HomeMy WebLinkAbout0086 HELMSMAN DRIVE .��= �� ►M sr�aan fir,
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Ill ME r Town of Barnstable *Permit#
�.O Expires 6 m,o'tJis ro issue
Regulatory Services Fee (ICJ
BARNSrABLE, : Thomas F.Geller,Director
A ' Building Division WOO
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 y Fax: 508-790-6230,
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press imprint
Map/parcel Number
Property Address 6 e) I
21 esidential Value of Works b® Minimum fee of$25.00 for work under$6000.00
—�
Owner's Name&Address prinalij �e1 I j
�� �e(vas S rr►a� cl�
Contractor's Name are'Free- t ',0yj.eS Telephone Number C20�7�TD5 /
Home Improvement Contractor License#(if applicable) 10yS43
[�orkman's Compensation Insurance )(..PRESS !T
Check one:
❑ I am a sole proprietor MAR 2 8 2008
❑ I am the Homeowner
5dj have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name 'S I Gad" J-W)5 u ra11Ce
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows/doors/sliders.U-Value "ti• r 5 (maximum.35)
*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 Lit609 is re.quir..ed.
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
M'JIFAN-28-2004 10:OOA FROM: TO:15087906230 P.1/1
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYTI)
09/18/2007
PRODUCER (508) 679-6418 THIS. CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Frank X. Perron Insurance Agency, Inc.. ONLY AND CONFERS. NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1311 Bedford Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. 0. Box 4158
Fall River MA 02723-0402 INSURERS AFFORDING COVERAGE NAIC III
INSURED INSURER A: National Grange Mutual
CARE FREE HCMES INC -INSURER R Star Insurance
239 HUTTLESTON AVE INSURER
INSURER D1
FAIRHAVEN MA 02719— INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AOIFL POLICY EFFECTIVE POLICY EXPIRATION
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MWDD DATE MWDDIYY LIMITS
A GENERAL LIABILITY. M80779830 09/01/2007 09/01/2008 EACH OCCURRENCE f 1,000,000
X COMMERCIALGENERALLIABILITY DAMAGE TO RENTED rr0,000
PREMISES Ee occurrence S
CLAIMS MADE a OCCUR I / / / MEO EXP(Any are on $ 5,000
PERSONALBADVINJURY $ 1,000,000
GENERAL AGGREGATE f 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMPIOPAGG S 2,000,000
X POLICY JEeT LOC
AUTOMOBILE LIABILITY / COMBINED SINGLE LIMB
ANY AUTO (Ea ecddenQ f
ALL OWNED AUTOS / / I I BODILY INJURY f
SCHEDULED AUTOS (Par person)
HIRED AUTOS / / BODILY INJURY
NON-OWNED AUTOS
(Peracdderd) f
PROPERTY DAMAGE
(Per acddenl) f
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT f
ANY AUTO / / / / OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESSIUMBRELLA LIABILITY / EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE / ' I I / $
RETENTION f f
B WORKERS COMPENSATION AND WC0378035 09/01/2007 09/01/2008 TORYIAMITS X DER
EMPLOYERS'UABILIT/
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L,EACH ACCIDENT f 1,000,000
OFFTCERIMEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE S 1,000,000
If yes.describe Under - -
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT f 1,000,000
OTHER /
DESCRIPTION OF OPERATIONSILOCATIONSfVEMCLENEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Officers Included for Workos Compensation
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES,BE CANCELLED BEFORE THE
.S L90
EXPIRATION DATE THEREOF, THE ISSUING,INSURER WILL ENDEAVOR TO MAIL
10 , DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Town of Barnstable FAILURE TO 00 80 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Building Department INSURER,ITS AGENTS OR REPRESENTATIVES.
367 Main .Street AUTHORUEDREPRESENTA71VE
Barnstable MA 02601-
ACORD 25(2001108) a ACORD CORPORATION 1988
�,w INS025(0108).05 ELECTRONIC LASER FORMS,INC.=(000)327.0543 Page I of 2
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021I1
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C 0,lr- C
Address: r ��� y1'H eSi---6 P1 AV
City/State/Zip: Fa t r-h v�� .�Q• O Z 7 t5r Phone.#: J� 59 7
Are you an employer? Check the appropriate bog: Type of project(required):
4. I am a general contractor and I
1.El I am a employer with � 6. ❑New construction
. employees(full and/or part-time).* have hired the sub-contractors
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. El Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp.-insurance comp•insurance.
t
required.] 5. We are a corporation and its 10.0-Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their ME]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.
YContmactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entitics have
employees. If the subcontractors 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 ite
information.
Insurance Company Name: ter lit 5 v�� ✓� C' —
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
Investizations of the DIA for insurance coverage verification.
I do hereby certify der the pains•an en " s of perjury that the information provided above is true and correct:
Si Date:ature: —
Phone#• 5Q el'9 7
Offu ial use only. Do not write in this area,to be completed by city or town officfaL
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 .a
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees:
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone numbers)along with their certificates)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 permiVlicense 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 applicuit 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
(Le.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
TO. #617-727-4900 ext 4.06 or 1-877-MASSAFE
Fax#617-727-7749
Revised 11-22-06
www.mass..gov/dia
registration valid for individul use only
date. If found return to
_ — --�_Q-
- Gff �janan� ` License or Tegiration
Re ulat�ons and Standards ` before the exp Re ulations and Standards
Board of Building g CONTRACTOR tl
HOME IMPROVEMENT CONTRA Board of Building g
,q one)shburton Place Rm;]301
Registration 1�00503
Boston;Nla.02]08
EXp�ration 611912008lug '
s Supplement Card
Type f-.
BARE FREE HOMES !NC`
/' �,,� out signa re
with
ROBERT PICKUP Notvabd, v=
239 Huttleston ave istrator
'° rt
Fairhaven,
Admin
MA 02719 -
1 i
OFFICE: (508)997-1.111 °® MA. Builder's Lic. #021330
FAX: (508) 997-1297 flCWARE FREE Home Improvement
TOLL FREE: 1-800-407-1111 �S Inc.. Contractor's License
WEBSITE: #100503 MA.
www.carefreehomescompany.com 239 HUTTLESTON AVE. (RT 6)•FAIRHAVEN, MA 02719 #15179 R.I.
NAME DATE 0
:ADDRESS ZIP CODE &,�_3-�
ADDRESS OF JOB TEL L 3 7_ ` 0:5'.��
JOB DESCRIPTION
10,
,.
AW
w
D
Scheduled Starter t�l o Scheduled Completion
A. Replacement of missing or rotted lumber is not included unless specified.
B.Ali start&completion dates are approximate and could change due to weather conditions.
C. Stripping of roof includes removal of up to two (2) layers of shingles,e ch additional layer to be charged @ _ C ft2.
D. Replacement of rotted roof boards/plywood to be charged @ ft2.
E. Existing chimney(lashings will be reused; replacement, if necessary, is not included.
F. Care Free Homes, Inc. is not responsible for mold/mildew conditions.that are pre-existing or result from leaks not brought to the
attention of C.F.H., Inc. promptly.
The Company hereby proposes to furnish labor and material to complete the above work for the amount herein. Fulfillment of this
order is contingent, however, upon the,want of strikes, fires and any natural disasters, the ability to obtain materials, or any other
conditions beyond the control of the Company.
Cost of Project$ c-2 L PAYMENT TERM
'77-
Date
1. You,the Owner,may cancel this transaction at anytime prior to midnight of the third business day after the date of this transaction.
2. You,the Owners,agree to pay any and all expenses incurred by Care Free Homes,Inc.in collecting money due under this contract
and enforcing the terms of this contract, including but not limited to, reasonable attorney's fees, interest and court costs.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACE
CAR F EE H /INC. CEP
By: G Buyer acknowledges Owner
CARE F E HOMES,INC. receipt of fully completed
copy of this Agreement Owner
All contractors and subcontractors shall be registered by the director and any inquiries about a contractor or subcontractor relating
to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place, Room 1301
Boston, MA 02108 f
Tel. (617) 727-8598
q Aeftlifown of Barnstable *Permit#�00(0(20
IrIAY 0 8 �406 Expires ont from issue date
roVVN or BA U Regulatory Services Fee.
RN8]-ABLE Thomas F.Geiler,Director
Building Division
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
j Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
4ap/parcel Number `
roperty Address �r�a 2)- • &6::�V166E 14'14.
t[
Residential Value of Work n ®®® Minimum fee of$25.00 for work under$6000.00
wner's Name&Address DION ®W/1(1
S6 �47_-Ml�I 4,4e, &5A-17 G
ontractor's Name_ 4� t?le ?C�P�5L Ma/117 3 //y6 ; Telephone Number
ome Improvement Contractor License#(if applicable) 1040,5�02
onstruction Supervisor's License#(if applicable)
Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
Mdam the Homeowner
eI'have Worker's Compensation Insurance
nsurance Company Name 14 ,t , CT r
orkman's Comp.Policy#
opy of Insurance Compliance Certificate must be on file.
ermit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
®/Re-side
1 Replacement Windows. U-Value ' "/® (maximum.44)
'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
ome Improveme License is required.
IGNATURE:
Torms:expmtrg
evise071405
. r
Town of Barnstable
Regulatory Services
II• _ 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
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf
in all matters rela ' to work authorized by this building permit application for:
(Address of Job)
-7-��
Signa f Owner Date
Print Name
Q:FORMS:0VWNWERMIM SIGN
r�
I Board of Building Re �
gulations and Standards
j HOME IN��OVEMENT CONT License or registration valid for individul use only
I `� RACTOR before the expiration date.
Regtstre'tion 100503
Board of Buildin g If found return to:
°1 '1912006 g Regulations and Standards
- , One Ashburton place lk: 1301
'� �ppement B
�f CARE FREE `w,? �� iI Card oston,Ma.02108
H01�1EF.j�C` �")
JESSE MOTTA
i 239 Huttleston ave``: >',by
I Fairhaven, MA 02719
r —
,k
Ia
�IHE r Town of Barnstable *Permit
Expires 6 months from issue date
BMWSTABM •
Regulatory Services Fee 41Z 100
"IAA Thomas F.Geiler,Director
i639 ♦0
�EDN1°'`A Building Division _
PERMI
Tom Perry, Building Commissioner �����
200 Main Street, Hyannis,MA 02601 J U L 1 0 2004
Office: 508-862-4038
Fax: 508-790-6230 TOWN OF BARNSTABLE
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address
Residential Value of Work V � Minimum fee of$2 00 for work under$6000.00
Owner's Name&Address v` �/L.� ? ON--AL_ CP3S!LG—
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate'must be on file.
Permit Request(check box)
C- e-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. 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: Pr a �O r sign Property Owner Letter of Permission.
ro a ent ontractors License is required.
i
Signature
Q:Forms:expmtrg
Revise063004
_ The Commonwealth of Massachusetts
Department of Industrial Accidents'
600 Washington Street
1� Boston,Mass. 02111 .
" workers', Com ensation.Insurance Affidavit-General Businesses
TFMrr-aF4`
:d:res
�
State.: a
work site location fall address):
am•a sole proprietor and have no one Blisiness Type: [IRetail ElRestaurantBai/EatingEstablishment
working in any capacity. ❑Office[] Wes(mcludmg.Real Estate,Autos etc.)'
❑I am an em toyer with em to es(full& art time'. ❑Other
I am an employer providing workers' compensation for my employees working on this tob.
` �t :.iJ F,,,::3:f•; ., '!,• �•d•'Te .5::'::• tt:f'•♦ t.'� _ i:• '�,'
'Ji �: `(. •'i' ..,.. t a''j• K� .S.' �ti�. ai.y i•1. :ii :,.'.,+' -,
coin"ari'•>inine: _ - r r
•d`�TeSS:' - �� >::_ .:�•fJ.:: :.�. .,'y`q�: ..a:• r..�.. .:4..c;"'•:1:••. xn. ,t`^i%.'.:::
71,
X.
:.
r=177117�
am a sole proprietor and have hired the independent contractors listed below who have the following workers'
compensation polices:
i•.y' :.1: ,A -i ••f:• ..1,i'•'•_ ...Y:iY••r,,,i.:iJL.v• �'!:`:.t:.,ti•�
V.
rF' .k':p •y`,•� :-'sjil0.�,C., 'ii• •2:,i' ,i,.t' ::
ei` 71
t <
•'r',•~ NCO. •:i%„,Fr rv-. .e• w�4t •U•l1C :#�. '.ita::�•:.:.'Y•. :�t:•.• t9.:i.'':. ,...
insurance '
•,:, .::/.1..` •Tyw• f,'V •Y9,':.).�Y', •::�.Jt;:y:'. ,Via vl!d
4. r'^t:J•:�•'.
:•Si:t ..f:: '.0 J•'r'. '` �•.S :t,• .Y?'.'•' t. •Yi:+' ;,:,:_ •„ar.•r ,�+,
Rorie f#`c
..x,. <+.i+
fasursuce�sb:•�'
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or
one years'imprisonment es well as civa penalties in a Ym of a STOP WORK ORDER and a fine of$100.00 it day against me. I understand that sL
copy of this statement maybe fo• to the O, ce f vestigations of the DU for coverage verification.
I do hereby-ce n e nd pen ti perjury that the information provided above is true a d rre
Date f 0
Signature - . . . ,• .
r.7 A y, 'l L Lv Phone# �� L
Print mime
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
_ ❑Licensing Board
❑-check if immediate response is required ❑Selectmen's Office
❑Realth Department
r
contact person: phone#; ❑Other
(revised Sept 70(3)
Information Instructions.
' nand Instru iao ns
.
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 defied as an individual,partnership, association, corporation or other legal entity, or any two or mgre of
the foregoing engaged in ajoint enfeiprise, 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.occupantpf 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 section 25 also'states thateve.ry 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,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 in fhe workers'compensation affidavit completely,by checking the box that applies to your situation..Please
supply company name, address and phone numbers along with a certificate of insurance 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. The affidavit should be returned to the city or town that the application for the permit or license is being
epartment of Industrial Accidents. Should you have any questions regarding�the"law"or if you are
requested, not the D
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
mbeF which will be used as a reference number. The.affidavits may.be'.returned to
be sure to fill.in the perrnit/hcens.e nu
the.Npartment by mail or FAX.uriless other'arrangenients have been made.
The Office of Investigations would hike 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
fiance of lairesflpugns
600 Washington Street
Boston,Ma. 02111
fag M. (617)727-7749
phone#: (61.7) 727-4900 ext:406
f
Town of Barnstable
o�sHE rojy�
Regulatory Services
�� $ Thomas F,Geiler,Director
Building Division
pTE° � Tom Perry, Building Commissioner
200 Main Street, gyannis,MA 02601 .
www.town:barnstable.ma.us
Fax: 508-790-6230
Office: 508-862-4038
Pro e Owner us
C1ornplete and-Sign This Section
If Using A Builder
as Owner of the subject property
to act on my behalf)*
hereby authorize
in all matters relative to work authorized bythis building permit application for:
(Address of Job)
Signature of Owner Date
print Name
r
..
, .`
i / CI
3��� � � 3 �� 'T ��,�
T
Assessor's mcip,,pnd lot number ..... .................. THE
Sewa,ge Permit number .......... ..... ..(.2- V
EARNSTAXE,
House number. ............X...... .......................... 90 MASL
1639'A,
TOWN OF BAR' NSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...... ............. .............................................
TYPE OF CONSTRUCTION ............. .....................................................................
......... ......................................19.1
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
... ............ ................................
Location . -V ......4.1.......... ..4
7...
Proposed Use ......... ..................................................................................................
.......... 7.. .....
............ ........52�
Zoning District ..... ........Fire District
Name of Owner ... ......444-le,...I........ ...Address ........ ......I.......................
Name of Builder--C4A.". -....,X-;1. ......Address .. ....../ .. .............................
Nameof Architect. ......Address ....................................................................................
............................... ✓Foundation .... .....Number of Rooms .........
%�.............Roofing ........ lq,:�i::�,41.....
Exterior ....
Floors ................. .........:............................Interior .................
Heating .... .....6-4x�. .........................Plumbing .... ....... ......... ... . ...................................
Fireplace ....................<0
.....................................................Approximate Cost ............7 ... ..................................
Definitive Plan Approved by Planning Board 19 21 Area ),P/ .......W
-----�11L-----------
Diagram of Lot and Building with Dimensions Fee .............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
C>(
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .... .......... ........ .........
Construction Supervisor's License ...... ..........
SMITH, JAMES K. A=193-236
'
No .~~~^ Permit~ . for ^~=^ S.^.^y `
Single Family Dwelling
. —.----------------'—.
`
Location ... .�....... ..
` ~^^~~~~~ D^ ��—.
,
Centerville------------------ ---''
Owner ---Ju�ea_��_S�i�b.. ...............
.
�
'
Type of Construction --Fr--me— ..... ' ................
~
'
-----------------'---------
'
' Plot --------- Lot ................................ `
`
^ '
~
`
Permit Granted ........MarcJI..5,.............. g 86
Date of Inspection ------------lA
�~^l"".= Completed ------------'lg ,
'~—
�^ \ `
' )
. .
-
+
1 /
}
! ~
/
o TOWN OF BARNSTABLE Permit No. ----------289y7-------_-
Building Inspector
saurem� = Cash -----------------__-- --
rra
OCCUPANCY PERMIT Bond I f
F ,
Issued to James K. Smith Address
lot #7 b6 Helmsman Drive, Centerville r
K Wiring Inspector®.�_ Inspection date
Plumbing Inspector Inspection date
Gas Inspector Inspection date
Engineering Department Inspectio_n date
' Board of Health Inspection date
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE. '
..�........................................ ...........................,............,.. ................ ......................_.... ....�._
J� Building Inspector
6 Y �
f j
��..� °•.ew TOWN OF BARNSTABLE
BUILDING DEPARTMENT
= rsaiaTAK TOWN OFFICE BUILDING
,r�ua
'639• HYANNIS, MASS. 02601
MEMO TO: Town Clerk
FROM: Building Department,�1��
DATE: /7
An Occupancy Permit has been issued for the building authorized by
BuildingPermit #......:?.�r...... ........................................................................................................................._.....................».......
issued to �-/........../?�. .... ci'��•�%
Please release the performance bond.
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR-
QUALITY ORIGINAL (S)
m A-
x 41-I.-IL
DATA
L.
,
` TOWN OF BARNSTABLE, MASSACHUSETTS
JOB WEA.TNER CARD
DATE 19 PERMIT NO. .- are
J<:�=i..•_- vi.t.�.'?.APPLICANT ADDRESS
IN0.) (STREET) (CONTR'S LICENSE5)r
NUMBER OF .
PERMIT TO (_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
._•:4L .r:y i.i� .: i2.f.>. p _ _.L': e .....!sr••.�'1 j .L.t'_ ZONING
AT (LOCATION) DISTRICT
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT, LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS:
i vif'.' �:. tf.• Cis; �r `)
AREA OR .. PERMIT � -
VOLUME ESTIMATED COST $ FEE
(CUBIC/SQUARE FEET)
OWNER —
_ ,.,....,,...,... tee., BUILDING DEPT.
ADDRESS BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR
® PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE .REQUIRED FOR
' ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND
1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
MEMBERS(READY TO LATH). FINAL INSPECTION HAS BEEN MADE,
3. FINAL INSPECTION BEFORE
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
l C.it?L' �� �✓v'v`�.
2 2 2
hu
{ C
3 HEAT,NG 'NSPECTiNG APPROVALS REFRIGERATION INSPECTION APPROVALS _
I II EEE G
I /
BOARD OF HEALTH
NCGK S-AL_ NCT O_EED i1NT L THE, R PERMIT w!LL BECOME NULL AND VOID IF CONSTRUCTION iNSFECTiONS iNDICATED ON THIS CARD
N`--EST SAS aPoRC'ED TyE WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CAN BE ^R-ANGED 'FOR B`' TELE"—NE
AGES „ '-oN`'�L'"T'�N. PERMLT IS ISSUED AS NOTED ABOVE. OR WRITTEN NOTIFICATION.
i.
DE c SIGN DA\T/-� •t, MI
5I NG-LE FAM t LY -- 3 f3ED12.c�o I`1 •
• � zs. '
No �AtZ SAG-E GI21�J DCtZ l z s\
DAILY FLovJ = Ito x 3 = 330 G.P. D. 75'�
56PT1 C. Tip Q K. 3 3 o x I So o • 44 9 , G.P. D• D \
USE 1 000 CAL. TAK 1Y-
(AS{0
DISPOSAL_ PIT' vsE W lono Cal...
s1 DC -L A 2EA LoT
S
�So s, r 3 7.t-) Cr. P. C)
Lo f- G
ToT'A L OESI&Q = 4ZT G. P, 0, sit �3 4
7-TAL UAILy Flow/
c t�
T O IV ( 1111 Z M i� .O IZ L,S�J 1 ' 48.3 0
i
JJ ` APJER M.
LOTI_
I
111c. 29733 4s r� Tl 1
T'E S-r N o l E 'd 394
12- 3 -cC,3
&ZL-:i/ 57�� Fes. - GZ•��� ��. � G��,�" •�;� Ta��7s�o: 63,E
/000
loon BoX /.v✓.
• P.7- a 7 :7me.
.• 3�4�7c IX: '� 56.2 SG G',E.2T/F/EO PG DT p1-:4,V
W�4sNCD ..
.t sroNE . :.a •.:;.
�� G•�I f r �'+-..�, ....._..,�� L.oG.�T/o.Y C
PKO F+ L -
NO SCALE
Tf/. 7-T.yE,4,- '/4'->4,r/I J SH4WiV. ?454. 3 2
q /�G
/JNO SETl/�GY ,e�4lJl�E'NI�NrS o� 7/y� €NYE /•uc.
TDWiV dF i2E6/ST�'PCI.G4N0.S!/.e j/�ryp,P,S
,l3i��tJST�t�LL .QN� /S it/OT G�S�.eY/LLc •a �yl,�.�
GDC.�T�.O W/ryiy �-.�r,E• .cLaooPt�Q�iV,
�4.�.G/caster- <
Cc
Ta ES��3G/.sy Lor..G/iYFS
Assessor's map and lot number .......,(..q..............................
`N "` 7
0THE0�
Sewage Permit number
..... 40 INSTALLED IN COMP �I
A�U
House number ..........�.. .�:... :.' L..........:.............. %�� BTGi TITLE 5 ,os �9
TOW.Nt OF BARj1vq STABLE
• F ,
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...... .. ..... 46:... . ............,....:... . .............................................
TYPEOF CONSTRUCTION ............. ....... ... .. .... ...................................................................
........ .......�...........................19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies fo. a permit according to the following information:
Location �6........1.......... .. ...... ... ..4•c -....�:.....
Proposed Use .... . . ...... .... ................................... .......................................... ........................
... ... .. . .....
Zoning District ................. .. ..... .... . . .........................Fire District
Name of Owner .... .... . . . . .... ....... .. .. . . . . .........Address ........ .: . . .... ....�.......................
Name of Build e !�YK-rG�... ....... .. .. . .. ..:..Address ........ �1 ... .........................
Nameof Archit ..................................................................Address ....................................................................................
Number of Rooms .............. Foundation ......
Exierior ........�4d,.
` ...�.. r.. :....,......Roofing ........ 4-
Floors .. ....
�L ............Interior
4
Heating....... G.... ......................Plumbing ...........
(/ ..............a.......
Fireplace .....................��-,- .........................................Approximate Cost ...........�� ....4 /....................................
Definitive Plan Approved by Planning Board -------
t-_16--------------- b_ Area � 1U.. :... ... ....
s
Diagram of Lot and Building with Dimensions Feed°
SUBJECT TO APPROVAL OF BOARD OF HEALTH
IVC2
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ... .........
Construction Supervisor's License
7,.SM?.Ttil JAMES K.
No ... Permit for Allje...StRNY..............
. .......... .....................
Location ....L Q.t...11.7.......a.6jjelRi§mAR.D.r.i.ve...
................... .....................................
Owner ........jajUpgq...K,...5mith
....................................
f Type o Construction ....Framp..........
Ilk ..................
........... ................................................ ...................
Plot ............................. Lot ................................
Yr
Pern-Cit Granted ........March...5, 19 86
Date of Inspection .......19
Date Completed Z44t ..........I