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HomeMy WebLinkAbout0209 PATRIOT WAY �, �� '� e f r r e �i� i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# (� Health Division Conservation Division Permit# Tax Collector Date Issued 1 Treasurer Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 4/s/06 Historic-OKH Preservation/Hyannis Project Street Address Village 1 " Owner Address Telephone Permit Request S Square feet: 1 st floor:existing proposed 2nd floor:existing proposed Total new Zoning District ¢ Flood Plain Groundwater Overlay Project Valuation Construction Type k .4 R I$i/LS Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. _s Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) �} Age of Existing Structure ��ns Historic House: ❑Yes �lo 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 Half:existing I 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 ❑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 - A-yes, site'plAh review-# Current Use Proposed Use BUILDER INFORMATION Names �Ayo Telephone Number 01 Address,?® 9 PA7/Z.,,T Gv ,4 V License# ¢.rL`7�P-2 vi A e. ` R Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE r- - FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. r i i ADDRESS, VILLAGE OWNER r , i i DATE OF INSPECTION: i FOUNDATION , FRAME S INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINALBUILDING DATE CLOSED OUT s ASSOCIATION PLAN NO. Department of Industrial Accidents Office.of Investigations ' 600 Washington Street y Boston,AM 02111 . ' ,Y• www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers kpplicant Information Please Print Legibly sin ss Organization/Individual): To - L4ddress:­ 2a �j /�f✓��d� �i�}/ ti City/State/Zip: .2 e lv le.rL vl t t c A Phone e you an employer? Check the-appropriate box:. • '❑ I am a employer with 4, ❑ I am a general contractor and I Type of project(required): 6. ❑New construction employees(full'and/or part time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for mein any capacity. workers' comp.insurance. g• ❑ Building addition [No workers' comp, insurance 5. ❑ We area corporation and its ,required.] � officers have exercised their 10.❑ E1ectrical r epairs or.additions LJ I am a homeowner doing all work right of exemption per MGL 11-0 Plumbing repairs or additions myself. [No workers' comp., c. 152, §1(4), and we have no. 12. Roof r insurance required.] t employees. [No workers'- ❑ rep comp.insurance required.] ' 13.❑ Other ny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: .e [omeowners who submit this affidavit indicating they are doing all work and then hire;outside contractors must submit a new affidavit indicating such mtractors that check this box must attached an additional sheet showing the name of the sub-contrabtors and their workers,comp.policy information. . cm an employer that is providing workers'compensation insurance for my employees Below is the policy and job site Formation. ,urance.Company Name: licy#or Self-ins.Lic..#: Expiration Date: b Site Address: City/State/Zip- tach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ilure to.secure coverage as required under Section 25A of MGL c. 152 cari lead to the imposition of criminal penalties of a ,e 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 up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of iestigations of the DIA for insurance coverage verification. 'o hereby certify under the pains and penalties of perjury` that the information provided above is true and correct A --- �� o�attire�, Date: one#:. Official use only. Do not write in this area,to be completed by city,or town offtcial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2..Building Department 3.City/Town Clerk 4.Electrical Ins 6. Other pector 5.Plumbing Inspector Contact Person: Phone#• a Information and. Instructions fassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. arsuant to this statute, an employee is defined as"...every person in the service of other under any contract of hire, Kpress or implied,oral or written." m employer is defined as". individual,.partnership,.association,corporation other legal eutity,_or any two or more f the foregoing engaged in a jo' t enterprise, and including the legal repres fives of a deceased employer,or the eceiver or trustee of an imdividua partnership,association or other legal ty,employing employees. However:tlie �wner of a dwelling house having t more than three apartments and wh elides therein, or the occupant of the welling house of another who empl persons to do maintenance, co coon or repair woi3C on such dwelling house it on the grounds or building appurten t thereto shall not because of ch employment be deemed to bean employer." ,1GL chapter 152, §25C(6)also states that` very state or local lic sing agency shall withhold the issuance or -enewal of a license or.permit to operate a b siness or to const ct buildings in the commonwealth for any ►pplicant who has not produced acceptable evidence-of compli nee with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Nether the co oawealth nor any of its political subdivisions shall ,nt.er into any contract for the performance of public work until eceptable evidence.of compliance with the insurance -equirem.ents of this chapter have been presented to the contrac ' g authority. kpplicants Please fill out the workers' comipensation affidavit complet y,b checking the boxes that apply to your situation and,if recess supply sub-contractor(s)name(s),address(es) an phone numbers)along with their certificates) of aT5' PP Y insurance. Limited Liability Companies (LLC)or Limited lability artnerships(LLP)with no employees other than the members orpartners; are not required to carry workers' co ensation' surance. If an LLC or LLP does have employees,a policy is required. Be advised that this affid t may be su fled to the Department of Industrial Accidents for confirmation of insurance coverage. At o sure to sign d date the affidavit. The affidavit should be returned to the city or town that the application fore ermit or license" eing requested,not the Deparfinent of Industrial Accidents. Should you have any questions reg ding the law or if y are required to obtain a workers' compensation policy,please call the Department at then er listed below.. Se -insured companies should enter their. self-insurance license number on the appropriate line. city"Town Officials . Please be sure that the affidavit is complete and prin legibly. The Department hasp vided a space at the bottom of the affidavit for you to fill out in the e ent the Offic of Inves igations has to-on y „regarding the applicant Please be sure'to fill in the permit/license number w h will be used as a reference numb In addition, an applicant that must submit multiple permit/license applications any given year,need only submit on affidavit indicating current policy information(if necessary)and under"Job Site Address"'the applicant should write"all cations in_____:_(city or town)."Acopy of the-affdavit that has been officially stamped or marked by the city or town ma be provided to the applicant as proof that a valid affidavit is on file for.Future permits.orlicenses..A new affidavit m. .be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or co ercial venture (Le. a dog license or permit to burn leaves etc.)said,11person is NOT required m complete this affidavit. The Office of Investigations would h'lce to thank you in advance for your cooperation and should you.have questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Co;aonwealth of Massachusetts . Departm6t of Ind4strial.Accidents Office gf Investigations - 600-Washington StreetU . Boston,MA 02111. r `Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-727-7749 evised 5-26-05 www.mass.gov/dia Town of Barnstable Regulatory Services BARN EM ' Thomas F.Geiler,Director ` Ec 3;9. Building Division Tom.Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us 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 excepdions,along nth other requirements. �.Estimate'd'Cost_�1��� -Type-of Work: /c®2i st va Address-of-Work:i 9 /`>A72/®T G�A� ���//� /�� `� Owner's Name: zo S e rP `lam Date�of-A.pplicati n 9 Zr I herey ceFrdfy that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under$1,000 []Building not o copied 00w—nerpulling.own-perrrut Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: , Date Contractor Signature Registration No. 0 Date (0-_er_s-Signs`e Q:wpfiles.forms:homeaffidav Rev: 060606 r THE Town of Barnstable „P Regulatory Services " Thomas F.Geiler,Director 3 BARNSTABLE. f 9 MASS. q, 1679. .m Building Division A�Ep �a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstAble.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: 0 / / '/7_191(0/ w A Awl FiV1 4 �' number (( �n street village «HOMEOWNER":SOS epL V`Pryo /,&) 7r-1-6: 3`A4,615 name j�� home phone# -work phone# CURRENT MAILING ADDRESS:.3 13 aeD cv iv/AJ S /2 /",y,4 c1a yZs 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 r quirement atur of Homeowne Approval of Building Official Note: Three-family dwellings containing 35,600 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 personas 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 iequire,.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:homeexempt ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION- Map t' cl 3. Parcel ' cJ Permit# ll Health Division 75-/�Z— � `�/�3U� d�c j Date Issued Conservation Division f", So/D d t Feeo��, 0 Tax Collector �• '' t • Treasurer INSTALLED i IN DDMPLI Wj Planning Dept. t WITH TITLE 5 ENVIRONANENTAL CODE AND Date Definitive Plan Approved by Planning Board TOWN AEGUI.ATIONS Historic-OKH Preservation/Hyanhis Project Street Address f Village eLk�L Owner f AddressP CU �.'�. Telephone l> L 6 "(3 r •Permit Request - N-ew �ne�t /V X1 �P��o ���� �[ �.p��d C_e 'son" Sr'`2e f X �� Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 3, OD a.od Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family J Two Family ❑ Multi.Family(#units) Age of.Existing Structure / _ Historic House: ❑Yes 5-No On Old King's Highway: ❑Yes PQ No ` Basement Type: A_Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) ' Number of Baths: Full: existing . ��- 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 IaOil ❑Electric' ❑,Other Central Air: ❑Yes ❑No Fireplaces: Existing = New r Existing wood/coal stove: O 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❑ y.W Commercial ❑Yes ❑No If yes,,site plan review# Current Use Proposed Use BUILDER INFORMATION ' Name ev>- dtj Telephone Number© Address 6 14 e License# rf F C eL -PL. Home Improvement Contractor# B d C o Worker's Compensation# W PIZ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE a'`"' DATE 0 FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS t 'e a r r VILLAGE OWNER Y Tt. .. � .�� � � .� r V:. � • / �;, ~ 1 . , . •: � .. { x + Ml DATE-OF INSPECTION }'"�� • + ,, t 'FOUNDATION — r FRAME INSULATION FIREPLACE ; ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ► r a GAS: ROUGH FINAL � FINAL BUILDING' DATE CLOSED OUT z � a • , M t ASSOCIATION PLAN NO. The Commonwealth of Massachusetts s Department of Industrial Accidents -% exce a/lAY85 0atioos f. 600 Washington Street Boston,Mass. 02111 Workers' Co m ensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workingin anv capacity I am an employer providing workers' compensation for my employees working on this job. com any name: tiI!s _. ,.:: ,::..:. .,.. ... X41'r h Ni insurance k'tic .. . . >7 oitcv#: 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: .. cons nnv name. :>':;::•;::;;<:':.;::'>'>:': address. <:>::::>;:>:>:' _.. .. ..:. ::::::::..... :. .is•:::i:: ....�:::..�: ri4 i. ::•iii:.i:i•:•iii:.: i::i.i?:'i:::.:is::::i:':.i:::^::i<ii•Ti}:ii:.:T:::i};}.....:.::.. ::. .:•..... ....................... ti.:is;::.;..:i':.::: .. ':. .. :S_:'�i'�: ' ritti* '' ��> > < ::>::::>::;' shone#: ................:::::::.............................................................................................. ........ ...... ...... .................................................. .:::.. oLcv ZMIOE address- . . >; :> :.;;::::;:::::::':>::» :'»<: on Ni citv-. p ::.:.. ..:::.:..:..;:.:::..:::.::::::: .- ::;::: ::: :::: ......... is':;:i::i:::i::i:::3:`;i i:i: ii ii:::i ::i:`::ti`::i:':::::::: CV o Faamm to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years,imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 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 the pairs and pen of perjury that the information provided above is truo and correct. Signature Date ?© — Print name PD Phone# 7 official use only do not write in this area to be completed by city or town official ti city or town: permit/licerue is (]Balding Department ❑Licensing Borud check if immediate response is required pselectmen's Office ❑Health Department contact person: phone#; ❑emu' 0evaed 9/95 PJA) The Town of Barnstable • BARNSTA13M MAW* �m� Department of Health Safety and Environmental Services rEn 39. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but.not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. ''11/t/� Type of Work: '� - a Estimated Cost U v d Address of Work: Owner's Name:—To S `P Date of Application: D I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law nJob 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.a t of the owner: s 3 0 (22�_CL2 D to C tractor Name Registration No. OR Date Owner's Name q:forms:Affidav STANDARD LEGEND 1 9 3 ; NOTE:not all symbols will appear on a map i MI c i - ` M? GOLF COURSE FAIRWAY i` -= EDGE OF DECIDUOUS TREES ,�-- 193 EDGE OF BRUSH r ORCHARD OR NURSERY i 9 ? EDGE OF CONIFEROUS TREES - ff- r%f MARSH AREA EDGE OF WATER DIRT ROAD DRIVEWAY E —PARKING LOT (—":... i �--- PAVED ROAD Ail 93 - -- r. r , t DRAINAGE DITCH ,ff ; I — PATH TRAIL 191 �Q + PARCEL LINE ff 90 »1 - - - --- Mellow MAP# MAP 1 / 3 ���FFF------ 21�PARCEL NUMBER I I #I860 —HOUSE HOUSE NUMBER t , - � i v it I! ry T 2 FOOT CONTOUR LINE 194 io — 10 FOOT CONTOUR LINE # 209 Elevation based on 29 _._.__... .... _.. _._._..._._._.__.. —I 9 ELEVATION 1 � NGVD ' f i ��4. SPOT ......_ ..._7 i f ----- `" STONE WALL FENCE _ { RETAINING WALL f J(J RAIL ROAD TRACK STON { t i 93 t E JETTY # # f` j coop i SWIMMING POOL ._ t MAP 1 3 a PORCH/DECK I # rv; Li BUILDING/STRUCTURE 19 _ r � I - DOCK/PIER r...... # 199j HYDRANT -- e VALVE O MANHOLE _ _.._.........�_ ........__..............._., ? _ o POST O" FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N IF R M A T 1 O N S Y S T E M S �U N 1 T .tr SIGN ® STORM DRAIN x PRINTED SCALE: FEET *NOTE:This map is an enlargemeniof a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Plonimetrias(man-made features)were interpreted from 1995 aerial photographs by The James w 1 e ` 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE ❑ TOWER 0 20 40 National Me P Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetria,topography,and vegetation were mapped to meet National Map Accuracy Standards $ 1 INCH=40 FEET* enlarged scale. on the map. of a scale of 1"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessor's tax maps. LIGHT POLE O ELECTRIC BOX ...\sitemaps\Public\m193p194.dgn May. 30, 2000 08.24.,31 X /off. . 1 -- �� r`S t_ ��filGP�r� I1 off o ' k�r0 2 7 l� / ZZ i - .v for-tlJ .l-aU..a„1 ...9'/J✓. ua..s.aM..✓.a.._. a—.�....... ... .. - -- �'Ice Pomzmoea�i a�,/�aaoac/+uaeda BOARD OF BUILDING REGULATIONS License:,CONSTRUCTION SUPERVISOR a; Number CS 028899 Birthdate 08L16/1136 ->E i . 1 Expires U&W2001 Tr..no: 3278 Restricted To: 00 GEORGE J ALLAW M. 116 SHEAFFER RD CENTERVILLE, MA 02632 Administrator s HOME IMPROVEMENT CONTRACTOR Registration 100105- Type - INDI.VIDUAL Expiration 06104L00 6EOR6� ALLAIN , 11G SHEAFFER Rd. terVille MA 02632 _.. .ADMINISTRATOR Town of Barnstable *Permit# %)50 Z X.P Expires 6 months from issue date RESS PERMIT Regulatory Services Fee o7s. QO APR 12 Thomas F.Geiler,Director ?0p6 �j Building Division SOWN OF 13ARNS7 Tom Perry,CBO, Building Commissioner ABLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.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 '�V Property Address 20 �f}— (�e�,�-✓1 �sidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �� ,y� a Contractor's Name f"( _ �f � Telephone Number 'S76� Home Improvement Contractor License#(if applicable) y Z25 Construction Supervisor's License#(if applicable) ❑Wo&kman's Compensation Insurance Che one: II am a sole proprietor ❑ I pifthe Homeowner have Worker's Compennss�ation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(c "ck box) Re-roof(stripping old shingles) All construction debris will be taken to /'�C//ih T� ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 0 Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: P perry O er i Property Owner Letter of Permission. ome I ro t ntractors License is required. SIGNATURE: Q:Fonns:expmtrg ReNise071405 C fj Bpard of Building Regulations and.Stand6i d �. FIOME IMPROVEMENT CONTRACTOR License or registration.valid for individul use only before the expiration date. If found return to: I l�egistrafion 149475 Board of Building Regulations and Standards Expiration Tp12l2008 One Ashburton Place Rm 1301 4 8 (4 Typre DB1 Boston,Ma.02108 I ENGELSEN CONSTRr�GTl01�t `r ERIC.ENGELSEN \ r r Jl f .95 OLD TOWN..RD.. HYANNIS,MA 02f 01 I Administrate Not valid withoyt sV- atu;re. . 9 Department of Industrial Accidents Office.of Investigations' ' . ° 600 Washington Street Boston,MA 02111 5y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plum hers Applicant Information Please Print Leeibly Name (Business/org nizationar&vidual):_� Address: o c� ��ju_�� City/State/Zip: 1� ��� ,� Phone#: Are you an employer? Check the-appropriate box:. Type of projeet(required):- 1.❑ I am a employer with - . . 4, ❑ I am a general contractor and I employees(fall 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. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition working forme in any capacity. workers' comp. insurance. g Building addition [No workers' comp. insurance 5. ❑ We'area corporation and its 10.❑ Electrical repairs or.additions required,] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.g-1q(6of repairs insurance required.]t employees. [No workers'- comp.insurance required.] 13.❑ Other *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. $Contractors-that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am.an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance.Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: RM(,;:5Z2 lz- 4 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500,.00 and/or one-year imprisonment, as well as civil penalties in:lie 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi der the an enaides of perjury that the information provided above is true and correct r Si ature: Date:". Phone#: Official use only. Do not write in this area;to be completed by city.or town offXiaG 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#• Information an' .d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ' pursuant to 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." ._< ciatio oration or other legal entity,or any two or more An employer is defined a _an incliyidual,,partpership, also : . . en a ed in joint enterprise,and including the egal representatives of a deceased employer,or the the foregoing. g g of receiver or trustee of an ind' ual,partnership, association or ther legal entity,employing employees. Howev the d who resides therein, or.the occupant of the owner of a dwelling house ha not more than three ap ents an dwelling house of another who a loys persons to do enance,construction or repair woik-on such dwelling house or on the grounds or building app nant thereto shall not ecause of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states at"every state r local licensing agency shall withhold the issuance or renewal of a license or permit to opera a business o to construct buildings in the commonwealth for any applicant who has not produced acceptab evidene of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) 6`Nei the commonwealth nor any of its'political subdivisions shall an contract for the performance of p lic ork until acceptable evidence of compliance with the insurance enter into y „ requirements of this chapter have been presented t e contracting authority. Applicants Please fill out the workers' compensation affidavi comp etely,by checking the boxes that apply to your situation and,if. names addr s es d phone number(s)along with their certificate(s)of necessary,supply sub contractors) ( ), ( ) insurance. Limited Liability Companies(LLC)o Limited 'ability Partnerships(LLP)with no employees other than the members orpartners, are not required to carry w rkers' comp ation insurance. If an LLC or LLP does have employees,a policy is required. Be advised tha this affidavit y be submitted to the Department of Industrial Accidents for confirmation of insurance cover e. Also be sure o sign and date the affidavit. The affidavit should be returned to the city or town that the applica on for the permit o icense is being requested, not the Department of A Industrial Accidents. Should you have any q ons regarding the 1 or if you are required to obtain a workers' compensation policy,please call the Departm nt at the number listed b ow.. Self-insured companies should enter their self-insurance license number on the approp ate line. City or Town Officials . Please be sure that the affidavit is complete d printed legibly. The Departne has provided a space at the bottom of the affidavit for you to fill out in the eve t the Office of Investigations has to c tact you regarding the applicant Please be sure to fill in the permiUlicense number which will be used as a reference ber. In addition,an applicant that must submit multiple permitllicense lications in any given year,need only s 't one affidavit indicating current policy information(if necessary)and unde "Job Site Address"the applicant should to"all locations in (city or town)."A copy of the.affidavit that has beln officially stamped or marked by the city o wn may be provided to the applicant as proof that.a valid affidavit is-an file for,future permits or licenses..A new davit must be filled out.each year.Where a home owner or citizen is obI fining a license or permit not related to any bus ess or commercial venture (i.e.'a dog license or permit to burn leaves etc.)said person is NOT required to complete thi affidavit The Office of Investigations would lie to thank you in advance for your cooperation and sho d you have any questions, please do not hesitate to give us a call. The Department's address,telephone and. ax number: The Commonwealth of Massachusetts . :. L1ep pnt of Industrial.Accidents Office 9ff Investigations r .6 ashin on•S pet 00•W gt �'_ . Boston,MA 02111. y Tel.#617-727-4900 ext 406 or•1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia 0 -A Town of Barnstable Regulatory Services S. La * Thomas F.Geiler,Director ]Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862.4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I1117 ,as Owner of the subject property hereby authorize - to act on my behaliy in all matters relative to work authorized by this building permit application for: , (Address of Job) S' ature of Owner bate o Print Name Q.F0RMS.0W,9EUERN MS10N APR-11-2006 09:23A FROM:ENGELSEN CO 15087781272 TO:5087906230 P.2 -,;. - y { Fkadeddshmmum9 br— COWAN=AFFGRDM COVMAGt Edit uwm A A LM Mufstal Insm m Co 85®ld Tewn Road Hyaad%ma. :. L�BaH��l�VHAvitumm[�9DY09� HA�AB®YB�`3�!®L3�Yl� AHiY l.ML4 MCMM lM(AWC4_CD lC� P� ICI20�41�i somm as sklmomfiffiwm l tA1.11�1M1f1 AM f sox s � s ocrunowm s uueus3rae,e•�®w s e�16(d�s�i s trssn,� its s AM mamas sou" AUM l LM E AV= BMW s DAUM s actin s Voraboom s oorax+aer� -:{ rs s� - s W osns crams m� ssar s Am 100 nm X r. i. 8pp6�J�IbbBa�Aqq��Al Y CM UM AWVR 1�I�7o;R ffiAyCg1S vim sm&vm To ' SUM W DMVMHM TOM, anAUYs s (i A`1Y MM i/iV67 Jiia COW0 i 93 AS"= CU . TOWN OF BARNSTABLE.. 2.11 i7 o`+ •g ; Permit_No. 1 DAUSTAU ' Building-Inspector Cashamm -—— 9+odp*P OCCUPANCY PERMIT Bond -------�'— ` No building nor structure shall be erected,and no land, building, or. structure shall be r used for a new, different, changed, or enlarged- use without a Building.,Permit therefor first having been obtained from the Building Inspector. No buil-ding shall be occupied;until a certificate of occupancy has 'been issued by the Building: Inspector." Issued to Siif ol'k Realty 'ftnu t Address Box 308, Centerville lot #28 209 Pp-triot Way. Centerville- Wiring Inspector ��F 7 Cam'/lam, Inspection date All l Plumbing Easpea7o r v Inspection date Gas Inspector Inspection date En gineering Department - �������' .��'�� �. Inspection date(�j- -17 THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE. OGCUPIEID UNTIL SIGNED BY THE- BUILDING INSPECTOR UPON SATISFACTORY_ COMPLIANCE' WITH TOWN REQUIREMENTS. r 7.......t. .............. 19 . l uildmg Inspector 71 Assessor's map and lot n u m ,. .........................n.............. SEPTIC SYSTEM MUST BE ' INSTALLED ►�y COMPLI Sewage Permit number ...................l..l ................................ V ITH ART ANCE t sCLE II STATE SANITARY C QyOfTHEropy TOWN N OF �f ARNS11�LA TOW' Z BJHBSTADLE, i "6 q BUILDI,NGo,. INSPECTOR APPLICATION FOR PERMIT TO r Suffolk Realty. Trust ............................ ........................................................................................ TYPE OF CONSTRUCTION .§ingle,,,family,, residential ................. ... ........................................................ ......Mar ch...21...................197.9... l y s ey TO THE INSPECTOR OF BUILDINGS: 9 The undersigned hereby applies for a permit according to the following information: Location Lot 28 Patriot Way..Centeryil.le.:...MA........Q.26�.2...........................................;,.. ...... Proposed Use .......single family residential ........................................................................................ Zoning District single, family...residential Fire District ..C,eAtg;_r �,1,�,-C, tPX,ya,l� . Suffolk Realt Trust Name of Owner ........................................Y............................Address ....P.,.Q.....B.Qx...3.Q8...CentP-r.V.11,1P................. Name of Builder same ........Address .................S.aMP................................................ Nameof Architect ..................................................................Address .................................................................................... Number of Rooms seven,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Foundation ........ppured...raon rj2te.................................. .......:...... ceder shin les Roofing ....aspk� J..t...S.hing�es...................................... Exterior ............................ .....g. Floors carpet. .oyer under.layment,,,,,,,,,,,,,,,,,,,,,,Interior .........S. iM-..CQ.a.t...plaster....................... ............. Heating fOrCed YIOt Wc}ter...r?y....�?.a,...................Plumbing ...............P.M C.....................................................I...... Fireplace ............brIGX..A...13a,faek...................................Approximate Cost .........P3 d09.-.0.0............................. Definitive Plan Approved by Planning Board -----------_-------------------19________. Area .....1840 . Diagram of Lot and Building with Dimensions Fee . ..................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH L :J t ` 5 Q i4,s- I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. � r '" Name 'Suffo-k Realty Trust A=193-194 ) No ... ... Permit for 5.inglA..fat1:UY........ dw�hl �;g....:............................................... t Location ...Patri.Q.t..Way..................................... . ....... I✓en .Villa.................................... � Owner ... ................ j Type- of Construction. ......Wood..]:x:ame.:............. r.................................................... Plot ............................ Lot .........28................... .y Permit Granted ...........Manch..22 19 79 Date of Inspection ...19 Date Completed[ .. ................19 PERMIT REFUSED ................................. ............... .... 19 .............................................. .............. ... .......... . ............................................................................... ` ...................................................................... ... Approved ................................................ 19 s ............................................................................... - �D• O Sti6�alG. i 6li?R V G�;r- Z'o 7- 4 0.0 ol ���' 22 99-�• �� SG It/4 j.. Xx '� G. � ,;,you c: �»; _ � - � • . _90 12 44'. 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