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'- rEo �a Building Division Tom Perry, Building Commissioner 200 Main Street;Hyannis,MA 02601. ., www.town:barnstable.ma.us Ur Office: 508-8624038 Fax: 508-790-6230 NOTICE TO THE BUILDING DIVISION OF WITHDRAWAL OF LICENSED CONSTRUCTION SUPERVISOR FROM PROJECT, Construction Supervisor License # hereby certify that I am no longer the.Construction Supervisor listed on the application for the project under construction as authorized by building permit # UP -a� g issued to'(property address) 06744. ��nrl� � I U)SIP on 201 I also certify that on V e� -( ,-201 , I notified the property owner, that the project under construction must cease until a successor licensed Construction Supervisor, is submitted on the records of the Building-Division. 6 LICENSE HOLDER DA E q/forms/newcontr reference R-5 780 CMR 'rev:1 10410 ' - . ,� cQ0r,,�� •��tHE) TOWN OF BARNSTABLE Bufid'ing 201105008 BARNSTABLE, Issue Date: 09/29/11 Permit MASS. 9� 1639• ��� Applicant: JOSEPH BUTLER arFo�.I A Permit Number: B 20112113 Proposed Use: SINGLE FAMILY HOME Expiration Date: 03/28/12 F cation 6 WASHINGTON BURSLEY WAYoning District RC Permit Type: RESIDENTIAL ADDITION/ALTERATIO Map Parcel 172165 Permit Fee$ 35.00 Contractor BUTLER,JOSEPH A Village CENTERVILLE App Fee$ 50.00 License Num 071488 Est Construction Cost$ 5,000 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND BATHROOM REMODEL-TUB/WALLS/TILE/FLOOR/PAINT THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN WHERE A CERTIFICATE OF CU NC S REQUIRED,SUCH Owner on Record: FARIA,JOSE&LUCINDA BUILDING SHALL OCC IED UNTIL A FINAL Address: 6 WASHINGTON BURSLEY WAY INSPECTION B N E. CENTERVILLE,MA 02632 Application Entered by: JL Building Permit ed By: eq— THIS PEP MIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY ORSIDEWALK OR ANY PARP.T EITHER'TV11 E N Y ENCROA NTSON.P,UBLICPROPERTY,NOSPECIFICALLY PERMITTED UNDER THE BUILDING CODE;MUSTBEAPPROVED`BY THE JURISDICTION:' T OR ALELL AS DEPTH AND LOCATION OF PUBLIC SEWERS:MAY BEOBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS:THE ISSUANCE OFTHIS PERMIT DOES NOT RE APE CONDITIONS OF ANY APPLICABLE SUBDIVISION.} RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQU OR AL C TRUC ON ORK: 1.FOUNDATION OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT TH HROAT LE B RE ST FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE CO ETED PRIO 0 F ME INSPECTION. 4.PRIOR TO COVERING STRU AL MEMBER ( DY TO LA ). 5.INSULATION. 6.FINAL INSPECTION BEFORE C ANCY. WHERE APPLICABLE,SEPARATE PE TS AR REQUIRED FOR ELECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL T INSPE OR HAS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WI L BEC E NULL AN VOID CONSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PE IT I UED AS OTED ABOVE. PERSONS CONTRA G W H TERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.142A). i BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 'Map I)-ZParcel Application # Health Division Date Issued tl Conservation Division -• Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address WVG � � oh �Q3� w Village )f Owner A2.P- 6- Address �W Telephone a 0 9- 5J t Permit Request d mn Re"A0V (16 f,U0( ✓!e f /it' . " ' JF Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family. Two Family ❑ Multi-Family (# units) 0= �' I Age of Existing Structure ,j., Historic House: ❑Yes _ANo On Old King's Highway: ❑YesV40 Basement Type: 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: J existing _new Y Total Room Count (not including baths): existing new First Floor Room Count - Heat Type and Fuel: 4 Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New _ Existing wood%coal stove: ❑As ❑ No w p Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing Id nevi,, size_ Attached garage existing ❑ new size �Shed:,'m existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION -� aa (BUILDER OR HOMEOWNER) Name U SAIev-Afoe-AA Telephone Number Address Y'�� bo I License # -71yq u Home Improvement Contractor# Worker's Compensation # /FA."a ll.MQ j ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO , J4SIGNATURE � ®ATE F ` FOR OFFICIAL USE ONLY f ;F APPLICATION# DATE ISSUED -r MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ,FOUNDATION. FRAME INSULATION. 'r - FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: . +-•- ROUGH i,,,. : . FINAL ,FINAL BUILDINGS_ F DATE CLOSED OUT 'r ASSOCIATION PLAN NO. 's The Commonwealth of A fassachusetts.. I Department of Industrial Accidents C j' r Office of Investigations 600 Washington Street Boston, MA 0.2111 c j www.mass gov/dia Workers' Compensation'Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): �l� LIVO� Address: r City/State/Zip: i 44 �E �z� : Phone #: M­764 u.,N Are you an employer?Checkj the appropriate box: [13.0 f project(required): I,�I am a emp.loyer with l 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractorsew construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. temodeling ship and have no employees These sub-contractors haveemolifion working for me in any capacity.. workers' comp, insurance. uilding addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised theirlectrical repairs or additions 3.❑ I am a homeowner doing.all work 'right of exemption per MGLumbing repairs or additions myself. [No workers' comp. _ c. 152, §1(4), and we have n000f repairs insurance required.] t. employees. [No workers' comp. insurance required.] er *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 subm it a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that is providing,workers'compensation insurance for my employees. Below is the policy and job site information. � . Insurance Company Name: 1��Jqe9K Policy#or Self-ins. Lic. #: Exprradon Date: &rv) /,, Job Site Address: 0i"I't U�$l✓'�/ l� 1 City/State/Zip: (e4lff L�� Attach a copy of the workers' ompensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required undr r 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 swell 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do here.y rt der ns d penafties of perjury that the information provided above is true and correct Si ature: Date: Ph one, 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 bean 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 I52, §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 Iisted 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 Iadust-ial Accidents Office of investigations 600 Washington Street B ton,MA 0211 I Tel. # 617-727-4900 ex't 406 Qr 1-8,77-MASSAFE Ii Revised 5-26-05 Fax # 617-727-7749 www.m.ass..gov/dia Client#:40595 2NORTHBAYAS ACORD. CERTIFICATE OF LIABILITY INSURANCE ° 01 ATE(MM,°°"YY'f' 12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THISI CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Dowling&O'Neil Insurance NAME: PHONE Agency CAIC,No,El):508 775-1620 a A c,No): 5087781218 EM 973 lyannough Rd., PO Box 1990 ADDRESS:IL Hyannis,MA 02601 INSURERS)AFFORDING COVERAGE NAIC# INSURED _ _ INSURER A:National Grange Mutual InSUranc Joseph Butler INSURER B:Travelers Insurance Company DBA Northbay Associates INSURER C: P.O.BOX 1197 INSURER D South Yarmouth,MA 02664 INSURER E: INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. US ADDLSUBR LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER POLICY EFF POLICY EXP MMIDD/YYYY MNUDD/YYYY LIMITS A GENERAL LIABILITY MPF7496Y 1/25/2011 01/25/201 EACH OCCURRENCE X COMMERCIAL GENERAL LIABILITY $1,000 000 PREMISES Ea occurrence $500 000 CLAIMS-MADE ❑X OCCUR - MED EXP(Any one person) $10r 000 ' - PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 ED PRO- PRODUCTS-COMP/OP AGG $2,000,000 JECT LOC $ E LIABILITY - COMBINED SINGLE LIMIT Ea accident TO BODILY INJURY(Per person) $ NED SCHEDULED AUTOS BODILY INJURY(Per accident) $ UTOS NON OWNED. AUTOS PROPERTY DAMAGE $ $ LLA LIAB �OCCUREACH OCCURRENCE $ LIAR MS-MADE AGGREGATE $ RETEBOMPENSATION ANYIEUB3996X81211 WC STATU- OTH- $ AND EMPLOYERS'LIABILITY Y/N 1/25/2011 01/25/201 X OFFICER/MEMBEREXCLUDED?ECUTIVEN N/A (Mandatory In NH) E.L.EACH ACCIDENT $500,000 If yes,describe under E.L.DISEASE-EA EMPLOYEE $500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD -#S81056/M81055 LS1 1 - . r Town of-Barnstable Regulatory Services s� MASL Thomas F. Geiler,Director 'Building Division Tom Perry,Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town.barnstable.ma.us - Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and .Sign This Section If Using A Builder ra�(; 01,� as Owner of the subject . J .Pm Pe rtY hereby authorize to act on my behalf, in all matters relative to work authorized by tbis binding permit application for. FA, Addr�Ss 0 Ob7) e 5 of Owner to Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS.OWNERPEPMISSION I 1 . F tKE r Town of Barnstable yw. Regalatory Services sett , : Thomas F. Geiler,Director MASS. g ,or t63�- 16 Building Division Tom Perry, Building Commissioner 200 Maid-S_treet,_Hyannis,MA 02601 RrYnY.to wn.b arnstabl a-ma-us Office: 508-962•-4038 Fax: 509-790-6230 HOMM0Vt NER LICENSE EXEMPTTON , Please Print DATE: JOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: eity/town statr zip code "Fhe current exemption for"homeowners"was extended to include owner-occupied dwelEng_s 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. D>rMMON OR HOM ROwI.Ex Persons)who owns a parcel of land on which helshe 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 faun structures. A person who constr4cts more than tine home in a two-year period shall not be considered a bomeowner, Such "homeowner"shall submit to the Building Of5cial 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) Th,e undersigned"homeowner".assumes responsibility for compliance with the State Budding Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies thatbe/sho understands the Town of Barnstable Building Departrpcnt m==nm inspection procedures and requirements and that he/she will comply with said procedures and requirements. i 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 borrreowner pm1huning work for which a building permit is rcquimd shaD be excatpt from the provisions of this section.(Sectian 1D9.1.1-Licensing of construction Supenrisors);provided that if the homeowner engages a parson(s)for hire to do such work,that such Homeowner&IWI act as supervisor.— Many homeowners who use this cxcnrptiart are unaware that they are assunung the responnbi7ities of a supervisor(see Appendix Q, Rules&Regulations for Licauing Construction Supervisors,Section 2.M This lack of awareness bft=results in serious problems,particu)ar)y when the homeowner hires unlicensed persons. In.this case,our Board cannot proceed against the unlicensed person as it Wrou)d with i licensed Supen-isar. The homeowner acting as Supervisor is ultimately responsible. To assure that the homcownar is fully awan;ofhis/herrnspoambilities,many communities require,as part of the prnnit application, that the bomeo"c:r certify that hrJsbe understands the responsibilities of a Supervisor. On the Ian page of this issue is a fomr cun-mt)y used by several towns. You may care t am=d and adopt such a fonn/ccrufication for use in your community. Q:forrru:homecxcmpt F i�ovrUnzaruu Office o ousumer Affairs Bausiness Regulation a _ HOME IMPROVEMENT CONTRACTOR t. Registration: .128086 Type: Expiration: -2%27J201.3 DBA N .H BAY ASSOCIATES JOSEPH BUTLEF2 -� 91 SOUTH STREET 'I' SOUTH YARMOUTH MAV2604 Undersecretary r 'L Massachusetts- Depai-tmcnt of Public Safct, Board ofBuildiw, Reuulations and Standards Construction Supervisor License License: CS 71488 JOSEPH A BUTLER PO BOX 306 r.+h E HARWICH, MA 02645 Expiration: 5/24/2013 < .nnmi..i me,i Tr=: 16906 T B D oJ b + R'�pd� z 1, J aic Y42Ri4. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION — DL Map Parcel Application # q0 Health Division Date Issued Conservation Division Application Fee jy Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board o 111/4/1' Historic - OKH Preservation/Hyannis lProjec'^ t Address Village � ICP �' .. c Address Telephone 5 3 Permit Request Square feet: 1 st floor: existing - proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay P_roject-_Valuafioa n- ~O� Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other CD Basement Finished Area (sq.ft.) Basement Unfinished Area (sgft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new v� Total Room Count (not including baths): existing new First Floor Room Couff *4 , Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name A Wal- e4g"�Cz; , _ Telephone Number-11 Address 31Se Sf License # C.S -5-"74'1 Home Improvement Contractor# /�7 d Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO a.. SIGNATUR DATE `R FOR OFFICIAL USE ONLY ' 4 4PLICATION# p 1 DATE ISSUED _ MAP/PARCEL NO. ADDRESS VILLAGE OWNER i DATE OF INSPECTION: 'r FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 'tee ' The Commonwealth of Massachusetts Department of IndustHal Accidents Office of Invesdgadons 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Bu lders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep_ibly . Name (Business/organization/individual): Address: 3�S r�¢s s City/State/Zip: ,r/ s -,�-4. Phone Are you an employ ? Check the appropriate bog: ❑ I am a general - ❑ I am a employer with 4. eral contractor and Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New.construction 2.0 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'[No workers'comp.msuraace comp.insurance.# 9 ❑$ g addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I 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 r insurance requII•ed.]t c. 152, §1(4), 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 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. lam an employer that isproviding workers'compensation insurance for my employees Below is thepoFicy 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 under the p enaldes of perjury that the information provided above ' true¢ Icorrect Si tore: Date:dor Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health.2.Building Department I. City/Town Clerk' 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: allft- vl'IRl Unl'n[ oi t'Unlil' J`lll't\ Board of Buildinh Rc!uulations and Standards Office of Consumer Affairs&Business Regulation + Construction Supervisor License OME IMPROVEMENT CONTRACTOR License: CS 57692 Registration-470473 Type. Expiration; t}0127/201.3 x Supplement MARCEL DURANLEALI ER MANTINI C6Q#f UC I 45 SILVER LANE HYANNIS, MA 02601 - MARCEL DURAL€�FEj P.O. BOX 148 G; I HYANNIS, MA 0260P` :-S �'" " 'sue ` Expiration: 9/24/2013 Undersecretary . t'ununissu Pile r Tr#: 5819 t y License or rbefog License or registratio ' ,j n valid for' ^ Opce f Consu►ne�n date. If found r�dul use only Card 10 ark PlazaAffairs eturn to: L! Boston MA 211 Uite 5170 and Business ge ' gulation j i 9 ! Not v - WItout Sig natuel r __ Town of Barnstable Regulatory Services Thomas F. Gefier,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstabie.ma.ns Office: 508-862-4038 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Usi_ri r A Builder as Owner of the sub)ect property hereby authorize_' Q- 0" co�f s Tad to act on my behalf, in O'=ttets relative to work•authorized by this building permit (Address of job) fences and alarms are the res onsibili ty of the are not to be filled before fence is installed and P of to Pools are to b. Pools be utilized until all final inspections are performed and accepted. Signature of Owner ture of Applicant Print Name Print Name Date Q:FORIZ:OWNERPERM MR0NP00LS r EVE Town of Barnstable Regulatory Services Thomas F.Geiler,Director .39. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 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. 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 m;n;m„m inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner , k Approval of Building Official- Note: Thzee-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section-127.0 Construction Control w HOMEOWNER'S EXEMPTION-The Code stateq that `Any homeowner performing work for which a building permit is re uired shall be ex of this section(Section 1AL'I-Liicensing of construction S Supervisors);provided that if the homeowner q ervisors erns from the provisions work,that such Homeowner shall act as supervisor." wner engages a person(s)for hire to do such 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 man com munities re that.the homeownerY quire,as part of the permit application,certify that he/she understands the responsibilities of a Supervisor. On the last a of this issue is p pp n, s y Se a form currently several towns. You may care t amend and adopt such aform/certification for use in your community. Wily used by i Q:forms:homeexempt r r - r , MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:2��P ,2—Al-36(t' MA. Date: Permit# Building Location: Owners Name: Type of Occupancy: Commercial ❑ Educational.[] -Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ 4 Plans Submitted: Yes ❑ No ❑ FIXTURES _ .1 co W W ❑ w O QW QOW v OI— ,O❑�x uxiIQY- 1 Xuw ~ j W Z.OZ WO w- Nw 0 F- ❑ U) > w z ¢ w W w W W w w ' Cn xW> v w z O w � w W z W >- WU) —' mwOzOU) . 1•- o 5 w = a = uI u, a > .o 0 > > o a U ❑ ❑ u_ 0 a x x _j O SUB BSMT. ' BASEMENT 1 FLOOR 2 WFLOOR Vu FLOOR 4 FLOOR I 5 FLOOR 6 FLOOR x 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: ❑ Corporation Address: City/Town: State: ❑ Partnership Business Tel: Fax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes ❑ No❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑ Plumber Title ❑Gas Fitter Signature of Licensed Plumber/Gas Fitter " ❑ Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer n� �) `• V < '� �� _ j �� �. ,. i .t r E T'neering+�e�t. 3rd floor) Map �� Parcel l (V S Permit#House# Date Issued lil/_ _11?9'9 7 Board of HJalth' 3rd floor)-(8:15 -9:30/1:00-4:30) �. Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Z Planning Dept;(1st floor/School Admin. Bldg.) $EPTi4EG T BE Definitive Plan Approved by Planning Board 19 iNSTND Nt TOWN OF BARNSTA W'O '�`TOWONS Building Permit Application Project Street Address 62 U o{-,P,0 g j�J L) Village Owner DAV i i G) L t n-)51t Address WAs+4,.x4( ) �y SLEX e,2," x Telephone —56_ — 4�-.O -- 0';1..I'P1 \ Permit Request SC,if E A) 6 � � 11V 4 S~! I- First Floor square feet Second Floor 01A. square feet Construction Type G O C-d Estimated Project Cost $ oc��- 0-2� Zoning District Flood Plain Water Protection Lot Size Grandfathered ElYes ❑No If? Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure —'1 4 yR S Historic House ❑Yes affo On Old King's Highway ❑Yes Basement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) d/19- Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing�_ New Half: Existing J — New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing_ New First Floor Room Count_ Heat Type and Fuel: Ullas ❑Oil ❑Electric ❑Other Central Air ❑Yes 10 Fireplaces:Existing INew Existing wood/coal stove ❑Yes Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ttached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Information Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) C f`i Gr �- FOR OFFICIAL USE ONLY e -PERMIT NO. _. s DATE ISSUED MAP/PARCEL NO. ADDRESS i VILLAGE _ OWNER — 4. � i ; ; 3 • _ • - DATE OF INSPECTION: FOUNDATION FRAME . � 9 . ; L ' _ }, Z7 INSULATION FIREPLACE t _ ELECTRI.CAL: RQ�14GH IL f FINAL GH FINAL , GAS*.-s . . ! ' FINAL + i FINAL'BUILDIN(rr DATE CLOSED O E ASSOCIATION PLR O. + i TIle Cunrmomrcalth of:Massachusetts Dcpartnunt of Industrial:4ccidcnts • plYlce'allnyest/gat%ans •��fill: _.�� 6011 h Street '. •c•Via':. � _ y; .4. Btatntl. Mays. UZlll �•' Workers' Compensation lnsurancc Affidavit �_ppiicint information • PIe•ue PRINT ZM �oc�tinn Co U)%1+s+4,0 it) C,�i=y a/ hnn•d Q — �0 DV. l am a homeowner performing al work myself. i I am a sole proprietor and have no one working, in any capacity �•••.•,•_•�w••__•_. [j 1 am an emplover providing workers' compensation for my employees working on this job. corm• ti n tmt iddrecc- city• Phone�• insurance cn nniic� tt [II am a sole proprietor. general contractor. or homeowner(circle one) and have hired the contractors listed below who the following workers' compensation polices: cnm nnv name! adtirrcc• cit.".Phone • incur-mrr rn cnm n.1m• natnr- nddresc- city Phone i#• insurance co, _ Pit Attach additio_n21 sheet if necesia_ry ...�=-= "" -"-"'�'`•' Failure tit secure cm•cracc as required under ticcuon 3SA of;11GL 1S3 can toad to the imposition of cnmtnai penalties of a line up to 51.50U.UU anc unc%cars'imprisonment:t•-ell:ts civil penalties in the form of a STOP WORK ORDER and a fine of St00.00 a day against me. 1 understand th.. copy of this statement may be forwarded to the Oftcc of Investigations of the DIA for coverage verification. /t/o herehr cc ' I.hh jj&t/he pains lard pchla/tics of pcj�uq that the information prorided above is true and comet. Q Si__naturc Date L t phone>r �� ➢/ Print name / S K � �D �" ■i w i�i ta�awwa+�aw ' ofticial ttse univ do not write in this area to be completed by city or town oRcial cin or ttnvn• permit/liemse> r Building Department • C3t.iccnsing Huard check if immediate respunse is required 0�deet s Orr"�.. �1lcaith Department .lassnchusetts General Laws chapter 152 section 25 requires all employers to provide workers* compensation for their mployees. As quoted from the "la%v**. an empinrec is defined as every person in the service of another under an\• ontract of iiire;.express or implied. oral or written. .n rmph rer isFdefined as an individual. partnership, association. corporation or other legal entity, or anv two or more . ►c foruaoin�_ cnuaged in a joint enterprise. and including the legal representatives of a deceased employer. or the :cen,er or trustee of an individual , partnership. association or other legal entity, employing employees. However the xner of a dwelling_ house haying not more than three apartments and who resides therein. or the occupant of the xcllin:a house of another who employs persons to do maintenance , construction or repair work on such dweliing hour oil the __rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. 'GL chapter 152 section 25 also states that every state or local licensing agency sltall tvitliliuld the issuance or neival of a license or permit to operate a business or to construct buildings in the communwen1th for any -plicant who has not produced acceptable evidence of compliance with the insurance co`=crave required. 7ditionall:.. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the -forntance of public wort: until acceptable evidence of compliance with the insurance requirements of this chapter ha en presented to the contracting authority. p icants ase f ii' in the workers' compensation affidavit compietely, by checking the box that applies to your situation and piyin:, company names. address and phone numbers as all affidavits may be submitted to the Department of istriai Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The 'ovit should be returned to the city or town that the application for the permit or license is being requested. tite Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required 'b:ain a «•orkers• compensation: polio}•. please call the Department at the number listed below. or Towns :se be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of ifridavt for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Pleas ire to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to Department by mail or FAX unless other arrangements have been made. Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. se do not hesitate to Live us a call. .._�� ..- .�•ter,.... ..���w�•�•.,��.��---.��...i_..��.r rw.•._..�_. .n"�r.���rw�_'�. Department's address. telephone and fax number. The Commonwealth Of Massachusetts Ir Department of Industrial Accidents _, t _.,R... office of Investigations : 600 Washin;ton Street Boston,Ma 02111 fax #: (617) 727-7749 phone u: (617) 727-4900 ext. 406, 409 or 375 CFtf1! The Town of Barnstable SAW$ Department of Health Safety and Environmental Services r 659. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissi 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 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: ACLEst. Cost Address of Work• Owner's Name Date of Permit Application: 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 Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner.- Date Contractor Name Registration No. -`� OR�k,, ` 0 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE - � - JOB LOCATION - • Number St et address Section of town t HOMEOWNER" �}V I Q FC 1 c_)Ls `tj S IC 1 ,5-6ff"4AD OAgk Name Home phone Work phone 1 f' PRESENT MAILING ADDRESS WA64JA39 1�� City town State Zip code The current exemption for "homeowners" was extended to include owner-occupie( dwellings of six units or less and to allow such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, 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 Offic on a form acceptable to the Building Official, that he/she shall be responsil for all such work performed under the building permit. (Section 109.1. 1) The undersigned "homeowner" assumes . responsibility for compliance with the St Building Code and other applicable codes, by-laws, 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 comp1 ith said proce ores and requirements. HOMEOWNER'S SIGNATURE .",� P APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35, 000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. II HOME OWNER' S EXEMPTION The code state that: "Any Home Owner 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 a Home Owner engages a person (s) for hire .to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for licensing Construction Supervisors, Section 2. 15) . This lack of awareneE often results in serious problems, particularly when the Home Owner hirer unlicensed persons. In this case our Board cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home 'bwner actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his responsibilities, man --ommunities require, as part of the permit application, that the Home Owner certify that he/she understands the responsibilities of a supervisor. On the la--t page of this issue is a form currently used by several towns. You may --are to amend and adopt such a form/certification for use in your community. t„ I - 105 '106 107 1 00.00 LOT 102 -15 , 040 -+- / - . F . 101 M IJ EC'- NO. 6 1 STY. a� S- C1 rq O 77.00 WASHINGTON BURSLEY WAY MORTGAGE SAGAMORE SURVEY ASSOCIATES IN.= 40 FT. UATE: DECEMBER 16, 1996 P.O. BOX 28 �r -� h \ SAGAMORE BEACH, MA. 02562 -� ��� T1111MAS yr 508 888 8567 ��.r ''2PC�? >tf (,�(�31 v__ m1 ; PON -ND COMPANY, INC. I CERTIFY TO PLYMOUTH MORTGAGE COPS a .e No.3431d`�!THAT THE LOCATION OF THE BUILDING SHOWN HEREON CONFORMS ` �' - ^i TO .THE ZONING OF THE TOWN OF BARPdSTABLE (CENTERVILLE) .}� I CERTIFY THAT LOCUS DOFS NOT LIE WITHIN THE FLOOD HAZARD ZONE AS DELINIATED ON MAP 0015C__l._COMMUNITY NO. 250001 PLAIT REFERENCE: BARNSTABLE REGISTRY OF DEEDS REGISTRY OWNER: BOOK/PAGE: PLAN BOOK 306, PAGE 024 LOT NO.: 102 BUYER: PLAN BY: ALAN C. SMALL, INC. DATED: SEPTEMBER 3, 1974 _ _ LF �ISPECTIUtl NC?T MAUE FROM AT[IT LOT,LI�ES SU OR�US. B NI ONLY. USED R FENCES, HEDGF� OR TO ESTh�3 _ � .a � Apr-21-97 .,09:51A AKSLAND CONSTRUCTION INC. 303-377-4002 P .01 - --'-'--'---^--------------------- -_.-------- -----� i` /i I I / f ! I I ( i I I 1 i ( I ( I I I I I i i I I DFCK 1321 i I I i I ! i I ( I I i I I I _ I L---------------- - ----, Apr-21-97 09: 51A AKSLAND CONSTRUCTION INC_ 303-377-4002 P.02 t.vw Yia �t�' SL•1 /�� 'ry ' Y Apr-21-97 09: 52A AKSLAND CONSTRUCTION INC_ 303-377-4002 P.03 Apr-21-97 09:53A AKSLAND CONSTRUCTION' INC. 303-377-4002 P .04 i i Apr-21-97 09: 53A AKSLAND CONSTRUCTION' INC. 303-377-4002 P.05 EEI r 106 /0 6 goo oc, - �02 J noa M�r✓� as�N GR� Q � M Prop �j J pO,U V 13 A r c� J a CEC'TtF1Ep pl_bT (�L.la„E,,_i LOCAT lOt-I T 2.111_I..L 5c-nl..l�y I CMRTtr=Y T14AT TNI; �OotJt7ATIOIJ 5"owu -A �Z lZc�.1GE NE�EntJ -O, lPLYG WIT" TWG 5i17� 1.1►-tom �p7. �p•� Auto SET$nC1G C'E4Ut2ENt�i,lj'S OF T-N� 'taw►.1 of~ �3Ai��J�,TA�3L.� 22 } r pt DATE Co 71t "i"] I iZeGIS'ruZ1!b LAWo 5UZVE-(uczS Tt-1t5 C�r_AE-t t; "OT E,Ae>eD AW v5TEZV%L-1E= o Ar(aSS� ►t.1srT.'rJ�Ec.tT �>U?'VCY �- Tt-lEr. o�G',�t's St-lowr.n �t>'r�t_I CA�tT t4:.,T' 6 r- lJsc 4 TU v tx;t etic t W Lo`c' Li t.rL /�Ld 7 M t�C ;Y5'1E1A MUST BE Assessor's map and lot'number .. ......... ......................... _ " O/< COMPLIANCE" 7 ; �.: i'd i li APN ICLE II SIVE Sewage Permit number ....... ............ r...... p sAMARI� cubE AND TOWN 1 � r o EGUL.ATIONSy yQFTHET�'`. TOWN" OF BARNSTABLE ^! 9 0 L ?" i639 BUILDING INSPECTOR :f. 44LICATION-FOR PERMIT TO ca TYPE OF CONSTRUCTION �. ........ .............. .+.. ........19....`. TO THE INSPECTOR OF BUILDINGS: I � The underai .ned. ereb -a -lies -for n :ermif accordin to the followin informatiori: . ' 9 Y_ PP P Location . . ,... .. .. ....... ` ....... ......... ... ... .. .... f . ProposedUse .. .. ............. ...........::'y.................:. ...................................................................................................... ZoningDistrict ..................................... � .........................Fire District ................................. a....................................... - Name of Owner .. .. . Address .... .... Name of Builder ..41-46, ...... ....... ................ ... .. .. . . :. .........Address .......... ..... ... ...,.... ,........: . . Nameof Architect ......._...:...............:...............:...................:..Address .................................................................................... Number of Rooms .............. ................................foundation Exterior . ... ...... .............................. .Roam. .... ..n.�...u......�..N�(.��n�.)..' Floors .Interior ,,, Heating .........Fl •""..... .. ......................: ..................Plumbing ............................. ........ ........................... Fireplace ................................... ..... ................ .A Approximate Cost .... Pp ..... .................... Definitive Plan Approved by Planning or ---------------—---------------19--------. Area /qW - Diagram of Lot and Building with Dimensions Fee / ........... ... .......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH 0. I� D I hereby agree to conform to all the Rules and Regulations of the Town of Barn;pbleregdrding the above construction. Name ... . ...... ............................................ A-172-165 klai- Small i Igo 193 ... P..ermit for ..DWgl. ing............. �D • • • •.•1 • •..........•.•• .............................• [ •. 1A AS 19cation Lat.1102.....Ceixterwill e................. s H l gl 1,antis...,..r en It ex v i l 1P.......................... o Owner .........Alau-Smal.l.......................1........... • i type of Construction .....lafpd................:.........•. ....................................................... Plot ..Ar.12.2-m165:...... Lot ................................ Permit Granted ...:.........Jn1Y•.... .......19 77 ` Date of Inspection ...71 -71��.•�9/ Date Completed 1.71............19 PERMIT REFUSED { ....................................... .................... 19 ....: .............. ................................. •.••••••......•.••...•.•.•.......••..•.••••D••.•.............•.................• 1 ..............•............ •••.•••.•.•••••..•.•••.••.••••...................... Approved ................................................ 19 Assessor's map and lot number L ... ... `. ...... Sewage Permit number .......................................................... �ofTNETo�` TOWN OF BARNSTABLE i BABB9TADL8, i 9� 101M � BUILDING INSPECTOR APPLICATION FOR PERMIT TO ........................................... TYPE OF CONSTRUCTION ................................................19........ TO THE INSPECTOR OF BUILDINGS: Tice undersigned: hereby::applies_ for: a permit according; to the following inforrnotion: Location .................:.............................:......... :....:.............:....................................................................................................... ZoningDistrict ..................:.....................................................Fire District .............................................................................. Nameof Owner ........... .......... Address .............. ................................................................. Name of Builder ........:......... ...... ... :`::' ........................Address .................................................................................... Nameof Architect ..................................................................Address ....................................:............................................... Number of Rooms ` ............ ................................Foundation ... ............'............................................................ QEaten r ...... ...........................:................................. .......R . mg .......... ...............:. ............,.............................,..�.�. Floors ......................................................................................Interior ...................' ................' ..............:......................... Heating .....................................`.........#................................Plumbing .................... �r. .'. ........°..................................... Fireplace .....................:..j:..........I.................................................Approximate Cost ... ............4.. ......... Definitive Plan Approved by Planning Board -----------______-----------19______. Area .... !. Diagram of Lot and Building with Dimensions Fee ........,` *fi„ .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH .i jj +i t . I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .....:............ ............................................................... A-172-165 Alan Small 19 0 .Q1--.—�n.—� � ��....�.�r���z' / . �/ � Lot #1O2 ' *_.ion_ .--.-.--...~—.—..--.-.----.-- � o , igg llla —~.�—'�`=��--�----.---------, � ��. � Alan Small Owner --.-------.--...--.--.---. . ' pe of Construction .............................Wood � —~^^--^'—`-------~^~^^'`------''' A-172 165 P�x —_---.�.--.. Lot ----------.. � July 8 77 Pmnni+ Granted ------.—..-----lP � ' Date of Inspection .................................... Dote Completed ...................................... PERMIT REFUSED ' ----.-_----------.--.—.—.. 19 ' —.---.'---_—.----.-----------..- . � - --------------'---'------'---- -------'--'---------'----'--'—'—'' ----- Approved � 0 w' ._—.�—.K�---.-------. lg � ' -----------.---....---.—,.---' � . \ —�---------`---^'---^---~'—'—^~'` � ! ^ | ,� �TME:T d .: : The Town of Barnstable • lARNBTABi.E, • 9 Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen ' Fax: 508-790-6230 Building Commissioner PLEASE FORWARD THE ATTACHED PAGE(S) TO: r TO: ATTN: FAX NO. �G FROM: -� DAT E: a5 , l 99� PAGE(S):# (EXCLUDING COVER SHEET) /v5 • /06 �07 1 ;vow 404w M P�oP U� j /C?= C i i7_t r - Mkot f � I M .h:. �� v� C•!:.. is i~ y► 3i10 I e - CEtZTtF LoCATlo i GMiZTlr-,4 TNAT TMi= �"Dvt1t7ATl0Q 5"0WQ Pt--A4.1 REFctZc�.1GE aWt� SET$ACIC S�EQUi2E�citc+-rrS Oi; TNT �(ow►.� of B� ;c�'��'A�L� -- ?'� �'�K 3c� �� . w:�.. y.4.- F3,4 xTEiZ. �. ►..IYE RcGtS�rc-�Z�D L�.t.�c� Su2v�Y�czs T{-I1�� t7LAN IS QOT E-yASE'D o" A&1 USTE2V�L�-E v ArC�SS� e>14C,UI_D APF,l-tCI1,"-r LO s TRANSMISSION VERIFICATION REPORT TIME: 10/25/1996 14: 55 NAME: BARNSTABLE BLDG DIV FAX 1-508-790-6230 TEL 1-508-790-6227 DATE DIME 10125 14: 55 FAX NO./NAME 93625593 PAGES}N ©2:00:44 RESULT OK MODE STANDARD ECM