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HomeMy WebLinkAbout0266 HOLLY POINT ROAD » „ . : w , o c° x A a a ° c ° ° ^ ° a • 0 ;y =e � , ° u ° v TOWN OF BARNSTABLE,BUILDING PERMIT APPLICATION , Map Parcel U�� J Permit# '7c3c��o Health Division - Date Issued Conservation'Division Feeo2.,S ao /fax Collector Treasurer t Planning Dept. f , r Date Definitive Plan Approved by Planning Board Historic OKH Preservation/Hyannis A Project Street Address ` 2-6 Village IG ` Owner L Address Telephone 7? .Permit Request S(-V,�l e t-u s Aseh..a-tt S �1��l�r, �� Sa✓'C Square eet: 1st floor: existing proposed ' 2nd floor: existing proposed Total new Estimate Project Cost _ c Zoning District Flood Plain Groundwater Overlay Constructi n Type _ Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting d entation. Dwelling Type: Sin Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: •❑Yes ❑N On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full Cl- wl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing Half: existing new Number of Bedrooms: existing n rR y Total Room Count(not including baths):e ' ing new Floor Room Count Heat Type and Fuel: ❑Gas Oil ❑Electric ❑Other Central Air: ❑Yes o - Fireplaces: Existing New Existing wood/coal stove:• Yes ❑No Detached gara existing ❑new size Pool:❑existing ❑new size Barn:,❑existing ❑n w size Attached rage:❑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 r BUILDER INFORMATION Name << 41(t) Telephone Number 34 Z Address 3Z ( �� _ t License# D OC Q�Z Grob 1 ti Po- — bZ�� .- Home Improvement Contractor'# Worker's Compensation# 'ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE`S ©l � . FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED _•. MAP/PARCEL NO. "�' N, ADDRESS �^ ' y VILLAGE t OWNER 6 �• - — . f ' 1 DATE OF INSPECTION _' - � °, .— •, . �, ..: :. .� "� r f FOUNDATION. FRAME r > INSULATION FIREPLACE' ._^ t t - •' ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH FINAL r GAS: 'ROUGH FINAL `e FINAL BUILDING , DATE CLOSED OUT . ASSOCIATION PLAN NO. • " t r of TMe rq� �. The Town of Barnstable • EABNSPABIZ. 9059.MAM �0� Department of Health Safety and Environmental Services rEc �" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building Commissioner 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. .-AType of Work: .544, �— Estimated Cost ooc)od Address of Work: �wner's Name: Lac.-� &C �at6 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 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 Contractor Name Registration No. OR Date Owner's Name q:fortns:Affidav f - -- ��— The Commonwealth of Massachusetts + = Department of Industrial Accidents A' '` - Vince ofinYestigWOOS 600 Washington Street Boston,Mass. 02111 `��vi.•Vs.• Workers' Com,pensation Insurance Affidavit name: (2,c s2(( fit• Gc b��ly t location: 3-2- Pt city 2 u'n"',o''� PD4- phone# 3 2 6 Y7 2- El I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any ca acity ❑ I am an employer providing workers' compensation for my employees working on this job. company name: address: city phone#: insurance co. policv# I am a sole proprieto�genel. r homeowner(circle one)and have hired the contractors listed below who have - the following workers' compensation polices: company name: U - - address: _... ,. city: 654-e- 1.1 .. �.. phone (.T .:. . .... insurance cm. rda;i�t l - I-5w�` -ems oiicv companv name: address: city phone#f- - insurance co. go CV# FaJIure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a COPY of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is truo and correct Signature p l ;C�V' Date 1 c?/z vW _ Print name SeCI 1`1- (_3 t�S'N Phone# r. Z 7 2 7 ofIIcial use only do not write in this area to be completed by city or town of Icial city or town: permtt/iicense 0 ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's OMce ❑Health Department contact person: phone#; ❑Other . . . (tevtsec 9195 P1A) 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 co==. , 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 c- 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa 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 contacting authority. Applicants 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 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. 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 rettn:aed 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 Invesugatfous 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 -. � 1 e L ` •r f p�} �.'�• 4 ,•k '•? f 3 r h.. 4 '.� \ A 2.-yf� - A3 y e •,-r ; +' � �+ S�. �t t •tc��`�' r .Y�„' '� za; � a t t�,",' ' b ":,�. G i-,,i�� �e,,: � a, k ` r .i,. ,.. '�:R� $•`.Rr.. _ F�' '� E It "�1,6.7. m yw,4 d f r t 4 y t3F z at �y r ! P. 2S �'r}�, x�' '�i h� �'3 y�",�•''+ �: 'er`�„ wr vxe r �aY•ti. t,.�R � 2 ;�4r•J �♦ s� t xx rf�' , NtiWLwv�fiGV' �' TM ,c 1 t.:Q�:n •c..t�.. ':.t<; .'[:�uj',�`, ..y�• MF r,�t� a � y,p b a , S1 x v T t��, �j ��r �.':,A' ke z,It t E.; a/ xa ., ,.tµ .a ,,x a�St§ �� ✓ 'nM`ta �e,r +. a p ra'M.' r SP xW! 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