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0122 LIETRIM CIRCLE
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C. r.( `.. `,t -tf :" , , ' 3',. t y� • t .t I7 ,.. ,R+ r,(,6 • fi , rtff.r r + ." '''..J! A '�' � a .:, ,. ,,-'-,.. t.,... v, Y t1R il5 "., *,'a•,t ,,' ,f„ ' Town of Barnstable Building _ PostTfiis",Card;So T,hat,�t,�SVisible Fromahe Street Approved-"Plans IVlus#fib„e�Retamed on�Jpb and thisCard Must be Kept ■AAEN3I'ACi1.C,. ,. erg, N _ Y ". MAC. Permit r� Where a Certificateof O.ccu anc. �s�Re u�red,such Bulldm shall Not be Occu red unt�l�a�Fina1 Ins ct e Permit No. B-18-1360 Applicant Name: DOUGLAS, ROBERT A&WAWRZYNOWICZ, Approvals * Date Issued' 05/17/2018 y Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 11/17/2018- Foundation: Location: 122 LIETRIM CIRCLE,CENTERVILLE Map/Lot 169-047 Zoning District: RC Sheathing: Owner on Record: DOUGLAS, ROBERT A&WAWRZYNOWICZ, s#� ContractoRr r Name.: Framing: 1 Address: ROBERT A DOUGLAS REVOCABLE TR Contractor License >: CENTERVICLE, MA 02632 Est Pro)6ct Cost: $0.00 Chimney: Description: 12x16 Shedd r RermtFee: $35.00 rd Insulation: Fee Paid j $35.00 Project Review Req: P Q, ;u x Date 5/17/2018 Final: Plumbing/Gas 0 � Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within sik months afte suance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents�for which this permit has been granted. All construction,alterations and changes of use of any building and st uctures shalPbe in compliance with the local zoning by lawslannd codes. Final Gas: This permit shall be displayed in a location clear) visible from access street ork roadand shall be maintained open for uwbl�c ins ection for the entire duration of the PY � P P Px r work until the completion of the same. P Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and F e Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: y' :t �,r: 1.Foundation or Footing ,� -, Rough: r„ 2.Sheathing Inspection MK 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with,unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). . Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT f, Town of Barnstable Op'THE r, Building Department Services ti Brian Florence,CBO t EMNSTABM Building Commissioner M►ss. n 39. ���� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERAM# _I J l(J FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY .Zy 200 square feet or Iess CJ � Location of shed(address) Village �: cn bce lL�' ©U Property owner's name Telephone number — rn Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? A C� You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITIDN THE JURISDICTION OF ANY OF THE ABOVE COMNIISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST U ACCOMPANIED 13Y A PLOT PLAN Q-forms-shedreg REV:08/6/17 (�100-V CcIST-. irej � v Legend ' :Parcels o '"Town Boundary \ r Railroad Tracks Buildings ` Painted Lines Parking Lots -, Paved f t Unpaved �+< 169048 � Driveways 4 1699 9 #137 Unpaved #'12t f Roads 13 Paved Road Unpaved Road Bridge t- ® Paved Median J , Streams r1 Marsh 1 Water Bodies i � 7 #f 134 169950. #"105 . �. I" 16903.169046 12 9:' t #"112 16965 t Y.-�� r? N U.1,511 ti. t 169046 ,"l6904Q� ,. 0 ❑� E'td/.. Z— ;141fl�tl a 3 Map printed on: 3/9/2018 This map is for illustration purposes only.It i y 1 J N V-44i i,��'�sBs�p n this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026ot O 42 83 0 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: 1 inch= 42 feet cartographic errors or omissions. gis@town.barnstable.ma.us r s � C90 ' _ BIKE� Town of Barnstable *Permit#_� Fx�gy�res 6 months la issue date Building Department Fee y - ,,,�„B Brian Florence,CBQ v 16 Building Commissioner 9. m iOrFD Mpd A 200 Main Street,Hyannis,MA 02§Q www.town.bamstable.ma'as.P M- tl Office: 508-862-4038 NOV 17 2017 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESID 1 ' ` M �IC� Y� Not Valid without Red X-Press Imprint Map/parcel Number Property Address /P X f-/rTg)NYC C I KC-L IF_ CiW TF Ky, L(-JE M IA ck�,I,-?.-a �]Residential Value of Work$ ;2 50a o() Minimum fee of$35.00 for work under$6000.00 . Owner's Name&Address R o k R 1 t)n`.! Contractor's Name_��11�,t9 vv 0 �6>l ty VAS 1'> S Telephone Number 5Cf- 5/1 f O(,*f , Home Improvement Contractor.License#(if applicable) /L16! /7 y Email: q I ; 0a) Construction Supervisor's License#(if applicable) C5 //O 7 5>� ❑Workman's Compensation Insurance, Check one: AI am a sole proprietor ❑ lam the Homeowner ❑ I have Worker's Compensation Insurance ` Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to A►V►4 5A,"-n4T1 Qrj ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is req SIGNATURE: QAWPFILESTORMMEXPRESS2017. t ' The Co€ momveakh of Massr r*usetts Departwerxt o,fgrrdustriatAcddq'zft @face a,f InvMligatiOns 600 Washirfglort&MCt Bosion#CIA 02111 wYvxu mm&g�fdia NlTurkers' Compensation Insm-ance Affidavit BudderslContractorsfEIec&kians/Pluumbers � APPEcanf IAfQrxnatign Please Prim 1`1 a=, cin�eclYSrag 7 inQw '> �QW 1V p Address: �_9-0 CovksTyc�&J C,E- P%PF- city� vKA- Phoneme s 94 Out'), Are you an employer?Check the appropriate box: ' Type of project(required): I.❑ I am a employer. 4. ❑I am a general contractor and I 6- [:]New aonstiuctkm employees(fRd and/or part-time).* have]sired the sub-contactors 2.. I am a sale proprietor orpartuer- listed on the attached sheet 7. ❑Remodeling soup and have no.employees Thew sub-contractars have g_,❑Demolition wodl<dag forme in any capacity. employees andhnre worms' [No wark=$comp.insurance camp- 9. ❑Ruildiag addition reg3ired] 5_ ❑ We are a coupomfian and its 14❑Electrical repairs or additions 3.❑ I am a bnmemmer doing all work officers have e=cised their 1L❑Plumbmgrepairs or additions myself[No woo=mn'comp_ of ememption per 14fGI. 13_�Roafrepaits iney�xancerequirred.]T c.152,§1(4�aadwe have na 13-❑Other employees.(No wo&=' cep-mstuance reed-] 'tiny WHcsCdst cbedcsbos ffl—st also fllontthe swdonbelowsbmaing du!irviorke s'compo satimpariir-y infmnm iw- #F�ameovuners Who saba�t this afiidavif ivdrocatiag they aredoing slFwant agd&aea}ffix outsideconitsctnrs�st sohmitanewaffidavit ind =ng s©cb_ ZConttacto45 that died this bmc must Or d ffi additional skeet shaarmg tbename of�e nab c ctva and stafe Whether ar not Phase evtities haves =VlUees.Iftbemb-can ashaveemployee%dieynastpn u edeir wwkers'c=p.policgnumbm lam au errtploj�w fliat is prouidhW wwrkers'compewidiati insrlrance for wyJ enrp&;ywes Heloiv is flue policy a d f ob isle infornxalion. Insurance Company Name: Pflhcy#or Self-ins.Lic-4. FKpiration Date: ' Job Site Address: citylstawzip. Attach a copy of the workers'compensatioupolicp declarafion page(shawwg the policy number and expiration date). Faffim to secure caveuage as required under Section 25A of MGL c.1572 can lead to the imposition of ccrimisual penalties of a five up to$150D OD anifor one-I{earimprisonment;as well as civil peualkes.in the farm of a STOP WORK ORDERand a fine of up to$250.00 a day a4aitu t the violator_ Be adtdsed that a copy of this statement maybe forwarded to the Office of lnvestigatians of the DIA for insurance coverage verificWau- I do hemby. arcter ' s rat uatties aifF n}'fhatfhe informadmi-protritw above is bare and correct zol Date_ l— Phone# OW&ial we s nly. Do not twrite in this area,to be completed by city artown afficint .City or Town: PermdtUrense# Issuing Authority(ca cIe one): L Board of Health 2.Building Department 3.(MyYrown Clerk 4.Etedttical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 Information and Instructions ' Masswimetts C e earl Laws chaptera 152 regoaw all a ployM51D provide workers'corapmsaiion for their employees. Pursumt-in this s atate,an ploy=is defined as."_.eveay p=63:L in the service of another under any dom ract,pf hire, eo press or implied,oral or WU f f An employer is defined as"an individng partnersbip,association,corporaion or other legal entity, or ao y two or more of the foregoing engaged in a Joint eoteaprise,and inchidiag the legal representatives of a.deceased cuipIoyer,or the receiver or trustee of an individail pa rtamship,association or other legal entity,employing employees. However the owner of a dweIling horse having not more than three apartments and who resides therein,or the occuat of the - dwelling house of another who employs persons tD do maintenance,r^^shuction or repair work on such dwelling house or on the grotmds or building appi ri=rnt thereto shaH not becanse of such employment be deemed to be an employer." MGL cbapt,r 152,§25g6)also states that"every state or local licen�a agency hall withhold the issuance or renewal of a licen a or permit to operate a business or to construct budding in the commonwealth for any applicantwho has not produced acceptable evidence of cdmpliianeewith the imsurance.cove�ragerequired." Additionally,MCrL cbaptnr 152,§25C(7)states"Neither the commoawmIth.nor any of its political subdivisions sha11 emote r rot o any contract for the perfinmmce ofpnblio work u3bl arxeptable evidence of compliancc vrhii the insm7an c8. requcmments of this chBpterlJ ave been presearted to the contracting arrthoi�iy:' Applicants- Please fill out the workers'compensation affidavit completely;by checking the boxes that apply to your siination and,if necessary,supply sub-contractor(s)nam e(s), address(es)and Phone numbers)along with their c -t reafe(s)of i„Lzance. Limited Liability Companies(I.LC)or Limited Liabffity Paztneasbips(LLP)with no employees other.than the members or partners,are not r&jaircd to carry workers'compensation insurance. If an LLC or LLP does have empIoyees,a policy is required. Be.advised that this affidavit maybe submitted to the Department of Industrial Accidents for confumalion of insurance coverage Also be sure to sign and date the affidavit. The affidavit should bezetrrmed to the tidy or town that the application for the permit or license is being mgaested,not the Departmeat of Tnrinstr-fa1Acmdenfs- Shouldyou have any questions regarding the law or ifyou are reed to obtain a workers' compensation policy,please call the Depadmea±at the number listen below. Self-rosined companies should mLte r their self-h sm=CZ Iicease number on the appropriate line. City or Town Officials Please be sure that the affidavit is completn and pried legibly. The Departmeaithas provided a space at the bottom of the affidavit for you to fill out in the event the Office of Inver�os has to contact You regarding the applicanb Please,be sure to fill in the penm;iY icemse mnnber which wM be used as a refe ante number. In addition,an applicant that mnst submit multiple p eamitiTicen se applications m any given year,need only submit one affidavit indicating cna eat policy bfo=&tion(if ne—saiy)and under "Job Site Address"the sprplicamt should write"all locations in ( 'or town)-"A copy of the-affidavit that has been officially stamped or madce:d by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fvfnre'pemiits or licenses A new affidavit must be fMc d oit each year.Where a home owner or citizen is obtaining a license or permit not n:Iated 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 like to thank you in advance for your cooperation and should You have any questions, please do not hesitate to givens a caIL The Department's address,telephone and fax rnrmber. ' CommmT : ItbE of I chnstt-- DeP--dMent Gf Iidustciak Accident% Office of Xnveggg tio-= Wean t Bo M&02111 T(,-L 4 617'27-49W oxt 406 or 1-977-MASSAM Fax#617 727 7749 Revised 4-2"7 mas gc���dia °FIMHE ro Town of.Barnstable Building Department s"u'ASS. Brian Florence,CBO 1639. Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 % Fax: 508-790-6230 Property Owner Must Complete and Sign This.Section If Using A Builder I, 1�0 0Y )�s qy,q A-S ,as Owner of the subject property hereby authorize/010 ill D ��t� � to act on my behalf, ' in all matters relative to work authorized by this building pertnit application for: vo. VI (Address of Job) **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. 1J ';'Z'ZL� Signature of Owner S' e o Applicant l2+Y►'10ryt� ���,►41e1� � Print Name. Print Name ll_:i.5 IAO Date Q:FORMS:OWNERPERMLSSIONPOOLS Rev:10/17 Town of Barnstable �OFTHE rokti Building Department o„ Brian Florence CBO STAB Building Commissioner MENM MAM 200 Main Street, Hyannis,MA 02601 1 a . s63p. �� 'OTFO N►p'�A. www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION• Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: City/town state zip code The current exemption for"homeowners"was extended to include owner-occupied.dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,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) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection,procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require, as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. on Office of Consumer Affairs & Business Regulation-Mass.Gov Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation A Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints = y � Registration# 144174 Home Improvement Contractor Registrant RAYMOND EDWARDS Registration Home Pa4e Name RAYMOND EDWARDS Address 80 CONSTANCE AVE City, State Zip W. YARMOUTH, MA 02673 Expiration Date 05/17/2019 Complaints Details . No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2012 Commonwealth of.Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. ment MassachusettsDepart Regulations and Standa ds y Corisf�uction Supervisor Board of Building Reg _ Restricted to.- License: CS-110758 Qmrestricted-Buildings of.any use group which contain rosor less than 35,000 cubic feet(991 cubic meters)of Construction Supe y enclosed space. f2AYMOND EDWARDS 80 CONSTANCE AVE WEST YARMOUTH MA 402673 Expiration: 0713012020 Failure to possess a current edition of the Massachusetts _ / ;Commissioner State Building Code is cause foF revocation of thislicense. .DPS Licensing information visit:WWW.MASS.GOV/DPS --- https:Hservices.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=144174 10/30/2017 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION , :k Map Parcel Application # o) Cd I 'l U Y 6 D, ( Health Division Date Issued 8 2 H Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis CProject-S-treet Address Iola L 1'ETR i►M► C%fLcA P_ Village �E���Ill lLE Ovine_Rbide,_'l2�1_ -A �oVqJAS Address. S\Am elephone (0`.5' fP_ermit}Requesf �a Y1(�. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Protect Valuation�-- --iO040 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King sll ighway:V Yes=❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other r '' Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft),' Number of Baths: Full: existing new Half: existing nevi to Number of Bedrooms: OZ existing 0 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 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 ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name -Z(a `Q-(-T 'P )�aUgI PCs TeIep ne Number-�, Addre�ss - L i rr-raj m C)Yz- License # CENIERIIILS m A Oato,3 a Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO _SIGNATU tilt=- _` rDAT_E=__A•4J 6.,_LI , ao q FOR OFFICIAL USE ONLY APPLICATION# Y DATE ISSUED MAP/PARCEL NO. b ADDRESS VILLAGE r OWNER DATE OF INSPECTION: MFOUNDA_TIO.NI. , " FRAME � r h� ,.INSULATION:�IVi Q2110 IV FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL I, GAS: ROUGH FINAL FINAL BUILDING- J e DATE CLOSED OUT ti ASSOCIATION PLAN NO. _p _ T die Commonnfeakh oaf Vassachuseitr Deperrtt t of htdmsft al Accidents _pace 600 Mashington meet Boston,MA 02111 - - _ nwivarzass.govIdia Workers' Compensatian Insurance Affidavit:Builders/f ontractorslEiectriciansMumbers A PPIkant Information Please Print Legibly NAme(Bld�niza6o�lfndnriduat):��lr�eV-T R 104IAS 1 - Oa�3Phone`# 7 �sz; : C �vTerzvo tc-� r �I Are you an employer?Check the appropriate box: Type of.project(required): 4_ I arty a contractor and I 3'1� �' I ��' d): . I_❑ I am a employer with ❑ f 6- ❑New won: employees(full and/or part-#ime)* 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:v3b-contractors have &_ ❑Demolition- working for mein any capacity� employees and have workers' $ 4_ ❑Building addition [No workers'camp-insurance comp-insurance- 5..❑ We are a corporation and its 10_0 Electrical repairs or additions ain a homeowner doing all work officers have exercised their I I_❑Plumbing repairs or additions C„3_.[�.I- right of emmption per MOL myst:i£ [No workers'c�mP_ I2_.❑Roof repairs insurance required-]T c_152,§1(4),and we have na employees_[No workers' 13_.❑Other comp-insurance required.]; *Amy appEcun that checks boa;#1 toast also fill out the section below showing/trek worceis'oowemsadian policy inf trmifim T H=wwneis arho submit this affidavit indicating they are doing all ztoric and then hire outside contractors nmst suboat a new:affidavit inrrcatin such- tcoatcactors that check this boot must attached an additional sheet showhxg the name of ifie and stste whpdw ormt these entities have employees. if the sub-contractors hale employees,they must provide their workers'comp.policy number Tam arz employer tiratisprmidbig tt�orkers'compe?Lvation insstraitca for rrty emptayees. Below is Ste poM7 andiob site i fotmadam Insurance Company-Natne: Policy 9 or Self-ins-Uc-9 Expiration Date: Job Site Address: Cityi''State/7ip: Attach a copy of the workers'compensation policy declaration page(she-+ ing the policy number and expiration date). Failure to secure coverage as mquiredundes Section 25A of MGL c 152 can lead to the imposition ofcritninal penalties of a fine up to S 1,500.OD 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 Im-iestigatitms of the DIA fior fimurance coverage verification- I do hereby cierhfy under the paJn alldpenaNes ofperiury that the informaNan prinided abate is fare and correct SiPnatare:�-�FIDate A-UG' q , ao t y L4—�3 O iciol use only. Do not write in this area,to be coutpLeted by city or town gfficiaL City or Town:. Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City.ITGwii Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#_ 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 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 building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct 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,,,rith 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 ceriricatc-(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no enanloyees 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 maybe submitted to the Department of industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit 'flit affida�rit should be returned to the city or town that the application for the permit or license is being requested,not the Deparment 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. Sell 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 permit/license number which will be used as a reference number- In addd_tion,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 filed 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 NTOT required to complete this affidavit The Office of Investigations would Ike 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 , Depaztment of Indnstrlal Accidents office of Imwe otiaas 600 wawngtan Street Boston,IAA 02111 Tel.4 617-727-4900 at 406 or 1-- -MAS R Revised 4-24-07 Fax# 617 ` 27-7749 www.mass gcv/dia Town of Barnstable Regulatory Services THE roly� Richard V.ScaIi,Director ' Building Division E � i BARxsz•AsM Tom Perry,Building Commissioner 1 ��� 200 Main Street, Hyannis,MA 02601 '�Ev tna't a www.town.barnstablema.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print s JOB LOCATION: j of dt L l E721 vn Q02— O E W ZV 1 I l L "HOMEOWNER" bL3F�r AJOUCv� SOf�-(��1�0355"' 7?14. 3 'Sy8'a , p work #r hone CURRENT MAILING ADDRESS: ms�l�e cityhown .•r-.�: "'.: Mate_,,-7, a-.. zip code The current exemption for"homeowners"was extended to include owner occupied dwellings of six ifsr&'.1ess 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, oa which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner''shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. �gnaiure_of Homeowner` Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persou(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 sor (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 last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form certification for use in your community. QNWTFILES\FORMS\building permit forrns\EXPRESS.doc Revised 061313 �'ME r, Town of Barnstable Regulatory Services MASS. Richard V.Scali,Director Building Division "- om erry; ii"- ng ornmrssroner` 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.maxs Office: 508-862-4038 - Fax: 508-790-6230 Property Owner M Complete and Sign Thi Section- -- ' If Usin-ABud er -- as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work autho d by this building permit application for (Address of Job) "Pool fences and are the responsibility of the applicant. Pools are not to be f* ed or utilized before fence is installed and all finial inspections ar performed and accepted. Signature of er Signature of Applicant Print Print Name Date Q:FO RMS:OV,TNMRPERMISSIOh'POOLS C oEl►2i m c i vz nn enT" '. O-t Avl-erzv i LL� AS li 1m YES o t2G eOL 1\D T 1N I fL v cTwo�K r boSE'`nee n r Two 1 S1*3 ows/-ro0 30 %/X tit `/W STR 162 we 1 i F rzo w1 1 RAT i o o P- 1&1 '. F►oorzro O- Lm% fv� S ee'rPocl- h10 �/T STu-b *FIOO2 R1i STul� S���76tacK 06 v N Gzso . M/ro 0 J a� 33 / 5 CJ il� hJ O 00 tq LA -ua�z1Q v�5`d "� �iv�daW �IIG M a _. -,ot 48 o �s 1plol 9 A � ' - a �1 U �. w � _ S I' 60 r�, I � � Qal. Y `t Town of Barnstable errnit:o2o6(0 vy�� �OFZHE Tpk, Regulatory Services D ate:///Fl0 Thomas F.Geiler,Director * BARNSTABLE, + Building Division Fee6'J,DD y MASS. $A�en 3 � Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: �dU�7 f l�'S� Phone: Install at: 6-�j/2G/PVillage: C�` �/V� V/�l- Map/Parcel: �� (/ � Date: stoyo A New sed B. Type: Radiant Circulating C. Manufacturer: , Lab. No. t D. Model No.:04141 Chimney A. New Existing f existing,pleas note date of last cleaning) B. Flue Size C. Are other appliances attached to Flue? /0 D. Pre-fab Type and Manufacturer E. Masonry: Y&-� Line nlined Hearth A. Materials: B. Sub Floor Construction: Installer e Name: % U Address: / Phone: qP- Location of Installation: I C= C APPROVED BY: LA� > Please make checks pay, le to the Town of Barnstable co *This constitutes an official stove permit after inspection,photographed, and approve by the Building Inspector Q:forms:stove Rev 122801 Al - • g..< «.4. r IM r.. .: ,: . .:.,. r g '.,.. ,'�. ^��. "b'' � AsrR �Q . ", ... �+ .•:,_. � F ,ems �'�'�� �, . '•.v . p: �� _s ,'fit ?� ..s " r-3 $a� - �* p P� .`, 3= `' 4 x< r • �- `CA, �,. ♦r ";�,``.:' x ,w " £ WARS"" �. z ter. J e i its It; x x , .. r, '�;,«� '. a�;,_>w; -:s• F ^;. fro.,,. Tyra' � < .. " 4 Zil S It 'e Am ARE Alt- Olt -77 e k =`k y " n r e k { t r y ' s, r ew k , } ° i 3 122 Lietrim Circle, Centerville 12/6/06 Assessor's Office(1stfloor) Map /(� ! Parcel .; d I rmit# Z/6( 3 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) `" Date Issued + Board of Health(3rd floor)(8:15'-9:30/1:00-4:45) 06 t �: Engineering Dept.(3rd floor) House# %�, 2• �,!� ✓Z.�,! � - LL2_D 114 MICE TH Planning Dept. (1st floor/School Admin. Bldg.) RA E AND Definitive Plan by Planning Board 19 � �"' _ S TOWN OF BARNSTABLE :�.. Building Permit Application' Project Stree YS �a a, " C1_11 'C,Z.&' Village Owner Address 122, Telephones �8 Permit Request I—yA1V,491 f-�n/6 l<L ��Y✓ �Zez :ad F wow �yar/iie1�lDys First Floor 11-700 square feet Second Floor square feet Estimated Project Cost $ 6"d Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential ►/ Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House .dam- Unfinished Old King's Highway Nd Number of Baths No.of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name �, j_Z �/iQ Telephone Number Address /�y�' /Gy11 "4711,17' License# eJ,,4 � d Home Improvement Contractor# JDD 7W Worker's Compensation# DM Gd6,M 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 DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO: DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE C r , OWNER - i , DATE OF INSPECTION: _ , , FOUNDATION FRAME' ` INSULATION ! - j c .. FIREPLACE } , ELECTRICAL: ROUGH FINAL . I PLUMBING- ROUGH FINAL _ GAS: .= ROUGH FINAL FINAL BUILDING t , ` DATE CLOSED;OUT 0 ASSOCIATION ANNO: *31 j ! ' i , + ` • •- , m .The Commonwealth ofMassachusetts v Department of Industrial Accidents i =-E 600 Washington Street 7 4 Boston, Mass. 02111 Workers' Compensation Insurance Affidavit = nam Z,, --sue location: �GJ�r�cJ cite phone I am a homeowner performing all work myself. 1 am a sole proprietor and have no Qne working in any capacity I am an employer pro%idina workets' compensation for my employees working on thisjob. company name: address: city. phone#: insurance co policy# -> _ . :_�`— -ass-.r1-• - am a sole proprietor. General contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: rill. / phone#: insurance co. policy# d-0 9 company name: address: may• phone#• insurance co - poti y•# Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a Oat up to SI,W.00 aad/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of S100.00 a day against me. I maderstand that a copy of this statement may be forwarded to the Office of Investigations of the DtA for coverage verification. t do hereby certify under the pains and nalties of perjury that the information provided above is true and correct Signature Date �� Z// IS - ,2 Print name �o ��—� Phone M Ccheck only do not write in this area to be completed by city or town oRcial - _ _ permit/license# nBuilding Department OLicensiog Board mediate response is required ❑Selectmen's Office Health Departmentn: phone#;_ __ -- rjOtber (revised 3/95 PJA) - - . .. The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Strut,Hyannis MA 02601 Ralph Crosses Offee: 508-790-6n7 Building Cone: Faye 508 775-3344 For office use only Permit no. Date AFFIDAVIT HOME 1WROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,'renovation,repair,modernization.conversion, improvement,runcn-4 demolition. or construction of an addition to'any pm-exiSting owner occupied building containing at least one but not more than four dwelling units or to stra==winch are adjacent to such residence or building be done by registered contractors,with certain exceptions. along with other requiremeau. Type of Work: row Cost, i CW Address of Work: I2i�T/�i� Oaner.Name: r�0 i � Date of Permit Application: 1� I hereby certify that: Registration is not required for the following reason(s): Work emcluded by law Job under S1,000 Building not owner-occupied Owner,pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WIT�IUNItEGISTERED CONTRACTORS FOR APPLICABLE HONE IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MM c I42A SIGNED UNDER PENALTIES OF PERJURY = ; I hereby apply for a permit as the agent of the owner. k. Date C r Registration No. OR n,fP Owner's name In. accordance with the Provisions of MGL c 40, S 54, a condition of Building Permit Number is that the debris resulting from this work shall be . disposed of in a property liceZsed solid waste disposal bcdity as defined by MGL c Ill,S The debris wM be disposed of in: (Location of Fumly) " . S•, ature of Pe=it Applicant Date Assessor's map and. lot number 1 , . r:... f` , �`j/1 /� #I e'� r 'TN �c< 11. ^ S£^l z � tr/�ri�r� �C'• i=-l=C= 7' Sewage Permit number ..............................................,......... ! yft"ET°�y TOWN OF BARNSTABLE 89HB9TSDLE. i S "6 9 BUILDING INSPECTOR 1M of APPLICATION FOR PERMIT TO .. ..�,.....�..:�....?....�...........r� P. . f�......��................................................... TYPE OF CONSTRUCTION ...... ...........................................�`n ►.'! �Il ............................................................................... .......... G.i......................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: y} Location .kc)�T..:�,Y)......�..!.�=..�.�t.ttd�!.........�..�.�.�...��- ....... .7-7A-) l--Zk�1i..��� ../ /'��5..� ........... Proposed Use .c...A, )Z--..�.'.I..�.. ......................................................... ... Zoning District ........................................................................Fire District Ct Aj-7?P J///T - 0�/7-0? U ! llc. ................... .......................................,.....P....... Name of Owner AlJa?'l' �F l . .?" . L ... ....................Address 6P : / .r. . //... � . Name of Builder ......Address ..�!�.,Z.... � .... l !l ..�..... ..; /�.iUAll .. jytj,j Nameof Architect r .........................................Address......................... .................................................................................... Numberof Rooms ..................................................................Foundation .............................................................................. Exterior ...Roofing ... s.. .. ............................................................. Floors Heating .....................................................................Plumbing ... ........................................................................... Fireplace ...................................................................................Approximate Cost ...: �1!'ln: ?....................................f......... Definitive Plan Approved by Planning Board ________________________________19________ . Area � ..G' ...... . Diagram of Lot and Building with Dimensions Fee "' ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH _ f� .fin ISO i --tog---- - -- I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name,. ................. _ �l� .... ............................................... Newcomer, Robert B. A=169-47 No .18022..... Permit fore.....,add carport to single family dwell ng Location 12�ietrim. . . . ..Circle. . . . ....... .... ......... ............... . . . .. .. . .... . . . .. Centerville enterville ........... Owner ........... Robert. . ..B.....Newcome ................. . .... .. . .................... Type of Construction ............fr.a.. . . .................... .................................................. ........................... Plot ............................ Lot ........................... Octfiber 28 75 Permit Granted .............. .........................19 Date of Inspection ....... ..........................19 Date Completed ......!:..............................19 PERMIT REFUSED r ........................ .................................... 19 ............................................................................... ...................:.......................................................... ..................i/........................................................... ............................................................................... Approved ........................................... ... 19 ............................................................................... ............................................................................... Assessor's map and lot'number .�.!�.l •:... Sewage Permit number ....................................... . ....... Pyo�Y"Er°��o TOWN OF .BARNSTABLE Z zAmrSTABLE, i 9 "6 9 ,•� BUILDING INSPECTOR 0 YP�a' 4i APPLICATION FOR PERMIT TO ...........C. ........................................... r TYPE OF CONSTRUCTION ...... .0.4►. .......1<'.Lz m.0 . ......................................................................... ........... ....�.....................19../.. TO THE INSPECTOR OF BUILDINGS: The undersigned'Hereby applies for a permit according to the following information: Location ... ......�..1.�?..A. .1./�1......... .1. ..�r...I. ,........ .�r. .�. 1a.�✓./../../. �:../..rl./� .5... ..... ProposedUse .�Z. .. ...............................................................'.................................'..................................... Zoning District ............................................Fire District (��.l P.vi.du....(2.5a u.t.!.1.. ....... Name of Ownerl2.t?f i�T. .,..� i f��roiu .................Address .'.L .11..0r..� ?zi..... /✓d.G.I6�.. �, . . !?��Za Name of Builder .AR.Ai..s 1�-k.I :S�:J.��l/A<C.k... ......Address .. +'..2-....c11..•..1.t1.�.d ... T..... `!.�. J �.f,.�/1.f^r.� Name of Architect ..............................Address .................................... .................................................................................... Numberof Rooms ..................................................................Foundation .........f.7...........-.►........................................................ Exierior ....................................................................................Roofing ..Arp.A!1f"�:I..1.......................................................... Floors .Interior .................................................................................... Heating ....................................................................Plumbing ...V............................................................................ Fireplace ..........00....................................................................Approximate Cost ...070,,40:o-V.................................. . ........ Definitive Plan Approved by Planning Board ________________________________19________. Area .. /..�.....�r. ....�........ 00 Diagram of Lot and Building with Dimensions Fee �— ....................................-....... SUBJECT TO APPROVAL OF BOARD OF HEALTH a. A AN 2 r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. /! ?� G Nam .... ... ... ........... -.. Newcomer, Robert B. 18022 add carport to . No ................. Permit for .................................... single family dwelling I � Lietrim Circle Location . .............................................................. i Centerville ` ..................................................................... ...... Robert B. Newcomer Owner ' Type of Construction frame tJ a . ....\......................................................................... ` #30 'Plot ............................ Lot ................................ y October 28 75 Permit Granted .............. 19 'r? Date of Inspection Date Completed � ...'..... ..19 r ._... 4, r PERMIT REFUSED r .• ` t .............................. 19 .......................................................... .................. ......................................... ......................................................................... r , ............................................................................... i Approved ..............................................:.. 19 ............................................................................... QyofTNETo�� TOWN OF BAR.NSTABLE i BARNSTABLE, i "b 9 BUILDING INSPECTOR O �0 am a' i APPLICATION FOR PERMIT TO .... ........................ .. . ...�!/ ..................... . .................. ...... .......... TYPE OF CONSTRUCTION ... ...... .. .. ... . ...... .... ... . .... ............19. ..... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location. ..(4..L........3.'Q..... ......... . Proposed Use �!1,/�- ..... .. ...... ........................ ................................... �" -- ZoningDistrict �'...... .... ...................................................Fire District .... ......Q........... . ........... .. ................................ r ' Name of Owner Q.. . .. ..... . .. ....... . ...Address ...A...1�.....OU....` .... s .. Nameof Builder ....................................................................Address ............................................:....................................... Nameof Architect ..................................................................Address .................................................................. ................... Number of Rooms ........ ...................................... .......Foundation Exterior .....`.k ...............................Roofing ........... ....................... ................. ............................. Floors ..........................................................;........Interior ................. ......... . ........... ... .......... ............................ HeatingP...H.w.......................................Plumbing ........ ....................................................................... / Fireplace .......` Approximate Cost 1 a U � �.. ...........................................F- Difinitive i Plan Approved by Planning Board ________________________________19________, FOR Diagram of Lot and Building with Dimensions HE PROPQSED METHQD OF PRO ���S®S L5 T < Y., SANITARY WATER SUPPLY, SE�� ED AND DR J TOWN OF Bi RNSTADI B, BOARD OF REALTH .79 A LIcErvs INSTALLER MUs r C jrurns A(;� PEI MIT. D KSTALL SYSTEM... 00 r� '?`!- � ram"i� t nnL C �® hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . ...4�r! 8.......... Dacey, Williara E. DEC 3 11971 No ...�3833 permit for ,, one story, single family dwelling ............................................................................... Lietrim Circle Location ................................................................ Centerville ............................................................................... Owner William E. Dacey . .................................................................. Type of Construction ffame .......................................... ............................................................................... Plot ............................ Lot ......... ................ f Permit Granted .......Nay.4......................19 71 Date of Inspection ` Date Completed ......................................19 1 PERMIT REFUSED ................................................................ 19 ............................................................................... I ................................................................................ ............................................................................... j Approved ..e......'7 /�.�...... .i..6P119 - 4 ............................................................................... ...............................................................................