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THE Town of Barnstable
Regulatory Services
a.atwsrware.
` Thomas F.Geiler,Director
lanes .
Building Division
PrfD Tom Perry,Building Commissioner
200 Mairi:Street�Hyannis;MA 02601 _..._ ........:... ... ._. __ ._. . . --..._..
www.town.barnstable-ma.us
Office: 508-962-4038 Fax: S08-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: 6,T� I 0
JOB LOCATION: G Q 6J A d EVE- �D Ge✓I e r L) t -e•
number �-n street village
"HOMEOWNER":( V�'S � ��1 T L�►'tA�� 5�� 53 9�3 Y
name home phone# work phone#
CURRENT MAILING ADDRESS: ""P
V,Ie
city/towo 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.
DEFINMON OF HOMEOWWER
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-ha/she understands the Town of Barnstable BuildingDepartrnent
m;,,;,,,um inspection procedures requirements and that he/she will comply with said procedures and
r ' ements.
Sign of omeowner
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 pcmvt 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 pcTson(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 s 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 unliumsed 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 respa=bilitiW 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 fornJcertification-for use in your community.
Q:forrns:homccxcmpt _
Trati Town of Barnstable
Regulatory Services
MANSr9 BM
MARK Thomas F.Geiler,Director
�gEn µ�- 16 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 Sigri This Section '
If Using A Builder.
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 complete the
Homeovmers License Exemption Form on the reverse side.
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."
r '
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-contiactor(s)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be.sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address" I.he 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 bum 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 C6mmonwealtlh of Ivlassarhuseas``.
Department of Industri.al'Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617--727-4900 ext'406 or 1-877-MASSAFE
6
Fax 0617-72,TJ74.9
Revised 11-22-06
www.mass..gov/dia
r5
� r
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/Individual): O.S��1 f e01iVt-e'�1,
Address: y��p U:e r f2 c� T
City/State/Zip: �Q lj�eIry [[::C Phone.#: �' S3 3
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
m
..2.0 I am a sole proprietor or partner- listed on the attached sheet. T. 0 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. 0 We are a corporation and its 10.❑Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 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 affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
xContractors 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 the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA'for insurance coverage verification.
I do hereby rtify under the pains d pen es of perjury that the information provided above is true and correct.
ASi ature•3 Date: 9
Phone#:
Official use.only. Do not write in this area,to be completed by city or town official.
.City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3. City/Town Clerk A.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Town of Barnstable *Permit#
�1 .
Expires 6 1 7ollisfroin issue date
BA STAB ; Regulatory Services Fee o� S
� MAC Thomas F. Geiler, Director
A i639� IN .
rfnnv�� Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis, MA 02601
www.toWn.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint �e
Map/parcel Number o�7 t)� -PRESS. PERA
.
Property Address 6 a Gyoa sJA r aeyj ��Y v A e 9CA-1 JUN
'K] Residential Value of WorkoD D Minimum fee of$25.00 for work underr($�
0 ()lY 8ARNST ,L
Owner's Name&Address c) S?i 1, 1Z 4 oC c)
6A 9-a. ue r ZA
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑�-, am a sole proprietor
[ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box) nn
['f Re-roof(stripping old shingles) All construction debris will be taken to K 5N�t�S1�r
V
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑ Replacement Windows. U-Value (maximum .44)
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owne ust si roperty Owner Letter of Permission.
Home Improv m nt f0tractors License& Construct Supervisors License is required.
SIGNATURE: 0�S
Q:\WPFILES\FORM \Exp�ess\EXP SS PERMIT.DOC
Revise06O4O9
PERMIT PRYMENT RECEIPT
10VIN OF BARNSTABLE
BUILDING DEPARTMENT
Zoo NNIS, MA E02601
H
DATE.* 0/19 0R _
TIME: --- -
1 ___-,. - -----_-- --
25.00
PERMIT $ PAID 25.00
AMT TENDERED' 25.00
AMT APPLIED.
CHANGE. )00902814
APPLICATION NUMBER NECK
pmKNT wf
Pp�,ENT �
r
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 2-01 Parcel 083 Application #C2 3-
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/ Hyannis ZJZZ1
Y r
oioe
Project St re ;Address P2- w4wv
Village
Owner o1A, Address
Telephone ,Lj
Permit Re uest �i' PSG t�ol�.�lfT� �� `� ` i cd bd- 4t5 `7&
q
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
"Zoning District Flood Plain '�,� 0 Groundwater Overlay
Project Valuation �� Construction Type Ala
Lot Size Grandfathered: ❑Yes ❑ No If yes, atta6i upport'r aj doGumentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) .
Age of Existing Structure Historic House: ❑Yes ❑ No On Old K 's Highwzy: OrYes Cl No
v,
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area ( q.ft)
Number of Baths: Full: existing new Half: existing ewo-
Number of Bedrooms: existing _new
t
Total Room Count (not including bath-,): existing new First Floor Room Count
Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals A thorization ❑ Appeal # Recorded ❑
Commercial ❑Yes /o If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name ' ` Telephone Numb r� 0 � 1
Address b� � � `� License# U
Uu r� Home Improvement Contractor# �� b
Worker's Compensation # N ewo5zs a1
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 2 l�
r
` FOR OFFICIAL USE ONLY
.F
APPLICATION#
r
DATE ISSUED
s
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: }
FOUNDATION
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
t
ASSOCIATION PLAN NO.
f
1 .
Massachusetts - Department of Public Safetc
Board of Builtling Regulations and Standards.
Construction Supervisor License
s,�.
Licen � CSC 100988 }_
HENRY CASSIDY
8 SHED ROW r � "
WEST.IJARMOUTH, MA 02673 >
Expiration: 11/11/2013
('uwulisimer Tr#: 7620
4^\ ._
= Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 153567
Type: Private Corporation
Expiration: 12/15/?_t14 Tr# 233831
CAPE COD INSULATION, INC
HENRY CASSIDY
18 REARDON CIRCLE "
SO. YARMOUTH, MA 02664
Update Address and return card. Mark reason for change.
Address Renewal Employment I Lost Card
SCA 1 ii 20M-05/1 I
(^'�!7[s l/'n771/II,00[-cLK.2(Cft-C'`�''l'lf.XOJGlO12 LLJ8�J
Office of Consumer Affairs& Business Regulation License or registration valid for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 153567 Type: Office of Consumer Affairs and Business Regulation
xpiration: 12/1`5/2014 Private Corporaticil 10 Park Plaza-.Suite 5170
M Boston,MA 02116
CAPE COD INSULATION;';INC:
HENRY CASSIDY
18 REARDON CIRCLE �L
SO.YARMOUTH, MA 02664 Undersecretary htvalr' itho t Wnatrey
The Commonwealth of Massachusetts Pnnt.Form '
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): la ha
Address: /� &VA&
City/State/Zip: 2, (4v a&M/ MA' Phone #: -r2OQ
Are you an employer? Check t e appropriate box: Type of project(required):
l. I am a employer with �10 4. ❑ I am a general contractor and I
employees (full and/or pait-time).
* have hired the sub-contractors 6. New construction
2.El 1 am a sole proprietor or partner- Listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ 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 101-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LF❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repay rs Q nI insurance required.] t c. 152, §1(4), and we have no I j e���Gt���ih
employees. [No workers' 13.� Other W i
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.
tContractors 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 the policy and job site
information.
Insurance Company Name: to h(.,
Policy#or Self-ins. Lic. #: WGA oO �Z,_) Expiration Date:
Job Site Address: i )1-9Val City/State/Zi
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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce n#er the ains nd penalties of er'ury that the in ormation provided above is true and correct.
Si nature: Date '2 I t
Phone#: '.
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Nu, I0U'.) I
Gllellt?V:4507 CCINSUL
ACORD,.
CERTIFICATE'OF UABILITY INSURANCE I)A I�(NiNlIllmy),).N I
THIS L e�Kl IFICA-I"C-.IS I_S,,iULj)An A �(OM(Oi2/20-12
C MATTER OF INFORMA"I ILIN ONLY `L
AND CONFERS N( R(GhT8 UPON THE CERTIFICATE It-IGATE HOLDER MI ills
ERTIFICATE DOES N01'AIFFIRMATIVIELY OR NEGATIVELY AlKNO,lZXTEND OR ALTER TFIE COVC-RACE AFFOROC-D UY Tlit:POLICIF_
it"I'l-.00.11-115 CERI-IFICATE OF INSURANCE DOES NOTCON,�I I I U I F
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61-1-ty lies. -So. oullms NAME E Nvial olet YU�
4J4 kou(Q- I J j VtHt,
'vC 4flq( _Ex,.508-760-4602
)uu0i I)ujjIjjE,
MA
_'N_t'URI�ALkI)AffUNDINq CQV[tN,tk(lV.
11":Ahil LiNAIL a
Peel'1055 11151.1rWIC0 '1 8 3 3 3—-----
Cape. Cac( tritiul"Woll 1110 Eva114toll Insuranco Colvipmly
4SS Yalmouth Ro wSuR&R c: T_r
lIV-11lits, MA 02kit)-1 :I N:1k:J:R:r.,
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(LR fIFICA1 L NUMBER:
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iiNY faIZQLIIREIVIENT, II5RN' QS CON01`101101'ANY CONTRACTOR OTHER DOCUMENT Wj"l'I-I RE.131-Ii-cr 'ro willcl-I jllls
MAY LtL__ 13SLJfiD OR MAY F`r_RT,'IIN, THE INSURANCE.. µ'
"01-MED BY THIS POLICIES DESCRIBED HEREIN IS 9U0JCCr 1O ALL '[fit- IVKNI6.
Ci.WSJON5 ANO CONDI I-IONS OF SUCH POLICIES. Llmn'S SHOw1\1 IV,�y I'Ayf BEEN REDUCED By PAID CLAIMS.
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LIMN APPLIC PL VUL lc'� PRO- GQMPIQIIAGG $2 llrlll 000
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--------------- CANCELLATION
cil I Apo GOO Imiulzition,lific SHOULD AN'YOFTHEABOV6 OESCRIOELI WE
THE EXPIRATION DATE THEREOF, NOTICL WILL bL Uk -k U IN
ACCORDANCE WITH THE rOLICV PIROV131ON3.
AU 4101,112LU REPReSEN I ATIVE
CORFIORA I ION,All 0910 tvaoiyylj.
(-U1U/U5)
'I Glf'I I'lie ACORU IILAII'd and 100owu fqh.,wrod marks ofACORD
mky
i
OWNER AUTHORIZATION f ORM
Al c c�
(Owner's Name)
owner of the property located at
b z �/e S ✓fir �G��
(Property Address)
(Property Address)
hereby.authorize C&v e Id ,
(Subcontra r)
an authorized subcontractor for RISE'Engineering,to act on mybehalf to obtain a building
permit and to perform work on my property.
Pee's*Siature
Date
I -
`fir
Or
CAPE COD '
INSULATION ft? `
/I\Ip Ola5f St.tmS[SS SPp♦TM— 3u1P[HO[Y
\Alfa Gullfpf IN\YUIION I:11UNYf �'#���� .L .
1-800-696-6611
•l'own. of Barnstable 3/2(0113
Regulatory Services
Building Division
200 Main St
1 lyaiuzis, 1VA 02601
Date:
Dear Building Inspector
Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. perforiiied &
completed the insulation and weatherization work at the property listed below, Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance Institute
(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements.
Property Owner Property Address Village
seph 4-0&46 �rame)
Insulation Installed: Fiberglass Cellulose R-Value Restricted Urwestricted
ceilings
Slopes ) ( 1 ( ) ( ) l )
I'toors
Xte Walls 40 ) ( ) )
Sincerely ,.
lie y E C- sidy J , President
Cape Cod nsulation, Inc.
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parce� �� p t Permit#
STABLE
Health Division o$b�� - -2///0 rJ Date Issued 22 0 y
Conservation Division �� ZZ 109t, Jill[. '15 P j: 10 Application Fee # 4- 00
Tax Collector--..-,n 0 03 f Permit Feee�.� 0
Treasurerire
` -PTIC SYSTEM MUST BE
Planning Dept. 1,.ISOTL.LED IN COMPLIANCE
Date Definitive Plan Approved by Planning Board VWT9 TITLE 5
r Y: : MENTAL CODE ANO
Historic-OKH Preservation/Hyannis TOW14 RECUL.00NS
Project Street Address
_ �� �ye,<
Village ( 1f��-e�C V i ,e
Owner J`i &O �r&S Address C2 We;_-\1fY e2L CeVy1QRSiLV_ lY A
Telephone S O x 0 1 2,__2
Permit Request c MW16A-ek (e_
Square feet: 1st floor: existing 11110 proposed` 2nd floor. existing < proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation SP 000 Construction Type \QQD� `Y Q
Lot Size (o'b >A► Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure 2>0-40 O Historic House: 0 Yes Zkl o On Old King's Highway: ❑Yes W11-0
Basement Type: Gull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 1 -06 Basement Unfinished Area(sq.ft) '516 Y�
Number of Baths: Full: existing new Half:existing N�c- new ?c
Number of Bedrooms: existing c3 new >< _
Total Room Count(not including baths): existing �z new First Floor Room Count Ll
Heat Type and Fuel: /Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing _ New Nc-_ Existing wood/coal stove: ❑Yes 01I10
'Detached garage:❑existing(new size Pool:0 existing ❑new size Barn:❑existing ❑new size
Attached garage:(/existingw size Shed:❑existing ❑new size Other:
X
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name JfT6 �kkyy-x Telephone Number
Address _T!&QQ0,MTUWI License# e 1'131.L-D
cU1MN� 'i��c� 0 31 Home Improvement Contractor# 11"1 L7,
Worker's Compensation# "1 Sv v aZS X 3a0_q_bq
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
J
P_ERMIT NO.
t
DATE ISSUED /7 '; - flo
1tiIAP/PARCEL'NO. rj
ADDRESS' `.r ; VILLAGE
4 OWNERel
` t - vu
DATE OF INSPECTION:.. f s
FOUNDATION
r i
FRAME J-CEer srArats �^
INSULATION Z jb/24 t Ak-
' FIREPLACE
ELECTRICAL: ROUGH FINAL-.
PLUMBING: ROUGH FINAL, r °t
_ of i
GAS: ROUGH FINAL'^, r ',
FINAL BUILDING
i
DATE CLOSED OUT
ASSOCIATION PLAN NO.
L7 �
_L
Town of Barnstable
y °�^ Regulatory Services
BAMSrABLE, Thomas F.Geiler,Director
9 MAM ,
�ArE p ,� 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. 15 J40 WtMI c`A " &MV L zl"., .,
Type of Work: K Aar,* $AVK RR-1v,4-k Estimated Cost t70 0
Address of Work: s�
Owner's Name: V. S&.,r x ►%
Date of Application:
I hereby certify that:
Registration is not required for the following reason(s):
E]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 hereby apply for a permit as the a ent o o er:
�3 v
i Date ontractor Name Registration No.
OR
Date Owner's Name
Q:forms:homeaffidav
I ,
The Commonwealth of Massachusetts -
Department of Industrial Accidents
� =� - Office oflnyesti9atiaas '
600 Washington
Street
_
Boston,Mass. 02111
Workers' Compensation Insurance Affidavit
ovation:
hone#
city
❑ I am a homeowner performing all work myself.
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Faihue to tecmro coverage as regIIirea
sutder 5ection?5A o[MGL 15Z can lead to the imposition of crt Mtn31 P=dde5 of a One UP to$1,SOo.00 mdlor
ris°nment as xeIl as civil enalties in the form of a STOP WORK ORDER and a flue of SIQO.QO a day against tie: I uadershmd a
p
one years'imp
copy of this atatententmay be f°x'ffatded to the Office o[Investigatlons of the DUfor coverage veriIIcation.
I do hereby P and penalties afPeJurY that the information provided above is tra,and corrtd
Date I S- 0
Signature
Print name
d C- V`l wl Phone#,,.TOW *!O_-3rl f�C .
official use only do not write In this area to be completed by city or town official
peradt/iicense# oBunding Depaitnent
city or town: []Licensing Board
ElSelectineWs Office
❑checkirinonedtate response is required ClHealth Department
phone#; ❑Other
contact p erson:
rya Bros PJ�
oF� r Town of Barnstable
Regulatory Services
s 13AMSrAs Thomas F.Gefler,Director
MAM
Building Division -
Tom Perry, Building Commissioner
200 Main Street, Hyannis,MA 02601
offace: 508-862 4038 Fax: 508 790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder -,
~... . a.
the
;as..0urner.of .sub'ect ro e
mil.� �.-• .. . � p p rtF- ._......._. ..
hereby authorizeV .
cis•,: :to-act on mp.behalf,.
sa all hatters relative to work autho=' ecl•bg this buiUdingpesmlt•application for:
(Address of Job)
Signature of Owner D e
•
e
Print Nam
µ
PWF R S
9
49
fr.noRM
a*
1 JQI UN F KLIM ,�K //
5 T4SQlUANTUN 07 pcttng.G °
CUMMA(1.U4D
i
Board of Building Regulations and Standards
HOME IM,PRC VEM'ENT CONTRACTOR
Re €� ► Al 7g22
Eipi�oi 1tE/2004
rCK kuM BUILD '
_ I K tM
tf4UM RD.
MA 02W7
FILE # F1959 . CENSUS TRACT # z
CLIENT:.- Attorney Cosgrove DEED .BOOK PAGE
OWNER : Pau M. & Patricia McNulty PLAN BOOK PAGE LOT
APPLICANT: Paul & Patricia McNulty ASSESSORS PLAN PLOT
Ma0RTGAGE INSPECTION PLAN OF LAND
I N
B A R N S T A B L E
SCALE: 1 = 40 ; 9�
AUGUST 31, 1987
9
d
36,76 ' 117 . 82)
00
v,
C
PA�EO OR1VE
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CD
W #62
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1
I CERTIFY TO JOSEPH G. COSGROVE, ESQUIRE, THE CO—OPERATIVE BANK OF CONCORD,
AND ITS TITLE INSURANCE COMPANY, THAT THERE ARE NO VISIBLE ENCROACHMENTS OR
EASEMENTS EXCEPT AS SHOWN AND THAT THIS PLAN WAS _PREPARED UNDER MY_
THE LOCATION OF THE DWELLING AS SHOWN HEREON
IS IN COMPLIANCE WITH THE LOCAL APPLICABLE
ZONING BY-LAWS WITH RESPECT TO HORIZONTAL 1ioF �<<�
DIMENSIONAL .REQUIREMENTS ,
o� KENNETH vim\
THE DWELLING SHOWN HERE DOES NOT FALL. WITHIN o R-1
A SPECIAL'• FLOOD HAZARD ZONE AS DELINEATED o:,
ON A MAP OF COMMUNITY #250001 DATER Ec,STE��°°��
BY THE F . I . A , Latfo/
Land Surveyors Civil Engineers
(g1Drz 2200ton ` ittn� 4uriieg (go., 4nr-
172 William �$#.
efneafara, 1 02740
GENERAL NOTES: (1) The declarations made above are on the basis of my knowledge, information, and belief as the
result of •a mortgage plot plan tape survey inspection made to the normal standard of care of registered land
surveyors practicing in Massachusetts. (2) Declarations are made to the above named client only as of this
date. (3)-.This .plan was,no.t. .made for recording purposes, for use in preparing deed descriptions or for con—
structions. (4) Verifications of property line dimensions, building offsets, fences, or lot configuration may
be accomplished only by an accurate instrument survey.
tl
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