HomeMy WebLinkAbout0207 MAIN STREET (COTUIT) o?D7 /1/laii,� Sfre�
Town of Barnstable. *Permit#off 0 l 1
Expires months from issue date
Regulatory Services Fee
Richard V.Scali, Director 16;q a�� 2�14
n, Tr II�� cc Building Division j
IvS'er�LG Tom Per CBO Buildin .Commissioner IZl(Sl1'/
F BAR Perry, g
200 Main Street,Hyannis,MA 026.01;
www.town.bamstable.ma:us
Office: 508-862-403 8 Fax: 508-790-623 0
EXPRESS PERNUT APPLICATION R]ESID]ENTIAL ONLY
r � Not Valid without Red X=Press Imprint
Map/parcel Number b lJ �'"
-
Property Address
Residential. Value of Work'$ Minimum fee of$35.00`for work under$6000.00
Owner's Name&Address i '. t �,
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable) Email: -
Construction Supervisor's License#.(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I 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 accompany each permit: '
Permit Request(check box) '
Re-roof(hurricane nailed),(stripping old shingles) All construction debris will
�6
❑Re-roof(Hurricane nailed)(not stripping. Going-over' existing layers of roof)
❑ Re-side
❑ Replpcement Windows/doors/sliders U-Value (maximum.35)#of windows
. . .. .. #of.doors:
'❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
*`Note: - Property Owner must sign Property Owner.Letter of Permission.
A,copy of the Home Improvement Contractors License&Construction Supervisors License is
r, i
SIGNATURE:
Q:\WPFILES\FORMS\building rmit forms\iX SS.doc
Revised 061313
1
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office vf Investigations
600 Washington Street
Boston;MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers'-
A licant Information Please Print Legibly
Name(Business%Organization/individual):
Address: :
/Z
,�
City/State,Zip: r3�' Phone#:
Are you.an employer?Check the appropriate box
Type.of project(required):
1.El..1 am a employer with 4. I.am a.general contractor and I` _
employees(full and/or part-time)
* have hired the sub-contractors 6. ❑New construction-
2.❑ I am a sole.proprietor or partner- listed on the attached sheet.. 7: [].Remodeling-
ship and have no employees: These sub-contractors have. .g, ❑,Demolition"
Working for me in any capacity, employees and have workers' 9.,❑Building addition
[No workers' comp..insurance comp.'insurance.#
re rued. 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3,PKq
am a homeowner doing all work officers have exercised thew. 1'l.❑Plumbing repairs or additions
myself. [No.workers'.comp. right of exemption per MGL 12.f.Roof 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 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance.Company Name:
Policy#or Self-ins.Lic:#: Expiration Dater
City/State/Zip: `
Job Site Address: ( 7`
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 aSTOP 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 unde- e ains nalti of perjury that the information provided above is true and correct
Signature:, i Dater
Phone#: _
Official use only. Do not write in this area, to-be completed by city or town official
or Town Pei miflLicense#
Issuing Authority(circle ones
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
,j,
s to provide workers' compensation for their employees. i
to er .2re `es all
Massachusetts General Laws chapter 15 P ,
P fir. employers P
Pursuant to this statute,an employee is defined as":::every person in the.service of another under any contract`of hir; k
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 adeceased employer,or the 1
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:"
1VIGL chapter 152; §25C(�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"
tates"Neither the commonwealth nor any of its political.subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have.been presented to the.contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance..Limited Liability Companies:(LLC).or Limited Liability_Partnerships(LLP)with no employees other than'the
..`
members
partners are not required to:carry workers' compensation insurance., If an LLC or LLP does have
mrblicy is iequired. Be advised that this.affidavrt
m o may:besub D nt of lndustnaT '•
p Yees a`p
Accidents for confirmation of insurance coverage. Also.be sure to sit and date the affidavitgn 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,pi6ase call the Department at the number listedbelow. Self-insured companies should enter4heir
self-insurance license niimber 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 redingthe`applicant.
Please be.sure to fill in.the'permit/license number which,willbe 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 curre'tit
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 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-7274900 eat 406 orl- 77-MASWE
Fax#617-727-7749
Revised 4-24-07
www,mass.gowdia
r Town o,.Barnsta ble
iG g9 �e
Regulatory Services
Richard Scali,Director.
B
uilding Division
Thomas Perry,CBO
Building Commissioner.
200 Main Street, Hyannis,-MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508=790-6230
Property Owner Must
Complete:and Sign This Section
If Using A Builder
as Owner of the sub' ct propeity,
.hereby authorize act on my behalf
in all matters relative to work authorized by this building permit app ation fo�r'"—
(Address of Job)
Signature of Owner k Date
_. .
•` 5
ptmt Name
If Property Owner is applying for permit,please complete the'Homeowners'License Exemption Form on the
reverse side.
QAW. PFILES\FORMS\buildmg permit formAsmokecarbondetectors.doc
Revised 050412
Regulatory Services
pU Richard V.Scali, Director
Building Division
swxwsrws� Tom Perry.,Building Commissioner
�sq
200.Main Street, Hyannis,MA 02.601
rEo www.town.barnstable.ma.us
Office: .508-862-4038 Fax:. 508-790-6.230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
-JOB LOCATION:
number: street t v'llape /� Q
`HOMEOWNER": . :
nam " home phone# work phone# d07
cCURRENT MAILING ADDRESS:
city town s to 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.
DEFWITION''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
e me in a two-year period shall rno t be considered a home
owner. Such
e than on home
person who constructs mor y p
"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) -
onsibility for compliance with the State Building Code and.other.
The undersigned"homeowner"assumes resp
applicable codes,bylaws,rules and regulations...
The undersigned"homeowner" certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requiremen
Signature H weer.
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply.with the
State'Building Code.Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required
shall be exempt from the provisions of this section.(Section 109.1.1 Licensing of construction Supervisors);
provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall aet
as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of
a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15)
This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed .
persons. In this.case,our Board cannot proceed against the-unlicensed person as it would with a licensed .
Supervisor. The homeowner,acting as Supervisor is,ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,.
as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a
Supervisor. On the last page of this issue is a form currently used by several.towns. You may care t amend
and adopt such a form/certification for use in your community.
` 6a#Warr S&eet
Aosfanr M,4 02 .
wnw.r gav/dra
Worlrers� Cumpe=5unIn&urance da RcedersfC�antra-cfars/Efer-friciansTImmbers
Appficant Iufarmafian Please Prio Legihfy
d
BIIlE MEIEWChr irrfirxnlFI .
l
Are yan an employ Checkdia appropriate btu T3 a'ect
k❑ I am a la vritli 4-#isne� ❑ I a m a gel contractor and I Cr- .of2�. ����
3
eFnplayees{falLandfocgatt * ha�hireafbe sob=cons -
-El New
2 I am a sole proprietor orgat4uer listed on flt attached shims �- ❑R PmndeltQg
slip and have m employees These sob-matractcu have g ❑Demalitiurt
farm is an emglayem andhave workers'
'^�"°�g y��- $ E]Build-mg addifian
[N�uror rs' ccmg_inn -m nce camp-ksu aaa
„ J 5_ ❑ We am a cotparaiionand its I0 ical repaim ac adddsonz
3_❑ I am a ho97. doing all WDIk officers have exercised their L f�Plumbing repairs ar s dditions
myseEf [Nowork='ramp_ rigw of en=pfionperMGL L Roof
Jnmm-are required.]. c-15Z §I(#),aadwe 1cna no ors' l3_❑O er
emglo -[No
Comp_Sir--=re hilt .
t�anp�Y ihat chPrks baz�1 nmst also ffi anttb�secfionhe7�shac¢mg theswo�eb�[omnegsatiou pot�-i** n+
1 irmeawneis nor s�tm 3vs sad-if Mffi- J tbzy sz daing II r. Eni ffi�hire Pxh-
tCortMCnrstlistrhorkthhboxmaststtarhedsn:ddi anal sheetshazcZinethenam£of9ie&,�camt z andstarRhetxerm:rmtfm&E lli'-P.
emPlrryees_ Ifthe sub ca dreshxm empla5ee-%rhea Est piwide the warhi�&comp.polirp MM31 .
Arun earz arrVlnyer'thrrtis pmi6W fvarke4-s'ratcr rrslThan izmzrautcz far rrzy e-nqYLOygcs. ��'�arr is f3Eeg�&i}curd}Qb surf
In$u=Ce GompalyName_ °
PDECY iv or S-X ias-1IC.4k �XpII3tIOrL�3te: .
i
"\ lob��A l G° ao► �Z�� ityt tatr rzp_eo D2 6 3S�
ALttacFi a.copy of&g w-orkers'comp en declaration page-(shoNyintg the palisy nuinber znd cKpimtion date).
Farlure.to sec¢rc cckvcrage as Section SA oEMC3L c. 152 can lead to the impositi=of criminal perms of a
fine up to L50Q_0D andlor aae yearim as Il as cit�1 p�alEies in fae fD:da of a STOP WORD ORDER and a fine
of up to$250.00 a day against the violator_ De advised that a cagy of tbi€st demimt may be fxwarded to the Office of
Imiestigatiom of fe DIA for;nsurAnC-eT covPraffe vn:iEc�tion-
t0 FFEc'CE .�cer,fy rc kaptzcns trt ,dies u.Fr,�ux'thatfh�zrz, `vr-rtza#irxn praT.rzcd attb �e r`/s rmd c/arrsct
S`ianAtmr late= I � O` �®!
Phone
cirrL Frss au£f, Da na€-tRrii�irz tFus rrrer�fix bs urutpiet�d'by�`rrr frzrFzt a�Zcia£
City or Town P=Ulib icease#
LSa�d4f�eaIth 2.$u�dingDegartm�it 3; Cii�'1`a•�zrClerli 4_I:Iectrical�zertar fi.Plumrbfng�ector
6.Other
Contat-t>?erson: p"htrne Az
. 5
1 Lassa Lmeds metal Laws chapter 152 regoires all employers to provide worliery'compensation for their employees•
this sstatott an ee is defined as erson in the service of''other uadcr any conL Dt ofhire,
Pi-usu�to tLrs,. em�£ay �e15'P
express Or implied, oral or written'.'
An ezrtp cy ar is deemed as'au individual,parlam3btp,association, corporation or other Iegal.entity, or any two ar more
of the foregoing engaged.in a joint enterprise,and including the legal represmtafives of a deceased employer,-or the
receiver or irastee of as individual,partaersdup,association or other Legal entity, employing employees. However the
owner of a dwellinghause having mtmore than three apartments and who resides therein, or the occupant of the
dwelling horse of another who maploys persons to do maintenance,mmfzuciioa or repair work on such dweiiiag house
or on the grounds or building appmtfmarit thereto shall not because of such employment be deemed to bean employer."
MUL 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 airy
applicant who has not produced acceptable evidence of compliance with the insurance.coverage required.
Additionally, MCIL chapter 152, §25C(7)states"Neither the commonwealth nor any of itspolitical subdivisions shall
enter into any mnlri act for the pcztimance of public work until acceptable evidence of compliance with the in suatnce
requirements of this chapter have been presented to thLe contracting authority.'
_ Applicants .
Please till out the workers' compensation affidavit complettIy,by checking the boxes that apply to yca sit ntion and,if
necessary, supply sub-coatractDr(s)name(s), addresses)and phone ntmmber(s)along with thew cerLncaic�s) of
i cumce. LmzitE Liability Companies(LLC) or Lmnited Liabiility Partnerships(LL P)withno employees other than the
members or partners,are not required.to carry workers' compensation insurance_ If as LLC or LLP does have
employees;a policy is requaeth De advised that this affidavitmay be submitted to tb.e Department of Industrial
Accidents for confirmation ofinsTu-mce Coverage• Also be sure to sign and date the azidavit The aiidavit should
be retuned to the city or town that the application for the permit or license is being requested, not the Department of
Indastc-iad Accidents. Should you have any ques c)ns regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department of the number listed.below. Self-iasrrr ed companies should enter their
self-in oaE-,license number on the appropriate liac,.
City or Town Officials .
Please be sure fiiai`tht affidavit.is complete and print d le�ly. The Department has provided a space at the boi im
e the lic&t
font you din
e da for ou.�fill out in the event the Office oflnvesti Investigations has to con y regarding app
of th affi vrt y l�
Please be sure to-FT1.in the peunitlIi.eense number which wU be,used as a reference n=ber. In adcLfiion,an applicant
that must submit multiple p=iitllicense 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 m' (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to file
applicant as proof that a valid affidavit is on fide for famine permits or Licenses. Anew affidavit must be i Iled out each
year.Where a homeowner or citizen is obtaining a license or permit not related to any business or commercial venture
(Le,a dog license or permit to ban leaves etc.)said person is NOT requaed to complete this affidaVit
T1ie Office of Investigations would at to thank you is advance for your caoperafim and should you have aay questions,
please do not hesitate to give us a call
The Depaxmenfs address,telephone and fax number: 4
a� CommQawt-,altIL of Massachu siVb
Dt_-paztnc�at of Jiic1w�tjal AQcidc is
of kve�g�tiuu�
6W Wasbingtan
$c amMA G21 I I
Tel,A 617 V-49j�0(�xt4-06 or 1-977 hEkSR, h . .
F=4 617-727-7745
Revised 4-24-07
r
r)
Town of Barnstable *Permit#
X-PRESS PERMIT Expires 6mo�ethsfrom issue date
Regulatory Services Fee ,: oC s o 6
MAR 30, 2w 'I� Thomas F.Geiier,Director
Building Division
TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner`"
200 Main Street,Hyannis,MA 02601
www.townbamstable.ma.us
Office: 508-862-4038 y Fax: 508-790-6230
EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number -
Property Address
00
Minimum fee of$25.00 for work ender$6000.00
Residential Value of Work
- Owner's Name&Address
Contractor's Name , Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
-----_— .— ❑ I am a sole proprietor --
WI 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)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
%Re-side
T ' Replacement Windows. U-Valuei r(maximum.44)
p "Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: PropertyjBwner must sign Pro rty Owner Letter of Permission.
Ho m enlb tra License is required.
SIGNATURE: ,
Q:Fortns:expmtrg
ReviseNI405
L
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/Pluffibers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � `
Address:
c
City/State/Zip: QPhone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6
El New construction
employees(full and/or part-time).* have hired the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sheet $ Remodeling
ship and have no employees These sub-contractors have 81. ❑ Demolition
working for me in any capacity.' workers' comp.insurance. 9. ❑ Building addition
[No workers' romp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.�I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
13.❑ Other
camp.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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
_ x
Insurance Company Name:
Policy#or Self-ins.Lie. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,50Q.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 a pains a penalties of perjury that the information provided above is true and corn ecz
1A. ature: Date:
Phone#: —
Official use only. Do not write in this area,to be completed by city or town official. 1
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 j
Contact Person: Phone#f:
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 employee is defined as "an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the .
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-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 listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials . .
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom.
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. 617-727-4900 ext 406 or 1-877-MASSAFE
F ax r 617-727-7749
Revised 5-26-05
uwww.m.ass.govicia
Assessor's officie (1st floor)- TWE
Asses' .......a ...0.0 r10 STWE
Assessor's map and lot number ........... ...!F......
Board of Health (3rd floor):
,?I —
Sewage Permit number ........... .............1, TZ 33ALI9TAMLE,
Engineering Department (3rd floor): 9-
VASIL
163
Housenumber ................................................................ ....... Ica
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 ...... .......P ...............................................................
TYPE OF CONSTRUCTION .... . ........................................
.......................... 19.?
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
.................. ......Location ....<A-07.......... .......5t...............CPT-U..1-7...............M.- A.-SK.............................................
ProposedUse ..... ................................................................................................................................
Zoning District ........ .......................................................Fire District .....co !,........................................................
6A67 ftAlk--)
Nameof Owner ...............................;.t..................... !........Address .......I........................................
Name of Builder0�
.............. ............................................Address .......N/....................................................................
Name of Architect ...............lv1�A.........................................Address ...../.\)/. A.....................................................................
Number of Rooms ...........0......... .. .....................................Foundation ..... ............. ........
Exierior ....................................................................................Roofing ......W\r\-I ...5--�'?/' -64...... f
Floors ........U�.Q. z,--o.....................Interior ........W-A� .................
Heating ........N). -.1...............................................................I Plumbing ........ . ........................
.................
Firepj,c*e--,.....t,j A
... ...../....................................................................Approximate Cos .........................................
Definitive Plan Approved by Planning Board ----------------------------------19-------- - Area ..... . fz*..
....................
Diagram of Lot and Building with Dimensions Fee ....15. ..............................
1W
SUBJECT TO APPROVAL OF BOARD OF HEALTH
II
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the R?le! pnd Regulations of the Town of Barnstable regarding the above
construction. ,
Name . .. ... . ..... .....................................................t�r.0
'Cl Supervisor's License Con t-ruetion Supervisor's License(4� .. ....
. ...........
SMITH, JOHN D. .,BRAGINTON A=.!:XXXXX A=023-002
6.2 3 - 0 a ?,
No 31535A Permit for ...Add Porch
................. .......... ............
S ngle,..Family Dwelling...........
Location ...2.07Main Street
...............CQ.tlA t................................................
Owner .....John D....Braginton. Smith
Type of Construction Frame
.. .................................
Plot ............................ Lot ................................
Permit Granted .......January 7 , .19 88
Date of Inspection ....................................19 y
Date Completed ......................................19
14
INE
TOWN OF BARNSTABLE
1 R - BUILDING INSPECTOR
01 Nix
� '� �
APPLICATION FOR PERMIT TO --..�I.M..... ^ .__.51 ___ ��^^ '��.._�^w.d--_________
- TYPE OF CONSTRUCTION ........... _.__. ..........................................................
. �
,
�/ lR.�� ��
--^-°,"`.°`-+':�x�. .. ..�.�
�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for o permit according ho 'th6 following information:_
`
Location ---- ' ./.4r.......... .......................�._�p�.�v...
~~......
. ............................................................
�
Proposed
Use ----.15.e-o ~ .----------.' '-.-------------.. '----------___..
Zoning District� ----.� -,.-.... ..---.—._Rne D�h�i ------..—.--____~_,________� ' ~��s�� �� ��r^� ^��� ' � |
' � ^' �
� Nome of Owner -^ $^.....77...&AAP.r R.P.......Address '-. _ ^'�_-- .�r--.�-. -----.
^
Nome of 8oU6e, - .. .--. . ---Ad6remx - ---._-. ---________________
Nome of Architect -------_.------.--.---..A66rexs ----------------__-'-._______'
�
�����/
Number of Rooms -----.----------'-----.Foun6otion ---- ......................................................
7__
Goe,ior ....................................................................................Roofing -'_---...... __-_____________..
��u�"�-���-
Floors ---'��.�����--------------------|nterior -__,:��.�--__~__................/,..________
Heoting -----'-----------------.—_-F1um6ing --.----,_._,.._,....__,__________.
��-
Finsp|oce ---------. �r----------.App'o»i--^ Co»/ '''/^�`
Definitive Plan Approved by Planning Board -------------------------------1g--------, �w�4- W
Diagram of Lot and Building with Dimensions
��,� ��
� � ~- ~~ �
SUBJECT TO APPROVAL OF BOARD Of HEALTH
� .
� ~
. �
/�/�
.�^� ��
` - �~ r°a —
�EPTl�
_ SYSTEM MUST BE
INSTALLED IN COMPLIANCE
WITH ARTICLE 1
cmw//8HY MID '
����i4�! �'\_�' -��-'�
, ` �.'~..^� '
� ~
_ 0
�
'
. .
�~�~~
� AJ ~� r
'
' | hero6y agree to conform to all the Rubs and Regulations of the Town of 8omnsto6|e regarding the above
construction.
momo -..���,-..,~��c:z---'. ................
U x'
U ^
' -
Radford, H. Neil & Ellen T.
16907.. Permit for add to single
No ............... ....................................
familydwelling...............................................................................
Location .......Main Street
.........................................................
cotuit
................................................................................
Owner .........H....Neil..&..Elle.n..T.,...Radford
... ......... ... ...... . .. .. . ........ ......
Type of Construction ......................frame.........
....................................................................
Plot ............................ Lot ................................
M,irch 20 ......19 73
Permit Granted .........................t.........
\�Date of Inspection ....AI-Ay..... ....19 -73
.Date Completed .......... ...........................19
,t4
.- PERMIT. REFUSED
................................................................ 19
...............................................................................
................................................................................
................................................................................
...............................................................................
Approved ................................................ 19
...............................................................................
...............................................................................
i
_ ��
I
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._- ����
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�,
,- , , ; � ; �j �.
I i � � i � � � � ' I
� ��
�_.
-_
,_
_.
F
r•■ t K
F' SERVING THE WATER&WASTEWATER INDUSTRY'
r
ry
FOR OVER 60 1�lrAFiS...y-_fq^_k' �}
-7 ,•- 1 a�
V. 9LAIIJ
4-41
i ` ' �}py � f 5 • p C
12 Industrial Park Road
West Yarmouth, MA 02673 �;
,rD i (617) 778-6464 1
t
Assessor's offioe Ost floor):
Assessor's map and lot number ...... �.:�-3::..Ova CA,, SEPTIC Si7fCV ' BE TMETO�`
Board of Health •(3rd floor): g�^ ss- INSTALLED IN COMPLI*!kaCE
Sewage Permit number ......................... !..............:,............ WITH TITLE 5 : BaaasTLUE,
Engineering Department (3rd floor): AGL
ENVIRONMENTAL CODE AND �°o Mb 9• 0�
House number ........................................................................ TOWN REGULATIONS
A'to�ava�
APPLICATIONS PROCESSED 8:30-9:30 AM, and 1:00-2:00 P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO ...... p." ON :�6 K•G�
..... ......... .................................................................
TYPE OF CONSTRUCTION ....i„x.�.oQQ..�Z. M! :.......................................................:.........................
..........................1....... ..- .....,9.g
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ....�.C>7........./V•�•�:�..�! .......;S.t.<...............CA-)me .t,->.1T..............IM— .. .a...........................................
ProposedUse ..... ...............................................................................................................................
Zoning District ....... ..................................Fire District .....Cr.af..1.
Name of Owner JaV�►J�: �.Q��a'` un�.....JivY!1 ...Address ....�.6. ......�A..l.!U.....4..1.......
AtJ/" ....
Name of Builder ......:.......N� Address .......N
Nameof Architect ..............1v ,AA.........................................Address .....1,\)- A.....................................................................
/ o
Number of Rooms ....... ....N.!Q1.....................................Foundation ..... ............ .A.U.AIN
Exterior ...Roofing .....
Floors .......<„SV.l.!x ? a1Z ®-....................Interior .......,�A...........................................J......................
........................Plumbin ........1�?/
Heating ........f�.[.�1....................................... g ............................................................
Fireplace ........1 // ................................................................Approximate Cos ....... ®r..........................................
Definitive Plan Approved. b Planning Board
Y g -------------------------------f 9-------- • Area ....................�....................
Diagram of Lot and Building with Dimensions Fee ?
.. . ............................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
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 . .. . . ... .. ... .....................................................
Con on Supervisor's License
SMITH, JOHN D. BRAGINTON
No- 3 T 5 3 5A Permit for ...Add...Porch
........... .... .....
Single. ...Fami.l..y..pWg,jjing.........
Location ...2.0.7...MA
q.t......................
Cotuit
............. .......................................................I.........
Owner .......John...D......B.rdq.int.qr�...Smith
..... .. .. . .. ...... .... .. ..... . .. .. . .
Type H6f Construction ....Frame. ........................... .... ..
...............................................................................
Plot .... ....................... Lot ................................
Permit Granted ......January...7............19 88
.. .... .. .... ..
Date of Inspection ........ 9
........ .......
Date Completed .................Q.,4 ............. 19
.vl
\
Assessor's office(1st Floor): 3 Ui Q S ` of Y"EAssessor's map and lot number $�MUSrE o r �o
Board of Health(3rd floor): _ IN-ST OMPUMCE
to w
Sewage Permit number ^ BABdSYADLL !
Engineering Department(3rd floor): Er� ]R CODE AND �o rasa
House number TOWN REOW 4TIONS o'EO YAY b�®�
Definitive Plan Approved by Planning Board 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 C-0 6a0
TYPE OF CONSTRUCTION /4
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location eCV I� o�6—j 'lA/N ST•
Proposed Use
Zoning-District Fire District C!D+V I
Name of Owner So�b7•� `�N � �M�1�'` Address 67 2h A IAI 'S7'
Name of Builder �>~ Address A ?30t/f-
Name of Architect Address AQd Ili
Number of Rooms Foundation
Exterior Roofing
Floors / Interior D>f12P
Heating Y=64c-r-D .4 )L Plumbing 90 N �•
Fireplace Approximate Cost
Area 14o
p d
Diagram of Lot and Building with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of'Barnstable regarding the above construction.
Name
Construction Supervisor's License
s ' i
'--BRAGINTON—SMITH , 'JOHN D . -
a
:`- 32735 ADD TO DWELLING
No Permit For
Single Family Dwelling
Location 207 Main St
Cotuit
Owner John D. Bragintnn—Smith—
Type of Construction Wood Frame
;
Plot Lot
Permit Granted March 2 3 19 8 9 1
A�,
Date of Inspection 19
19
qte'Compl."eted
t 00Mal_ f -
l-� y
Assessor's office(1st Floor)- � 3 Q ��EPTIC SYST • is
Assessor's map and of number ��iQ�,p `�
t
.1 , -- a, aE®d�9 C�
Conservation Asa* WIT1#14,71 •►
Board of Health(6rd floor): ����
Sewage Permit number. NTAL
9 '
Engineering Department(3rd floor): TOWN REGUL 39.
House number Za 7
Definitive Plan Approved by Planning Board 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 J'egOV2e i�l✓eYk�r� C �CYGS , /`7d lie /y Etl 1 d, te"T41,yy4.1- .�.rCd A CY 4
TYPE OF CONSTRUCTION 00zV getir— JJ
1/L3 19 �Z
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location .007
Proposed Use
Zoning District Fire District Lk�2;71_7_
Name of Owner ^�✓ e � Address
Name of Builder Ljtd zp(l Address<?J 016 ��r.�� ,eJ ,��rar ,�c� /r, 410S32
Name of Architect ,1 Address Number of Rooms `7 Foundation caiceck ill
Exterior A)I,-te cede.,- S�/ /s Roofing a6,44/7
Floors L�� Interior 61PGl�oak
Heating 'r Plumbing
Fireplace AD Approximate Cost DOO
Area
Diagram of Lot and Building with Dimensions Fee
I
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r gardin he above construction.
Name
Construction Supervisor's License ��� 7
PRESTON, BILL
34805 RENOVATE r r
No Permit For - - -
Single Family Dwelling J
Location -207 Main Street r� r
Cotuit
Owner Bi-11 •Pre"ston
Type of Construction• Frame
{
Plot ` Lot
Permit Granted
Jarivary 23 , 19 92 { i
Date of Inspection 19 {
y -
Date Completed _ 19 -
... S . 'Ya;' ,µAy { •!• `t
r v
,:6 joists 16" u. l —
LEI
4x6 beam
y � ,
4X posts
a..
101'sono i u be f'oo i i ng
q