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Thomas F.Geiler,,Director
rEo � a�
Building Division ItInIit
Tom Perry,CBO, Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.bamstable.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
Z
Address CJ� U�} L V
ential Value of Work Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address 1 a
v� n rs�
/Contractor's Name wo jb"V b" \ Telephone Number e-4 M
Home Improvement Contractor License#(if applicable) 14
Construction Supervisor's License#(if applicable) G
3
❑Workman's Compensation Insurance
C�hec ne:
0 1 am a sole proprietor
❑ I am the Homeowner
have Worker's Compensation Insuran^ceA
Insurance Company Name yJ .
Workman's Comp. Policy#
Copy of.Insurance Compliance Certificate must accompany.each permit.
Permit Request(check box)
e-roof(stripping old shingles) All construction debris will be taken to
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
#of doors
❑ Replacement Windows/doors/sliders.U-Value (maximum .44)#of windows
*Where required: Issuance of this permit does not exempt compliance with other town department regulations;i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Ho nt Contractors License&Construction Supervisors License is
required.
SIGNATURE:
QAWPFILESTORMSIbuilding permit formslEXPRESS.doc I.
Revised 070110
I
x+� 5 �
a r} 3
r
P.O. Box 311E,MYMAly u ESL' 508-367-1679
Centerville, MA 02632C�ONSTRUCTIONj"h
Fax: 508-790-1856
PROPOSAL SUBMITTED TO: PHAE: DATE:
Ait- %/4G-Herz, Suk- 36 Y. Uy y� // /: 2v/
STREET: JOB NAME: JOB#:
v'2 %o j3c y L
CITY,STATE and ZIP CODE: JOB LOCATION:
ARC ITE T: DATE OF PLANS: JOB PHONE:
- t� & C�VctAl
We hereby submit specifications and es'gates for:
s � b 17,
�-�� Y ✓ f O v
( jot ld Ito Ufe �uCl� G� �� . ��d
�K( p 6(it C 0(�✓'vIC' f C ct Ue GL
V'I(f V,
�-�-
C [� l 0 V-cui:
)c 17SIS I o,
UU
i IvE 0 105C hereby to fu ish material and labor- o ete in acco dance with the above specific tions, for the sum of:
Vfcf AA dollars ���
�$. )
`Payment to be made as follows: ,
All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from above specifi- Signature
cations involving extra costs will be executed'only upon written orders,and will become g
an extra charge over and above the estimate. All agreements contingent upon strikes, s
accidents or delays beyond our control. Owner to carry fire;tornado and other.necessary Note:This proposal may be
nsurance. Our workers are fully covered by Workman's Compensation Insurance. Withdrawn by us if riot accepted within days.
�LCe�1t�jYCP Of �CO�IOgAr-The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature: _
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: � ' i ���L Signature:
09/19/2011 14:16 FAX 15088776980 WAYSIDE IN5 Q 002/002
4/ zz/ '4V11 z : JU : J0 F;M 89/5 0 02/02
CERTIFICATE OF LIABILITY INSURANCE °"� =2011
� y � � O�-rYWl1
TEIB CERTIFICATE IB IBBBao AS A lOITTn or Ift0f1IATI0I ONLt AND calms s0 RINBTS UPON Ta emRTIFICATB BOLDER. THIS CENTIrICATH
DO." Not ArFIRROISIVELT OR M=rXVSLY ARM, EXTEND OR ALTIM TBE COVERBSE ArNORDED By TBE POLICIaN BELOW. THIS CaRTxrsCATE OF
INSDRANCE DOER NOT CONSTITUTE A CONTRACT BXMMMN THE ISSUING IBSOBBA(S)I ADTBORIZED REPMARITATIVE OR PRODUCER, AND THE
CERTIFICATE BOLDER.
Z"01TA17: If the certificate holder is an ADDITIONAL INSUR®, the policy(ies) must be endorsed. If SUBROGATION IS VAIV®, subject
to am the teams and conditions of the policy, certain policies may require an endarsemeat. A atataaant an this certificate does not
oonfsr rights to the certificate holder in lieu of such andorsement(s).
ssae corat�
Wayside Insurance Agency Inc . ��
SM
RO Nicholas Road wc.N..ast): arc.N.).
PO Box 3337 N :
Framingham, M& 01701 �=se•
nsosw nasmfs) areomas asaosss Matt e
HeC'tOr Sanches =w="A.I K. ADftual Insurance Co
rismma it.
dba Emanuel Construction mniazz c.
286 Strawberry Hill Road
Centerville, Lin► 02632 ■_
COVERAGES CERTIFICATE EW03ER: REVISION L1MXR:
Two Is Ta 'PRAT SM-rom2cles OP 1�.
mllt'a[rnuzND An RINOWMIZINT, Ma OR CONDITDOB or MY CONIRACT 02 0' DOCtaRaT vim xzan CS tD-=xx CUT===MY aL 0sUm on my
M=n' M MNfasANaf Ar&M=D By TOM PaSM=11=U=Zs>m HRNNIf IR 1020 T 0 ALL TM�, ==valma an conazwwas Or ROC!POzD .LTD M amp
NRY fAPR HaB mum RY PAID CLANaa.
w TWE or inn POLICY IWINNf r't M ROMY an
aga.nsa, ww,n:,r,
ORf®AA LiABILIM
acs sccoasce •
�rnreseLu selrsu s:Assstxr am.to sssss
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❑❑tusve feat ❑�
aMOM In IAv Pazwo, •
Nm®L a ao.loss ,
GWZ AafRMn 1=0 AMMS sae Mon Aaissan e
❑smm Oasaoee!❑sac Nmauas-CM/0 an •
1aN01�Ra,N LIABa.1T7t COOMM s
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Dan AM
❑Aw,awro AOSae -
snlsr aril O.e P-4 P
❑sc®ssss Au= sa•fiI nM=uw*.musq 0
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pea-saes,Amos loftinfamy •
afacRSA LJAB acts, am wMalaw N
❑sassy LZkD ❑c+DO rum aassosOs •
msserlscs
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❑snasrta s �
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ADD 001L0411a LIAAa,ITI
THE PROPRIETOR/PARTMM/ E.L.n�
A HXaCW=OFFI= ARE a 100,000
❑ incl ® excl 702 454 3012 011 04/05/2011 04/05/2012 X.L. Ncsas 4POLres cloy • 500,000
s.L.as®o-ss aacofss • 100,000
car®rs nsfaarlss ar arwssea s facarsma:
HECTOR SAECHEZ IS HOT COVERED BY THE `QORBERS'CaWEHSATIOa POLICY.
CERTIFICATE HOLDER . CANCELLATION
TOWS OF FM STABLE
HHORM Aft or M ABOPR Dian=POLDCSa of CtImmain mcar,M
200 101IH ST sxrlRAxoor.am maze", ROTICR Vas oy Dmmn m in Acc aDAmNE aria s
Psi u=PROMMONs.
HYA9NIS, 2W 02601 smmils>m seasaNrusa�C .
i
9419
I
Officr�t oinsu r°A° ors Ba>if ell egu License or reg�st anon valid for,�ndrv�dul use only, I
HOME IMPROVEMENT CONTRACTOR before the:expiration date.;If found return to:.
Registration 145356 Type: Office of Consumer Affairs and Business Regulation.
Expiration ,1/121013 DBA~. l0 Park Plaza-Suite 5170
4 Boston,MA 02116
I NUELCONSTRUCTION 7i,r
i c
r` HECTOR SANCHEZ� r ! j
286 STRAWBERRYvHILLRD
P Q2632 Undersecretary W.,Not valid wit uts
CENTER VILLE, VA
t
c
. N1astiachusetfs- Department of Public Safety
136ard of Buildinl- Regulations and Standard
Construction.Supery sor.Specialty License
License: CS SL.99382,
Restricted to: RF,WS
HEC
TOR SAN CH EZ
286 STRAWBERRY HILL ROAD
CENTERVILLE, MA 02632
Expiration: 9/14/2013
Commissioner Tr#:'2314
The+Commomsealth of massach"seft
Deparbnent of Indusbza1 Accdd
Offlue of Investigations
600 Washington street
Boston,M4 02111
nwiv.muss.govfdi4ff
Workers' Compensation hsamuceAffidavit- Btdlders/CCmtractors/EI ici;anslPh mbers
Applicant Infarmatian Pease Px int •bh-
Name ideal): (N�- (/�.
Address:
Ci fStatef C
� �= � Phflne#_ !�
Aro yo loyer?Check the appropriate box: Type of project(required):
am a contractor an I
1. I am.a employer with 4. ❑ I d 6_ ❑New ccrostrazctor<
employees(full andlerpar#4ime).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have . $_ F]Demolition
wodring for mein any capacity- employees and have mcw1:ers'
o wod=s'camp.insurance comp_irmwance$ �. ❑Building addition
required.] 5. ❑ We are a corporation mid its 10.❑Electrical repairs or additions
officers have exercised lw� r
3.❑ 1 am a liomeowuer doing all wok 11.0 Plumbing repairs or additions
myself o workm' right of exemption per MGI.
mY � �P- 12.❑Roof repairs.
insurance required.]T c. 152,§1(4),and we have no
empk J -[No workers' 13,❑Other
camp.instuaam required.]
•Any appIcant that checks boot#1:mnst also fi hie Ila t t section below dhaaring thwwarkes'com �psatiozipolicy in&matiotL
1 Homemuers wbo submit this affidavit in&cxwig they axe doing aQ watt and they like outs&canuactuas roes#submit a new ailidseit indicating ankh
ors that check this boot must attached am additional sheet showing the nzDe of the sub-t�and state wbethm at not those eumes have
employees. Ifthe snh-wntmacs hale employees,theymost:provide their werkeW tcomp..policy number.
I am an employer that is ptmi&Rg nwrirers'conrlreaswdi#s inmrance for my ampdn;} Maw is the pvUey and job site
iRformrriiart. '�
Insurance Company Name:
Policy car iss_Lic.# `. ` b ExpiratiouI}ate: -�
Job Site Address: �� �V r✓ CitYlStateZ4-Vl
Mach a copy of the workers'compensation poLcy declaration page(showing the peficy,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 S 1,500:00.and,`or one-year im risont nt,as well as coil penalties in lie form of a STOP WORK ORDER and a fine
of up to$254_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-
Ida hereby cer#r;&,inAer thepabis acid na �peryury_that the informad en pr0t idad. F077aniCorrect:
Date:
Phone#:
O, al use only. Do not aarite in this area,to be cnuipitew by city or tow official
City or Town: Permit/Ucense#
Fssuing Authority(circle one):
1.Board:of Health 2.Bw1ding Department 3.City/Town Clerk d:Electrical.Inspei xer 5.Numbing Inspector
b.Other
Contact Person: Phone#:
6
oFTME r Town of Barnstable
ti
. . �� Re ulator Services
y Mass. $ Thomas F.Geiler,Director .
1639•
'�sD„�►a Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnsiable.ma.us
Office: 508-862-4038 Fax; 508-790-6230
i
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this'building permit application for. -
Address of job
Signature of Owner Date .
Print Name
If Property Owner is applying for permit please comp lete the
Homeowners License Exemption Form on the reverse side.
Q TO RM&O WNE RP ERM IS S ION
Town of Barnstable
O
Regulatory Services
w BMWSTABM Thomas F.Geiler,Director
Mass.
1639• A,O� Building Division
TEn � 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:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
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.
DFFINITION 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
requirements.
Signature of Homeowner
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.
Q:forms:homeexempt
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
c � !! � °
Map Parcel Application# fU
� l
Health Division {
Conservation Division '" Permit#
Tax Collector Date Issued �Zq
Treasurer Application Fee '
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic-OKH Preservation/Hyannis
Project Street Address 6�i_ `rpogY jzxggy 4A'1A._
Village
Owner 6&VZ ci- YK i tq DY Address
Telephone �75
- 7 5 — A q, 744
Permit Request r ITC E(F_4 Ad b T ATq 'REM 0_D 6
Squ afeet: i st floor:existing proposed 2nd floor:existing 1 proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuatim DPI OD 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 7 Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No
Basement Type: 14 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 �YkOil ❑ Electric ❑Other
Central Air: kYes ❑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:�xisting ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes, site plan review# Cie)
— - — - �'
Current Use Proposed Use - - - - two
BUILDER INFORMATION r
,"� I
Name/ /Zl =0 Telephone Number O 64 irY
rn
Address License# 0
a (A S l ISLk Home Improvement Contractor#
Worker's Compensation# -Y6,44.PT_
ALL CONSTRUCTION DEBRIS RESULTING FROM,THIS PROJECT WILL BETAKEN TO
'-1 11J 2 i t D/11
SIGNATURE, DATE 63c�
E FOR OFFICIAL USE ONLY
PERMIT NO. +
DATE ISSUED {
MAP/PARCEL NO.
ADDRESS VILLAGE ,
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME -
INSULATION ( 01
FIREPLACE
r
ELECTRICAL: ROUGH FINAL
1 �
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
I,
Department of Industrial Accidents•
_ Office of Investigations
i 600 Washington Street'
Boston,MA OZIII
www.mass.gov/dia
Workers, Compensation 11�surance Affidavit: Builders/Contractors/]Electricians/Plumbers
Ago licant Information Please Print Le ']bI
Name(Business/Orgmizationadividual):
• •Address: �;t:?� sM�•I�i..�. �T�.rL� - •
City/State/Zip: , 9A 4 , M A Phone:#:_
Are you an employer? Check the'appropriate boa: -Type of project(rewired):,
1.❑ I am a em toer with 4. 0 I am a general contractor and I
P. y 6,.El New construction
emplayees (fall and/or part-,ime).* have hired the sib-contractors
2.[] jam,&'sole proprietor or partner- listed on the-attached sheet, 7. Remodeling
ship and have no employees These sub-contractors have g, L]Demolition'
working for me in any capacity, employees and have workers'
I.[No workers' comp:insurance • comp.insurance.
t. . 9,.•[�Building addition
. required._]
S., We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11. Plum repairs or additions
3.❑ I am a homeowner doing.all work , g P
myself[No workers' comb. right bf exemption per MGL 12,E]Roof repairs
insurance required.]t c. 152,§1(4),and we have no.
employees. [No workers' 13:0 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 affidao•itindicating they are doing all work and then hire outside contractors must submit a hew affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the'sub7contractars and state whether or not those entities have
employees; If the sub-contractors have employes,they must providb their workers'comp.polidynumber.
I ain an employer that is providingwo.rkers'compensatian insurance for my employees.-Below is.the policy and job cite
information.
Insurance Company Name:
Policy#•or Self-ins.Lic,#: Expiration Date:
fob Site Address: City/State/Zip•
Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date).
Faihze.to sectrre&overage as required tinder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine uF 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 OfSce of -- -
Investi¢ations of the 13IA•for insurance coverage verification.
Ida hereby cer ' er t pains nd penalties of per'ury that the ' ;motion prgvided above,is ue and•correct-
SI attlr e �. Date: d
Phone# Y 0 2 /
Official use only,.Do not write.in this area, fb be completeii by city or town official
City ar Town: Permit/License#
bsuin.g Authority(circle one):
:1.Il•oard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector
5, Other
ContactPerson: Phone#:
I•nforma io and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. r
pursuant to this statute,an employee is defined as"...every person is the service of another under any contract of brie,
�Pzess or nnp. lied, oral or written."
•
legal enti or an two or more
defined as an individu artnershi asso"ti co oration or other ty, y
to er is al,p p, n, rP g
An ernp y w ,
of the foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the
or-tal tee-of an individual,partners ' ,association or other legal entity, einploying-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 emplayriient be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local•licensing agency shall•witbhold the issuance or
yenepral.of a license or permit to'operate a business or to construct buildings in the commonwealth for any
applicant-Who has not produced-aceeptable 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!his 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),addresses)and phone number(s)along v#their certificates)of
insurance. Limited Liability Companies'(LLC)of Limited Liability Partnershipa(LLP)with no employees other than the `
members Or partners,are not required to carry workers'compensationins„mnce. If an LLC or LLP does have
employees,a policy is required. B.e advised that this affidavit maybe submitted to the Departrhent 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 perrnit.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 pezmit/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"an-locationsIn (City'or
town)."A•cbpy of the affidavit that has been officially.stamped or marked by the city or town maybe 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.Vdhere 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 brim leaves•etc.)said person is NOT required to.complete this affidavit.
The Office of Investigations would hke to thank you in advance for your cooperation and should you have any questiogW,.—-
please do not hesitate to give us a call. .
The Department's address,telephone•and fax number:-
• �•�azt�aa��alt�of l�assa�b�s�t€s
Dqpadmmt of liduWal A.oci.d=ts
Office Qf ln-yutigafions
RoStan,MA U111
W.9 617-727--491-0.0 ext 406 or I-8 77-MASSAFE
Fax 617-727-7 749,.
Revised 11-22-06 w .�ass.gdl .
°FTVEroy� Town of Barnstable
Regulatory Services
sB MASS. Thomas F.Geiler,Director
�p 1639.
Building Division
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
Office: 508-862-4038 Fax: 508-790-6230
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: [RA t L. Estimated Co .00 000�CD
Address of Work: 6 rl 71+O�`iV L CkA TE?VILLL
Owner's Name:
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
❑Job Under$1,000
❑Building not owner-occupied
❑Owner 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 hereb app y for a peFta the age of the o
Date Contractor Name Registration No.
OR
Date Owne s ame
Qlomms:homeaffidav
°FTNe 1pw Town of Barnstable
ti
Regulatory Services
t BnxxsrABr�, ` -
Thomas F.Geiler,Director
�lf2619. , Building Division
Tom Perry, Building Commissioner
200 Main Street Hyannis,MA 02601
Ymw.town,b arnstabl e.ma.us
Office: 508-862-4038 Fax: 508-790-62.30
Property Owner Must
Complete and Sign This Section
If Using .A Builder
, as owner of the subject property
hereby authorize ST,� �,�/ �,� TOW to act on my behalf,
in all matters relative to work authorized by this building permit application for: .
6 c 71409n/, Y . 4,41V t- C_a7 2 VY&
(Address of job)
Signature of er 0 Date
Print N
QTORMS:O WNERPERMIS SION
91te -6
Board of Building Regula ions and Standards
One Ashburton Place - Room 1301 .
- Boston, Massachusetts 02108
Home Improvement;Contractor Registration
Registration: 148798
3 ' " Type: Ltd Liability Corporation
Expiration: 10/26/2007
ARTISAN KITCHENS LLC
STEPHEN BRITTON
PO BOX 282
WEST BARNSTABLE, MA 02668
Update Address and return card.Mark reason for change.
IS-CAI 0 5OM-04/05-PC8698 Address n Renewal Employment Lost Card
-- ----_.-....... ._
�� ✓/ze 1°omz�nzo�rcusP,cc/C� a�.-/l/�.,ac�iu6elCa r
Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards'
Registration ..148798 One A hburton Place Rm 1301
Expiration 10/26/2007 Bosto , a.02108
Type Ltd Liability Corporation
i
ARTISAN KITCHENS LLC
STEPHEN BRITTON
500 MAPLE ST —
WEST BARNSTABLE,MA 02668 Administrator Not valid without signature
` � fie�anvrnoauaea� �✓�•aaaac�u�arlla.� .
BOARD'OF BUILDIN REGULATIONS .t
T License CONSTRUCTION SUPERVISOR
. 012414
Number..CSC
Brithdate07/21/1951
Y3
Eicpires •07/21/2007 Tr no : 755p'
Restncte�i 00 ,7
` STEPHEN W BR1TT0 t'
PO BOX 897/50Q MAPLTr � C
_` W BARNSTABLE MAC 12-668
t< Cofnm�ssioner
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FORM 153 The Commonwealth of Massachusetts DIA Use Only
Department of Industrial Accidents
Office of Investigations-Dept 153
eet-7th Floor,Boston,Massachusetts 02111
600 Washington Str
http:l/www.mass.tov/dia Invest./swo ID 0:
AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE
OFFICERS OR DIRECTORS
Chapter 169 of the-Acts of 2002 amended M.G.L. c. 152, §1(4) by adding the following paragraph:
"This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of
the issued and outstanding stock of the corporation.Notwithstanding section 46, these provisions shall
apply only if the corporate officer provides the commissioner of industrial accidents with a written
waiver of his rights tender this chapter. Said commissioner shall promulgate regulations to carry out the
purpose of this paragraph.Violations of this paragraph shall subject the corporation to the penalties set
forth in section 25C."
Pursuant to M.G.L.c. 152, §1(4)as amended,I/We the undersigned officers of
(T ("Lod Z� 1L,-,�La5 I C4.
(Imams of Cirporation and Addrsm)
each holding'at least 25%of the issued and outstanding stock in said corporation, do hereby invoke the
right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a
workers' compensation policy covering the undersigned corporate officer(s)or,direetor(s). I/'We the
undersigned do also waive any and all rights to make claims for benefits as defined in M.G.L.c. 152 for
any injuries that may be sustained while in the employ of the above-named corporation.
Further,Uwe the undersigned do understand that, should the above-named corporation hire or have in
its employ any employee(s)in addition to the undersigned-corporate officer(s)or director(s),said
corporation is required to obtain workers' compensation coverage for the employs)as prescribed by
M.G.L.c. 152, §25A.
I/We the undersigned have read and understand the statements and obligations as delineated above and
I/we have checked the appropriate box below my/our names)indicating my/our desire to be exempt or
not to be exempt from the provisions of M.G.L.c. 152. ;
S1 ed unyier the pains and penalties of perjury: ;
S• Print Name&Title Date(mmldd/yyyy
' I wish to exercise my right of exemption.or.. ®I wish NOT to exercise my right of exemption
/ 1
atu�e Print Nay&&Tide Date(mmldd/yyyy)
I wish to exercise my right of exemption or ® I wish'NbT to exercise my right of exemption
Signature Print Name&Title Date(mmlddlyyyy)
® I wish to exercise my right of exemption or I wish NOT to exercise my right of exemption
Signature Print Name&Title Date(mmlddlyyyy)
I wish to exercise my right of exemption or ® I wish NoT to exercise my right of exemption
Note:A"ELIGIBLE CORPORATE OFFICERS MUST SIGN. THERE CAN BE No MORE THAN 4 SIGNATURES.InStructlonS
on back Form 153-Revised 10-IM2
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THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I A �- I
m / �C(L� L
DATA
TOWN OF BARNSTABLE, MASSACHUSETTS L"Lo'ING PERIVall
BUR
DATE
r" PERMIT NO.
�PPLICANT_ S I...
#0 0 5045
uw"I I 1 (CONTR'S LICENSE)
PERMIT TO I STORY NUMBER OF
(PROPO-SID USE J
i-j U 1(3 %Mj!FjDUfij DWELLING UNITS
_kOE N .
IAT (LOCATION) ZONING
CSTREliT) DISTRICT,
'BETWEEN
(CROSS STREET) AND
(CROSS.STREET)
SUBDIVISION LOT
LOT BLOCK SIZE
BUILDING IS TO BE -FT. WIDE BY
FT. LONE BY_ .FT., IN HEIGHT AND SHALL CONFORM IN CONSTRUCTIC
TO TYPE
USE GROUP BASEMENT WALLS OR FOUNDATION
f. ITYPE)
REMARKS:
'i'.;W
AREA OR
VOLUME 1.D u ESTIMATED COST $ i 31-i PERMIT 7 12- ..Ci 0
.11(1(CUIII�CASOUARE FEET)
FEE
dwNFA',
ADDRESS BUILDING DEPT.
By
THIS PERMIT CONVEYS NO RIGHT"ro oCcI.,pY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITH I ER-TEMPORARILY 0
PERMANENTLY. ENCROACHMENTS ON FUSLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING
PROVED BY.THE JURISDICTION. STRr ALLEY GRADES AS WELL AS CODE, MUST BE AF
ET OR A DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINE
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITION
Of ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MJNIMUM OF THREE CALL
INSPECTIONS REQUIRED FOR APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
ELECTRICAL, PLUMBING AND
P"FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2
'PRIOR
0 COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE, OCCUPIED UNTIL
'"
3�MEMBERS(REAOY TO LATH).
.,FINAL INSPECTION BEFORE
FINAL INSPECTION HAS BEEN MADE.
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE F'w"M STREET
BUILDING INSPECTION APPROVALS KV
PLUMBING INSPECTION APPROVALS
ELECTRICAL INSPECTION APPROVALS
2 2 .Fj 2
HEATING INSPECTION APPROVALS
3,
G NGIN IN C)EPARTMENT
g.
BOARD OF HEALTH
OTHER
SITE PLAN REVIEW APPROVAL
WORK SHALL NOT PRC..&.'p i ..AdT 'W!LL BECOME 14ULL AND VOID IF CONSTRUCTION
!NSPE(
I IG.IS INDICATED ON THIS CARD CAN F
qNGIN
TOR HAS APPROVED TdE VARIOUL 15 NOT STARTED WITHIN SIX MONTHS OF DATE THE CONSTRUCTION. Al-, %GED FOR BY TELEPHONE OR WRITTE FRMIT IS ISSUED AS NOTED ABOVE, ')N.
Ne" .'ICATit'
ai�"vsF. -,z'+ -•rr.�.,-'gi.-'�.r'9°`.-"'�r"'-y,.°Q,6w5'AY:�,ws.'.'awl^�,r,�4ti,�-":,�.,.•�;�,.�,�,.,�.'•,-x-�.�j�s�-��kt�n.:.y�'..1r�A,1�.. �:s"art-',�--�^� �::..v.--..:..'-";� �':�"'�1
T TOWN OF BARNSTABLE, MASSACHUSETTS "" -BUILDING P 'Rm l f
A=186-088 DATE ,, i j 19 •'•.• PERMIT NO. k
APPLICANT #005645
V TRnee (CONTR'S LICENSE)
J
PERMIT TO �y (�_) STORY �.+ .. ce .r -e , ya„_,-.,Y •x NUMBER OF
Uj(Tl&E O,F)[Ilk_lI10V„EMCk_,T') NO.
f�.i16 .i.1c..' i yy ,,�,•w y.sx DWELLING UNITS
t3 f
_ ZONING
'AT(LOCATION) -- -t( '-. .- ,.,. _ -.._ ! t 'e ,_ '.es .n 025- r ")55AW, DISTRICT-,"RE)
.,. �G �e(NO?.)�S,iktl�,t,.Y.�f sJY:ill`�'.:/ (�S'TRE'ET'1'4"L V.iL.L.¢.y:: � 3tr�. Yf a..,a ax w.+ra® .,
BETWEEN AND
(CROSS STREET) (CROSS. STREET)
LOT
SUBDIVISION LOT_ BLOCK SIZE
f
¢BWLDrING IS TO BEFT. WIDE BY FT. LONG BY ;FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
i + �a0'TYPE USE GROUP - BASEMENT WALLS OR FOUNDATION
IJ�f (TYPE)
` REMARKS: .-• _ f• .. ,,..,.+,
r Bond
AREA OR
VOLUME - ESTIMATED COST $1 3Q C1_ FEE
Q $172 r 00
fZI 6(4(C Up FL40fUAR E-YE ET) ° '
J
a.
OWNF_,R 1
Ly+I.�i'Y ��• BUILDING DEPT.
ADDRESS
^ BY
,a r t w •. • `w..J;
THIS PERMIT CONVEYS NO •RIGHT TO OCC'U,PY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER,TEMPORARILY OR
PERMANENTLY. ENCROACHMENTS ONPUBLIC -PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE API
.PROVED BY.THE JURISDICTION. STREET,OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS! THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE�APPLICANT FROM THE CONDITIONS
-OF ANY'APP'LICABLE SUBDIVISION RESTRICTIONS. -
MINIMUM 'OF T-H;REE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS ,WHERE APPLICABLE INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRE^ FOR SEPARATE
ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND
1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR s:0 COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL,
MINAL INSPECTION
TI TO LATHE FINAL INSPECTION -HAS BEEN MADE. �
3. FINAL INSPECTION BEFORE '
OCCUPANCY. ,
POST THIS CARE) SO IT IS VISIBLE Fit M STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
G)
/"mill EJ f_a r
z /CMG
� >,�-
3 HEATING INSPECTION APPROVALS NGIN RING EPARTMENT
` 2
BOARD OF HEALTH
s
OTHER SITE PLAN REVIEW APPROVAL
tt i
WORK SHALL NOT PRC EE y�U INSPEC + .p +�IIT WILL BECOME NULL AND VOID IF CONSTRUCTION "Inico r l ,lS INDICATED ON THIS CARD CAN BE
TOR HAS APPROVED TIE VA91OUL'.V'" . 'ES L'r- 4 rr�'a; IS NOT STARTED WITHIN SIX MONTHS OF DATE THE
-+ - a �' .; AFC �NGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. o ' k ERMIT IS ISSUED AS NOTED ABOVE. N ,ICATiON.
o �
c
.r
• 1
r'
t
a ��
Asse4r's office(Ist.Floor):
Assesr's map and lot number
® r t e
Conservation ` ITL
Board of Health(3rd'floor): � i - � � ENVjpo ��j�'�pT •
Sewage Permit number �Q z/� 7 TOW f," �� � �� •
Engineering Department(3rd floor); lj� EGU���
House number,
Definitive Plan Approved by Planning Board r 19
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ZG�
* �
TYPE OF CONSTRUCTION
19 y�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby/applies for a permit according to the following information:
Location
Proposed Use
Zoning District Q —( Fire District ^a /ll
Name of Owner Address
< Cl
Name of Builder Address
Name of Architect Address
Number of Rooms Foundation
Exterior —� �` CCG % ✓ Roofing
Floors. C�6/ �"!� o�L/� Interior /�
Heating D Plumbing
Fireplace��?�'� /� Y^ � e%2�i�� Approximate Cost
AreaC4 IL !P
Diagram of Lot and Building with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
Name _ ? -7 Lctc�,
Construction Supervisor's License �� �'
i
BAYSiDE BLDG. CO.
34952 permit For 12 Story
4
Single Family Dwelling~ {
Loc,a'on Thornberry Lane -
Centerville
Owner '_ Bayside Bldg. Co J
Type of'Construction Frame -
• Plot ' Lot cv• '
Permit Granted Apr i 1 9, 19 92
Date of Inspection' _19 _
f -
Date Completed _ 19
3
K-
O"TM[ 0
TOWN OF BARNSTABLE 9 52
PermitNo. ...3...4:.........
BUILDING DEPARTMENT
TOWN OFFICE BUILDING Cash
7 .M�
'6TT ` ..
+ ` HYANNIS.MASS.02601 Bond ......X ..
CERTIFICATE OF USE AND OCCUPANCY
Issued to Bayside Building Co.
Address Lots #25 & 25A) 62 Thornberry Lane
Centerville, Mass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID. AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
August 26, 19 92
. ...... .. .............. ................. .............. . ........ amG .--....
Building Inspector
f
I
a'fy�••'. TOWN OF BARNSTABLE
BUILDING DEPARTMENT
_ 1►IIaT = TOWN OFFICE BUILDING
rua
'9 '6�q• �� HYANNIS, MASS. 02601
�`OIUY M.
r
MEMO TO: Town Clerk
FROM: Building Department
DATE:
An Occupancy Permit has been issued for the building authorized by
BuildingPermit #........31��95Z..... ... ................................................... ...... ......................_......... .....»...... . ...... ..... ...
issued to A�!5id�- .../(5,j ........... ...........................ay..40-* ......._.._....
�.
l
Please release the performance bond.
i
\ 48
-