHilla �kid F�GEss �eE Wldw� HdLLE;Az4-Add W Lt1�JLp C-abldt1 TV M>" e.xl'I"".'1 I I '--'- �"__ L•_� -___. .,.L_ T '..;L.: ,. �t-._ _ ._.._.__._- .___...._._._.__ .—1JH11L c:P�•'C 9M��LEar .u�a:t/. .�r� ...potm7w�:y �j a...ww - — - - - - c^11o,�FH�1�1 EXp. s+y"� I I "I`-•f� i�ME-�I 7,1 • � 1 I_ p 1 r • SHto 1. 30. 9 . i r l93 � � I L. o T z l PARCEL IS LOCATED IN FLOOD ZONE C TO THE BEST OF MY INFORMATION, KNOWLEDGE, * AND BELIEF THE AS BUILT " PLOT PLAN _ ,nnas S. , SHOWN ON THIS �y�..,, 5 T��c l PLAN HAS BEEN LOCATED ON THE Z a t 2 Z L r C' /S-� g y I� GROUND AS INDICAT�,ax^ANQ DOES __- -- �o IaI�T 1: z_/ g 5Cl1L E..._ 3 0- . . C?NAM TO THE ZON11V�- )9-� ...� LIMITS. ... .. - J013 06)5 CLIENT_ ,� � ,s,r. Y s- /r0/f//V IV II/MCO� + . r NR01-I:SSIONAL LAND SURVEYOR Z( 203 SETUCKET ROAD >�1 c r'R01:1_ i: lJti.'111z;;L�a °l) ��..ii�'i:11:12 1,'�5 C�IIA SOUTH DENNIS, Ml1SS. o�sc�