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A py of e Hom pr vement C ntractors License is required. SIGNAT Q:Forms:expmtrg Revise061306 The Commonwealth of Massachusetts .Department of Tndustrial,lecidents Office efInvestigations 600 Washington Street Boston,AM 02.1-7I VV W,M ass-gov/dia Workers" Compensation insurance davit: Builder s/Contiactors/Lleeirieians/Plnmbers Applicant Information Please Print Le 'bI Name (Business/Organization/Individual): . - •Address: j( ( I City/StaWZip: MN 1'I I� Q��Q.� Phone.#: 19 O Are you an employer. Check the appropriate box 1.❑ am a employer with 4. [] I am a general contractor and I -Type of project(required): employees (full and/or part-time).* have hired the sub-contractors 6• ❑New construction . 2. I am a'sole proprietor or partner- listed on the-attached sheet. •7. []Remodeling ship and have no employees Thew sub-contractors havo working for me in any capacity, employees and have workers' 8' ❑Demolition , [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 l 1 El Pi -mg repairs or additions myself [No workers' comp. right df exemption per MGL insurance required,] f c, 152, §1(4), and we have no 12 v Roof repairs employees. [No workers' 713.0 Othcr comp. insurance required_] *Any applicant that checks box#1 most also fill on t Homeowners who submit this a t the section below showing their workers'compensation policy infamnation ffidavit mdicating 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 additionalsheet showing t}w niune of the sub contrzctors and state whether Drool davit entities have employees. If the sub-contractors lave employees,they must providh their wohilm'co olio nurnbcr. thosecomp.P y Ism an employer that is providing mockers'compensation insurance for my employees Below isl'he policy andjoh si'fe information. Insurance Company Name: Policy#or Self-ins.Lie#: __ Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(sboSying the policy number and e Failure_to secure covers e as re xpiration date),, g quired under Section 25A of c. 152 can lead to the imposition ofcrjminal penalties of a. fine up to$1,500 d and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and.a fine of up to Rations 00 a day against the violator, Be advised that a copy of this statemeritmay be forwarded to the Office of Investi ations of the]CIA f - -e cove'ra e verification. I do h 're y cece e the pains• nd allies ofperjrcrJ,that the inforrnatipn provided abov is trice sort corec Sienatur \., Date Phone #: Official use only. Da not Write in this area,'fo he compleeed by city or town a�ciaL City or Town: Permit/License# Issuing Authority(circle one); L Board of Health 2,Building Department 3. City/Town Clerk 4,Electrical Inspector 5.Plumbing Ins ector 6. Other p Contact Person: Phone#: i NIassuchusetts- Department of Public SafetN Board of Building Regulations and Standards Construction Supervisor Specialty License License: CS S 99138 =.L Restricted.to: ,RF,WS JAMES CURLEY 287 FULLER ROAD CENTERVILLE, MA 02632 I Expiration: 1/28/2012 Commissioner Tr—,: 99138 fze;Uio?;zyx7�0 �� � t , Boa d of Building au1_ 8 �. b_ atinnsan.d-St nd3rds�•.R z �• I Iceb'se"or ;isiration tiahc.for indi idui use only HO E IMPROVEM• r CONTRACT R on dafe eurn NT e y Re stration�_.12410 Board of Bui ditil2egiilatrn sand SFandards E irati'on ,6l1l2 9"' One Ashburt Place Rm 13 Tr# .1 0873 Boston;Ma.0 108 -Type andi:Vid.al t James urle James Burley -= 287 FRd. ull r Rd Administratorwlfhout .b re ,a i ons an an ar s o��✓lt � Bb�ao1a beau a i b License or.registration valid for individul use only juHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 124310: Board of Building Regulations and Standards . Expiration: 6/1/2011 Tr# 284683 One Ashburton Place Rm 1301 Type; Individual Boston, Ma.02108 - James Curley James Curley. ., 287 Fuller Rd. 7. — - — Centerville, MA 02632 Administrator ot valid without signature .�_ ti0fIHE� � Town of Barnstable. Regulatory Services i lARNSfABLE, + - y asAss * Thomas F. Geller,Director 16o,a'� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 "'W-town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Properly Owner Must Complete and Sign This Section If Using A Builder n , as Owner of the subject property herebyaut4orize Tkqx!s, v ) to act on my ea bhlf , in all matters relative to work authorized by this building permit application for: (Address of Job) Si a 4C) &- wner Da e Print Name Q1012MS:OWNERPERMIS S ION fTNETo�♦o� TOWN OF BARNSTABLE BARNSTABLE, i "ASIL 6 9 B M d' BUILDING INSPECTOR PY APPLICATION FOR PERMIT TO ................� ......�.... �t f'1'j ...k-.e l ......................................... TYPE OF CONSTRUCTION ....... .yl J4f GI I.T./•l`.. .......................................................................................... TO THE INSPECTOR OF BUILDINGS: ........ .A, ..........1 9z..Z The undersigned hereby applies for a permit according to the followin information: Location .........../.... �'� i� �... � .. d1 ��1 ......................................... .... ..................... . ... ..... ... Proposed Use ....... 1���1...... :... ! 7��✓... . a ��'ieg..................................................................... Zoning District ..................................7�................................Fire District .....0221..'....05t .............................................. Name of Owner ... �p 7-1 .�lAddress ....... %�..... .. ..,,....., Nameof Builder .....................deli ..................................Address .................................................................................... Name of Architect ......� Q�f�..... .. . ..:. .. ./( ...............Address 1 1�/ 'j ....:�/ ................. Number of Rooms / ......................................Foundation ...... � 1"t�.. ....' Exterior .............. T� Zj...................................................Roofing ..........(�� :, .. .q�.T....�_1 /. ?................. Floors ` ............................................Interior ............ . ...... . 1 Heating ............ .:-..... .'1.,4.f.... ..........Plumbing ...................... .... ....:............................................... Fireplace .......................... .Q...............................................Approximate Cost ............... � .................... Difinitive Plan Approved by Planning Board ___________________----'19 � � Diagram of Lot and Buildingwith—Di'm`ensio L o � o t tZ„ LU LL O (n CL O 0 �r- 0 -JW � < < � 2' CLw 00 U) Lj w w tQ�¢ l\ 30 -_-� \ CL z z p _q i �t ��N�11 en q QLQ a. f'7r0--zc.-S -c,- ' I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above 1 construction. j Name ...... ... ........... ��-..:..( �'. Campbell, George K. DEC 31 1971 No ...14203.. Permit for .........add to single family dwelling . ................................................................. Location ........1, Lumbert Mill Road ............................................. Centerville ............................................................................... George K. Campbell Owner .................................................................. k Type of Construction frame ............................... ................................................................................ 1 Plot ........................... Lot .......... .................... /! ' � l A Permit Granted .......ugust 30 1 g 71 Date of Inspection .....:..............................19 t �... �Date Completed .... .... ...... ........19 n V� A PERMIT REFUSED ................................................................ 19 ` ............................................................................. ............................................................................... ............................................................................... Approved ..,.............................................. 19 ............................................................................... ...............................................................................