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HomeMy WebLinkAbout0047 LONG POND CIRCLE aef ACTIVE u. Town of Barnstable *permIto t#� ��✓✓ icee >Aatveru;u. : : x Regulatory Services. » �e, Thomas Fi Geiler,Director g / Building Division Tom Perry,CBO, Building Commissioner '200 Main Street,Hyannis,'MA,02601 ` w: A www.towt%barnstable ma.us Office: 508-862-4038 Fax:508-790-6230 EXPRESS PERMIT=APPLICATION; RESIDENTIAL ONLY ,p Not Valid without Red X Press Imprint t Map/parcel Number ,p�CJ `1.0010 Property Address �1 '�> =Y'U► tl C:l°f Ac- Restdential Value of Work _ . Minimum fee of$35.00 for work under$6000;00 ... ' Owner's Name&Address' � �»r,�e � �►mtma.nn �D'-s Bad 53 Sprink a ome Improvement ` 508 775-1178 Ek"10 Contractor's Name'o-199 Barnstable Road Hyannis MA'02601 ".` Telephone Number - Home Improvement Contractor License#,(if applicable) 108757 Construction Supervisor's License ]Workman's Compensation Insurance y Check one: ❑ I am a sole proprietor ` r k Lam the Homeowner' " ' 3.? �] I have•Worker's Compensation Insurance Insurance Company Name. A I M'Mutual,lnsuranoe Co 8,� �� . E _ 7004943012013 rge�F Workman s Comp.Policy:# ; x Copy of Insurance Conipliance.Certificate must accompany each permit. . ' Permit Reques check box) Yarrnouth Transfer Station JW Red-roof.(hurricane nailed)(stnppmg'old shingles) All constr iction'debris will betaken to . Re-roof(hu'rricane nailed)(riot stripping Going over', existing layers of roof) 0 Re-"side of doors 0 Re lacement:Wmdo_ws/doo"'p sltders::U-Value°' '(maximum.35)#of windows 0`Smoke/Carbon Monoxide detectors 4 floor plans marked with red'S and inspections required Separate Electrical&Fire Permits required . 'Where'requiriid: Issuance of this permit does not exempt compliance with other town department regulations,i.e Historic,Conservation,etc. * *Note: Piopetty'Owner must,sign Property`Owner Letter of Permission tco., fa a Improvement Contrac_tors License&'Construction Supervisors"':License is ` 07 SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Te rary.Intemet Files\Content.outlook\ IT6ZUBMEXPRESS:doc " Revised 053012`: •:' I The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information k Please Print Legibly Name (Business/Organization/Individual)'- Sprinkle Home Improvement Address: 199 Barnstable Road ' City/State/Zip: Hyannis, MA 02601 Phone#: 508 775-1778 Ext.10 Are you an employer?Check the appropriate box: Type of project(required): 1.[XI am a employerwith 10-12. 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑Newconstruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition workin for me in an capacity. employees and have workers' g Y p ty 9. ❑ Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 1Goof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other, comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: " t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: A.I.M*Mutual Insurance Co: Policy#or,Self=ins.Lie.#: 7004943012013 : Expiration Date: 1'/01/2014 (� Job Site Address: 4 QN/ �SCl` City/State/Zip: lL lIe_ I Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.Section 25A of MGL c. 152 can lead.to the imposition of criminal penalties of a fine up to$.1,5100.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine , of up to$250.00 a day against the°violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covera rification. ' I do hereby certify under th s a ties of perjury that the information provided above is true,and correct. Signature: Date: Phone#* 508 775-1778 Ext. 10 Official use only. Do not write in this area,to be completed by city or town official ti City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2:Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town.of Barn�staUIe N . • Reguator Searvrces ,16mas F Geller,TDirecWr '�Fo xte JBu Id* T1�Yiszon Tenn Parry,Building Comniiwi6ner: 2(10 Main:Strect;Hyannis,MA 02601' ; www.tawmbarftstable.ma.us b.arnstabte.ma.us Office: 50&o862, 403$ Fax: 508-790-6230 a Property Ow nermust" omp ete and ;71 n T us-Seca on If Ixia A 8u lde r ,.: as Owner cif the subject property he.J*yY*the raze Sprinkle HomeAmpr,.ovement rn:act on,n g-b half, ux al1 matters reWiye to work aut£ioz�d by this b old ng perMLt,applicatioa.for. a., w R ' Addicss of Job} cIrPat: Print N' - f Proeity ORmer is agply .ng.for pearrljt please co>�Plete axe omeownexs License ]Exempt oft Form on the reverse side, A F(1R'Aii.CefJWKTF.RPFRNFT.CCi!?TJ'.'.. SPRIN-1 OP ID:DS .. .4COR0` DATE ` CERTIFICATE OF LIABILITY INSURANCE: (MM/DD/YYYY) ,2/211112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE,ISSUING,INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. a IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)mutt-be endorsed. If:SUBRO.GATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights-to.the certificate holder in lieu of such endorsement(s). PRODUCER Phone:508-775-6060 CONTACT B den&Sullivan Ins Agency NAME: 88 Falmouth Road g y Fax:508-790-1414 a/c°"N Ext. FAX No Hyannis,MA 02601, ` E-MAIL ' Kelley A.Sullivan ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# ` IN SURERA:As'ociated Industries of MA INSURED Sprinkle Home Improvement Inc._- `' INSURERB: - - - 199 Barnstable Rd Hyannis,MA 02601 INsuRERc: INSURER D: INSURER E INSURER F: ._ ..:. . < -... COVERAGES CERTIFICATE NUMBER: " ' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN.ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. ,NOTWITHSTANDING ANY'REQUIREMENT, TERM OR CONDITION.OF ANY CONTRACT OR OTHER.D000MENT WITH RESPECT:TO WHICHTHIS CERTIFICATE_MAY BE.ISSUED OR,MAY PERTAIN;THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT.TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS., w . INSR .. - DDL SUBR - - - POLICY EFF POLICY EXP L LTR TYPE OF INSURANCE. `' POLICY NUMBER t MM/DD/YYYY MMIDD LIMITS GENERAL LIABILITY -� `- � ... :EACH OCCURRENCE_, $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ - PERSONAL&ADV INJURY • $ . GENERAL AGGREGATE- $ GEN'L AGGREGATE LIMIT APPLIES PER. f ^ PRODUCTS-COMP/OP AGG $• POLICY JECT PRO- LOC $ AUTOMOBILE LIABILITY COMBINED Ea accident SINGLE LIMIT ' ; . ANY AUTO - BODILY.INJURY(Per person] $< -ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS .NON-OWNED , PROPERTY DAMAGE AUTOS Per accident` �. $. UMBRELLALWB OCCUR `',' EACH OCCURRENCE $ .77 EXCESS LIAB CLAIMS-MADE f AGGREGATE" $' ' DED RETENTION$ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN ' r TORY LIMITS .1 ER' A ANY PROPRIET H)IPARTNER/EXECUTIVE N/A AWC7004943012013 01/01/13 01/01/14 E.L.EACH ACCIDENT- $•. 500,000 OFFICER/MEMBER EXCLUDED9 .' (Mandatory In y E.L.DISEASE-.EA EMPLOYE $• -50.0,000 If DESCRIPTION OF OPERATIONS below ' E:L:DISEASE-POLICY LIMIT $ 500,000' • DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) .M i•+ ` •. ,E•- •, •' � .V • III CERTIFICATE HOLDER' CANCELLATION SPRNKHO. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE.CANCELLED BEFORE E EXPIRATION DATE THEREOF, NOTICE WILL, BE •DELIVERED-IN- Sprinkle Home Improvement,Inc_ ACCORDANCE WITH THE POLICY PROVISIONS :Margo Mack ' 199 Barnatable'Rd. AUTHORIZED REPRESENTATIVE Hyannis,MA 02801 Kelley A.Sullivan ©1988-2010 ACORD CORPORATION. All rights reserved. ' ACORD 25(2010/05) The ACORD.name and.logo are.registered marks of ACORD '� Unrestricted Buildings of any use group which. contain less than 35.000 cubic feet(991m3}•Of' Massachusetts -Department of Public Safety enclosed space. Board of BuildingRegulations g s and Standards C'nnctruction Supcnisor . .License: CS-006643 'BRAD,K SPRIN4--E': t90:LOTHROPS.iJAN' .failure to possess a current edition of the Massachusetts W BARNSTABLE MA«0 State Building Code is cause.for revocation of this license: r For DPS Licensing information visit: wwW-Mass.Gov/DPS ` J.:�w.. �/ Expiration Commissioner 10/08/2013 Office.of Consumer Affairs&Business Regulation License or registration valid for,individul use only 41OME IMPROVEMENT CONTRACTOR before the expiration date. If found.return to: t registration: 103757 Type:. Office of Consumer Affairs and Business Regulation ;expiration: 7/9/2014 Private Corporation. 10 Park Plaza-Suite 5170 "x Boston,MA 02116 - SPRINKLE HOME IMPROVEMENT,,IWC. Brad.Sprinkle 199 Barnstable Rd. � Hyannis,•MA 02601 - -- -w - Undersecretary Not valid witho signature Town of Barnstable *Permit Regulatory Services �ees 6 nwnths from issue date . g ry KAM 1"9. Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - :RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number QnCj QCj0 Property Address_`4-1 LmY Pad. C;i r c.`p_ p Ag TY\A [Residential Value of Work Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address��v\,e_ r)d,y\(\,e_M o_n Contractor's Name Sprinkle Home Improvement Telephone Number 508 775-1778 Ext. 10 103757 Home Improvement Contractor License#(if applicable) Y®R C S C ®IE R AAA T Construction Supervisor's License#(if applicable) CS 6643 J.UNI 5 2012 )QWorkman's Compensation Insurance Check one:. ❑ I am a sole proprietor TOWN OF BARNSTABLE El am the Homeowner ® I have Worker's Compensation Insurance Insurance Company Name Associated Industries of MA / A.I.M Mutual Insurance Co. Workman's Comp.Policy# AWC 7004943012012 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) 0 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) e-side #of doors ❑. Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *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 coy a Improvement Contractors License&Construction Supervisors License is e e SIGNATURE: C:Wsers\decollikWppData\Local\Microsoft\Windows\Te rary Internet Files\ContenGOudook\DDV87AAZ1EXPRESS.doc Revised 072110 r The Commonwealth of Massachusetts L Print Form Department of Industrial Accidents t Office of Investigations �. 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual) Sprinkle Home Improvement Address: 199 Barnstable Road Ci /State/Zi Hyannis, MA 02601 508 775-1778 Ext. 10 h' P Phone #: ,t Are you an employer?Check the appropriate box: Type of project(required): l. I am a employer with 10-12 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance . comp. insurance.» 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 L[] Plumbing repairs or additions myself. [No workers' comp. right ofoexemption per MGL 12,❑ Roof repairs insurance required.] t ' c. 152, §1(4), and we have no rj F 13•�Other employees. [No workers' �Su comp. insurance required.] Any applicant that checks box#1 must also till out the section below showing their workers'compensation;policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.. Insurance Company Name: Associated Industries of MA./A.I.M Mutual Insurance Co. Policy or Self-ins. Lic. #: 70049430120t2 Expiration Date:_ 01/01/2013 Job Site Address: y 1 1 .l'0✓tCL. City/State/Zip:Clu Y,,Q-e (Y14 Attach a-copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to,secure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penaltiesofa 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 insurance coverage verification: I do hereby cert)t unde ain n enalties ofperjury that the information provided above is true and correct Si ature: Date Phone#: 508 775-1778 Ext. 10 Official 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. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Town of Barnstable Regulatory Services Thomas F.Geller,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder LAVy e-wkaff\ ,as Owner of the subject property hereby authorize Sprinkle Home Improvement to act on my behalf, in all matters relative to work authorized by this building,permit application for. c41 Lcsv,q Pon A (Address of Job) Signature of Owner Date t Print Name IffProperty Owner is applying for.permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Usersldecoltik\AppDaU\LoW\b icwsoMWindows\Temporary tntemet Files\Contmtoutlook\DDV87AAZ\EXPRESS.doc . Revised 072110 J 12/ ZU/ZU1.1. 9 : 35 : 33 AM . 8740 2 02 /09 CERTIFICATE OF LIABILITY INSURANCE DATE(Mioi2oii —1 THIN CNN.TIrICaTt Is Ing= As A NUMM or IRrOR1wIOR ONLY AM CONPZRS so RIGX" OPON Tom CZRTZrICATN NOLDNR. TNIN CNRTIFICATN Oots.NOT +ArrlRmwzvsLY OR /ZSATIVZLy AnoD,, ZMED OR ALTN= TNZ COVZRASN ArrCm= BY TNZ POL2CIZS'•siLOs. =NIB CNRTIricATN Or LISORANCZ DOZE NOT CONSTITOTN A CONTRACT NNTSZNN TNZ 2SSOINO 2999Rd(s), .AOTNOLIiZD RZPRZSNSTATIVN OR PRODOCNR, AND TNN CRRTIrICAU NOLDMR. - XWORTANT: If thS OSrtifieata holder is an ADDITIONAL INSORZD, the policy(ies) must be endorsed. If SORROOATSON Is wAIVND,, subject to the teas and conditions of the policy, certain policies fry require an andorsa eot. A statement on this certificate does not confer rights to the certificate holder in lieu of Such enliorsesent(s)cimbET . 1 rsDs Srydea 4 Sullivan Ins Agency TAX Inc (lVc:s.. on1: (bc. ■.1: 88 Falmouth Road Hyannis, M& 02601 CIIDTemA I». '"Dann+arsolfl rr•"imo mesh" Sprinkle Hame Mmpravemeent Inc Leo„ A.I.M. 1[utual insurance Co 33758 T- 199 Barnstable Road: ,o Hyannis, NX 02601 Ia•„Ao ., Isfsao[: COVERAriES ca"IPICATE N0MtR: REVISION NOIBER: Vw IS To c mem sw ISNI POZACM Or XXXONAM Lrflm,MISM mars ago Iif -M TO in LsamNo YNa man POR In POLICY P301200 ZEDrCs7ED. i N 22222 N An O-N , 100M OR oosp;Tros or any cormacr an onn, NUCSPNOr tea amrwv To Nsra wn C�am .ISSUED an am PNR'87N, L>i zoammance AP'NORNa By la PoiLrCM onscaaED sass Is smwwv To ALL vwx seam M=azIoe[ Am OcEnTLof1 or Paco so[sem. nears Ssoel � MT sass eTa UMMM MIT SAW C&&= -Posen Ndr♦ss - roLrnr an PaLreY m LINZ" MR or Lssoaallo ,tw.n..► ruanT.T - iA01 KatmAK[ • 000MfaCGL "AIR" LIADILITT ��.„��.. — • .. — . [eitY[l[..�owtt..al 00 CLLIRO 1MD[ OOCCDR O m Ifagte.DreMatl • —,.. QI •O L G S&V IDoral • Dff'L AGUI"n.LOUT►►ItIn Is: DDiYL SAMMI[ • i ❑,CLICT 13rameT❑IAC. rosaDCT•- c[De/tr.ADD-- • • aUloroeai LtaR>?.ITr Ce =0 SENILE LIMIT • /.� t4Da1 QAST ADSO -CALL OIe[D AUTO* Y DILT MISS to., .—I • }}} ❑KD2 DO1.fD ADTCO [D►[LI La4m t"..mtY.t/ D �[OD-0e[D ADTD• _f • OeARLA LIAR13 ACC aR LA01 KQeaOa • t :❑[Ttfp LG•` Q GL DO RMDD � ` ADiADATi • ---__.— ,NO„LOYOi.,IaRA�TY - .. M ^;.DT Laos, Try P)DOPRIEIVI"ARTNLR31 [.L. SAM ACCI.sIN • - 500,000 EXCCVPIVG Orr ICGR3 ARL A. ® incl Q excl 7004943012012 [•L• •IfiAQ .DUCT LIMIT • Soo,000 01/01/2012 01/Ol/2013 S.L. DluafA SA f[eLDIM • 500,000 taemrt 868O1mTIM K KOlamms IS LwwxT D. - - - -- -- -- -- WORXZRS' COWOLSATION COVtRkM APPLIES TO-MASSACHOSCTTS OMLOYMS i CERTIFICATE HOTIM CANCELLATION DQOOP OP INSORANCL sEDOLo ANY Or Ta ANOTN DEXCU a) PaLZCXSS RX CAMMUKAD um=M fazaav= Asa TSORor, NOT=WIZZ So COLIYOED IN aOCDROfsCY wM VWX 4.. POLICY va"=LORs. l f _ ardDAISDS 5289 • i 1tttirro ,4lim irr�At�t�airs.1Iustnes% t.ulatmii z HOME IMPROVEMENT CONTRACTOR Registration: 103757 - 'Type: 6643 Expiration: 7/9/2012 Private Cwpuratu ;• SPRINKLi. HOME IMPROVEMENT INC BRAD K SPRINKLE 190 LOTHROPS LANE 1130 Spr nnir W BARNSTABLE, MA 02668 ,95 i3anuia.,:e Ra nder�ccrrtan 0�1 n:L3. [iO04 CegWraliun.%alid for individul,usc nul� Failure to possess a current edition of the hcf,n'i ;hr r�jtiration date. If found return lu: Massachusetts State Building;('ode t tifiri'uf(•unsumer Affairs and Business Reguiati,m' is cauw.for revocation of this license.' Parr. Plata-.'suite 51711' . KIa.Iun. \1 \ 11�1 Ib Refer to: w'WW.Mass.(;uv/I)PS Nol �alid Without sign,turc 1" { I t►,E Town of Barnstable fermi �{. t Expires 6 monthsm •ss e Regulatory Services Fee . Thomas F.Geiler,Director p AL AT fD MA't��' Building Division Tom Perry,CBO, Building Commissioner . 200 Main Street,Hyannis,MA 02601 www.town.banistable.ma.us -Office: 508-8624038 Fax: 508-79.0-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint a�c� Map/parcel Number C 01 �. Property Address `4-7 L C►r C1 Residential Value of Work" / Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Po gip( 531 (,)P,- 04U3� Contractor's Name LTelephone Number 5b7 --.l-7 S-l l 18 Y Home Improvement Contractor License#(if applicable) 1 0 7 5 7 Construction Supervisor's License-#(if applicable) C,5 CpCp y `' ~ &kman'sCompensationInsurance - j PERMIT Check one: ❑ I am a sole proprietor J I� 7 ❑ I am the Homeowner ®Thave Worker's Compensation Insurance TOWN OF BARNSTABLE t � Insurance Company-Name QmQcia-JtA Workman's Comp.Policy#�l:�C������U�O�� Copy of Insurance Compliance Certificate must accompany each permit. Permit Requestheck box). ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors - Replacement Windows/doors/sliders.U-Value 3 (maximum.4'4)'#of windows *Where required:Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,eta ***Note. Property Owner must sign Property Owner Letter of Permission. �ome Improvement Contractors License&Construction Supervisors License is. re , SIGNATURE: .Q:\WPFILES\FORMS\buildingpermit forins\EXPRE S.doc Revised 090809. , t ._ The Commonwealth of Massachusetts > Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 . ,www.mass.gov/d�a Workers' Compensation InsuranceAffidavit: Builders/Contractors/Electricians/Plumbers Aaalicant Information 'Please Print Legibly Name(Business/OrganizatioNlndividual)'S k-I2 40M inn 11 Irb ve—rA e.A - Address: bye RwA City/State/Zip: 4 A6 MLIq Oa(00) Phone#: -60 Tr- _7 7.5 l-77 3 A�ree,yyou,an employer?Check the appropriate box: Type of project(required): 1.LJ 1 am a employer with 4• Q I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* sub-contractors.have.hired the _ hed 2.❑ I am a sole proprietor or partner- listed on the attache sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• ,E Demolition workingfor me in an capacity. employees and have workers' Y P tY t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.Q Electrical repairs or additions + 3.[] I am a homeowner doing all work officers have exercised their 11.Q:Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c.152,§1(4),and we have no employees.[No workers'� MR Other.Ro,,�r� comp,insurance required.] ,^ 0 *Any applicant that checks box ill must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: SSOC. Q.� Z'�nc�.t ts�ftC,S . es�- Policy#or Self-ins..Lic.M AWC, 700 q 9 q ,301 e1b 10 Expiration Date: nt 01 [ Job Site Address: 9? t'1�i P6 City/State/Zip:"14r� tc��e. wlA 6��3 Attach a copy-of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 Invests ations of the DIA for insurAinge coverage verification. I do hereby cent' nder ns and penalties,of perjury that the information provided above is true and correct. Si nature: Date Phone !#: 5 U6. ?7 5• 0 IRI Official use only.. Do not write In this area,to be completed by city or town ofjlclaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: coRv® CERTIFICATE OF LIABILITY INSURANCE RIDS DATE(MM/DO/YYl'Y) l O1/05/10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 - Phone.: 508-Z75>6060. Fax:508-790-1414 4INSURERS AFFORDING-COVERAGE. NAIC# ---- - —INSURED I— INSURER A Associated Industries of MA Spprinkle Home Improvement Inc. INSURERc 199 Barnstable Rd INSURER o Hyannis MA 02601 ----- --. _..--- ---- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN.IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - ^ —.— �'0rFCYM FEZTTV I N --- --- LTR NSRI TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YYYY DATE(MMIDDIYMI LIMITS: GENERAL LIABILITY EACH OCCURRENCE $ „COMMERCIAL GENERAL LIABILITY "I .PREMISES TO-RERTE Ea occurence - $ - CLAIMS MADE OCCUR I I MED EXP(Any one person $ _ ) PERSONAL&ADV INJURY $ GENERAL AGGREGATES� GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGGPRO- $ i POLICY ECT LF LOC w -- — AUTOMOBILE LIABILITY - - - - - COMBINED SINGLE $ " ANY AUTO 1 (Ea accident) - i j ALL OWNED AUTOS BODILY INJURY SCHEDULEDAUTOS (Per person) i$ i HIREDAUTOS I' BODILY INJURY NON-OWNED AUTOS I (Per accident) PROPERTY DAMAGE I$ (Per accident) - GARAGE LIABILITY i AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S. _ AUTO ONLY: .AGG. $ EXCESS/UMBRELLA LIABILITY =" EACH OCCURRENCE $ OCCUR r CLAIMS MADE AGGREGATE $ DEDUCTIBLE I g RETENTION $---- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TORYLIMITS ER _ A ANY PROPRIETOR/PARTNER/EXECUTIVELJ AWC7004943012010 01/01/10 01/01/11 E.L.EACHACCIDENT $.500000 OFFICERIMEMBER EXCLUDED?: - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $5000,00 If yes.describe under .'. SPECIAL PROVISIONS'below I' E.L.DISEASE-POLICY LIMIT $500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS.I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER - CANCELLATION' . FSE Y OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SPRNEQiO EOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL.,10 DAYS WRITTEN THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, -Inc OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ` FaX Margo Mack ATIVES. REPRESENTATIVE 199 Barnstable Rd. A.Sullivan • ' annis MA 02601, ACORD 25(2009/01) ©I9884009.ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r 1ia�•.le:fi,u.�t is Di.l�arttilrnt rfit� if Pobh ' , i3ir;ud of E3uiltlin Ilt<ulatlrm. iunr ShIn,l trt•1 : con S struction upervisor License License: CS 6643 v.,., Restricted to 00 t BRAD K SPRINKLE 190 LOTHROPS LANE ' W BARNSTABLE, MA 02668 Expiration: '1018/2011 , r 7r 5478 x• Restricted to: 00 00 Unrestricted: _ 1G.-1 2 Family Homes + Failure to possess a current edition of the Massachusetts State Building Code- is cause for revocation of th_is license: Refer to: WWW.Mass.6v/DPS . ,p� ✓/ce.Pamananuieall�i o�✓vuuoae�iud , —\• 8.6atd of Building Regulations and Standards-r. HOME IMPROVEMENT CONTRACTOR Reeist 103757 s :. 9/2010 1W 9 10:3:3 SPFf1T9k�i.E rio rJe Brad Spd► le 19A Bsrrfist0le.Rtlr' ,�,:e s•ao�g L Onse,- r reg►s rg -bit)'e fhe expiratiaq date If found return to ;RQard;of guildpg#'egulations and Standards -.0. Ashburton Place•Rnt 1301. ' r..Bostoq,�Ia 02f;08 . - • -.,' ?. *,< Not trghd wlt out silgl `ture s Yz Tori of: arritbie' Reo�tory Sexy ces Thomas$.:Getter°Dixeefiot Bux IviSTOII ToYn Perms, uil iTO C0mrit1s prier, .204 Main'Siree�,H'yaniu�;2y�A U2.6Q1. - www towm baTxlstablg ma;us: Office- 508462409 fax: 50$ 7,90-623.0 I'rOper (J'mi C�oUVI ee, aM Sxgxx'�'h�s'`See o n If U.ixzg A Bu cher +�T � �'1ciy�i ( nnecav►✓� : as derstbJct prpperty hereby aut Ooze 'SPRINKLE HOME IMPROVEMENT, INC to act ou rzxy behal€, in all rnattiers relatiae,tc warp authortzeci b this bd n permit application for:'' ddrss af o a: 5�1 �L S' Of r date . PnntNarne: I I� o e C caner a pl�tng for pcxx3n p e se co rnp E`^�e e, �axneo�vne�-s L�cnse.;Ex�n�pkion�a .an �e revers-e side,; Q FORM.SAW1IERI'BIt1r1tS5102t' i p TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION yMap :�o I Parcel 0 0^ Permit# Health Division `' Date Issued `6 Conservation Division w Fee �s�. c7 O Tax Collector. � 041, 2klol cfit: Treasurer Cc%II&Y7 SEPTIC SYSTEM MUST BE Planning Dept. INSTALLED IN COMPLIANCE WITH TITLE 5 2 9�j Date Definitive Plan Approved by Planning Board ENVIRONMENTAL C,OrE)7 At, Historic-OKH Preservation/Hyannis Project Street Address LZnNPond A aC, e Village � � v Owner Q:0 '- 4. an ICE lean Address F1 Telephone _ �� 7119 Pe.imit Request ; ' 1 C k bs m a SGa Vy 16 X D w rN• N � 1 k�A Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation � QQO Zoning District Flood Plain Groundwater Overlay Construction Type Z-0 y 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: O Yes A No On Old King's Highway: ❑Yes A No Basement Type: Full ❑Crawl Cl Walkout ❑Other Basement Finished Area(sq.ft.) On Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 426 new Half:.existing new Number of Bedrooms: existing_ new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric Cl Other Central Air: ❑Yes No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 5°No Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn: ❑existing ❑new size Attached garage:Xexisting Cl new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization 0 Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION / q e D Name Telephone Number Address W( &e sgy-\ �%� e�in t�, License# O Home Improvement Contractor#' a� � 6 97-6/c'11/U II7#h Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t /. V-yo a SIGNATURE DATE 4 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS _ VILLAGE OWNER s _ i DATE OF INSPECTIONr , ! FOUNDATION FRAME j INSULATION r FIREPLACE ti ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH"1 "t FINAL ''! l GAS: ROUGHS FINAL # ; FINAL BUILDINGcr DATE CLOSED OUT AAfa '. ASSOCIATION PLAN NO. t , °F IME 1'4 The Town of Barnstable 9 BARNSTABLL MASS. g Regulatory Services 059.TEp t�.t r Thomas F. Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date a19 Jh'i 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. Type of Work: 1 Ce, d� � CX Estimated Cost Address of Work: PbV) CA Ed �' Owner's Name: k4/1 Date of Application: �� a I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 ilding not owner-occupied owner pulling own permit I 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: N)Da tractor Name Registration No. / OR Date . !f Owner's Name q:forms:Affidav f The Commonwealth of Massachusetts =`-- :N Department of Industrial Accidents Office 010YOSM91 /oas 600 Washington Street gt ` }J% Boston,Mass. 02111 ////// Workers' Cow ensad n Insurance Affidavit FRIF 4 name: Aaff,V 5i},(J' 41 ndt9 location: ��' � ( 1'J city I am a homeowner performing all work myself. L., tf l tf j J am a sole p roprietor and have no one working m anv capacity ❑ I am an employer providing workers' compensation for my employees working on this lob ........ Camt)anV flame' ..: ........... .. :..: address QtV'" pilbfl@�#. :.:.. .. insurance co. ? v ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: ..::.....::.::::,: ::::. :.:::.::.::::::::.::.:::.::.::.:.:::::::. ::::.::. :.: .:.:::::::::..::::::.:::::::::::.::::::::::.:::, comoaflv name ....: ,::.:::;.;:;;::;.>::::.::.:;;:;;;::..::.::..:.�...:.:. :....:....... ........... :: ::•:.:.................:::.::................................................. citv�:,.: ::::<::.. .olione nsntance-co:.:;. ,....: ..... •:::::• ..:.. ... .........:.. ................. $rtv name: - address. _ _. cltn-:; - nsnrancevo. ..... WIN ------------- � . game to secure coverage as required under Section 25A of MGL 152 can had to the imposition of crtminal penalties of a fine up to S1400.00 mi/or one years'imprisonment as well as dvfi penalties in the form of a STOP WORK ORDER and a Hoe of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Inv of the DU for coverage verification I do hereby certify e p pen es of 'thee forniatson rounded D above is true and coned Signature— J r ate 117 Print name 1 Phone# S official use only do not write in this area to be completed by city or town official dty or town: permdt/license if ❑Buiidinc Departmentsi ❑Licenng Board ❑check if Immediate response is required ❑Selectmen's Ofte ❑Health Department contact person: phone d; ❑Other ; (revaed 9/95 PJA) 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 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 to ' employees. However the owner of a or other le y trustee of an individual,partnership, association gal entity, emp vurg emp 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 renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public worm until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting 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�*+�,*ance as all affidavits may e Accidents for canfimmation of insurance coverage. Also be sure to sign and submitted to the Department of Industrial 'cease is 'on for the permit or h date the affidavit The affidavit should be returned to the city or town that the apphcan p being requested,not the Department of Industrial Acciderrts. 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 peimit/license number which will be used as a refer©ice number. The affidavits may be ruined to, the Department by marl 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 hesitaie to give us a call. ��_{X - ME The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents amce of Invesugadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat. 406, 409 or 375 ""1 � t• R S�,i/liw�:1�1 '�. � �18-� }:�r 1 Leff !ri. '4 � 1 .Ii'1,. 1 " I�b tgU1��e (07Sn -- ------- 3G G:, 000 Soo Nip h \ IC �,t oe2 s�RntsrnaLe. e 9� HAS& ��� Regulatory Services .39. Thomas F. Geiler, Director Building Division Elbert Ulshoeffer, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-62:0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: �o 3 v JOB LOCATION: / �U �U OLCLJ l /�. P l ��✓1 G�'�' number q 1 ,pstreet villag—e "HOMEOWNER": / �/��J��/ /��/!t//V L' Y�1 (/ JM� 7 3 name home phone# work phone# CURRENT MAILING ADDRESS: city/town state up 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. e and r e "homeowne 'certifies that he/she understands the Town of Barnstable Building t� nimum inspec on procedures and requirements and that he/she will comply with said pro a res irements. ignat e f H meowner 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 t amend and adopt such a form/certification for use in your community. Q:FORMS:EXEMP'L'i`! r � - F hi , r •' gg -.-..+IrF�+• f�,a +p�, .,< 3 ��,�... � ��•_..; -ti .i' •� ., s sy{ F i +.++++.++.++.++.++.++.++.t �r" • ni Srdpa. ; #i•+ttttt+t+++t++t+i „v_ x f+,'"f� + 4 f •- a,. +t+++tt++'+++++++'"r ��+ '�_"'" �' .i'`•} w r.7g 4 • t• �a +t+ttttt++ * +++++++++++++*+t+t+t+t+t+t+t+t+4.4 ++i+ ,w • }t}+}+}+}+}+} a ++++++++•++•++•++++4: '� • •c- , .,�ttt+ttttttt+ttttttt+t+++++++++++ k. 'fir � ■: .' ++++++++++++++++i ++**++*+*+t+t+t+t+++ �``'� its„•, � -�+*+*+++*+*+*+++*+v*t*�* �� ' i a, k' ! L M l • � Riot r .Plan , 0 BEDROOM _J --_ --- BEDROOM n r X n r BA '(l I rr X a Ir �J BATH HALL, BEDROOM _ - BEDROOM I i .. .. SEW" / a.x..xo•lu^ Upper _ 24'0"-- ------ —6#Q-- -- 36#0'"_...... . . a.—._....a_n n___ 1 . orctt ti'o'•x Io'o' I I ' I TWO-CAR GARAGE -- cr 717 i - turcitE N-FAMILY ROOM ENTRY Tm .�xnamavau_.wc• � I �` (• DNNG ROC)M t VNG ROOM FOYER Lower --- --. 1 SIC � , V, !.Sa i� Aspes'sor's, map,and lot number :/........`.....(..... 4 CF THE T� Sewage Permif,number .....&gz`7:.... ...................... SEPTIC a r-a. r. INSTALLED BE BAHE�98TADLE, i .. 6 C —.. V Z House number /. ....'........... t�4 �� �,� + 'f' db �,tle WITH y LE 5 ib79`��e� R = TOWN OF BARkTPTP5C, f: BUILDING - INSPECTOR APPLICATION FOR PERMIT TO "-1........ ...................:. I(/`/d /�� .1✓ TYPE_ OF CONSTRUCTION ...................51.............................�....................:..........................................................:. ......................... .. .......... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby! applies for a permit according to th'e following.,information: Location ... :.... .d...... ./a.°'^!. ......... dr.U.d............?k.C.ee........ . ........ .r • ✓).,mu. 4�4...................... Proposed Use ....s !�M.. .(s�......V..d Ma1.. ........................ .. ...................................... p.....:......................,.:....................... Zoning 'District ........�. /............:...............................Fire District ................0 .k.. .,......................................... 1.. �. •�J 7 Jd�.lA�C1�..:Address ....�•.Cd. .�.... C/... Name of Owner Q:k .. ct�.. .Y.r�s. ... -� �- .67* ter'../.................Address *:e.: ............ Name of Builder .... . . .. :... Nameof Architect ... . . ...................................................Address .........:.........................,:..........................:.................... A/ Number' of Rooms ...........��..................................... ...............Foundation .......... ....................................:......................... C€ , . Exterior .......�!d!,..t��......��..��.��-�....1 a��� c��r��......Roofing ................ .. � .. !........................,.............. Floors , ..........( c�[�.1 .....:.ay. , .d: ?. ................................:....:Interior. ...........5.,L J... ,`a i .............................:...... Heating ........`&IT....A.°r.......... ..Jay............... ..... .Plumbing o� .�....�t?�L�. Y................. ................... Fireplace ...... ..... Approximate. Cost.......:..:. .. ......................................................... ... �........... Definitive Plan Approved by"Planning Board _____________________________19________ . Area ....,/ �.�.. ......,? Diagram. of Lot and Building with Dimensions Fee (��' .6 (�/' SUBJECT ,TO APPROVAL OF BOARD OF HEALTH c � OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS ' I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regar hg the.above •, construction. _ c. Nay .... . . .... 1�.,,� .,, ........ Construction Supervisors License �r _ — -- rA BAYSHORE BUILDING TRUST t r •Noi.,,27197... Permit for ...One Story............. `....5i gle..Family...i wePZLing...................... Location .....Lod..90,••47••Lor�g.•�ond Circle Centerville Owner Bayshore Building Trust, Type of Construction ....F:rame . ................................................................................ Plot ............................ Lot ................................ I Permit Granted .....N.........ovem..b..e.......r 7.:.............19 84 Date of Inspection ;�......;..!"1i` ..21° 19 .... .y. ...... Date Completed :.." �.` r .1...............193'' r f- y. S.j _ k I qj 9.3 , � -, .30•o0 r G4 0oo :5 0 M ' rrnn 0 v1 M 5- 97't Q n • 9 W S? . N U G 0 ,0 CE-,E?T!F'/&'ZZ7 PL oT /o.L AN 3CO7 L-C-: / : 40 a.4Te :Oc . 2 .eEFELC�t/cE: Bei�JG �1 /�F�,2cEL o� 1 GA,VD �5 5H�7l.�)�/ /N PL. BK, Z59 f�•8�• ��, S U/LD/1,J G CO. j d S /-/GCt"AY CL'GT/FY TNt7T THE BCJ/LD/•t/Qr �,�"�--'A -k'a SNoN/.V O.t/ TN/S P4,0* / /S LOC,4TEa ON Tx/E y�ovNa fi3 3NoWN //BCBaW A:7Ava T.ygT /T DOES COAA-C>&-A-f TiO T•'�� zO.t//�l/G e �c' GEOA ,E '•',� BY-Li411/.S OF T'h/E Tt lWA/ OF'F/G}1NST1943LE • s L 4 JR. } • 1 #V A-I&A./ cov, 807 N O!mot/ LV E L L E- //y c, ��c r�:` : �. Y/9ie MO UT H , A119 S S. afa�•e�- 8�- 3/4 TOWN OF BARNSTABLE � Permit No. Building Inspector 1 �,ua.n Cash --------— °""'� OCCUPANCY PERMIT Bond Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health ! r _- lit, Inspection date �— �� THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ....................................................... 19............ :z ' ..: A'�...__ C..:...Y._�......�.... `ry Building Inspector .JOgEP'H'D`DALuz _ TELEPHONES 775-1120 Building Commiuiontr EXT. 107 TOWN OF BARNSTABLE BUILDING INSPECTOR TOWN OFFICE BUILDING HYANNIS, MASS. 02601 �EMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the buil'dinR authorized ,by Building Permit # r l issued to /1 Please release the performance bond. i p,S T. 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