HomeMy WebLinkAbout0017 SYLVIA LANE 117
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Town of Barnstable *Permit#
Expires 6 moniks from issue date
'PRESS SPERM ReIgulator Seli-vices C - -
�T �. Fee_ 3 v
Thomas F.Geiler,Director
FEB ' 1 2013 Building.Division 'I
Tom Perry,CBO, Building Cominissioner �U��13
200 Main Street,Hyannis,MA 02601
TOWN OF BARNSTA13LE www.town.barnstable.ma-ms
Office: 508-862-4038 7 ,
Fax: 508-790-6230
EXP SS PERMIT APPLICATION R.ESIDENTYAL ONLY,
q Not Valid without Red X-Press Imprint
l
Map/parcel Number o
Property Address1 ", . . f
WResidential Value of Work J J OO •IDO Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address �1 1I C� �4 1.f I I
Contractor's Name Telephone Number• �O _ .
P
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable) I 1
❑Workman' Compensation Insurance.
ck one:
I am a sole proprietor
j ❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Worklnan's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
[�Re-roof(stripping old shingles) All construction debris will be taken to, I �jS.
k(
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum.44)Y.
*Where required: issuance of this permit does not exempt compliance with other tovm department regulations,i.e.Historic,Conservation,etc.
***Note: Property must sign Property Owner,Letter of Permission.
A copy f the ome Impr ement Contractors License is required.
SIGNATURE.
Q:Forrm:expmtrg
Revise061306
i
- °oF rHe, Town of Barmstle.
ti
. h:egulatozy services
i HA"SPABLE, • .. .. -
T� .MAS&
Thomas F. Geller,Director
AIFo �b Building,Division.
Tom Perry, Building Gomunfssioner
200 Main Street, Hyannis,NIA 02601
1 WW.town.barnstable:ma.us
Office: 508-862-4038 j
Fax: 508-790-6230
Pr,OPex-y Owneir Must
Complete and Sign This Section
If Using'A Builder'
k.
as Owner of the subject property
hereby authorizeTM � e
to act on my behalf,
in'all matters relative to•work authorized bythis building permit application for:
:..(Address of Job)
x �f J
Signa f Owner .
Da e
Print e
Q:FoP-fS:OWNERPERM]SSION -
x
The CoM,Monlpearrh ofmassachusetts
M De art p menuoffndustrialAccidents
4frce oflrivestigattons
.600 Washington Street
_B0sf0n,At,4 02XX1
wrvw.rnass..gov/dia
'workers`Compensation lnsur,'nce'Affdavlt Builders/Contractors/Elecfiicians/Plumbe
�4 licant Ynformafion rs
Please Print Le 'bI
Name (Business/Organizationflndividual)
Address:
City/State/Zip:
Phone.##:
Are you an employer? eck the appropriate box:
L❑ I am a employer with 4. 0 I ani a general contractor'and T 'Type.of project(required):.
_. fam'.a.
oyees (Mull and/or—part: have hired the sib-contractors 6• E New construction .
2.Tj 'I 'sole proprietor or partner listed on the'attached sheet'
ship and have no employees :, These sub-contractors have y' Remodeling
worldng for me in an ca aci' ern to ees and ha • R. ❑Demolition
Y P tY• P Y e workers
[No workers' comp.insurance' .comp,insurance•t' 9: 0 Building addition
required_] 5. [] 'We area corporation and its 10.
'3.❑ T am a homeowner doing all work ❑Electrical repairs or additions
officers Have exercised their 11.(]Pl Bing repairs or additions
rnysdE [No workers' comp. ' right of exemption per MGL
insurance required,] t c. 152, §1(4),and we have no 12. Roof repairs ..
employees. [No workers'. .•13.0 Other
Hns urance
comp, required..• '
°Any applicant that checks box#1 must also fill out the sc�tion below showing lbcirworkers,compensation policy infdmiation.
t Homeowners who submit this affidavit indicating they are doing all work and lhcn hire outside contractors must submit a new af5davit' d'
$Contractors that check this box muss attached an edditionaIsticct showing the niuna of the sub-conhactors and state whether,or not those entitirti have
crrtployccs. If the sub conhactocs hays C to ccs,tic must toyi&their ryorkcrs co Ica g such.
°'P Y Y P ' mp.policynumbcr:
iam an employer that is providing workers'campenstrttnn iacsrtrarice for my eratployees Beloit is�he polic and 'ob
information. y j. safe
Insurance Company Name:
Policy#/or Sclf-ins.Lic.#:
— -- Expiration Date:
Job Site Address:
City/State/Zip:
Attach a copy of the workers' compensation policy dedaxation page(shorting the policy number and e '
Failure_to secure coverage as re quired tmder Section 25A ofMGL c. 152 can lead to the imposition c ' xptration date) ,
fine t to$1,500.01)and/or one impnsonn7ent, as well as.civil penaltii;s in the form of a STOP WORK ORDER ties of a
of up to$250.00 a day against•the violator. Be advised that a co R and a fine
Tnvesti ations of the DIA for insurance coYera e verification• PI of statemerifmay be forwarded to the Office of
16 Ice y ce sander e p ins. ndp alties of perjurj,thae the information provided ab lire is u
Siena e rid correct:
tare:
Da te:
L3
Official use only. Do not write in this area,'to he completed by city or fawn official
City or Town:
.Permit/License# '
Issuing Authority(circle one):
L Board of Health 2.Building Department 3; Ci * :
6. Other >`Y/TownClerk 4.ElectricalTnspector. S.Plulnhinglnspectpr
Contact Person:
—___ Phone#
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>► r Town of Barnstable . *Permit of ofyti Permit#
O E.rp/res ror° jro srre r/n1e
Regi>latory Services Fee
a.ARvsr�stE, : .
e Thomas K Geiler, Director
OCTERMIT
� .1. �p1r
Building Division
Tom Perry,CBO, Building Commissioner
®WIti1 OF ��R�S����� 200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax 5087790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Nn/Valid wi fthorr/Red X-Presls'Imprint
Map/parcel Number
Property Address _<,' W 1 N Lk. C wty'a e1 ®ZfolZ—
6esidential Value of Work 000- Minimum fee of$35,00 for work under$6000.00
Owner's Name & Address-Lk k L0—A 9--�
Contractor's Narne. --
'telephone Number —'—
Home Improvement Contractor License#(if applicable) 121"Jr�
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
❑ I have Worker's Compensation insurance
Insurance Company Name
Workman's. Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request (check box)
N1 Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to bAoigeu UL�1
❑ Re-roof(hurricane nailed)`(not stripping. Going over existing layers of roof)
❑ Re-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.copy of the Home Improvement Contractors License & Construction Supervisors License is
required.
SIGNATURE; .
Q:IWPFILESV0IZMSIbuilding permit forms\EXPRESS.doC
Revised 072110
XN The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations.
' 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information l Please Print Legibly
Name (Business/Organization/Individual): Li //4 1./4vu
Address:
City/State/Zip: � ��2 �S� ` Phone #:
Are you an employer?Check the appropriate b x: Type.of project,(required):
1.❑ I am a employer with 4.N I am a general contractor and I
6..❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 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 me in any capacity. workers' comp, insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑_We are a corporation.and its
required.] officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §](4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers'
comp, insurance required.] 13.❑ Other
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
I 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.
1 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: 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 STOR 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 under the pains andpenalties f perjury that the information provided above is true and correct.
Signature: Date: -
Phone#: I
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#:
k
Information and Instructions f
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."
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 trustee of an individual, partnership, association or other legal entity,employing employees. However the
owner of a 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, §25C(6)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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have.been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. 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. 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 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year;need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to-thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600.Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax 4 617-727-7749
www.mass.gov/dia
��plHfro�o Town of Barnstable
Regulatory Services
r �JASS.BLE, ThomasF. Geller, Director
ab;9,�a Building Division
Tom Perry, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.ba rnsta b l e.ma.us
Office: 548-862-4038 Fax: 508-790-6230
-----------
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: 10 &L A<)
10BLOCATION: ` v S 7 Ma- CF_Nqt1ZUAY _ 026S2—
„HOMEOWNER" number street village
.\ LWO KTp O�
� OQ 't-l®0Z_gq
name ! home phone# work phone#
CURRENT MAILNG ADDRESS: \� ��/�V1,4
0263�—
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 an that he/she will comply with said procedures and requirements,
ign ture of Flomeowncr
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 ofconstruction 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 ofa.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:\WPFILESIFORMSIbuilding permit formslEXPRESS.doc
Revised 072110
OF THE TOE
s t
r HARNSI'AHLE, ,•
6 ,�� Town of Barnstable
pTfD MA'S A
Regulatory Services
Thomas F. Geiler, Director
Building ]Division
Thomas Perry, CBO
Building Commissioner
200 Main Street, Hyannis, MA 02601
www.town.barnstable.ma,[is
Office: 508=8 2-4038 "� Fax: 508-790-6230
Property Owner ust
'.KCompkte and Sig/ his Section-
, !
If Using /Builder
i
as Owner of the subject property
hereby authorize ��'� to act on my behalf,
in all matters relative to work authorized y this bLi lding permit application for:
t�
f
(Address of Job)
i
Signature of Owner 7{ ate
1
Print Name
11'Property Owner is applying for permit, please complete the Homeowners License Exemption Form' n the
reverse side.
QAWPPILESTORMSIbuilding permit forms EXPRESS.doc
Revised 072110
The Commonwealth of Massachusetts
^, Department of Industrial Accidents -
1gT Office of Investigations
� 600 Washington Street
Boston, MA 02111
r www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: 07-61Z Phorie #: 2A 14
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and
I' 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.1Wam a sole proprietor or partner- listed on the attached sheet. t ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers' comp. insurance._ 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.El am a homeowner doing all work right of exemption per MGL 1 i:❑ Plumbing repairs or additions
myself. [No workers' comp, c. 152,;§1(4),and we have no 12.WRoof repairs
insurance required.] t employees. [No workers' 13.\/Other VP- toot'jt
comp, insurance required.]
*Any applicant that checks box#I 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: 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 un e e rs and penalties of perjury that the information provided above is true and correct.
Si nature: Date:
Phone#: �Lo_-2-4,14
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#:
Information and 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."
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 trustee of an individual, partnership, association or other legal entity,employing employees. However the
owner of a 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, §25C(6)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, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. 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. 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 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 permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727--7749
Revised 5-26-05
www.mass.gov/dia
r -- ,_ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel - Permit# v
__4ealf Birion Date Issued
GonsefyMio�vision - Fee 'o?� t�
.Tax Collector _
"Treasurer .1Cf / F
wept , ' c
Date Definitive Plan Approved by Planning Board
Histe �t4Fl- Presewatirns '
Project Street Address �VCU t 14' kJ19?Jr_
Villagee-
Owner (P�(�r� GC>�1 �" ! Address rn�
Telephone
Permit RequMo e_ Sfe- I-r �l. l� e-1 (06
Square feet: 1 st floor: exist'in4- ,proposed 2nd floor:existing proposed Total new
Estimated Project Cost"f G; Zoning District Flood Plain Groundwater Overlay
,
Construction Type '
Lot Size Grandfathered: ❑Yes 2(No If yes, attach supporting documentation.
Dwelling Type: Single Family 1q/ , Two Family ❑ Multi-Family(#units).
Age of Existing Structure Historic House: ❑Yes 6Jo On Old King's Highway: ❑Yes
Basement Type: 0 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 ❑Oil ❑Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: Cl 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 0I10 If yes,site plan review#
Current Use Proposed Use
/n BUILDER INFORMATION Q
Name � �Zf e- cT�h0' Telephone Number.
Address /Ik.GJ lsW 9d
1 License# C,6 b
R d14TnA- DCIG 3 5 Home Improvement Contractor# Q ��
Worker's Compensation# i g
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO i
SIGNATURE *a�d� 1z,
DATE
t't - FOR OFFICIAL USE ONLY _
Pam . {• f , '� ` '• '"` •• ,l - • - Y •, ... t -
PYG IT NO.
DATE ISSUED
MAP'/PARCEL NO. ,< ' Y n" i• ` .. x '
` I r
ADDRESS F ' VILLAGE
tti OWNER . 4k "- r' . _ t ..
t7T
41
DATE OF INSPECTIO1: ' w• : =
FOUNDATION ~ / t ? ) r r } • } i
FRAME
INSULATION
FIREPLACE + i i
ELECTRICAL: ROUGH FINAL I ! 3 s s {
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL '
FINAL BUILDING
i
. t
DATE CLOSED OUT y"
-ASSOCIATION PLAN NO. t
• r f
a '
An
- _— ---- The Commonwealth of Massachusetts
Department of Idu nstrial Accidents
Dl�ic�otic�stipMM
600 Washington Street
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
can or�atlutc•. , ///�/��/��-'��/D%�//7 �
e:
ovation:
P
city 212h 62 52' hone# q O / /
❑ I am a homeowner performing all work myself.
❑ I am a sole proprietor and have no one WorldZ in any ca acity
I am an employer providing workers'compensation for my employees working on this job.
componv name: /u./ 11h;Me _AkeA&v'r—W 61 r
address: Flo#s Aleam4dAl
city: CoMir baI, 3-T nhone#:- Oa'�
Insurance cn. nolicV#
./ii//,l�vi,�/,✓/ivi,�v////i�//�/aia <u�U.�/////iira,�//.�/i/.���%/////// .�// ;r�,V:s
❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who
have
the following workers' compcnsation policcs:
companv name•
address
dtv ...... ......
phone#-
insarance cn.
company name: :. ,.. ...:..,.:,...
address:
phone#:
...-
ftslarlince CO.
Fallure to secure coverage as required under Section 2SA of MGL 152 can lead to the imposition of criminal penalties of a Me up to S1300.00 andlor
one pears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a line of 31oo.00 a day against ma I mtderstand that a
copy of"statement may be forwarded to the OMce of Investigations of the DIA for covetge verineation
I do hereby certify under the pains anddppfe/tallies perjury that the information provided above it ten.and corrects
Signan=/ Date l0-Id
—_
Print namedie Ed Sec - It. RA S C H_IIt �e a� z nc 1 ,��S—9 S I S
olUdal use only do not write in this area to be completed by city or town ofIIdal
dtp or town: pennitNcense 0 Miluilding Department
- oucensi ng Board
❑t3tech if tinmediate response_ .�- - d --____—_—_-------------------_.._-____-- —-
re -----DSdeaea's OfIIu -- -
D13calth Department
contact person phone
(Rv"Q 9,95 PJA)
The Town of Barnstable
9 & �e�' Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Ralph Crossen
Office: 508-790-6227 Building Commissioner
Fax: 508-790-6230
For office use only
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
r to
owner occupied building containing at least one but not more than be done by reoustered Iling units contractorsowith
structures which are adjacent to such residence or building g
certain exceptions,along with other requirements. ``,,
7' l P0- Est.Cost
Type of Work: ��
Address of Work: `? �1
Owner's Name-
Date Date of Permit Application: 1 u " L L�
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
Owner pulling own permit
I
Notice is hereby given that:OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
E IMPROVEMENT WORK DO
CONTRACTORS FOR APPLICABLE QGZO1M10R GUARANTY FUND UNDER MGLO 142A�
ACCESS TO THE ARBITRATION P
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner. D
D 7
t a IS I
Registration No.
Date Contractor Name
OR
owner's Name
a->
T e �aiwnzaczzuea��. o��-llaa:;ae/uoeClJ
cc
✓�'C�091H)tOftUACQLU[O� lIJCCIb �eC:•r 1(:l,?� T0: '�65"'/THOMA') CAP I ZHOME IMPROVEMENT CONTRACTOR -
x THOMAS CAP
Registration 100740 h', HEWTOWN yl, ,
' Type - PRIVATE CORPORATION nIIT; NA .1F;a
Expiration 06/23/00
CAPIZZI HOME IMPROVEMENT, INC
as Capizzi, Sr.
ADMINISTRATOR logs Newton Rd. .
Cotuit MA 02635
DEPARTNENT OF PUBLIC SAFETY
CONSTRU&TION SUPERVISOR LICENSE
Number: Expires:
Restricted-To:. 80
THONAS X C'APIt2I JR
286 PERCIVAL OR
W BARNSTABLE, NA 02668
w
„i
z T ✓�e fccnr»ranaeal�� o� l-ja�cuely;
DEPARTMENT OF PUBLIC SAFETY
CONSTr,UiTION SUPERVISOR LICENSE
Number: _xpires:
Restricted To: 66
_ FREDERICK V RASCH iii
a68 6OURNE RD
PLYMOUTH. NA 02368
• � .� - � ,-�^err ;,:r-�"-.•r-..� _
r:
r'}rr _raj: �• F �� � ..�
. . : The Town of Barnstable
9039.MAM �m Department of Health Safety and Environmental Services
Eo Mop'' Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
SHED REGISTRATION
� •7 .'S•Y L VJA L A/VE ���1 Z'4ro—V1Pe
Location of she (address) Village
04010 1-0.9 kfN1- & �7 -78 s �
Property owner's name. Telephone number
/D 0ex
Size of Shed Map/Parcel#
Signature V Date
Hyannis Main Street Waterfront Historic District? Olt D
Old King's Highway Historic District Commission jurisdiction? NO
.t/ Conservation Commission(signature required) Z ,
THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN
Q-forms-shedreg
viJUU1,UUL
MORTGAGE INSPECTION PLAN
NORTHERN ASSOCIATES, INC.
-74P H.MAIN STREET AAVOVER MA 01810 ML: (508)474-4410 FAX (5081474-5067
MORTGAGER: CHARLES J. HANLON DEED REF. 9841S/ISA
LOCATION: 17 SYLVIA LANE PLAN REF. 139/133
CITY, STATE: BARNSTABLE (CENTERVILLE). MA SCALE: 1" = 20'
DATE: 11/10/97 JOB 97/7182
LOT 5
LOT 2 W/s
,525 S.F.±(PLAN)
T S.F.±(CAL(�.)
at 6
WD B 39*
o W/F LOT 1
LOT 3 O GAR, o
1 st 1 STY W/F a
#17 C7
-H
n
f
N
1 1
-- 130,00 ,
SYLVIA LANE
CERTIFIED T0: OLD COLONY MORTGAGE CORP
NO7L1 file■ortp•gw lMpaotlan ra• prepwcad fi!• ►orti•g• 1neDgOtlon n• pieDhr.d In •avornnee.10 "a1 to ba row•ort�gw pv[9awe only end With the u0bn10.1 et•ndar0• (of NOrt a we.
ll ro• e4 be n1l.e seen •1 . trod or prap.roq �11 0! q g•
llna .one wed ler raw[a1. lnppaetlene n •dovtoa ey th• g/ntonue•cte Dore of/. t. Dr•parinq dewa V' 1
d■acf tlom, er oenwtrvotlan. No earner.r.r• ?�' Mg elntlen e/ ►rele•.l anal rngln•gra one Land
wee. gulldlnq lee•elen.nd,ellu..... CARMEN q sore•ren fie Con Co.
orKowloeoly lse■tad en tn1 grerne and y t tartMr ■lees that
!n yr preHewlen•1 ODlnlon hot
tit •nave agelflael ly fOf waning datenln•tion thw etcraNne ehwn evnlerr vl to tM looel tonlpq norllontal
.1F .ne •re net to w wea to a.rabll.b plabortr dl•.nalenel owtb.et ngulrw.•nc• at cn• t1r• 0r oonwcrvoclon o
11nn. Tn••nt.n •hwn n•rasn an be on •re w.wpt under pterLlono of q.O.L. cq. .o-. t.a. t,
cllwnt-furnlehad lntenatlen .nd..y be eubl.at f�l ��p•l.froptrty/Rout• is not in t rlood guard.
w rartn.r vut••e1ro, ruln�e, o■.wrota .na Apnea J/ S1 P� []L.prop■tty/Hou•a 1w 1n a Flood•Hature Arap.
of r.1, ..0 etn•r oaten a naara .ne pr.etrlptlre ON,�(LANa C]7.Inlorrtrlon 1• lnaottleiwn! to ewurnine
at etner rf pn tw. Nwftn•tp r.waal.tae, tna*
ae■rpww no
rvponelllllq Main to tm land ern•r a oveup•nt, Flood Na terd.
.vegan•n•n•ponrlblJ![7 far aa•ryga r•■uleing erew a•le It 11 47 flood Httatd date-r.lned fro tewwt der el Flood
rafimee ar•nptna atn.r coop tow•ue.vertesotejhgpoi •ea its wul•na Inaunna• v t• �1np anwl In veneeet en vlcn lu prepowd romps•• Llnrnalnq ee aal0 .eregget' Dtt. �- /�'d'.� Lon•
i,
K a
VM
s .
Q Lo T 2
M SKfA �
v
CA k A 6E
(AL S'YoR.a6_� SLED _
rr- •
1,Pa�PiP�
i
Assessor's map and lot.number .. ...... . 7. 1,� 7
THE
Sewage Permit number .... &�7
.1 �Q ~�
House number ........................................................................ �b39. \0
WITH TITI. ' n wnr a.
-TOWN - OF �'BARNST ' �EGULATIIONS
BUILDING -INSPECTOR
APPLICATION FOR PERMIT TO ....... v/ ........... .......................................
TYPE OF CONSTRUCTION ...............1�r� ... .......... ® ............. ... .......................................
/............... .19.2j"
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ................e__.,... ......... �/. /i ............:4eq. ...................................................................................
Proposed Use ................... i4 :.................:..............
ZoningDistrict ...............................................Fire District '......................... ..............................................................................
Name of Owner ......................Address � ..............
Name of Builder .... li? -5 �1 ddress
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ...............................................:............:.....Foundation ..............................................................................
s
Exierior ........ .... .. ...............:...............................Roofing ..... �� .1 ....m ✓� d��.....'=-
Floors•' ��„ Os1! G a. ..............:.................Interior ................... �?...z.......................................
.............. ...............
Heating ..................................................................................Plumbing ..................................................................................
Fireplace ..........Approximate Cost..:..................................................................... .................... ...................... ............ .. ......
Definitive Plan Approved by ,Planning Board -----------_-----_-------------19--------. ' Area D�
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
a
Narte..... ................ .................................................
Martin, G.
No .... 11 Permit for .........garage
........ .............
41
I
...............................................................................
Location ...........
jv...i..a....Lan.......e........................
Centerville
...............................................................................
Owner ...............G. Martin
...................................................
Type of Construction ..........................frame................
............................................ ..................................
Plot ............................. Lot ................................
Permit;Granted ............24ay..21......:.......19 79
Date of Inspection .....................................19
Date Completed ....611RI ..............19
PERMIT REFUSED
......................................................... .... 19
.......... ...... ..................................................
.......... . ......W--. ...............................................
0
.......... 1W....................................................
.......... ..............................................
ApproM 1.U.J0, ..L................................ 19
Sm
...........0.3........ ..............................................
...............................................................................
Assessor's map and lot number .. -- f;; � �/�" / C — l
' t y0p TM E
Sewage Permit number /!(�!2�•.y., �!, •d�tea+ �� d� �" ,
✓� Z EA"ST1IDLE, i
House number r NAB&
�p 1639. 00�'
0 OR a\
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ... � . + ... � ',' ' .! .:...........................:......:..
........
TYPE OF CONSTRUCTION ��''�°� ......./?� °'' - +
......................................................................................
.c .. �...................19.. '"
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ................z: �7.......... ��►/ ?!............ ............................:........:...
ProposedUse ................... .....-...................................................................................................................
ZoningDistrict ........................................................................Fire District ..............................................................................
Name of Owner :.•' tea •" :!.......................Address ...............
Name of Builder 5./ri'S ,« asrr "t.�.�Adss ...... .........
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ..................................................................Foundation ..............................................................................
Exierior ........° ..... .'`�.. r'�.......................................Roofing ! ..... +-�.? ....� «~ .'S' s
Floors ................................Interior ................... ►9 ...'��.......................................
Heating ...........................Plumbing ...:.................
Fireplace .................... ..........................................................Approximate Cost e,.r t G ss r
............................................................
Definitive Plan Approved by Planning Board ________________________________19________. Area ...... (...yl.......: ..........
Diagram of Lot and Building with Dimensions Fee
SUBJECT TO APPROVAL OF BOARD OF HEALTH
" ram z* .
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name .. -�''.
Y
Martin, G. A=189-82
No ..........213"Permit for ...........garage............
...............................................................................
17 Sylvia Lane
Location ................................................................
Centerville
...............................................................................
Owner G.,...Martin
.. ...............................................
Type of Construction ............iframe
..............................
........................................ ./...............................
Plot ............................ t ................................
Permit Granted .. .........MY...21.............19 79
Date of Inspect'n ....................................19 .
Date Completed .........................................19
PERMIT REF SED
................................ .n. . ......... 19
n. 1. i.. .,�. . �...................
........... .......... .
............................. ............................................
...............................................................................
Approved ................................................ 19
............................................... ...............................
...............................................................................