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y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
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� Map ��_ Parcel �� � f�� � O4 SA,�'i'�:i�ABLE
Permit# ��`
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Health Division ® — ® o' Date Issued , ?"ISO
Conservation Division 42
.o 63 H34 MAR 29 FM 1: 24 Application Fee � ^
Tax Collector Permit Fees
Treasurer € f%71SIOPf
SEPTIC SYSTEM MUST Dr. t
Planning Dept. IpSTALLED IN COMPLIANC FE
Date Definitive Plan Approved by Planning Board 'TITLE 5
ENV1f20IVMEHTAL CODE ANO
Historic-OKH Preservation/Hyannis -rovM REGUI-'!10N3
Project Street Address
Village''���a(1�-P
Owner 1)[0"_B( � ) af,, U)t'!QQ_1'19SAddress 2Q ; ems(
Telephone d 6"p J " a �7 �/ Co
Permit Request Rero.el �_Et Lklif ln_���F� 6c
Ao- ®7` I, V
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 35406 Construction Type 4;faboe,
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family l Two Family ❑ Multi-Family(#units)
Age of Existing Structure I'MI Historic House: ❑Yes 4 No On Old King's Highway: ❑Yes No
Basement Type: ❑Full Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) _
Number of Baths: Full: existing ( new O Half: existing new
Number of Bedrooms: existing_ new 0
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 O
Commercial ❑Yes No If yes, site plan review#
Current Use Qlt) Proposed Use_2en5,
BUILDER INFORMATION
Name � u IL(, ,►,t Telephone Number 50 S ' 670 _C110 0-
Address_in License# C5014 '2�0 Lk
Home Improvement Contractor#
Worker's Compensation# U1(!�-OCJ -7 S 3 ( 1 t 10 0
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT-WILL BE TAKEN TO Ol 0/Ah .�
SIGNATURE DATE f 0%6/0
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FOR OFFICIAL USE ONLY
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PERMIT NO.
1
DATE ISSUED '
MAP/PARCEL NO. _
A
ADDRESS VILLAGE
OWNER
i DATE OF INSPECTION: r
t FOUNDATION
FRAME
INSULATION
O
i FIREPLACE
Ik
a ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
t f GAS: ROUGH FINAL
C FINAL BUILDING tr ;
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4 DATE CLOSED OUT
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ASSOCIATION PLAN NO.
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_ The Commonwealth of Massachusetts
-= Department of Industrial Accidents
Office of/osestigatioos
600 Washington Street
- = s Boston,Mass. 02111
Workers' Com ensation Insurance Affidavit
name:
location:
city phone#
❑ I am a homeowner performing all work myself.
❑ I am a sole netor and have no one working m' capacity
I am an c nployer roviding workers' compensation for my employees working on this job. : : ::.:::::::::::::::::::..............:. <'<::<......
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❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who
have
thefollowing workers' compensation polices;..:........................................:::::::::::::::::......::.::::::::::::.:,._::::.::::::::._::::::::.:::::..;}:;.>:;}:.;}}:.:;.}:.::.}:.}:.}:::.,:.,::<::;>;:«<::::g.................:.:.::::.:::.:::::::::::::::.:::::::::::::::::.:.:.........,:.,::::::: ::::::::.:::::: . :. ::.::. :.::.:.:.,...:.::::::::::.::.:::::::::::::....:..:....
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Fafim a to sec u a c over age as required under Section 25A of MGL 152 can lead to the imposition of erlaninsl panellise of a fine up to$1,00.00 and/or
one years'imprisonment as well as civil penalties in the form of a S or WORK ORDER and a fine of$100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties jperjury that the information provided above is true and cored
Date. to -a �•��
t Signature �� r —
Print name Jv�- t� F U V�•� Phone# ���' 1 o ' y
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Bnfiding Department
❑Licensing Board
❑checkif immediate response is required ❑Selectrnen'a Office
❑Health Deparbnent
contact person: phone#; ❑Other
Umsed 9195 PJA)
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Information and Instructions
Massa4husetts General Laws chapter 152 section 25 requires all employers to rovide�vorkers' compensation for their
emp 1` ees. As quoted from the"law", an employee is defined as every perso in tl�e ce of another under any contract
of hire, ess or implied, oral or written.
An employer is efined as an individual,partnership, association, corporation or ther legal entity, or any two or more of
the foregoing eng ed in a joint enterprise, and including the legal representati s of a deceased employer, or the receiver or
trustee of an indivi ,partnership, association or other legal entity, empl employees. However the owner of a
dwelling house ha ' not more than three apartments and who resides ein, or the occupant of the dwelling house of
another who employs p .sons to do maintenance, construction or rep ' work on such dwelling house or on the grounds or
building appurtenant them shall not because of such employmen a deemed to be an employer.
MGL chapter 152 section 25 o states that every state local licensing agency shall withhold the issuance or renewal
of a license or permit to oper a business or to con truct buildings in the commonwealth for any applicant who has
not produced acceptable evidenn of compliance wi the insurance coverage required. Additionally,neither the
commonwealth nor any of its pohti subdivisions s enter into any contract for the performance of public work until
acceptable evidence of compliance the ins ranc requirements of this chapter have been presented to the contracting
authority.
Applicants J \
Please fill in the workers' compensation 'vrt t�� letely,by checking the box that applies to your situation and
supplying company names,address and p o numb along with a certificate of insurance as all affidavits may e
submitted to the Department of In ccidents confirmation of insurance coverage. Also be sure to sign and
k' date the affidavit. The affidavit shoal returned to city or town that the application for the permit or license is
being requested, not the Department o. Accid Should you have any questions regarding the'law"or if you
are required to obtain a workers' co ens lion policy,pl Call the Department at the number listed below.
City or Towns
Please be sure that the affidavit' lete and printed legibly. The D ent has provided a space at the bottom of the
affidavit for you to fill oust m th the Office of Investigations has ct you regarding the applicant. Please
be sure to fill in the peroit/h a ber which will be used as a reference n her. The affidavits may be reftrneil to
the Department by mail or ess other arrangements have been made
The Office of Investiga ons w uld like to thank you in advance for you coop lion and should you have any questions.
please do not hesitate giv a call. 0
The Department's address,telephone and fax number:
j�
The Commonwealth Of Massachusetts '
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone #: (617) 727-4900 ext. 406, 409 or 375
RECEIVED: 10/22/03 1 :59PM; ->DALE R. NIKULA CO. , INC; #550; PAGE 2
OCT-22-2003 15:14 FROM GD IMSE TO 915087600002 P.02/02
October 22,2003
To Whom It May Conce
.RE: 64 Nyes Ne ' Road,Centerville, MA
1, Dij ne Bradshaw, as NER of the subject property, hereby authorize Encore Construction
Company, Inc.to act in behalf in matters regarding the obtaining of building permits and
construction work on th iroperty,
OWNER: Dare:
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Initiaa, 14
Initini;
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°FISE T° Town of Barnstable
Regulatory Services
BMWSTABLZ " Thomas F.Geiler,Director
y mass.
�A 9 7 t 6 • ♦0
6. Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
GCS{i
Type of Work: 4TC, /Estimated Cost
Address of Work:
Owner's Name:
Date of Application: 1 O/Z 1/0-5
I hereby certify that:
Registration is not required for the following reason(s):
❑Work excluded by law
❑Job Under$1,000
Building not owner-occupied
Downer pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of th owner:
J
10 tio— � U1� n � )a(a � !
ate Contractor Name Registration No. -
OR
Date Owner's Name
Q:forms:homeaffidav
i
,l fr.0 't9rn7a//az0�7T.uP,CX 7 0,� QD 2L(.dP�O
BOARD OF BUILDING REGULATIONS
-. License: CONSTRUCTION SUPERVISOR
I y.c, Number: Cs 00044
i Birthdate:•091!61a 958 ,
' Expires:•09116/2005 Tr.no: 3395
Restricted: fl0
IDALF R NlKUL4
� 1iO3 MAIN ST
DENNiSPORT, 1+AA 0 Admi
nistrator
inistrator
I
. iII - ,: - ��in, �omvrazoou�ea�o�✓��au:%ac>/ivael�a
I Board of Building Regulations and Standards
HOME iMPROVEMENT CONTRACTOR
Registration: -j2678'!
Expirafion: T11912004
hype Individual
• � ���R�IIiCULA
� I 3�AL� N�lC�3Lia•
103 MAIN ST.
DENNI.SPORT,MA U2639 Administrator
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Section II
Job Specifications
All specifications herein according to plans and notes.
Scope of the work: Remodel kitchen and replace eating area windows,
Special Conditions:
• Dumpster ALLOWANCE: $375.00 "
• Excluded from the contract:
Replacement of any concealed rotten or unsound materials
General Specifications:
1. Demolition:
Remove kitchen sink, countertop and cabinets. Remove kitchen flooring and underlayment.
�r Rem owe T2-mndows in the kitchen and Ww_indows in the eating arel Remove shingles on
the;srnalt dormer on the lake side.
2. Frame:
Window franing
2x4 studs-Wth 1/2" CDX exterior sheathing at the reconfigured window in the kitchen
- , Exterior trim
�. E_xtenor. nm will be:pre-primed colonial sized to match existing. New window casings to
have# 5# _It splines.
Vllmdows .
Andersen windows with white exterior, natural interior,maple grilles, stone screens and
r hardware fialp, wood sills.
o TW2436
-One
Maple iratenor-grilles for 4 Anderson windows in the"Lake Room"
Extenor;Pa�ntrag
Two coats of finish on ail:pre-primed wood.and one coat of primer and two coats of finish
of unprimed vuood:ALLOWANCE: $750.00
3. Sidewall White:cedar clean rade�,shingles with 5"nominal exposure to the weather and
TYPAR heusewrap underlay on small dormer on lakeside and patches as-needed at
windows.'
4. Insulation R13-with vapor barrier at altered window openings.
5. 'lu- bmg: Disconnectsink prior to. lemo:lition.'Re-connect after new kitchen cabinets are
- —
�rltailed11_Lfli11A1�iCE $ZOt .tD___ ---_— - -- ---- _ --------- ----_----
6. Electrical: P,rNde ore raew 1�20 volt outlet for the refrigerator
7. Floors Tile#loot m the #citchen to be 12"x12" Daitile; Provance glazed; Hazel C✓^ ��
8. Drywall '%2"drywall p irualls at the.reconfgured window in the kitchen, taped and sanded
9. IntenornFiriish:
___ __ .._�._:.-a:.^ ➢_--�nterior�rundow trim to-be 3=3=/2°=colonial�asings�-_.�-<--=�-�- ----=-=-=------_ -- -- =.�--
➢ Kitchen Cabinets: Dynasty Puritan Maple wood with Autumn Stain per Mid-Cape :
--
.design panted 9/17-1t103.
➢ Cab'inet'handles and drawer pulls: ALLOWANCE $250.00
➢ Countertops:Corian "Taragon"with standard profile finished edge; loose 3 %Z"
Initial:
5
Initial:
RECEIVED: 10/22/03 9:18AM; ->DALE R. NIKULA CO. , INC; #538; PAGE 5
No 5666 P . 5
97i"
58 r�' 39 1-6'
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.�2.. 30" --- -15"
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All dimensions size designatidns given arc • n^ T.kuls is an otjginal design and must xkot be Designed:4/3/2003
subject to verification on�ob site and S�C`N-N�OIrSe�fe+a mloascd or copied unless applicable fee has Printed:9/17/2003
adjustment to fit job conditions. been paid or job order placed.
ENCOECOMTRUCUON09-03-03 Fp 1 llratwing#:1
Oct .2T. 2003 12:37PM — 62.4 qNo.5611P ,1,
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Note:This drawing is an artistic20 D!Signod;4/3/2003
itIterp%etation of The genepal appearance of recn r+ 20 Printed:9/17/2003 the design.It is not meant to be an exact
rendition.
ENCORE CONSTRUCTION 09-03-03 Drawing#:1
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RECEIVED: 10/22/03 11 :47AM; --DALE R. NIKULA CO. , INC; #544; PAGE 2
No-5671 P. 2
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Note;This drawAna is an artistic Designed,.4/3/2003
interpretation o£the genera]appearance pf ecH oiociEa Printed:9/18/2003
the design,It is not meant to be an cx ct
rendition.
F'NCOXtffi CONSTRUCTION 09-03-03 prawin6#: i
RECEIVED: 10/22/03 11 :47AM; ->DALE R. NIKULA CO. , INC; #544; PAGE 3
Oct -2;- 2003 12*38PM _. ON • 5671—"i+,P - 3
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Now:This dra-dnz is an artistilc n1§11% Designed!4/3/Z003
inte prctation oftho general appearance of I'rintod:9/17/2003
the design.It is not meant to be an exact
condition.
ENCORE CONSTRMIXON 09-03-03
RECEIVED: 10/22/03 11 :48AM; ->,DALE R. NIKULA CO. , INC; #544; PAGE 4
_._ ,No .567 P 4, .
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Wore:TINS drawing is an artistic "� Designed:4/3/7-003
interprntationo£the general appearauco 0£ ecN o 0o s printed:9/17/2003
the design.It is not meant to be an e&uct
rendition.
ENCORE COMMUCTION 09-03-03 )Drawing�':1
Assessor's map, and lot number ..........:........................::..... / r
a SUM SYST A S,,T
INSTALLED IN 'CO AA _IA
Sewage Permit number ....... ...... ........:::............ Va'ITH:A LE 'lC !! TAWE
T€ A
SANITARY CoD, �
�FTMET� } TOWN OF BAR
yi Z BASBSTADLE. Q
MAE
039. 6;UILDING INSPECTOR
p� i63q.a\0 J .Cy
p; .."'ill
ter' t� Ofe/r{�.�
APPLICATION FOR PERMIT TO ......:.....i::: ...
TYPE OF 'CONSTRUCTION ...................:........` !!Y! r................ .................................................... ..
...... . ..... ...........jq..2
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit according to the followi g information:
011
Location r, P 41..
.. .... ...................................
................W. . .......................... .. ... � [.....PProposed Use .................... ... ........I...' +..............,........................................................................................
ZoningDistrict ....... .Y. . ..............................................Fire District .......I�... ...................
Name of Owner . ...... Address ..�..� ...1..... .... ..... ........... t �,
Name of Builder s ... .. .....................
` i ':j. ................- ....— �`i"?............:....Address ....I ....�..... . ...........�: C` �....:.. `
Nameof Architect ..................................................................Address .................................. .................................................
Number of Rooms ....................../........................................Foundation .......... .. . ....X91D
...............................................
Exterior ° � ......Roofing .
Floors ......................................................................................Interior ....................................................................................
Heating ....................................................................:............Plumbing .................................. ... .....................................
Q�
Fireplace ..............................Approximate Cost . ....
.......................................................................... /
Definitive Plan Approved by Planning Board _____________________________19________. Area S^..........................
Diagram of Lot and Building with Dimensions Fee �—�
SUBJECT TO APPROVAL OF BOARD OF HEALTH
((5 7Z
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I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ........a...... .
ytarilyn Tyler
No 18046'; Permit for Addition................. +
Location ....� Y. re. .......................... 1 t
E ........................CentsrvilIe..............................
Owner ....Maril
Type of 'Construction Frame -- `-Y �' • r
e.
............................................................................... ,
4 "
Plot ..D.................... .. Lot ................................ ^: Y
Permit Granted ...............Nov ...?........19 75
Date of Inspection .........................�.... i
Date Completed �j . I.. '19 _ r
PERMIT REFUSED
................................................................ 19
......................... ........ ti �. V '*.• '
...............................................................................
........... ........................................................ i
................................................................ ....: t
'Approved ...........:.................................... 19
:.................. ................................... .......... ......
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Py�%7M F
' BAsasrem:
NAB639
a MAY
Town Offices, 397 Main Street, `
775-1120 Ext. 129 : Hyannis, Mass. 02601
STIPULATION AGREEMENT
I, Mrs. William . N. Tyler, do hereby'agree.to'..the following conditions set
forth .by the Barnstable Conservation .Commission and intended to reg
ulate
work done under m0 authorization at NY es Neck Road, Wequaquet Lake, Cen
teiville, Massachusetts: .
1.) All excavated material not necessary for.back fill around the foun-
dation of .the addition to the residence at the site is to be removed
from .the site.
2.) Work is to be conducted in such a way so as to avoid erosion of the
bank of the pond at the site.
3.) Work is to be conducted. in such a way as to .avoid siltation of the
pond during and after construction. .
4.) . This A re en►_e
g , t apes only to the additoh prsently=being con- - _
---8tfuctecT-an&any future work must be done under separate agreement
or filing, as .deemed necessary by the Barnstable Conservation Com-
7;J C,�
This Agreement`"should—in no way be construed as a_Idaff r , g'of the srights: of
the Barnstable-Conservati-on CommissioTi.u4dex, G,L.(qh,-+ ,.;;k.3
J, Sed, 4 ue under
fArtl6l`e XXVIII -f't]ie Town of BarnstalAe By-Laws. Should the conditions set
forth herein be violated, the Commission -may-exerci2e :those-rights and re-
quire complete compliance with the above statutes.
Signature
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Y 19 51,rbe ore �me _ pr�o�s,ally�_aPPeared
t6 die •known �d' be t�e per-
son described in and who executed the foregoing instrument and acknowledged
that he,d�id same as his 'free act and deed.
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