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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
-TOWN OF BARNSTApLE
Map Parcel O� r Application #C�(���
Health Division
'j« JCIL t b Pik 3: 53 Date Issued
Conservation Division Application FeeW)
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Planning Dept. D8 Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis < -71Z3)13
Project Street Address
Village
Owner 71D 1,ama P Address
Telephone 7�L'J°a— VCOL
- dPermit Request / Z_
v
AAA
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District �1 Flood Plain Groundwater Overlay
Project Valuation `���®�®® Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area (sgft) 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 ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name _Diaj�17���;6 Telephone Number
Address _4 )!!e C/ License#
Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO%
_SIGNATURE DATE
t �
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
.MAP/PARCEL NO.
ADDRESS VILLAGE
it OWNER ,
i"
DATE OF INSPECTION:
gLFOUNDF►TI.QN� +
FRAME
INSULATION.
FIREPLACE
t
!
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL '
GAS: ROUGH FINAL
FINAL BUILDING" �g
•
" DATE CLOSED OUT
4 ASSOCIATION PLAN NO.
' r
•r The Commonwealth of Massachusetts
• Department of IndustrialAccidents
fag Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:_ � 04/
City/State/Zip: NPhone#:
Are you an employer?Check the appropriate box:
Type of project(required):
1.ElI am a employer with ` 1 4. I am a general contractor and I
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
shipand have no employees These sub-contractors have
employees and have workers' 8' Demolition
working for me in any capacity. $ ' 9.- Building addition
[No workers'comp.insurance comp. insurance. f ; .
required.] 5,'❑ We are a corporation and its 10.0 Electrical repairs or additions
, 3 I am a homeowner doing all work- officers have exercised their' " 1.1. Plumbing repairs or additions
myself. [No workers' comp. 1,right of exemption per MGL
/ 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no .
employees. [No workers' J ' 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. '
#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.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 certify zin Her the pains and pe alties ofperjury that the information provided above is true and correct.
Si gnafore: Date:
Phone#:
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
F
Contact Person: Phone#: 1
' 1
J 4
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
;ant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
expor implied,oral or written."
J
An e44oyer is defined as"an individual,partnership,association,corporation or other legal entity, any two or more
of the forgoing engaged-in a joint enterprise,and including the legal representatives of a deceased ployer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing emplo eels. However the
owner of a d1vvelling house having not more than three,apartments and who resides therein,or the cupant of the
dwelling hous of another who employs persons to do maintenance,construction or repair work, n such dwelling house
or on the group or building appurtenant thereto shall not because of such employment be deep ed to be an employer."
MGL chapter 152, 5C(6)also states that"every state or local licensing agency shall with old the issuance or
renewal of a license r permit to operate a business or to construct buildings in the co' onwealth for any
applicant who has no roduced acceptable evidence of compliance with the insuranc .coverage required."
Additionally,MGL chaplXr 152, §25C(7)states"Neither the commonwealth nor any of it political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of c mpliance with the insurance
requirements of this chaptehave been presented to the contracting authority."
Applicants
Please fill out the workers' compen tion affidavit completely,by checking the "oxes that apply to your situation and,if
necessary,supply sub-contractor(s)n e(s),address(es)and phone number(s) ng with their certificate(s)of
insurance. Limited Liability Companies LC)or Limited Liability Partner Is(LLP)with no employees other than the t
members or partners,are not required to c workers' compensation his ace. If an LLC or LLP does have
employees,a policy is required. Be advised at this affidavit may be sub ed to the Department of Industrial
Accidents for confirmation of insurance cover e. Also be sure to sign date the affidavit. The affidavit should
be returned to the city or town that the applicatio for the permit or lice is being requested,not the Department of
Industrial Accidents. Should you have any questio regarding the law r if you are required to obtain a workers'
compensation policy,please call the Department at number listed ow. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibl a Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Inve ations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will b us d as a reference number. In addition,an applicant
that must submit multiple permit/license applications Am any, en ye ,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Ad " ss"the app 'cant should write"all locations in (city or
town)."A copy of the affidavit that has been officially s" ped or marke by the city or town maybe provided to the
applicant as proof that a valid affidavit is on file for fu permits or licens . A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a lic nse or permit.not relat to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said erson is NOT required to c mplete this affidavit.
i
The Office of Investigations would like to thank ou in advance for your cooperate\ ,and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fa�toonwealth
er:The of Massachusetts,
artment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. 17-727-4940 ext 446 or 1-877-MASSAFE
Revised 4-24-07
Fax#617-727-7749
www.mass.gov/dia
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�,,� Town of Barnstable
Regulatory Services
MASS.,�ss.
Thomas F.Geiler,Director
g
'� ►`� 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
HOMEOWNER LICENSE EXEMPTION
DATE:
Please Print
/ i
JOB LOCATION: G ��
number ,� 40A
street village..HOMEOWNER":
name home phone# work phone#
CURRENT MAII,ING ADDRESS: `�9 -
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 pemut. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations.
TheunriMigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
proce and requirements that h; she will comply with said procedures and requirements.
i o eo e
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.
C:\Users\dewHik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBN\E)2RESS.doc
Revised 053012
of r Town of Barnstable
Regulatory Services
MASS. Thomas F.Geiler,Director
z639. 1�
1 " Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: -790-6230
Property Owner Must
Complete and Sign This Sec n ,
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized b / building permit
(Ad ess of Job)
}
Pool fences and ala s are the responsibility of the applicant. Pools
are not to be filled or tilized before fence is installed and all final
inspections are perf rmed and accepted.
Signature of et Signature of Applicant
7
Print Nam Print Name
DateV
Q:FORMS:OVJNERPERMISSIONPOOLS 62012
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Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Building Division
aAMSTAMX
XAn g Tom Perry,Building Commissioner
'OTFp ►�® 200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Approved:
Pee:
Permit#:
HOME OCCUPATION REGISTRATION
Date: —i.l�D�
Name: 016 4'1p y9 Phone#
Address: ;3 ��e I7 Village: Q �
Name of Business: Ws
Type of Business: 'A E) N 1 1M D, Map/Lot: �
E-TITNT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation
within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity
shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the
premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;
and no increase in air or groundwater pollution.
After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the
following conditions:
• The activity is carried on by the permanent resident of a single family residential dwelling unit,located within
that dwelling unit.
• Such use occupies no more than 400 square feet of space.
• There are no external alterations to the dwelling which are not customary in residential buildings,and there is
no outside evidence of such use.
• No traffic will be generated in excess of.normal residential volumes.
• The use does trot involve the production of offensive noise,vibration,smoke,dust or other particular matter,'
odors,electrical disturbance,heat,glare,humidity or other objectionable effects, .
r There is no-storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of -,
normal household quantities.
• Any need for parking generated by such use shall be met.on the same lot containing the Customary Home
Occupation,,and not within the required front yard.
• There is no exterior storage or display of materials or equipment.
• There is no commercial vehicles related to the Customary Home Occupation,other than one van or one
pickup-t aek•natto exceed-one ton.capacity,and one trailer not to exceed 20 feet in length and not to
excr,&.d 4 tires,parked on the same lot containing the Customary Home Occupation.
• No sign shall be displayed indicating the Customary Home Occupation.
• If the Customary Home Occupation is listed or advertised as a business,the street address shall not be
included.
• No person shall be employed in the Customary Home Occupation who is not a permanent resident of the
dwelling unit. .
I,the undersigned,have read ee the restrictions for my home occupation I am registering.
Applicant. Date:
Homeoc.doe Rev.5130103
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS
NAME in town (which you must do by M.G.L.- it dos t give you permission to operate.) You must first obtain the necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 15` FL., 367 Main Street,
Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law.
Fill in please: Date:
CT-3 1t Aft U =, APPLICANT'S NAME: YY1 1� QFos-L
.:
YOUR HOME ADDRESS: 1 en
�.
BUSINESS TELEPHONE y Q (p 5t1 b HOME TELELPHONE #: 77,y a1$V a`ja
BMW
NAME OF CORPORATION:
NAME OF NEW BUSINESS V"aC TYPE OF BUSINESS kAarM��--,
IS THIS;A HOIVIE OCCUPATION. AYES - NO �
ADDRESS OF BUSINESS �, Prey l Ut4� t'� Ce It MAP/PARCEL NUMBER p1 1��C (Assessing)
When starting a new business there are several things you must do to be in compliance with the rules and regulations: of the Town of
Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St (corner of Yarmouth Rd.
& Main Street) to make sure you have,the appropriate permits and licenses required to legally operate your business n town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been inform of any permit requirements that pertain to this type of business..
MUST COMPLY WITH HOME OCCUPATION
horized Signatur * RULES AND REGULATIONS...FAILURE TO
COMMENTS: a COMPLY MAY RESULT IN FINES.
2. BOARD OF HEALTH
This individual has been informed of the permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
�ff���� /,/ 7
G Assessor's mci and lot-number �.:....... ...Y..II.d: � �� �`I � .�C� � ,� 1Z ' 7
t- SEPTIC STEM MUST B_ E
Sewage Permit number :..:........... ...:..................:......' f (� V���J INSTALLED IN COMPLIANCE
WITH ARTICLE II STATE
THE TO�yO TOWN OF �B A R N S � AND TOWN
i EARNSTA334 i i Cii C
"6 9 = r w BIJ LD:IHG ; INSPECTOR
o
APPLICATION FOR PERMIT TO U.� ....... 0v. `. ......... /....Z.............................
4. TY"eE OF. CONSTRUCTION .... .f).Cj...w., :..COi�C�' ... V :. .r.b.^..........................
;ram ........ ...................1g. .
�r
TO THE INSPECTOR OF BUILDINGS:
The undersigned herebyG�applies for a permit accor
ding
to the following information-
.
Location .. ...... Q�. ��. .� �..l.�e.. ....... ...�..
p....... .. . ...... .. ... e c, �. d. ....................
Proposed Use .... .......1!.v .
Zoning District .... �. 0 f fi.�. ....Fire District vs �P.� �.�.I�.. .........................................
Name of Owner Ka..'R)!1►!1;�:.....GDI. ...........................Address C?... ..J ru !�.�./.� . . .�.(,1... ..Ka..^.........
,
Name of Builder .4.V. ...... .'!... ...............................Address ..Z.... .t.or,4 f- A'.t?.:...!.
Name of Architect .. .VU..: .....1...'S. 6:d.........................Address ..............................................:..................
Number of Rooms .............Foundation ..4Y.Mcp�A: ... fP.(..Vy\.4............................
0 4 C-C/�l. r... . C.'.!1 �I�J. g ..i s .� 0. "\`l�n .1. ...
Exterior .... ...................... . .. .. ..............Roofin .. (�
VJ o 0 0, 1
Floors ..................................... .Q.... ....................................Interior
,
Heating ............Plumbin g .l , �� ...: ... ....(w � g ................ .. . .....
Fireplace ..... ...........................................................Approximate Cost ...... Oj.... of5b..................:.. .............
Definitive Plan,Approved by Planning Board ----------------_-------_-------19�_-. Area .... .....1 7.Z":°. ..............:
Diagram of Lot and Building with Dimensions Fee e..
SUBJECT TO APPROVAL OF BOARD OF HEALTH
h
.I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction. .
Name .. .. ....... ..... ..............1...
Gold, Roseanne
No 19838......Permit for ...1�..s toga„IDWek.l.ing ,
...............................................................................
Location...:A .9....3.5..Pg p..ToAtd..Rd............
. ..........................rAeut exville..............................
Owner ..AQSesXtAe...GQ1d...................................
Type of Construction
Wood Frame -
......................... . ..................................... r
Plot ............................ Lot ............. .9.. .........
t
Permit Granted ......December 19 - 1 q 77 -�
Date of Inspection . �.19 _.................................
Date Completed AA/.........................19
'. s
'PERMIT REFUSED - -
...... ........................................ ......... 19
t _
...............................................................................
' ........ ...................................................... {
........................y .........................................................
......... ....... ........................... ...................
Approved .:.............................................. 19 �r
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A -p No.22167
NA L
s�titiir'
LEE
E};�.ST+fNf3 So'oTGEtLEVATION Oro CERTIFIED PLOT PLAN '
EXISTING CONTOUR- - - O �-c T P�--E:P 7CAZ> PzL
FINISHED SPOT ELEVATION '
F!NI SHED CONTOUR. p -
''--
APPROVED , BOARD OF HEALTH . -
DATE ' 'AGENT _ - — '.CALE /"- 4.0 DATE `-- 6Ad 77 �
�,1JREDGE ENGINEERING CO UK) CLIENT�C�''. L_� 1 CERTIFY THAT THE' PROPOSE®
€6ISTERE REGISTERED ,IOB NO. 7..�' .� BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING ; LAVES
r.c E.I4}�IN ER URVEY-OR DR.BY: A./l f''h OF BARNST 8L E , MASS.
53 110. AAAIN ST. 712 MAIN ST. CM• BY'
4 Sty.,YARM9UT#i, MASS. HYANNIS, MASS. _ .
M SHEET QF - D TE '; REG. LAND SURVEY®A, �`
1 _ 20 FT. MIN.
5 FT. MIN.
� r CONCRETE 4#1 PVC PIPE MIN. PITCH - 4" DOUBLE
I COVERS I/8 PER FT ` PERFORATED
- „ PVC PIPE
A 10'� _
���LIQUID LEVEL
ems- CLEAN SAND
o.. 4 CAST j i a
IRON PIPE
PITCH-
a�. j4 PER }4SEPTIC TANK -ST. ° a • (SE_E_
FT EOX C TABULATION)
( , LEACHING FIELD
SECT/ONk OF GROUND WATER TABLE
Ss. SEWAGE D/SPO7AL SYSTEM '
3 F T. 6 FfT O.C. , SCALE //4."= /-O'f X �-� SOIL LOG
2 LAY��R I 4'' DOUBLE j I ELEVATION '
OF 1/8 -3/8 PERFORATED SCAL TEST
WASHED STONE PVC PIPE _ �_ -.-_•,
DATE OF SOIL TEST �-
CI.EAN RESULTS WITNESSED BY
`n AND 1 PERCOLAI ION RATE MIN./INCH
=8. DESI, M CRITERIA
4"DOUBLE ° e 3/4' - ( 1/2 ° o !
PERFORATED WASHED STONE WOOD STAKES NUMBER OF BEDROOMS
PVC PIPE SET 8 FT. GARBAGE" DISPOSAL UNIT
ON CFNTER
_ ESTIMATED FLOW GAL./DAY
SEC TIOIU t'.�,- .X LEACHING AREA `�' �SQ.. FT.
SCALE � //4""= / = O RESERVE ,. AREA SQ. FT.
TABULATION
' DIMENSION A FT.
INVEST ELEVATIONS DIMENSION B - FT.
j DIMENSION C "�FT
INVERT a AT BUILDING ` FT.
INLET c�EPTIC TANK ' FT
OUTLET . SEPTIC TANK 60, ;s FT c - •�' :; • ;i
INLET Di >TRIBUTION BOX 61 ` FT.
OUTLET 01STRIBUTION BOX FT ELDREDGE ENGINEERING CO. INC.
END OF LEACHING FIELD L FT. 712 MAIN ST.
< ; T 33 N0. MAIN ST.
S0. YARMOUTH, MASS HYAN.NIS, MASS
�b �g-: , . )�, JOB NO.i' 7 SHEET—OF