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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3 2-. Parcel_ 037 Application #Z0 5 �
Health Division Date Issued 1S
Conservation Division Application Fee 56,
0-6
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
*Project Street Address
Village v rr1/ 2- K 3 Z
Owner c ev,' Address �� W
-Telephone
,Permit-Request - vo a✓e L4Zcc- 1_0 arc�,� c,
Square feet: 1st floor: existing L.i proposed 2nd floor: existing �roposed �G Total 1
Zoning District FJ000d Plain Groundwater Overlay
I_%ec �_� --_ +y
.Project Valuationsjaasot 2aConstruction Type
Lot Size_ Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 0 Two Family ❑ Multi-Family (.# units)
7Age of Existing Structure Historic House: ❑Yes U40 On Old King's Highway: ❑Yes Wq-o
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sgfit)
Number of Baths: Full: existing new Half: existing Q�; new
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing new First Floor Roo Count,
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other k_n
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ 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 ❑
Commercial ❑Yes LM/0 If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name e&� Pjc-� � C�1�� '"Telephone Number ��� Z
AddressK 17/o I O License#
' l H �Z �J _ Home Improvement Contractor# NZ14
Email <gc k ev,` q,1 Co," Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESU TING FR THIS PROJJECT ILL BE TAKEN TO
r M v► ��-'/ i c c�f�e n/ Ate' ou
SIGNATURE DATE ��
e
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
' Town of Barnstable
E
Regulatory Services
oFTUE rOiyy Richard V.ScaIi,Director .
° Building Division
t RnRn�rARi.F. Tom Perry,Building Commissioner '
ZMAIM
200 Main Street, Hyannis,MA 02601
prED t` www town barnstable.ma_us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
r YleasePrint
DATE: 2Z1 C
(( f
JOB I:oCATIor> c ► �. a/1TP�' ✓ 1/P Z 2—
number
stieeE } village
MIdEOWNER": '0 Le- �r'` Sc. ;n ce llJ 32 - OeS" Z C6e(� 14,-e
namc ` home phone# work phone#
CUERENT-MAILEI id ADDRESS: •� !per / a� G�r�� y?
ciiy/tnvm state ap codc
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel.of land on which he/she resides or intends to reside,on which there is,or is intended to be,.a one or two-
family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"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)
4
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
The unde d eo s at he/she understands.the Town of Barnstable Building Department minimum inspection
proc d r e is h she will comply with said procedures and requirements.
o£Homcowner
Approval of Building Official s -
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: ti t
HOMEOwNER'S EXEMPTION
The Code states that: ""y 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;RuIes&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 Iast page
of this issue is a form currently used by several towns. You may care t amend and adopt such a formlcertification for use in
your community.
Q:\wPFn2SW0RMS\bmldmg permit forms=RESS.doc
Revised 061313
Town of Barnstable
Regulatory Services
* anxxsTnsr.s,
HAM $ Richard V.Scab,Director
1639.
ATfo �� 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
I, Rcl 0-r4— t t/` (;06 2eo I c as Owner of the subject
l property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for
r
(Ad ss of Job)
"Pool fences and alarms are the responsibility of the applicant. Pools
are no to �art
ille utilized before fence is talled and f'
e o � e o ed and accepted.
P P
ignatvre of r Signature of Applicant
Print Name Print Name
Z�<5
Date
QF0RMS:0WNEUERMISSI02e00LS
27ze CommornreaItii gfMaFssad inset s
_ �D'egartrne�zt o,f�r�rdrustrial�lcc�r�eFats ,
f} -cc af 1- m.ws igadaxu
{r 600 Washington Street
-- Boston, 02HI ,
-- iviviv.s narsmgrrnIdia
117'arbers' Compensafian Insurance AffttlaviL-BmtderslConti actar--JEIec{ricians/Phunbers
ApipHcant Informatian Please Frinf�e
Iarlle3a'ssazerganizatianFlonal �e-/. , ' e un
L-6 3 2
gfyFf�faf tel�ig: C� �f'Y/r/ Ile-
Are
you an employer?Checkthe app rap " to box: ' T of project r
�---��- Type F ] ( �e�'-
l_❑ I am a era to er uitb. CL❑I`ajn a general contractor and I
P Y - �' 6_ ❑New construction ,
employees(RT-11 andlor part-time),* iia a lured-the sub-contrarfors
2.❑ I am a sole prpprietotr orpartner-`t wed an the attached sheet I ❑ o��g
ship and have no employees. These sub-contrac-tors have. 8.'[a'�etnnlifion -
w far many capacity- employees and bate wo&cers'
oddnb y9. ❑Building addition.
INa ors'comp.insurance comp_iosuraatl--
gained 1` 5_ ❑ We are a corporation.and its lll_❑Electrical repairs or a,ddiE m
3.V1 am.a homeoumer doing all work officers have e ercfsed their ll-❑Flumbingre-pairs or addition.
uzysel£[No,voakers'camp- right of'esemption per MGL 12.❑Roofrepairs
insurance required-]I c.152,§1(•4�and we bave no
employees.INa workers' 13-0 Other
camp.insurance required-]
•dam'spp1iciutthstdhedmbox"lmustelsa fill outthesection below showing itiekworkes'campersatiaaporieyiafarntsaon_
#Mx'nieuw nersuho submit dzis effi&nf inE;rst ng,SM&iag alE woA Ma(hM hiM outride tontMCtnrs and sabmit a near affidavit indicating snc13L
fCoutrsctmstEut rl,xY this box mast attached sa sdditinnil sheet showing thename of the sub-cautrzdmrs sad stela whether ornot these eaddesbarm'
employees.Ifthesubtontmctofshaveemployee%they mistpmtvide-their norken'rnmp.poHUniimb-er-
I a�tt an slrlpl r tiantis pia czding u�arkets'co►r3pertsatitrrt i�rsrrranca f,,r m}*enrp£a} es HatotV is the poMV and job 7i
informaliars
Insurance Company Nratue:
Policy or e f-ins_Lic_ Ekpirat onDate:
Job Site Address: CitylStafdz�p:
Attach a:copy efthe workers'compensxtionp.olicydet Iarafion page(showing the policy number and expiration date).
Fai3ure to secure:coverage as required under Section 25A of MGL c 152 can lead to the imrposition of czirninal penalges of a
fine up to$150D=00 anjitor one yearinTrisortmmi,as well as civil penalties,im the fora of a STOP WORK ORDERand a lime
o€,up to 0.00 a clap against the violator- Be adtase t a t opy of this statement maybe£arwarded to.the Office of
InvestigationsoftheD insuranc cave�a tip`
Ida hereby c r .9 its m1 thtrtthe iajFarmatior>prar-ided abot is b-ue acid correct
(5
Phone y d Z
Qj%r iaf use apt£}: Do not amnia in t£as area,fa be camp£eted by city artemn off- r tat
City or Town: PermitlLicense#
]ssuit'ng Authority(circle one):
L Board of Health 2.Building Department 3.CitS-Irown Clerk 4 Electrical Empectoc 5.Plumbing Inspector
Other
Contact Person: Phone#:
W. ormation and Instructions
Massachusetts General Laws chapter'M req� all=play=to provide workers'compensation for timir employees.
p to this sate,an MTL9y w is defined as.¢-.every person m the se-vice of another endear any comract of hue,
express or implied,oral or written."
Aaernpkyer is de$med as"an i adividag partaersb�,assodati&A corporation or other legal eddy,or any two or more
of the foregoing engaged is a Joint enterpr se,and inclnding the legal repmsenfafives of a deceased employer,or the
receiver or trustee of an individual,partnersbip,associat m or other legal entity,employmg employees_ However the
owner of a dwcM ghouse,having not more tbanthree aparfinerds and-who resides therein,or the occupant ofthe -
dweIlnag house of another who.employs persons to do mafitmance,construction or.repair work on such dweIEag house,
or on the grotmds orbuilding alrpu�themto shallnotbecanse ofmch employraentbe deemed to be an.employer_"
MI GL chapter 152,§25C(6)also sites that"everystafe or local licensing agency shall withhold the issa2nm ar
renewal of a llcease ar permitto operate a business or to contract buuZdmgs in the commonwealth for any
appliraatwho has notprod-aced acceptable evidence of coniphanr_e wn tTxe hnmrance.eoveragerequsea."
Additionally,M(M chapter 152,§25C(7)stains Neither the commonY*ealthnor nay ofiLspoEtical subdivisions shall
enter ink any contract for the,perfu anw ofpubho work until acceptable evidence of compliancevtith the incrT*ance..
req�eurie�s of this chapter have Been presented m the contuaciing amb or ity"
App'Iicanfs
Please fiIl obt the,workers'compensation affidavit completely,by �a tl e chec boxes that apply to your situation and,if
necessary,supply sIIb-contractors)name(s), address(es)an.dphonenumber(s) alongwiththeir certific (s) of
ha=n ance. Limitr_dLiabilityCompanies(LLC)orLizaitedLiabl7iL7Parfnerships(LLP)withno employees other thsntiie
members or piers,are not rbquned to carry workers' compensation iamnance- If an LLC or LLP does have
employees, a policy isregaircd. Be,advisedthat this affidayitmaybesubmitt dtotheDepartmentofIndustrial \
Accidents for confirmation of in¢rrrance coverage. Also be sure to signand date the affidavit. The affidavit shouldti
be•rrtzmmed to me city or town that the application for the permit or license is being requested,not the Department of
TnrTn striaT Acciderds. noraldyou have any questions regSdiag the Iaw or ifyou are regaaed to obtain a workers'
compensation policy,please call the Department at the m=ber listed below Self-insured companies should enter their
s elf-m saran ce license nuraber an the appropriate line.
City or Town Officials
I - -
Pkase be sure that the affidavit is completes and painted Iegbly. The Department has provided a space at the bottom
of the affidavit for youth fill out in the event the Office oflnvestigations has to contactyoumg-ardirigth_e appIicanf
Please be sure to ft11 in the permit/Iicense number which will be used as a reference nrmber. In addition,an applicant
$oat must submi-L multiple penniVlic=r,applications is any given yeu-,need only submit one affidavit indicaimg cc¢rent
policy information Cif necessary)and under`Job Site A ddress"the applicant should write"all lomEms is (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 proofthat a valid affidavit is oa:ale for fafnr,pemrits or licenses A new affidavit must be filed oiot each
year.Where a home owner or citizen is obtaining a license or permit not rahi d to any business or commercial v&
(Le,_ a dog license or permit to bum leaves etz;.)said person is NOT rujaircd to complete this affidavit
The Of of Iuvestigai ons would like to thank you m advance for your cooperafiou and should you have any questions,
please do not hesitate to give urs a calL
The Dep_artrumf s address,telephone and fax number.
Tht Cammmweal*of Massach
Department of 1aclust ink Aoaidenta
( �4��ivesffrv�fio.A`i
�Q��asbin�#an�`iz�t
Bastort�Y4 02111
Tf,-L 4�l�•27-490a Qxt 446 ar 1-9 MASSSAFE
Fay 617 727 7M
Revised424 mass
MA
� Uc� Dc +� -
ATERED ORDER TAKEN BY
E ORD
( 17
SOLD TO PHONE NO. CUSTOMER ORDER#
%/� • JOB LOCATION
( JOB PHONE STARTING DATE
TERMS '
Wla . �. RJ►111 " ' 1 _ 1 1 L•JtL"iJal►]
Ail
TOTAL MISCELLANEOUS
TOTAL MATERUU.S TOTAL LABOR
"WORK ORDERED ;
TOTAL LABOR
DATE ORDERED TOTAL MATERIALS
DATE COMPLETED
TOTAL MISCELLANEOUS
CUSTOMER e SUBTOTAL
APPROVAL SIGNATURE
TAX
AUTHORIZED SIGNATURE GRAND TOTAL
A-2817-3817/T-3866 10-11 777
o�VEr T®WIl ®f Bgrusta.ble *Permit#
® ' Expires 6 m nths rom�e dai
Ao * 1 � R �� I���lT��tOry SelCV1CeS Fee
saaDrsABLE,
Richard.V.S. li,Director
�TfD MRt
TO N d �ARNST Building Division
ABLE = U
Tom Perry,CBO,Building.Com mission er
200 Main Street,Hyannis„MA 0260'l
www.town.barnstab le:ma:us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY
j Not Valid without Red X-Press Imprint
Map/parcel Number 37
"
Property Address A�
„ Residential Value of Work: c ✓ Minimum fee of$35.00 for work under$6000.00..
Owner's Name &Address..
Contractor's Name > � //V.h/. � Telephone Number
Home Improvement Contractor License#(if applicable) / ®�� 'Email:
Construction Supervisor's_License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor
❑ I am the Homeowner
-I have Worker's Compensation Insurance
Insurance Company Name '� -�o � y✓1�'.S
Workman's Comp.Policy# G�/CG j SRO r y-/7� O `�
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to:
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
'Replacement Windows/doors/sliders.U-Value. 3/- (maximum:35)#of windows
#of doors: _
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and..inspections required.
Separate Electrical Fire Permits required: r
Where.required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License`&,Construction Supervisors License is
SIGNATURE.:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
The Cozimornw-akh e,f Massachusetts
r Deparhnent cr,f ln&rstrial Accidmis
[ffke c f'.InvesligatiOnS
600 Washington..Street
Boston l4 02111
www.mass govIdia
MFarkers' CGmpensatian Insu any Affid:ivit: Bnildersi nti-actors.Ele.ctt inns fPiumber s
Applicant Info rmatian Please Print Leeihly
Name(BumeL-.urga=aucut dn-iduai): //J 4,1V VE,1/
.Address:
City/Stat&Zip- Phone 47- 5-0,5 5-9`-
:ire you an employer?creck the apprapriate box T of. ra ect r -e
�. F am a general contractor and I }� Ir .1 .. � e4� �'=
l�l am a employer with�_ 6. ❑New construction.
11 employees(full and.-nor part-time).* have Hired the sub-contractors
ry.❑ I am a sole proprietor or pages- listed on the attached sheet. Remodeling
slip and have no employees These sub-contractors have 8_ Demolition.
working forme in any capacity_ employees and have workers' }_ Building addition
[No vvorlmrs'coinp_insurance cam'.insurance:$
required] 5. We:,are a corporation and its 14_❑Electrical repairs or additions
officers.have exercised their
3.1711 am homtvou�uer doing all work 11.0 Plumbingrapairs or additions
myself:[No workers'comp_ dgAt of exemption per MGL 17_❑Roofrepairs
insurance required.]T c_152,§1(� andwe have no
employees-[Na workers' 13.0'Other
comp_insurance required.]
*A.ny applicant th2r checks box#1 um also Ell oat the section below shoging dl&wode&'compeusatian policy iuformatim
Famemimers who submit this affidavit in ica=g they are doing all wcA and,then hire outside contractors mx=submn a new of fixvit indicating,sack
" ontracturs dutch this box must attached an additional sheet showing the ns ira.of the sub-cotawAnn and state whether or not those entities have
employees. iftbe sub—contrsctors have employees,they nnLstprrouide their workers comp.policguiiinber.
lain an employer tltat is'pros idilag it�orkers'compeitsrttiott hmirance for uy empIay-ees. e-low time policy and job site
inforrrtadiom J7111PI—Oe
Insurance�Conmpanyll .e: AZ-� _iL_S
Policy ft or Self-ins.Lim _ (i'� 'Jr 0 6` 0 0 `� �l/D�o�'� y E�piration Bate_ -Q-/
Job Site Address: ��' ��� �� Citylstat zip: � .f7
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 MUL c_ 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 ancVor one-Fear inrprisonrnent,as well as cavil penalties in the fomx of a STOP FORK ORDER and a fine
of up to$250.00 a day against the violator_ Be advised that a copy of this statesnt nt may be forwarded to.the Office of
Investigations.of-the DIA for insurance coverage verification.
I do hereby certtf it -r tThe ills i p�era s of pergia.rt.that the inrfortvtntionprati4ied above is trite and correct:
Sinstatur I)a3ec:_. �✓= /
Phone _ ` -6 3
Official use only. Do not ivrite in this area,to be completed by city or totim of tcia£
City or To-"u: Fern tlUcense
Issuing Authority(cu-clae one):
1.Board of Health 2.Building Department 3.fityfro,%m Clerk 4.Electrical Inspector S.Plumbing,Inspector
6.Other
Contact P erson: Phone#
THE FOLLOWING
IS/ARE THE BEST .
IMAGES FROMPOOR
QUALITYORIGINAL (S)
IM
DATA
ss
0 ,�`7�/b�j ���a�0� ��� ®� LIABILITY �8 e , . J8'�Si_Ul4
.. . d
n :'THIS CEP.TPCATE IS IScliErl AS A 11AATTEk:OF, _E INFORMATION
QNIY AND OWFERS MD ph3H1 UPC)N THE GERTiPiG�TE
HO-DER.T 15 CtR!!FICATE DO-5 NQT ANIEND,EXTEND DR
co e lnEurance ALTER T1E:0VE GE AFF4RCEJ 6
Y THE-P^i_ICIES SELOW.
#N i'
box 3144 NAIC
INSURERS AFFORDIWG COYrE1ZAGE
X �Uorcester,_MA 01bt�
—(—sup R A E 1—C
INSUPEr
Linneil Enterprises
59 Fr eeboarj Lane i
Yarmouth, NA 020'5
f( - tDII IG'�l u t\J '11 po \ WG !.
c� i.Y gyp. ,.'.
COVERAGES ;+^6rc !Is' i l ;'.�E
THE ors'-IC1c:Gr LJSC:RnKGE L,57ED EE ' ,� F vy l:OR
F
ti+ENT,TGR"!,OR C��RJiTi�P�rJ AC r�:O n
.Ai�li R_vU" - . PrL'IC c.,.,ESCRi6EJ
?ER7k,N.T E f"dSURANCE AI Fr'.RuED�, r REDULE4 8�'r?ID_ Cyr P x f l^41 �K CT' 11iT
JGIE -AGGREGATE-LiViTS 5H'�VJ?•VIA)
F�l�`E � G rE'M�+:DDh t v,i: .tvPA;UDY
l.t.i.)RK_HN c'�_!PE OF INSURANCE I i _ .. -
LiR IN�{Gi - I, DhfCc J REI_v ED ). I.
a I GENFRALLIAOIIJTY _ ; 1
LOofl f ERG AL GENERAL t I_ 11 _ .:i PE'
CL/.IMS h1ADE J•JCCUR { L ( r+ERSUNA v AO/iNJUFY i
} �EkErAL:+GGREC�r•T`-
PtICTs�^.OF9P REF aGt: x
AG`S°EGAT LIWT;FF�-L-IET
I-A f�
AUTOMOBILE UABILtTt` -
.. ANYAl:7C _ - Wei I 2Y
- ALL CN%4ED AUTOS 1 1
SGHE:JI: PD AL:T.D -� •� ! Of L1 JUVRy S
. .HIRED,-.1) O7
r` NCN-L`NNED A"j.OS..
`J
- - AuTC R Y. ACCIDENTZ
S
GARAGE UABiLITY - i HEC T IAN
EA AGc
?.SIG t',V' AGG
ANY AUTO 4P(.. -0t,t.URR6�r,_ i s
tXCESSYUFADREL:.A LIABILITY � i - A !'E'•"aTE
5
f{ 5
GGCUF CLF tm$MAC f:
I . CiEDUC 16E - vo >,.ty i
RCrENTIGn- a Pv-� -`--_"-I f _ ..tir •,J
WDit}CEaS GOMPEM1S4TION A71. ! Gj1;Z' '- ' Y�r i2J1.. E
i ErAPLoreRs LfAB jC,ir'f 0 r 4 f t � F �,
A I p»Y�R:�PRIETGF Paf—NERIEK UT!'Jc ( 5n D?J I
III Crr10ERlPSEMl3_. I �
1 /ec,durc,a,uISIO
?!iGvISIONS kalcv
II. . I OTHER
Eft ,.
f ��orkers coma n Zion pci!c;'
Davin Linnet is coverad b)' r'e,'
GANCELLATi0t1 ''
GERT IFICATE HOLDER. - gI-L�CLG AA!1'CP THE k6C•VE.DESCRiBf=D POLtG!ES BE GAFCE QED BEFORE THE WRIT T N
` DAYS WRITTEN
.I _ - DATE THEREOF,THE i£SUING INSURE +V:LL ENDEAVURYO 69A.L
Town-Ot.Barnstable :E{'TIf'IGA c N.t�_UEH NArdED;T^T,?;AFT,BUTFAt!.UFE TO DO SO SHALL
TO THE
C
NOTICE OR
BL411Lifng Department
N_ A^EFTS
11 q T�n
...I - 3�j!.IYral;'1.St - . IFAopc NC OB 1GATICN�C'n 'A31LI"1 D K!NO UPON THC IF.SUR-R.1T.. �
I' Hv@nrvs, MA 02501 _ _ .
REPFtSENTA+IV S -
. rd2cD.REF RES"NTAThlE _.✓... .
` J CORD c, PPORATIOW 1988
ACORD 25(200110£)
f
I
rt, s
i
�TWE To�ti Town of,Barnstable
Regulatory Services
y MASI g Richard VA calf,Director'
t63p
'��►��" 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 I r-))e to act on Im behalf
in all matters relative to work authorized by this building permit application for.
(Addre s of Job) 02b 3 Z
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
(S' a of Owner. {' Signature of Applicant
Print Name Print Name
Date
QTORMS:O WNERPERMISSIONPOOLS
9
Massachu.setts-Department of Public Safety
Board of Building Regulations and Standards.
Construction Supervisor:l'&:2 Family . t
License::CSFA-071507
DAVID J LINNEJR
59 FREEBOARD- Pt
YARMOUTFIPORT MA i0267
954 JJJ ..�� Expiration
Commissioner 08/11/20`15
(624e Wpo�rrvnwaacaealm a�C� aac�uiel r
. \ Office-of Consumer Affairs&Business Regulation I License or registration valid for mdividul use only
I before the expiration date. If found return to:
IIOME IMPROVEMENT CONTRACTOR y
registration 120659 " Type: Office.of Consumer Affairs and Business Regulation.
r 10 Park Plaza-Suite 5170 .
e ,"Expiration 2119/2016, DBA
it s Boston,MA 02116
LINNELL ENTERPRISES si
I DAVID LINNELL
59 FREE BOARD LANE
YARMOUTHPORT, MA 026755 j
Undersecretary_ I t Not without sig- ture.
�' i l
Town of Barnstable o*Pert
THE
Expires 6 months from issue date
�T Regulatory Services Fee
• BARNSZABIA
9� 16� � Richard V. Scali,Interim Director /0 /4/ 3
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
2 O� t Valid without Red X-Press Imprint
Map/parcel Number Ho
�J nn �
Property Address �6� r101'�/ eo��-� l� Cenfery I le-
[I/Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 12✓+h Qoseei b,k44
Contractor's Name )o DO Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) "PR SS PERMIT
❑Workman's Compensation Insurance O C j 1
C�hec one: 2��3
L� I am a sole proprietor
❑ I am the Homeowner •�.®w� ®�
❑ I have Worker's Compensation Insurance ARNSTA13LE
Insurance Company Name !J�®�f✓ePq �nsd�c.hl�✓
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to
❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required..f/J
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
27te Commonwealth of-Vassachusefts
Deparhnenf oflyub ft al Accidents
Offike of Im afiga ions
1 600 Mashi rgton Street
Boston,MA 02111
wn n nass.govldia
Workers' Compensation Insurance Affidavit:BuilderslContractors/Electricians/Nttmbers
Applicant Information Please Print Legibly
Name(Rudnewiorganization&dividnat): --)o J O t lh's
Address: 33 Ia2r Hd 1Id w Af
City/Stat&Zip: P mov+" m,+ d 2 3 6v phone g' f k1-`l
Are you an employer?'Check the appropriate boa.: T : of project r uire
4. I atrt a contractor and i 3'I� � � (� �-
1.❑ I am a employer with ❑ P 6. ❑New oonstruction
e Ioyees(full and/or part-time).* have hired the subcontractors.
2_W4 am a sole proprietor or partner- lid on the attached sheet; 7. ❑Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition,
working for me m any capacity employees and have woticers' 9. ❑Building addition
[No worloers' comp.insurance comp.insurance.t
required.] 5. ❑ We area corporation and its 10_�Ctrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their i -E]Plumbing repairs or additions
myself[No workers'comp- right of exemption per MGL 12..❑Roof repairs
insurance required.]f c.152,§1(4} and we have no
employees_[Na workers' 131-1 Other
COMP-insurance rNUired-]
*Any appti>aat that checks boa#1 roast also fill out the section below showing rhea workers'compensation policy Wformateam..
T Sstmeawners who submit this affidavit irnffcatoxg they an doing an walk and then hire outside contractors must submit a new affidavit indicatin such.
%Contractors that check this boor must attacked sa additional sheet showing the name of the sorb-eontracmus and state whether or not those entities have
employees. Ifthe sub-contiamrs:have employees,they must provide their workers'comp.policy number.
I am an employer that is providhV workers'compenmidon insurance for azy employees. Belau is fhepoiic}and job site
infotmatiom
Insurance Company Name:
Policy#or Self-ins.Lim 4:. Expiration Date:
Job Site Address: City/StatelZip:
Aftach a ropy of the workers'compensatixa i policy declaration page(showing the policy-number and expiration date).
Failure to secure coverage as rmquireduuder Section.25A of MGL c. 152 can lead to the imposition.of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK:ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurm a coverage verification_
I do hereby certify under the pains and penalties afpetjury that the informationpratided above is trite acid correct
Situtature: % 1� t� h4- Bate:
Phone#: —o22-Z
l2kial 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.CityfI'own Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 9:
6
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto 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 bsilding 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 shalt withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the co,iiraonwealth or. auy
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants —
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cez ificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with n.o 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_ De advised that this affidavit may be submitted to the Department of lndussial
Accidents for confirmation of insurance,coverage. Also be sure to sign and date the affidavit. 'I1e affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Deparbnent 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 pennitllicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit(license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to 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:
The Commonwealth of Massachusetts � }
Depaitnent Gf Industrial Accidents _
' office of Xnvestigatlons
640 Washington Street
Boston,MA 02111
Tel.A 617-727-4940 W 406 or 1-977-MASSAFE
Revised 4-24-07 Fax# 617-`727-7749
www-mass-gGv/dia
,
I Oct. 15, 2013 12:01PM No. 0430 P. 2
OCt-19-14 1U=94d® rium-uILVARTINNAGENCE-NEWTON 617-064-4321 T-31,. /006 8A
d
a Town of Barnstable
• Regulatory Services
Thom;V.Goilar,Dlm--tar
30 Building Division
Tom Porry1 SnIlding Comlaivulaber
200 Main Street,Hyannis,tvfA 02601
•� ' l4WSY{C4Vt1.b7N1'hsl8�10.ID1i.V9 .
Office: 508-862-4038 F= 508-790.6230
x'roperty OIVMe7C Must
Complete and Sign TJ318 Section
if Usiuk.A.13 tdei•
use b 1t as.�u of&e subject ro
X, � 1 P PAP' .
heeeby authorize l D dd MI K _ to act on my b&4
in aA mad{ebs sc6dve to work authMizect by this Wldia ig permit � • 5
1� Il Po rat fi Zr�l C�tivl/le,
( amse of Job)
**Pool,fences and alarms are the responsibility of the applicant. Pools
ante not to be filled or utilized before fence ie installed and all fnal .
inspections are perfomied and accepted.
c 9f chc r c Sigoatu;e•of Appliclwt
A/fn Ro1ergbj4tfi
P&t Nome Pxivat N--Une
Date
Q:,FORMS:oWNTsAPgRM1SS1oNiPooL•�•b/iU12 � .
COMM6NW LTH_OF M.1.5 CHUSEI
90ARf3 >r
r
ELEC�'�tic;rANs
LSSUES , MEIFOLLOWINC LICENSE
AS A REG JOURNEYMAN ELECTRI I AN
' 33 'FOX HOLLOWk S �, � ,IW
RL�rC�O H A"",i:AmwwN mayson
MA o 36o 773:7
p
h SMOKE DETECTORS REVIEWED
A P S"A '. BUILDING DEPT. DATE
Sf 15114 _
-
FIRE DEPARTMENT DATE
b ,80rH SlGN'AITUPES dRE REOUIRED FOR PERMITTING
• - _.ram
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4 )o Hody.�ain�'
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Engineering Dept. (3rd floor) Map oZ 3 Parcel 3 FS) , Permit# -�9 u
44; r-
ak
d `'^ House# (o F_`1-S Date Issued % �'
Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee
Conservation Office(4th floor)(8:30- 9:30/1:00-2:00)
Planning Dept.(1st floor/School Admin. Bldg.) INV
De Witive 1 n Approved by Planning Board 19
BARNSfABLE. n
TOWN OF BARNSTABLE
Building Permit Application
Project Street Address � ® / 7
Village `
Owner 1;1-1V %�� d 13 Lh-j:1 Address � z fir
Telephone _ S6&l•-O 2 J ,
Permit Request �� �5+� ��,?�d a r.�i'/i� �, �- ' �i.���ir3 r/A
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $ Y
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
Dwelling Type: Single Family U"" Two Family ❑ Multi-Family(#units) ,
Age of Existing Structure Historic House ❑Yes fONo On Old King's Highway ❑Yes WINO
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
No. of Bedrooms: Existing New
4
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
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑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 V/Z?/ � -; Telephone Number `29-?5IF
Addresszir _W AV G J i j License# o S`�q c�';'-
�i '7i�� ✓ ,� »�✓/ v4 Home Improvement Contractor# ,/p®7V6
?' 0 Worker's Compensation#
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
SIGNATURE , z;a DATE
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
FOR OFFICIAL USE ONLY
A
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO. '
ADDRESS VILLAGE
OWNER
f
DATE OF INSPECTION:
o
FOUNDATION
f
FRAME f
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
I
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
i
DATE CLOSED OUT
ASSOCIATION PLAN NO. '
oFrt+e rqw
The Town of Barnstable
saiuvsTns[.E.
9q, MAM Department of Health Safety and Environmental Services
'OrEc�no'�° Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
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.
45
Type of Work: irdGrol Est.Cost f,Oec
Address of Work• B
Owner's Name
Date of Permit Application: z —_;_7 6� f�
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
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION 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 Virtractor Nalfie Registration No.
OR
Date Owner's Name
The C(1 inton",calth of,llussachusctts
Department of ludrrstrial Accidents .
' - 011ice allnvestigalinns ,600 N dshin,;htn Street
y: Bostotr, A1ass. 02111
Workers' Compensation Insurance Affidavit
mf rm ""
A ltcan tt n• ..•.:- - j- -- - - - - -
' PI ase PR
name: / Z v�j717Dy6~
location:
City,(�07�►/rT— i� 4��i 3 12honef
1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
:iti• a'T^"�'*"itt. ., -;.;_i-'?"?T�.*- r A e^:•� ?-^� r.S3?�- riff
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I am an employer providing workers' compensation for my employees working on this•lob. r
company name:
address:
city: Vhnne h• r,
insurance co f- / l� Jtolicy # �� Lib ,GC� �13�Y
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1 am a sole proprietor, general contractor,or homeowner(circle one)and hav a hired the contractors listed below who have
the following workers' compensation polices:
company name:
address
city. phone#•
insurance co. olicv h
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company name:
address
city': phone try
insurance co. polio•#
(:attach addthonalsheet►fnccessa :' ; rc' ,:: s ,h:xi _ ,Y,,.,�Mr, •. , µ;�, ,;�,
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Failure to secure coverage as required under Section 2M of PICL 152 can lead to the imposition c•`criminal penalties of a fine up to 51.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP R'ORK ORDER and a fire of 5100.00 a day against me. I understand that a
cope of this statement may he forwarded to the Office orin,cstigations of the D1A for coverage vc.-ification.
I fro hereht•certify und, �t7ains and tialties of perjwy that the nrfortnation provided gore is true told correct
Signature Z
Date
Print name Zi�d/ �C�II Phone fr 2 'Sid'
official use onh do not write in this area to be completed by eiq or town official
cih or town: permitAiccnsc k aBuilding Department
k: 01-icensing Board
check if immediate response is required C]Scleetmen's Office
Dllealth Department .
contact person: hone#:
' P nOther
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