HomeMy WebLinkAbout0087 WARWICK WAY d�
Town of Barnstable arns .__ ��.,�...�. Building
f BAR1V8'TAMA
Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept
Musk Posted Until Final Inspection Has Been Made. ° Permit
t
Where a Certificate of Occupancy is Required,such Building shall Not be Occupied.until a Final Inspection has been made.
Permit No. B-19-2158 Applicant Name: CHAFETZ,OLIVIA Approvals
Date Issued: 07/16/2019 Current Use: Structure
Permit Type: Building-Addition/Alteration-Residential Expiration Date: 01/16/2020 Foundation:
Location: 87 WARWICK WAY,CENTERVILLE Map/Lot: 171-096 -�-s Zoning District: RC Sheathing:
Owner on Record: CHAFETZ,OLIVIA Contractor N me::. Framing: 1 D 91T� 4
Address: 23 N WOODFORD ST Contractor.License: 2
� Est Project Cost: $3,500.00
WORCESTER, MA 01604 Chimney:.
Description: RENOV- REMVE 2 LIVING RM WINDOWS. INSTALL 3 DBLE'HUNG IN Permit Fee: $85.00
Insulation:
PLACE REMOVE 2 KITCHEN WINDOWS&RELACE LN,SLIGHTLY Fee Paid:= $85.00` �
DIFFERNT LOCATION. REMOVE 2 DBLE HUNGIWINDOWS IN Date 7/16/2019 Final:
BEDROOM 1 AND REPLACED WITH A SINGLE AWNING STYLE
"
WINDOW. REPLACE 4 OTHER WINDOW ON UPPER LEVEL TO FIT p
Plumbing/Gas
EXISTING OPENINGS. REPLACE FRNT DOOR . INSTALL STEEL DOOR
FROM KITCHEN TO GARAGE,ELIM DOOR,CHANGE CLOSET Rough Plumbing:
LOCATION -CHANGE KITCHEN CABINETS ° Building Official
Final Plumbing: .
Project Review Req: Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Final Gas:
All construction,alterations and changes of use of any building and structures-shall be in compliance with the local,zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be-maintained-open for public inspection for the entire duration of the Electrical
work until the completion of the same. �-
Service:
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Roughs
Minimum of Five Call Inspections Required for All Construction Work:L_.q 1 ,",_.___.. ,,,, ,., -• � "'
1.Foundation or Footing
Final:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction.
Fire Department
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Final:
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
` � 2
ays N
Application Numbe
JO A40.
61oz g.0
MASS. Permit Fee.......................................Other Fee:.......................
63
TotalFee Paid................................................................ ......
.................
TO" OF BARNSTABLE Permit Approval by.... on...A111..........
BUILDING PERMIT
...................P,=l.......0.... ..(0...............
APPLICATION
Section 1 — Owner's Information and Project Location-
Project Address- f7 Walzwi r-j,/ U4 u Village ceA)zc-,-1z Ile-
Owners Name— 2 v4 Aj
Owners Legal Address
City State zip
Owners Cell#_ 5OP-390 E-mail 1 1-4-LOb
Section 2 —Use of Structure
Use Group— ❑ Commercial Structure over 35,000 cubic feet
El Commercial Structure under 35,000 cubic feet
R'Single/Two Family Dwelling
Section 3 — Type of Permit
El New Construction EJ Move Relocate F-1 Accessory Structure ❑ Change of use
E] Demo/(entire structure) 0 Finish Basement El Family/Amnesty El Fire Alarm
Rebuild El Deck Apartment ❑ Sprinkler System
Fj A ❑ Retaining wall F] Solar
Adition
Renovation Pool D Insulation
Other-Specify
Section 4 - Work Description
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Last undated: 11/15/2018
. , 4
Application Number .4: t... . ... ..........................
Section 5—Detail.-.,-,
Cost of Proposed Construction DS'o o.oo Square Footage of Project
Age of Structure /f f Z' Dig Safe Number
# Of Bedrooms Existing Total#Of Bedrooms (proposed)
110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics '
a
❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors
❑ Plumbing ❑ Gas ❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom
Water Supply - Public ,
❑ Private
Sewage Disposal ❑ Municipal On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: I am using a crane ❑ Yes LJ No `
Section 7—Flood Zone
i
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq. Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site)
Setbacks Front Yard Required Proposed
'Rear Yard Required Proposed
q P
Side Yard ' Required Proposed
Has this property had relief from the'Zoning Board in the past? ❑ Yes ❑ No
Last updated: 11/15/2018
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The Commonwealth of Massachusetts
Department of IndustridAccidentv
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/Organizatim/tndivi(ival)' �J
Address:
City/State/Zip: re i,w-k;4 /P/ 1974 3 Z Phone M .SaV 3 C D S
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with- 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- 13sted on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. employees and have workers'
t 9. El Building addition
[No workers'comp.insurance comp•insurance•
r��] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3�JI am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself[No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4)9 and we have no
employees.[No workers' 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 mast submit a new affidavit indicating such.
xContractor;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 insurance for ray employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 under the pains dp!g#1ks of perjury that the information provided above is true and correct
Si atom- Date: Z 9
Phone 'SlJ�- 3 4U 3 F 42
Of,jlcial 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.EIectrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r r
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 i i 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLQ or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation fi mmce. If an LLC or UP 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 woticers'
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 buusiness.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 munber:
The Commonwealth of Massachusetts
Department of Industrial Aoddents
Office of Investigations
600 Washington Street
Bastian,MA 02111
Tel.#617-727-4900 ext 4.46 or 1-877 MASSAFB
Revised 4-24-07 Fax#617-727-7749
Vvww:mass.gov/dia
j
Application Number............................................
R Section 9- Construction Supervisor
N
Name Telephone Number
Address City State Zip
License Number License Type Expiration Date
Contractors Email Cell #
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
f CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable:Attach a copy of your license.
Signature Date
Section 10—Home Improvement Contractor
Name Telephone Number
Address City State Zip
Registration Number Expiration Date
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C...
Signature Date
Section 11 —Home Owners License Exemption
Home Owners Name: 0� �,/ 6!/� / c✓
Telephone Number Cell or Work Number SDI` — .740 ' 35 9 Z
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR an e Town of Barnstable. f
Signature,
APPLICANT SIGNATURE
Signature Date 61Z 7//
Print Name Ay� �,5 /C Telephone Number ..5 - 36 D -3 S s Z-
E-mail permit to: f(,y�✓crf�i,o/.�r 2 @lD�• L,��
Last updated: 11/15/2018
Section 12 —Department Sign-Offs,
Health Department ❑ Zoning Board(if required) ❑
Historic District ❑ Site Plan Review(if required) ❑
Fire Department ❑
Conservation
For commercial work,please take your plans directly to the fire department for approval
Section 13— Owner's Authorization
i
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
Last updated: 11/15/2018
P `t
Town of Barnstable Building V
PostTh�s Card So That�ts:Uisible Fromhe:Stneet°-:A roved Plans Must bezRetameiion Job antl�this Card Must be K t
MRN'31`Aea.ia,
e Posted Until Finallnspection Has Been Made u � • '�,►
3P ,� ? ,.�: m.. .. .. .: ,. ,. :. ;' - .. ,... Permit
x)
Where a Cert�ficatetof Occupancy,is Required,such Building shall Not be Occupiekd until a Final Inspection`has been made '
H..bb„ „fie�.... ..�.., ..�.,.�...dig. ..ai. s�. ,.e«:L��w ...«SaeFwz.�a .r• a.::.r. .m.. m,..w .,.3«:u« •..>a#a«, r:.eS.. , �:,;...a,.v..., µ ..3 " . w. ,_..a. ."....u..,.�„�ati,..»....,<. ,...,«ua
Permit No. B-19-1961 Applicant Name: CHAFETZ,OLIVIA Approvals
Date Issued: 06/18/2019 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 12/18/2019 Foundation:
Location: 87 WARWICK WAY,CENTERVILLE Map/Lot 171-096 Zoning District: RC Sheathing:
Owner on Record: CHAFETZ OLIVIA $ ContraCtOf Name Framing: 1
Contractor'License ,
Address: 23 N WOODFORD ST 2
WORCESTER,MA 01604 _ a � Est Project Cost: $4,000.00 Chimney:
Description: siding,'windows(4)& 1 door P�ermitFee: $35.00
Yk � Insulation:
i f, Fee Pald�y' $35.00
Project Review Req: r 6/18/2019 Final:
Plumbing/Gas
nx Rough Plumbing:
Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authonzeel by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and�tRapproved construction documents four w e this permit has been granted. Rough Gas:
i yam
All construction,alterations and changes of use of any building and structures shall'be in with the local zoning by law"s arid.codes.
This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same.
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures,by the Bu i lding and Fire Officals are prro de, on this permit.
Minimum of five Call Inspections Required for All Construction Work: Service:
1.Foundation or Footing s
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed priorto Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Rough:
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Building plans are to be available on site Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
Application number...... ................/....1.(�t.
Qa6Fee...... . .......s. ...S................................................
Building Inspectors Initials
' 16. n� �� i
Date Issued.................. ..�.. ........................
P/
Ma ce a � ........P r l... . .7l .......6 � {O
.........................................
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION'
PROPERTY INFORMATION
Address of Project: 4 i 4 el ; I t ;
NUMBER l ) STREET VILLAGE
Owner's Name: /hb Phone Number 50Y 3 6 0 39?--
Email Address: ' n l U 2 ell Phone Number '
Project cost$ VOW Check one, Residential Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make application for as b in accordan with 780 CMR
Owner Signature: Date: CIZ ZI19
I '
TYPE OF WORK
Siding !n Windows (no header change)# r t 0 Insulation/Weatherization
Doors(no header change)# f Commercial Doors require an inspector's review
Roof(not'applying more than 1.1ayer of shingles)
Construction Debris will be going to
CONTRACTOR'S INFORMATION
Contractor's name >'►
Home Improvement Contractors Registration(if applicable)# (attach copy)
Construction Supervisor's License# (attach copy)
Email of Contractor r u �vs e�vv. to; Phone number 3 0 313',1
ALL PROPERTIES THAT HAVE STRUC%URES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED.
APPLICATION NUMBER.............................A, ....�....:�.......
*For Tents Only*
Date Tent(s) will be erected Removed on number of tents total
Does the tent have sides?Yes No ' (If yes please attach floor plan with exits marked)
Dimensions of each Tent• X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent
Fuel source being used LP tank 20 lbs. or>Yes . No______,if yes, a gas permit is required.
Natural Gas Yes No , if yes, a gas permit is required.
If food is being served at.your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4.30pm. Commercial events may require Fire Department approval.
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
C
Telephone Number SOS .7`y 3 9 9 z Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signa Date
C111 �F
APPLICANT'S SIGNATURE
Signature Date G
All permit applications are subject to a building official's approval prior to issuance.
J A
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 Please Print Legibly
Name(Business/Organization/lndividual):
Address: cl1
7
City/State/Zip: 10V wl- Phone#: 99 Z
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 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.❑ I am a sole proprietor or partner- " listed on the attached sheet-, 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers, comp.insurance
comp.insurance.$
required.] 5. ❑ We are a corporation and its 10.R Electrical repairs or additions
am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.POther i vt OGJ
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 insurance for my employees. Below is thepolicy 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 certi er the_p ins an ties of perjury that the information provided above is true and correct.
Sianafore Date:
Phone#: J`USl 3�0 35'�Z
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-contractors)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-fi=ed 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 4-24-07 Fax##617-727-7749
v ww,mass.gov/dia
TOWN OF BARNSTABLE - 39`ry 1t
Permit No. __------�-- '_--
I ���� Building Inspector Cash __ �+ �► n!�'
OCCUPANCY PERMIT Bona __—_____
No building nor structure shall be erected, and no land, building or structure shall bed
used for a new, different, changed, or enlarged use without a Building'
Permit therefor
first having been obtained from the Building Inspector. No building shall be occupied'until a
certificate of occupancy has been issued by°the Building Inspector." ' t
s
Issued to LeWi8 Gordpn Address
'Lot #21 87 Marwick Way . . Centerville
Wiring Inspector Inspection date }
Plumbing Inwector � .�'c Inspection date
Gas Inspector. �.1 �� • Inspection date
Engineering Department �f� �t 1 Inspection date —� -
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..01
Building Inspectorf
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is ma and lot number / / Z p ......... ...... ...... iW i SYSTEM
f a��� �Y MUST fig �OF THE TO
r 1'�AN.. �
Sewage {Permit number .�.-2:-✓...��.. ......................... , . NTALLED IN C�}I�"I �
WITH TITLE 5
•
House number / /m .......................... 3........................ ,,.� NVIRO ENTAL COPS�� 9 BaaMU& s. . r,
� r r U: Op i639.
- � �o war a• r ,
TOWN OF BA�R.NSTABLE �•� �� y/� z�.,
RUILDIC [N S�?ECTQR '
APPLICATION FOR PERMIT TO 4 L I1-11641. ..1.:... fl✓ l,%..
........................................................
TYPEOF CONSTRUCTION :....I �. .. ......:.. r. .....................................................................7
.............. .. ...............19lJ....
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: /
Location .... ..... ..... ' ...� ......�.�.� G�.........�.../... .. .
.. ... . .
r
ProposedUse .... ` ....................................:..................................... ................
l
Zoning District ..... ..............................................le ........Fire District /��'`'
s........... .
Name of Owner G� 6✓ J6' ��
...........................................Address .......°°............ . ....................
Nameof Builder ....................................................................Address ..... ..............................................................................
Nameof Architect .............................-...................................Address ....................................................................................
Number of Rooms ........ ..................: ..............................Foundation
ExterioXw/.jL..... -10--Z'...... .e.Z< ....Roofing z....G'v..... ..., ..� ... 1���1 �............
Floors
v.. .. � .../ .'�a l ...............Interior f� �✓�
?Heating ....... �.... g -..............Plumbin ....... ..
Fireplace ./ �nl� "....................................Approximate Cost ..��.1�J. gd�
ocv
..........................
Definitive Plan Approved by Planning Board ________________________________19________. Area ..............................
Diagram of Lot and Building with Dimensions Fee ....... ................
SUBJECT TO APPROVAL OF BOARD' OF HEALTH �QQ
I 0
0
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 . .............. ..... ..... ........ ..........
IORDON, LEWIS
23941
................. Permit for ..112- Story
..................................
Single Family Dwelling...............
Lot #2
Location ... 1 87 Warwick Wgy........................................................
Centerville
OwnerLewis Gordon...................................................................
Frame
Type -of Construction ..........................................
..........-
.........................................................I............
I
Plot .....*................. Lot ................................
Permit Granted AP.ri.l...6.....................19 82
Date of Inspection. ..........19
Date Completed .............. ....19
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P p�..�:. co,vr�e�t.r►:� >n >�s� �/ :u. '���PCs�� � �
Assessor's map and lot number f
~.�..:........e'.... %TH E TOE
Sewage Permit number -� - w`` � ♦�
g y.....................�..............................
Z EAUSTOIILE, i
House number ....9 7 �..?.,..�............................................... 9 rues
..., ,�
'Fp YFY A
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO �.7
TYPE OF CONSTRUCTION ........................- .v./ ` �'!�. "......................... ...................................................................
...............�/�..............,9�Z,
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies fora permit according to the following information:
Location ..... �' - .. ......z/......
L ...Ysc !!l/l / ..... ., :��'✓!UI//
_M
ProposedUse `r.. !4,.�7. ; .........................................................................�;a....................:..............................
ZoningDistrict ......en�..................................................................Fire District ......,.................:.......•. .............................
Nameof Owner / ° >��� �l8 .......Address....................I. .................. ................. ........................... .............. .......... ..............
Nameof Builder" °� `Jid ................Address��................................. ..... .................,.......................................................
Nameof Architect ..................................................................Address ....................................................................................
Number of Rooms ..............................Foundation I.A......
... ..a '✓2 �,/ /_o i'"'C 2' /
Exterior I�� � '^!'.��-e'.. ....../G '/L'���....Roofing .....
�� ....?.......; ! ..... ..� ✓/7� 1 �...........
.................
Floors-V...') ` ^� /\l...d/!�.°.!? /...............Interior ...'. .....
v-. ...... . ...............................................................
Heatingg y....... .. -.1'.1.. ..4- .............................Plumbin -........ ?.. ..... .......................................
Fireplace pp a....................................A Approximate Cost ..........................................a
Definitive Plan Approved by Planning Board ----------------------_---------19_______. Area S.................
Diagram of Lot and Building with Dimensions Fee ...` .........
SUBJECT TO APPROVAL OF BOARD OF HEALTH
` 0 �
iJ
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 .....::................... ...���'"'�;..; ..........................0 a ... .
GORDON, LEWIS =-171-96 ^
No ... Permit for —.J.12-.. ...........
�
—.S ' le.. ... )we.11i.ng................
'
Location ..Lot..#2_I__87..WcuzvvicX..]�ay * _
Centerville
----'---''~^—^^^^^~''~'--^^`~-----''
�e�io
Owner —'--'-----~—~^—^----'—^--''
Type of Construction —.4�KAJpQ--------. `
--'--~^-----'—'—'—^-------'---''
Plot ............................ Lot ................................
Permit Granted —..Apz.il—S�----.]g 82
Date of Inspection ------------l9 .
DoteCompleted ......................................
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