HomeMy WebLinkAbout0048 CRYSTAL RIDGE ROAD � -� ,� e
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Assessor's office(1 st Floor): SG a ��
Assessor's map and lot number SEPTIC SYSTEM, MUST BE yoi TNc to`
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ij Conservation �� - �l2 INSTALLED IN CO PUqNCE
I Board of Health(3rd floor): ' �^ WITH TITLE 5 { •
Sewage�Permit number ENW O ENTAL CODE
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Engineering Department(3rd floor): ",TM4 °o �a�o. \�d°
House number *Y7 .��- ii RE0,U ..��,�0NS �o asr
Definitive Plan Approved by'Planning Board 1 19 �
APPLICATIONS PROCESSED 8:30-9.30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABLE
! BUILDING INSPECTOR
APPLICATION FOR PERMIT TO -
TYPE OF CONSTRUCTION
(p 19 g s�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location /e[
Proposed Use
Zoning District / Fire District
Name of Owner ��pL D� Address _ ✓'�.
Name of Builder Address
Name of Architect Address
Number of Rooms Foundation ( o7ild
Exterior Roofing .5u1 'yl�l
Floors v Interior >� ✓lyt
Heating �� `y ziQ Plumbing
Fireplace (` / Approximate Cost10917
��.
fi Area U
Diagram of Lot and Building with Dimensions Fee e
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 154t4w 7 ba�
Construction Supervisor's License
DORNFR, HORST
$- No 35247 Permit For 1 z Story
1� 5
Single Family dwelling
Location Lot #18 , 48 Crystal Ridge Road `
{ Cotuit a
Owner . Horst Dorner S '
Type of Construction Frame
Plot '�` Lot
-i
Permit Granted August 3 , 19 92
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i n
Date of Inspection 5 Z - __19
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FRONT -LF-VAMN ;'
CEILING ASSEMBLY G.WA.'
TCP SJRF rC U= ,.0 W111DOWS „. _
R
f N #1IFIEERGLAS3
INSULATIC:1 s . �•
SHEETROCx DQ)RS:
BOTTOM SURFACE <• ::�s';x"v-wea..
R= 0.61 '•
PLYWOOD INSIDE. SURFACE y rrt
0.62 R= 0.68 REAR EL• �. ..;�.;..
El/ATlON '
• WALL ASSEMBLY c.w.A: 4
.. ?.'° �� q
.)D I/2"SHEETROCx
OGLES - R 0.45. TOTAL R _ ::•. a... SST �'
0.87
U= . Q� �. .►.•:;Yi1ND07i' :Sa`j' i;���,i'��``�;
•. .,�..�. .+�, sue?
'SIDE. 3 1/2"FIBERGLASS ti'i :1
.!FACE- INSULATION 1 '�' ;,',•;��,• ` ,_'
0.17 R a 11
•is
1—, SURFACE RESISTANCE
{
FINISH FLOOR DOORSer w • *� :��D
R- 0.91 FLOOR
1/ oo
2" PLYWOOD
ASSEMBLY
�I susFLooR TOTAL. R - 3,2•7S.
f R=A.62 .:�3% RIGHT. SICn .EL
EV�TiC• .
y ` .i•j M„
;IDE
�T6 Uu �uVuuNOT
,` ...
's,:� xiw+ �••• " FIBERGLASS
� � +. •� INSULATION
sic. Rzz%;�- FOUNDATION
0 I.WA • WALL-L A „ ' is ..,y•'.
SU?F4 _ �A SSEPIaLY
g CE ' R..SIST:�1.Cc MAY Be USED N//�- I �•'i:Y `3' a�R•0.61 INSTEAD OF FLOOR `
'•' INSULATION1 ) _ i i ; i •i
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;•:►; TOTAL. R a 11a�.:T
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TM.> TOWN OF BARNSTABL.E 35247,f o Permit No. ...... .......:.
BUILDING DEPARTMENT
TOWN OFFICE BUILDING Cash
,6�0•
HYANNIS.MASS.02601 Bond .....X.........
CERTIFICATE OF USE AND OCCUPANCY
Issued to Horst Dorner
Address Lot #18, 48 Crystal Ridge Road
Cotuit, Mass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE. i
December 1, 19 92
... ........ .... ........................
Bui ding Inspector
�'fy�••'. TOWN OF BARNSTABLE
BUILDING DEPARTMENT
TOWN OFFICE BUILDING
one.
HYANNIS, MASS. 02601
MEMO TO: Town Clerk
FROM: Building Department
DATE:
An Occupancy .Permit has been issued for the building authorized by
BuildingPermit # , �� 7»........................................................................................»...................»........ .......»..»»....»»»».
issuedto /�i�'I.,�df.........................................................................................................»»..»...»» .... ».»......»..»»..»»».
Please release the performance bond.
TOWN OF BARNSTABLE, MASSACHUSETTS WING PERMI'
A=5672.25 �p /}Q /�
DATE AL1C�t1St. 3/ (B 92 PERMIT NO: NQ 35247.
APPLICANT Bayside Blda. CrJ. ADDRESS Centerville #005 .45
(NO.) (STREET) (CONTR'S LICENSE)
PERMIT TO _-Build Dwellinct (I�) STORY S].nc71CJ Samily DWEb1ling NUMBER OF
(TYPE OF IMPROVEMENT) NO. DWELLING UNITS
� � (PROPOSED USE)
AT (LOCATION) Lot #18, 48- Crystal Ridge Road, COtuit ZONING b
(NO ) (STREET) DISTRICT— RF'
n
BETWEEN __ AND
(CROSS STREET) (CROSS STREET)
SUBDIVISION LOT BLOCK S ZE
BUILDING IS TO BE FT. WIDE BY FT, LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTI,
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: Sewage #92-55
Bond
AREA VOLUME 1.7a7. '��. it.
ESTIMATED COST •250 000 0o FEEMIT $ 223.00
F .$
(CUBIC/SQUARE FEET) !"'
OWNER Howst Dorner _ ._ --
ADDRESS Germany BUILDING DE PT.
a BY
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY C
`PERMANENTLY. ENCROACHMENtS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE At
PROVED.;BY .THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEW"ERS,MAY BE OBTAINE
=, FROM;7HE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE C'ONDITIO:
s r OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL INSPECTIONS REQUIRED FOR •APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
"
ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
A. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY 1S RE- MECHANICAELECTRICALL INSTAL81ATIONS,O
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL
3. FINAL INSPECTION PECTION BEFORE FINAL INSPECTION HAS BEEN MADE.
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREon
ET
BUILDING INSPECTION APPROVALS PLUMBI G INSPECTI N APPROVALS
ELECTRICAL INSPECTION APPROVALS
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I/. HEATING INSPECTION APPROVALS ENGI ING D ART ENT
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BOARD OF HEA TH
OTHER
' q SITE PLAN REVIEW APPROVAL
�a
6RHAS
ALL NOT PROCEED UNTIL THE INSPEC- PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN
APPROVED THE VARIODUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THECTION. PERMIT IS ISSUED AS NOTED ABOVE, ARRANGED FOR BY TELEPHONE OR VVRITTF
NOTIFICATION.
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SECTION DETAIL O\VG No 4op .8
87•t4
B4`{51DE LDING Go"lut a FIG?/AE.J.
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A PPRO VED
TE CH - S
TOWN BARNSYASLE
Building Inspection Department
r .
a 0o5(.0 �b7
Oc1HE r Town `Of Barnstable Permit#
Expires 6 mnronr ire elate
Regulatory Services Fee
*. BARNnABLE, * - -
MASS.
v� 1639. ��� Thomas F. Geiler, Director
AlFb MP'�A
Building Division aQ/
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
�Q Not Valid without Red X-Press Imprint
(�
Map/parcel Number '" 0D 0 a
Property Address
Residential Value of Work � [QjU.L� C� Minimirni fee of$25.00 for work under$6000.00
Owner's Name & Address _ L 96'r.1q Kovi
c� 6 � t'�l ,4 J� rn, I/�
Contractor's Name wl �\L, �\�', S Telephone Number
Home Improvement Contractor License# (if applichle)_
Construction Supervisor's License#(if applicable)
[]Workman's Compensation Insurance
Check one: OCT �QQ�
❑ I am a sole proprietor
❑ I am the Homeowner
L-_�I have Worker's Compensation Insurance TOWN OF BARNSTABLE
Insurance Company Name ytt
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request (check box)
Re-roof(stripping old shingles) All construction debris will be taken to
C
❑ Re-roof(not stripping. Going over existing layers of roof) _
❑ Re-side
❑ Replacement Windows/doors/sliders. U-Value (maximum .44) Lp
*Where required: Issuance of this peinit does not exempt compliance with other town department regulations,i.e. Hist c,Conseeuation,e►u1
***Note: Property Owner must sign operty Owner Letter of Permission.
A copy of t. Home Im rovem nt ntractors License is required.
i
SIGNATUREi
Q: WIT-1LF..S`.FORMS\building permit Forms\EXPRESS.doc
Revised 100608
r The.Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations -
600 Washington Street
Boston,MA 02111
°,� ,Y•'y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `` Please Print Legibly,
Name(Business/Organization/Individual): . VVI n �tom—
Address:
City/State/Zip; C �1 Phone.#: (�8 �{ C� •�o°Z< CO
Are you an employer? Check a appropriate box: .'Type of project(required):.
4. I am a general contractor and I
1•[�I am a employer with � � 6. New construction .
employees(full and/or part-time).* have hued the sub-contractors
2.❑ I am a'sole proprietor or partner-
listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have S. []Demolition:
workingfor me in an capacity. employees and have workers'
y p t5'• 9. []Building addition
comp, insurance.$
[No workers comp.insurance p 10.❑Electrical repairs or additions
required.] 5. [] We are a corporation and its,
3.❑ -r 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.H-koof repairs
insurance.required.]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 subcontractors 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. q
Insurance Company Name: V)1
Policy#or Self-ins.Lic.#: �;E) Expiration Date:
lob Site Address: a � City/State/Zip: /l ' • ni
Attach a copy of the workers' compensation po .cy 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 tip 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
Investi ations of the WA for insurance covedRe verification.
I do hereby certify and r he s• altie o Jury that the information provided above is true and correct.
Signature: Date:
Phone#: ��f
Official use only. Do not write in this area, to be completed by.city ar town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
J.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector
6..Other
Contact Person: Phone#:
jL11k J AJA"a,sLW1Lm "JL.EL%AL $$gam a a am �mds_•��.
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 hiie,
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 ofcomplianee with:tlie 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-conti:actor(s)name(s),addiess(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 maybe submitted to the Department of Industri
al
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 numbe
r on the a ro Aate-hne.
G PP P
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 do license or ermit to burn leaves etc. said person is NOT required to complete this affidavit.
(
g P )
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:.
�CoW-oRW(,-"of Massaehusetts
Departomt of tuft ial Aeeideuts
Office of Investigations
600 Washington Street
Boston,.MA 02111
TQL #617-727-4500 ext 406 or 1-S77-MASSAFE
Fax#617-727-774.9
Revised 11-22-06
WWW.mas,%gov/dia
Construction Supervisor License-,
�, .
Li nse CS `48546
E.x !fitl ff
P _1/27/201.0 Tr# 14362
- rRes n
MARK HERBST "
# 35 PL.-'T'TOAD RDD,D E
h CENTERVILLE,MA�02632 � .c
Comsionec 'P
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�!e -�aninio,zurea/,l�i o�✓�craaac�ucaelfia r —-�------- -----.�-- ._.---.-• - -
Board of Building Regulations,and Standards
f License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registra on:, 126480 Board of Building Regulations and Standards
Expiration=6jg/2010 Tr# 267766 One Ashburton Place Rm 1301
T t" Boston,Ma.02108
� s
Ype Individual
R
MARK HERBST 13
MARK HERBST7.
35 PEEP TOAD RD:
CENTERVILLE,MA 02633
Administrator Not valid without signature
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwe a lth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENT'S
600 Washington Street, Boston, Massachusetts. 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we)have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
AWC 7016215012008 01/10/2008 - 01/10/2009
POLICY NUMBER EFFECTIVE DATES
P O Box 494
Leonard Insurance Agency Inc Osterville, MA 02655 (508)428-6921
NAME OF INSURANCE AGENT ADDRESS PHONE
Mark Herbst 35 Peep Toad Road " Centerville, MA 02632
EMPLOYER ADDRESS
01/04/2008
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY)' DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable bospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.-
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEARESTAND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYED
L_
EVE �G _
The Town of Barnstable
• 1ASNSPABM •
9ebMASS
1659. 1��' Department of Health Safety and Environmental Services
iOrEo " Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
For office use only
Permit no.
Date r
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 re uirements.
Q 1 ro v t G�
Type of Work: I Od 6^ Est.Cost s LA 4-J Q le � 0 .
`Address of Work: C-
Owner's Name
(2)6 r A(,,A Lcw Y-e-g\—
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under$1,000.
Building not owner-occupied
Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent oft a owner:
L `2) Y clkS
Date Contractor Name Registration No.
OR
7,1 (41 r�
`�
Date Owner's ame
04
Tht• Contntonlrettlth of Afassacltuscus
Department nt of Iurlustrial Accidents
1 rG Office oflttvestfgatlons
'� 600 I1 uAiirgtun Sireet
Boston. Ma.u. 0 111
` Workers' Compensation Insurance Affidavit
r It ant information• _ PleT'ie PRINT lebjj r -,
1
name: �UZ(•P 6 �GC�1 S
LILL l
cin CAInInI S AA[' O'D(10 I rihon• 7 L
❑ 1 am a hon6owner performing all work myself.
❑ I am a sole proprietor and have no one working in any capacity
l a i an emplover providI a workers' co pensation for my employees working on this.job.
cant tanv name: ` Poo
address: —1,W
city: hone#• L
insurancecn. CQ,� �i !� lic%-# 9 lJ
❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the followinc workers' compensation polices:
comnam' natnc: LL7�r" 1 -e
address: "l � � l�A q l�r
a vi• ✓l v hnne#• - \ Z
insurance ro. ALI�At-v�—L
I_ •f.::..-.. Y^ - - .-•r�•Y•"•..•-.� __ _- _fir_I.:�"--.tt�T"I�w�.1 ._fir...-. _-.-.....ti...�.._._...
common.' nnmc:
addresr-
city: Phone#•
insurance co noiic� #
Attach additional sheet if nt:ccsiary; _ J� ' ' __- - _ice. '�•'•�"*�+•+"+•• + y..w •�'_T��•�-�
Failure to secure covernize as required n cr Section 35A of AtGL 152 can lead to the imposition of criminal penalties ol'a line opt S1.500.00 ndiur
une scars' imprisonment as w ell as civil penalties in the form of a STOP AVORK ORDER and a fine of S100.00 a day against me. I understand that a
cop} of this statement mas be forwarded to the Orrice of Investigations of the DIA for coverage verification.
1 do hereht certif corder the prrius mr perra11. of erjun•that the information provider/above is true and correct.
Signaturer[ � Datc
c
Print name Phone# 7 i —
:.'•olricial osc only do nut write in this area to be completed b�•cin•or town oMcial
cin'or town: permit/license# -Building Department
Licensing Board
tt I]check if immediate response is required selectmen's Office ►
r' [311ealth Department
contact person- phone#: -Other
information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers ctmtcitsation for the
employees. As quoted from the "la++ an entptoree is defined as every person in the service oi-another under anv
contract of hire, express or implied. oral or written.
An rtnph rer is defined as an individual• partnership, association, corporation or other legal entity. or airy two or mo
the foreuoing enLagcd 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 tl
owiler of a dwelling, house having not more than three apartments and who resides therein, or the occupant of the
dwcl ling house of another who employs persons to do maintenance , construction or repair work on such dwelling lic
or on the wounds or buiiding appurtenant thereto shall not because of such employment be deemed to be an employc
MGL chapter 152 section 25 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 ++•ho has not produced acceptable evidence of compliance with the in coverage required.
Additional[+•, neither the commonwealth nor any of its political subdivisions shall enter into anv contract for the
performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter
been presented to the contracting authority.
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
Supplying_ company names. address and phone numbers as all affidavits 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 require.
to obtain a workers' compensation police, please call the Department at the number listed below. .
City or towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom c
the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Ple
be sure to fill in the permit/license number which will be used as a reference number. Tlie affidavits may be returned
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questio
please do not hesitate to give us a call.
Tile Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
-
Department of Industrial Accidents
Office of Investigations
600 Washinaton Street
Boston,Ma. 02111
fax #: (617) 727-7749
' phone 4: (617) 727-4900 ext. 406, 409 or 375
109735
DEPARTMENT OF UBLIC SAFETY 109735
ONE ASHBURTON PLACE, RM 1301
BOSTON,,,MA 02108-1618
CONSTRUCTION SUPERVISOR LICENSE
Number: Expires:
Restricted To: 00
TIMOTHY R LUZIETTI �yy`
',1uIV 'Z 5
79 ARBOR WAY
HYANN i S, MA 02601
Keep top for receipt and change
. of address notification.
_ ....
109735
Restricted To, Be l ' �ie �oo»mzoo:�ueall o���iiJaa�[tJ�//J
I 00 - None I { ! DEPARTMENT OF PUBLIC SAFETY
IA - Masonry only I x� CONSTRUAK SUPERVISOR LICENSE
IG - 1 12 Family Nomes 1 S
t I yri Numbef, Expires,
Massachusetts State Building Code
i is cause for revocation of this license, j i I JIestPi trlO: 00
iI
TIiOYN' ;LU2li'TI
i 79 R-WAY11
WAY
1 �� �( + >NYANNIS, MA 02601
rr-
U-BBHOME IMPROVEMENT CONTRACTORS REGISTRATION oardard of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston , Massachusetts 02108
HOME IMPROVEMENT CONTRACTOR
Registration 108238 Expiration 08/14/98
Type - PRIVATE CORPORATION
LUZIETTI , INC .
Timothy R . Luzietti
955 Rt . 132
Hyannis MA 02601
JAN-28-98 WED 14 ;58 A D Calfee Ins 508 457 1715 P. 01
X
ACORDDATE(MN•,.DBIVVI
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAYION
ONLY AND CONFERS NO RIONTS UPON THE CERTIFICATE
HOLDER, THIS CIRSTIFICAT8 WES NOT AMtNO, EXTEND OR
ARTHUR D. CALFEE INSURANCE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
AGENCY, TNC. COMPANIES AFFORDING COVERAGE
336 GIFFOPID STREET COMPANY
FALMOUTH, MA 02540-2967 A TRANSPORTATION' INSURANCE CO.
COMPANY
LUZIETTI, INC. B TRANSCONTINENTAL INSURANCE CO.
TIMOTHY R. LUZIETTI COMPANY
955 ROUTE 132 c
HYANNIS, MA 02601-1826 COMPANY
2:
THIS IS TO CEATtIZY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BffN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT To WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PEATAIN, THE INSURANCE MFORDEV By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIoN8 AND CONDITIONS OF$tJ0H POLICIES.LIMITS 15HQY'M MAY HAVE BEEN REDUCED BY PAID CLAIMS.
DO TYPE OF INSURANCE FOUCY NUMBER POLICY EFFECTIVE POUCYRXPIRATION
LTR DATI(MMIODfM DA7E(MM1DDfVY) UNIiT1
GENERAL UABILITY GENERAL AGGREGATE t2,000,000.
COMMERCIAL GENERAL LiABILtTY PRODUCTS-COMPIOP AGG $1, 000,000.
CLAINISMADE r—v-)OCCUR I
I IL I PERSONA Il 000 000WSPAOT Cl 4.5039404 �A L-=-=
OWNER'S&CONTRACTO
02/01/97 02/01/98 EACH OCCURRENCE .1r000'000.
Cl 45039404 02/01/98 1
M Eb EXP(.k,,one uereony S 5,000.
-T
ANY AUTO LIMIT
ALL OWNED AVTQ5 5ODILY INJURY
SCHEDULED AUTOS (Plir person)
WREDALIT69
80131LY INJURY
NON-OWN ED AUTOS
PRUPEATT PAmAtiE
I GARAGE LIABILITY AUTO ONLY-EA ACCIDENT
ANY AUTO CTHEA THAN AUTO ONLY:
EACH
AGGREGATE 11;
EYrfftt I IfRIIlTW FArw f)r'rl ISOFNirF
UMBRELLA FCAPA A1111FIVIAll
C)THEA THAN UMBRELLA FORM
IOTW.
WORKERS COMPENSATION AND L
EMPLOYERVILIABILITY
EL EACH ACCIDENT 1 $500,000.
A THEPROPRIETOR) F-v7INCL WCC 1 45033120 02/01/97 02/01F98 EL DISEA26.IOLIC'Y LIMIT s500,OOO.
PARTNERSIEXECUTIVE
OFFICERS ARE: E KC L WCC 1 45033120 02/03,/98 02/01/99 ELDiSEASE-EAEMPLOYEE-- ,-�6-0.000.
OTHER
DESCRIPTION OF OPERATtO4VaiLOCATIONSIVEMOLES;SPgtlAL ITEMS
SWIMMING POOL INSTALLATION/SERVICE/SALES
4
` I'0 � A E!"
SMOULD ANY OP THE AbOVE DCOOMOEO POUIDIES BE oANceLL0 DEFOYlIf, THr,
Towu OF` BARNSTABLE FXPIRArioN DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
SOUTH STREET 10 DAYS WRITTIN NOTICE TO T"t CMTIFIQATIE HoLO134 NAMED To T14C LCPT,
HYANNIS, MA 02601 awr rAJLVF(g;TO A&SUCH NOTIC A tHALL IMPOaE NO OBLIGATION OR LIABILITY
OP ANY KI U 00 E CO#0A%Y, Wf A"Ta OR FiErRES07ATIVRO.L J64
Aurwowll)R
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Engineering Dept. (3rd floor) Map Parcel 60„2- D�Z� Permit# 115k"? Cp
House# 4F Date Issued
Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) Fee
Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Z '7 ' '
��T6C �Y��'E�� �a=���il
apt. (1st floor/School Admin. Bldg.) INSTALLED IN C NCE
NM IT Hefimtiw-F4an Approved by Planning Board 19 `���®IIVITW
TOWN RE �
TOWN OF BARNSTABLE
4. Buildi Pe it Applicati n
Project Street Address
Village '
Owner 064-�. i'�t/1_ I Ott►�,?_P,('' Address �p✓( i'
Telephon
Permit Request in Q F o uiaA, v
First Floor square feet Second Floor square feet
Construction Type
Estimated Project Cost $
Zoning District Flood Plain Water Protection
Lot Size Grandfathered ❑Yes ❑No
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
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: Existing New Half: Existing New
No.of Bedrooms: Existing r New
Total Room Count(not including baths): Existing New First Floor Room Count
Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other
Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
• ❑Attached(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 na License# Q
V ti
q a 0 (o� J Home Improvement Contractor# 3�
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
S
SIGNATURE h-1�hL4�2� DATE �j
BUILDING PERMIT DoEDNIED FO THE F LLOWING REASON( _
C
1
FOR OFFICIAL USE ONLY
r '
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE x,
OWNER
DATE OF INSPECTION:
``.
FOUNDATION • 2�3 �� - •
FRAME
INSULATION .. -
FIREPLACE
ELECTRICAL: ?ROUGH ! FINAL'
PLUMBING: ;ROUGH FINAL i t
- 7
GAS: I-r ROUGH FINAL
1
FINAL BUILDING
• 'a
DATE CLOSED OUT -
ASSOCIATION PLAN NO.
R
N PRINCE
.� COVE
GRAPHIC SCALE
LOCUS B 0 30 60
4
EAGLE C�, p RD. x
FND.
POND
LOCUS MAP
0 °r t
SCALE 1 i 25,000
MAP 56 PARCEL 2.025 Z, yg4Q4 ?3j4)e
ZONE `� �`� d►! �'V►
A.P. o
Q b
& N
RF
150' FRONTAGE
560 S.F. AREA
SET BACKS / 99 0�• 1,,� i a
30 �tONT , gip• /,VI �'IZ '�e2'
LOT 25
15 SIDE do REAR g90 /�00 v�
ti'5 • �,. b• �� 58 S.F.
8 B. .>.
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BARNSTABLE PLANNING BOARD r� �' ,V%
APPROVAL UNDER THE SUBDIVISION or.4
,�.lj►��1 t. �J IJ,d j�''CONTROL LAW NOT REQUIRED. '
DATE:
PR 1 VATE ;��t..� WIDE,
_
NOTE LOT Z IS TO BE COMBINED Wt'[N LOT 17 PLAN CIF' LAND
AND IS NOT TO BE CONSIDERED AS A
SEPARATE BUILDING LOT. IN
NOTE: NO DETERMINATION AS T' :� ( COTUIT ) ;I
COMPUANCE WITH THE ZONING BA R N STA 8 LE MASS .
ORDINANCE REQUIREMENTS HAS
BEEN MADE OR INTENDED BY -111 BEING A SUBDIVISION OF LOT 18
ABOVE ENDORSEMENT.
AS SHOWN ON L.O.C. 23747B
CERTIFY THAT THIS ACTUAL SURIVEY WAS MADE
ON THE GROUND IN ACCORDANCE YATH THE LAND SCALE:1" 30' DATE: SEPT. 3,1992
COURT INSTRUCTIONS OF 1989 ON .OR BETWEEN
JULY 28,1992 AND AUGUST 31,19 C-2. BAXTER & NYE INC.
DATE: I-3-052 REGISTERED LAND SURVEYORS
�—_ CIVIL ENGINEERS
REGISTERED LAND SURVEYOR OSTERVILLF, MASS$
812 MAIN sT.
OSTERVILL.E, MASS. 02655 �
(508) 428 .9131
ERROR OF CLOSURE = 1' IN 68,575' Soto:
DIRECTION OF ERROR S25'23 43 E 0.015
BRIAN T. DACEY TR. FOR WATERFOC i,D HILLS REALTY TRUST OWNER #92026A
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