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0709 MAIN STREET (COTUIT)
5 j ,L r Town of Barnstable *Permit Deb Expires 6 m VS om issue ate Regulatory Services Fee + anitxsrnaia.. • 039. Thomas F.Geiler,Director Building Division (�)7/2ykl Tom Perry,CBO, Building Commissioner d" 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint. . Map/parcel Number a.3(0 / r7 o q Property Address / h l C( M Residential Value of Work$ Fit= Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C�t��2-c�D 11j LZ L"bf Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: 5AA—A 60-A1 &A . co-" Construction Supervisor's License#(if applicable) - { 1 ❑Workman's Compensation Insurance Check one: 4I am a sole proprietor JUL 2 3 2013 I am the Homeowner 1 have Worker's Compensation Insurance TOWN of BAR- NSTASL Insurance Company Name Workman's.Comp.Policy# � Copy of Insurance Compliance Certificate must accompany each permit. ` Permit Request(check box) w e r� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken top, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) r ❑ Re-side ❑ Replacement 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 required. SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Tempora met Files\Content.0utlook\8R76BDVA\EXPRESS.doc Revised 061313 lie Coutmonwealth of Massachusetts Department of Industrial Accidents -_ Office of Investigations 600 Was1iinglon Street _ Boston,M4 02111 wn'11'.mass;.gmldia Workers' Compensation Insurance Affidavit: BniIders(Contractor ectricians'Plumbers Applicant Information Please Print LegibI Name(Busiuessiotganiationadividual): y l-,3 jGLC, (��rL Address: vnCA k el City/StateJZip: T MA- Phone#_ — 2 Are you an employer: Check the appropriate box: Type of project r. � 4_ I�a contactor and I � P J � e9,� '�= 1.❑ I am a employer with ❑ 6_ ❑New construction employees(full and/or part-tie)_* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet_ "T_ ❑:Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for the in anycapacity. employees and have wodoers' 1 9_ ❑Building addition [No workers'comp_insurance comp•insurance. required.] 5_ ❑ We are a corporation and its 1 Q.❑Electrical repairs or additions / `I am a homeowner doing all work ` officers have exercised their 11_❑Plumbing repairs or additions myself[No workers'comp- right of exemption per MGL 12.(�Roof repairs insurance required.]u c_152,§1(4),and we have no / ` employees_INo workers' 13_❑Other comp-insurance required.] *Any applicant that checks box#1 mma also fill out the section below showing the6r workers"compensation policy infor min 9 Homeowners who submit this affid nit indicating they are doing all.work and t ea hie outade contractors m=submit a new affidavit indicating such =Contractors that cheers this b must attached an additional sheet sho i g the mime of the sub-toad¢actors and state whether or not those entities have employees- If the subcontractors have employees,they nisi provide their workers'comp:policy number. I am an employer that is pnniding.ie�orlsers'compaisadon insurance for my employees, Below is the policy and jo.b.site inforination. Insurance Company Name: Policy 4 or Self-ins-Lie_4: IaacpirationDate: Job Site Address: City/Stateaip: 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 2:5A 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 certtt&under the ins andpenaldes f peaury that the infortual on.prm ided above is tree and correct Si toe: Date: Phone#: 'Itto1 0 O,,a`icial use ontr. Do not write in this area,to be completed by cih'or tonvi official. City or Town: PermitlUcense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CityfFovim Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: " -- ------ 6 o Town of Barnstable BAMsTMIX Regulatory Services i679 �� Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION DATE: Please Print �� � 1 JOB LOCATION:' number street TWD village "HOMEOWNER": D V t' T 4 LI` Smmr-lp 2 name home phone# work phone# CURRENT MAILING ADDRESS: 1 ►' 1 h + C >6A� 1 i3nsa- 1l�. �wz3s city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with.the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building.Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signa a of Homo er Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or largerwill 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 person(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 a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often e results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed personas it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 Parcel Detail Page 1 of 5 ��. - , y B1i4A3TACilr Logged In As: Parcel Detail Tuesday, July 23 2013 Parcel Lookup Parcellnfo Parcel 036-009 -I Developer LOT 3 ID Lot - Location 709 MAIN STREET(COTUIT) Frontage i Sec ---- --- -- - .. Sec Road' I Frontage � Fire . ,__ __ ..... .. ....... VIIIage;COTUIT COTUIT District' Town sewer exists at this Road ---- ---- -- .......... ......... .............. i 0951 address ,No Index Asbuilt Septic Scan: Interactive 036009_1 Map - Owner Info Owner 1JACKSON,GUY L,TR I. JACKSON FAMILY TRUST Owner' Streetl C161 UPPER JAFFREY ROAD I Street2 city 16666 I State NH Zip I03444 Country Multiple Ownership Info % Owner Name Co-Owner Address JACKSON, GUY L, JACKSON 161 UPPER JAFFREY 25 TR FAMILY ROAD, DUBLIN NH TRUST 03444 JACKSON C/O KEVIN M 25 GARDNER, III, TRS ORME, ESQ MANCHESTER MA JACKSON, C/O KEVIN M 25 CHRISTOPHER, ORME, ESQ- BILLERICA MA TRS JACKSON GORDON C/O-KEVIN-M— ``� 25 TACOMA WA �. FISKE, TRS ORME, ESQ - Land Info http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2313 7/23/2013 Parcel Detail Page 2 of 5 J Acres on - Use Single Fam MDL-01 Zoning jRF J Nghbd I0111 _f Topography Level l Road Paved Utilities JSeptic,Gas,Public Water I Location I Construction Info Building 1 of 1 Year,isoo p Roof Gable/Hi EXt _._ f Built IStruct _ l Wall'Clapboard Living j2483 I Roof IAsph/F GIs/Cmp l AC iNone l Area Cover Type' P y tit Bed - Style Conventional I Plastered l 16 Bedrooms ) Wall Rooms' -- - Model;Residential I Int�Hardwooa I Bath;2 Full+1 H �l Floor - Rooms' Heat -- Total;-. Grade;Average Plus I Type`None l R00111S9 Rooms Heat Found- StorieS'2 Stories l Fuel None l ation'Brick waus l Gross� Area 5712_.-- - --I Permit History Ir Visit History Date Who' Purpose 10/3/2012 12:00:00 Nancy Finch In Office Review AM - 9/18/2012 12:00:00 Nancy Finch In Office Review AM 2/3/2011 12:00:00 AM Denise Radley Change of Address 4/27/2007 12:00:00 Tony Podlesney New Construction AM 10/23/2006 12:00:00 1AM Paul Talbot Cyclical Inspection 6/6/2005 12:00:00 AM Paul Talbot Meas/Est 1/5/2004 12:00:00 AM Andrew Meas/Est Machado 5%25%2000 12:00:00 Meas/Listed-Interior AM Donna Dacey Access 6/1/1999 12:00:00 AM Andrew Meas/Est Machado http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2313 7/23/2013 f Parcel Detail Page 3 of 5 Sales History Line Sale Owner Book/Page Sale Date Price 1 10/8/1998 JACKSON, GUY L, TR C150404 $1 2 5/2/1997 JACKSON, GUY L C144331 $84,000 3 4/14/1997 SMITH, DEBORAH J ET AL C144119 $0 4 8/15/1983 TRH COHEN,. W.M & RAUH B M C93209 $0 Assessment History Save Building Land Total # Year Value XF Value OB Value Value Parcel Value 1 2013 $185,700 $38,100 $217300 $3961900 $6421000 2 2012 $161 ,900 $321500 $201200 $3961900. $611 ,500 3 2011 $2141400 $31400 $171800 $3961900 $63.2,500 4 2010 $2141800 $31400 $181500 $3961900 $633,600 5 2009 $2311 200 $21 300 $141400 $4661 800 $7141 700 6 2008 $2311200 $21300 $141400 $4867600 $734,500 8 2007 $229,800 $21300 $14,400 $486,600 $733,100 9 2006 $193,000 $2,300 $157100 $4781700 $689,100 10 2005 $1631000 $23100 $15,600 $438,800 $619,500 11 2004 $148,300 $2,300 $15,900 $518,600 $6851100 12 2003 $127,700 $2,300 $16,500 $216,200 $362,700 13 2002 $1271700 $2130.0 $161500 $2161200 $362,700 14 2001 $1277700 $21700 $16,500 $216,200 $363,100 15 2000 $109,900 $2,300 $12,100 $130,300 $254,600 16 1999 $901100 $11 900 $101 000 $130,300 $2321 300 17 1998 $154,500 $6,900 $5,000 $171 ,600 $338,000 18 1997 $1561000 $0 $0 $160,100 $320,100 19 1996 $1561000 $0 $0 $160,100 $320,100 20 1995 $1567000 $0 $0 $1601100 $3201100 21 1994 $146,500 $0 $0 $1541400 $3047400 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=2313 7/23/2013 • • �r • • 1 � rr � rr � �► 1 � rr � � � � • • • ar • 11 rr 1 rr , r► • • • 1 1 rr 11 � • � �r � 1 / r► 1 rrt r► i � • 1 / �r 11 . . � ?"� A► }�,- .fit y'}.Fr', � ,�► G 4 � � a l "� ° ry _` �•�r�a r 09/19,2017 s_ -ril ./T::7 .a Y�� i�� ` r° '•*"' Pam' #.. `� .�' a .� `dl� .r eaf .' a h,y..�.0 a°. � ,i�,� �r` ► Y fit. �� .� t. ��� -��� *�.,'y � ` �,�• _ e. 3: 1►-� � � err°' r ry n . H f W,. w �.g -h �-OJ1191201r 091i912012 r v t � N"'g '�be .y,,f�� y •Y,� I r: } f wl "Yas ����5 r, ��. 09(1912012 - 0911912012 fV _ s W � ,,,�,,:rw»- " 09✓1Jf'[lfl%„ �'y';z-=�- L9'�'i9f20i2' N f 04 ilia w ,a` - all ... 0 9•Jml JP2pl2- -. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map A A Parcel Permit# Health Division C,1 1 1�L,T_ A:3 7 10, A cr s Date Issued 4 . Conservation Division _�j F-5>= l 8 plication Fee Tax Collector '— � 2' Vt, �I 'I mit Fee o Treasurer lA•, CA�Q r,� z a�^F53 E•3US T g �� Planning Dept. - 7 o ED IN COMPLIANC F, J'' S •ARTF;TITLE 5 Date Definitive Plan Approved by Planning Board etc C, y,-)N ENTAL CODE AND Historic-OKH Preservation/Hyannis TOWN REG (LOONS Project Street Address � )0 4 Q Village e, y Owner C-S wu Telephone IJ Permit Request 6 1-116LI a,X ; rs Square feet: 1st floor: exist ng proposed S 2nd floor: existing proposed Total new Zoning Di}st'rict _ j Flood Plain Groundwater Overlay Project Valuation� , Construction Type -- t r,. , Lot Size ' " Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. t Dwelling Type: Single Family 0 Two Family ❑ Multi-Family(#units) Age of EAsting structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Full :❑Crawl O Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric 0 Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size _ Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial-❑Yes —❑No If yes,site plan review.#-"- Current Use Proposed Use UILDER FORMATION ��— Name T r (/1L� Telephone Number 5 nq Address —�6v c, License# Dg.,3�s7 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO J SIGNATURE DATE lob r FOR OFFICIAL USE ONLY t PERMITNO. t DATE ISSUED ,i MAP/PARCEL NO. ` ` ADDRESS VILLAGE OWNER- DATE OF INSPECTION: FOUNDATION lam!a t FRAME V!�' I C 0 Ct,�O `- INSULATIbN FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT "w c ASSOCIATION PLAN NO. r • r•rr '� _ The Commonwealth of Massachusetts Department of Industrial Accidents _ _ : . �Ics el�sd�sd� • 600 Washington Street _ Boston,Mass. 02111 vsy,. e_ rr Workers'.Com ensation,•Insurance Affidavit-General Businesses IIflme: t : u' U �, state w site location full address : I am a sole proprietor and have no one Business Type: [�Retail Restaurant/Bar/Eating Establishment Vj working in any capacity. [] Office[] Sales(including Real Estate,Antos etc.) ❑I am an em to er with . etn to ees(full& art tim�: ❑ Other // % /%/ %% %/% %/%/� Jim an'em�loyer,providing viorkers' compensation for my employees working on this job.: . coin - �; :•i'•�'' hone:.#::.:'� ��.�•: Snsura!uce.cus �' '` / I am a sole proprietor and have hired the independent contractors listed below who hWRI ave the following workers' .compensation polices: . :'� .:tin °:�1 4:,ri..,1;,M•, .':n,,.?`••�'' com an na$�i Y:r.ttij... t "T.i'•, iadress:. ' .4<:. oiie'#. tit, tr: v f'' 'r"1.;'r:' ' .,.' r •r• .•t'' insurance'co. C. an. nape..,, ._•.:... _ addresse 1 .. •noiie:#c .. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that copy of this statement maybe forwarded to the Office of Investigations of the DIAior coverage verification I do hereby certify u der the ains and penalties o rju hat the information provided above is true and correct _ Date Signature Print name Phone# official use only do not write in this area to be completed by city or town official permit/license# []Building Department city or town: ❑Licensing Board []Selectmen's Office D check if immediate response is required ❑Health Department contact person• • phone#; ❑Other ' (leveed Sept 2003). Information and Instructions Massachusetts General Laws' .chapter i52 section 25.requires all employers to provide Workers' eompensatidn for their. employees: As quoted from the `law", 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 d in a�'oint enf rise, and including the legal representatives of a deceased employer, or the receiver or the foregoing engage �P 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 • i another who.emplbys.persons to do.maintenance, construction or repair work on such dwelling house or on the grounds or ereto shall not because of such employment.be deemed to be an employer. building appurtenant th 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 who has not produced acceptable evidence'of compliance with the insurance coverage regwre& Additionally,neither the ' commonwealth nor.any.of its political subdivisions shall enter into any contract for the performance of public work until lia"ce with t e insurance requirements of this chapter have been presented to the contracting . Of co q . P acceptable evidence � � . . authority. Applicants Please fill is the workers' eonpensation affidavit completely,by checking the box that applies to your situation.. Please supply company name, address and phone numbers along with a certificate of insurance-as all affidavits may be submitted nfimlation of insurance coverage. Also be sure to sign and date the to the Department•of Industrial Accidents-for co affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Departrnent 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 Departrhent at the number listed.below. ; City or Towns . Please be sure that the affidavit is complete andprinted legibly. The Departrnent 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 filYin the permit/license number.which will be used as a reference nuu-ber. The.affidavits.may.be'.returned to. the Department by,mail or FAX.uriless othei'ariangements have been made. The Office of'Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Departrneht's address,telephone and'fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents emce of MvesUggens 600 Washington Street Boston,Ma.•02111 fax#: (617)727-7749 phone#: (617) 7274900 ext.406 h E r Town of Barnstable Regulatory Services • Thomas F.Geller,Director Se HP:Rl[STABLE, Building Division ''lED MA'S k Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 , Fax: 508-790-6230 Office: 508-862-4038 permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERJV=APPLICATION MGL c.142A requires that the"reconstruction,alterations,renovation,repair,moderniza io u led Ion, improvement,removal,demolition,or construction of an addition to any pre-existing owr� occ P building containing at Least one but not more than four dwelling units or to structures which are adj scent to such residence or building be done by registered contractors,with certain exceptions,along with other, requirements. 'Type of Work: Lstim4ted Cost Address of Work 7®� A% Owner's Name• Date of Application: l I hereby certify that: Registration is not required for the following reason(s): []Work excluded by law ❑Job Under Sl,000 []Building not owner-occupied ' [owner pulling own permit Notice is hereby given that: RED py�RS PULLING THEIR LIC - NHME R DEALING WITH�NREGISTF MUROVEMENT WORM DO N HOE CONTRACTORS FOR APPLICAB ACCESS TO.THE ARBITRATION PRO GRAM OR GUARANTY FUND UNDER MGL c.142A• SIGNED UNDERPENALTIM OF PERJURY Ihereby apply for permit as the agent of the owner: Contractor Name Registration No. Date OR Owner's Name RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings,Additions $50.00 Alterations/Renovations $25.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET NEW LIVING SPACE �l �aayl �/Z� square feet x$96/sq.foot= 1/03 Z— x*06 = plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0031= plus from below(if applicable) GARAGES(attached&detached) square feet x$32/sq.ft.= x.0031= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75:00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch _x$30.00= • - (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00 (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool , $25,00 Relocation/MoAng $150.00 (plus above if applicable) e�3 Permit Fee projcost Town of Barnstable Regulatory Services BAMSTABLE, « Thomas F.Geiler,Director . MASS. .��" Building Division '°rEc ter►+ Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village , "HOMEOWNER": (Qr6 rf11, SOu name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building_permit. (Section 109.1.1) , The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures requirements and that he/she will comply with said procedures and requirements. P gnature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any 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 aperson(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 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. Q:forms:homeexempt ouf 'D C4, — � 19: ai - -_ SICK axe JolSTS n C XT r BC CALL®9.1 DESIGN REPORT- US Thursday,June 02,2005 15:01 Double 1 3/4" x 51/2" VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:FB01 Job Name: Description: Address: Specifier: City,State;Zip:Barnstable,MA Designer: HBB Customer: Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: BO 61 LL 329 Ibs LL 329 Ibs DL 221 Ibs DL 221 Ibs Total of Horizontal Design Spans=08-09-04 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 08-09-04 Live 25 psf 03-00-00 100% Member Type: Floor Beam Dead 15 psf 03-00-00 90% Number of Spans: 1 Left Cantilever: No Controls Summary Right Cantilever. No Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 1206 ft-Ibs 24.3% 100% 1 1-Internal Slope: Neg.Moment -0 ft-Ibs n/a 100% 1 1 -Right End Shear 483 Ibs 13.0% 100% 1 1 -Left Total Load Defl. U612(0.172") 39.2% 1 1 Live Load Defl. U1023(0.103") 35:2% 1 1 Disclosure Max Defl. 0.172" 22.9% 1 1 The completeness and accuracy of Span/Depth 19.1 n/a 1 the input must be verified by anyone who would rely on the output as Notes evidence of suitability for a Design meets Code minimum(U240)Total load deflection criteria. particular application. The output Design meets Code minimum(U360)Live load deflection criteria. above is based upon building Design meets arbitrary(0.75")Maximum load deflection criteria. code-accepted design properties Minimum bearing length for BO is 1-1/2". and analysis methods. Installation Minimum bearing length for 131 is 1-1/2". of BOISE engineered wood Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing products must be in accordance with the current Installation Guide Connection Diagram and the applicable building codes. Consult project design professional of record or BOISE technical representative for connection design To obtain an Installation Guide or if Member has no side loads. you have any questions,please call (800)232-0788 before beginning Connectors are:16d Sinker Nails product installation. BC CALC@,BC FRAMERS,BCI@, a minimum=2" b d BC RIM BOARD-,BC OSB RIM b minimum=3" BOARD- BOISE GLULAM-, c=1 a VERSA-LAMS,VERSA-RIMS, d=12" • • • VERSA-RIM PLUS@, VERSA-STRAND-, C VERSA-STUD@,ALLJOIST@ and AJSTm are trademarks of • • Boise Cascade Corporation. i3 ,18 � 2c� , 28 Z -2�g Page 1 of 1 f BC CALL®9.1 DESIGN REPORT- US Thursday,June 02,2005 15:01 Double 1 3/4" x 51/2" VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:F1302 Job Name: Description: Address: Specifier: City,State,Zip:Barnstable,MA Designer. HBB Customer: Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: Ak BO 131 LL 329 Ibs LL 329 Ibs DL 221 Ibs DL 221 Ibs Total of Horizontal Design Spans=08-09-04 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 08-09-04 Live 25 psf 03-00-00 100% Member Type: Floor Beam Dead 15 psf 03-00-00 90% Number of Spans: 1 Left Cantilever. No Controls Summary Right Cantilever. No Control Type Value %Allowable Duration Load Case Span Location • S Pos.Moment 1206 ft-Ibs 24.3% 100% 1 1-Internal Neg.Moment -0 ft-Ibs n/a 100% 1 1 -Right End Shear 483 Ibs 13.0% 100% 1 1 -Left Total Load Defl. U612(0.172") 39.2% 1 1 Live Load Defl. U1023(0.103") 35.2% 1 1 Disclosure Max Defl. 0.172" 22.9% 1 1 The completeness and accuracy of Span/Depth 19.1 n/a 1 the input must be verged by anyone who would rely on the output as Notes evidence of suitability for a Design meets Code minimum(U240)Total load deflection criteria. particular application. The output Design meets Code minimum(U360)Live load deflection criteria. above is based upon building Design meets arbitrary(0.75")Maximum load deflection criteria. code-accepted design properties Minimum bearing length for BO is 1-1/2". and analysis methods. Installation Minimum bearing length for 131 is 1-1/2". of BOISE engineered wood Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing products must be in accordance with the current Installation Guide Connection Diagram and the applicable building codes. Consult project design professional of record or BOISE technical representative for connection design To obtain an Installation Guide or if Member has no side loads. you have any questions,please call (800)232-0788 before beginning Connectors are:16d Sinker Nails product installation. BC CALCO,BC FRAMER®,BCI®, aminimum=2" b d BC RIM BOARD-,BC OSB RIM b minimum=3" BOARD- BOISE GLULAMTM', c=1 a VERSA-LAM®,VERSA-RIM®, d-12" T VERSA-RIM PLUS®, IT VERSA-STRANDTM', c VERSA-STUDS,ALLJOISTO and AJSTM'are trademarks of •� e Boise Cascade Corporation. Page 1 of 1 SO♦$E- BC CALC@ 9.1 DESIGN REPORT-US Thursday,June 02,200515:01 Double 1 3/4" x 51/2"VERSA-LAM@ 3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:F603 Job Name: Description: Address: Specter: City,State,Zip:Barnstable,MA Designer. HBB Customer: Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: 1 08-02-12 AL05-02-00 BO B1 B2 LL 346 lbs LL 1198 lbs LL 561 lbs DL 148 lbs DL 619 lbs DL 288 lbs Total of Horizontal Design Spans=13-04-12 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 13-04-12 Live 38 psf 02-07-06 100% Member Type: Floor Beam Dead 15 psf 02-07-06 90% Number of Spans: 2 2 FB01 at bearing Conc.Pt. Right 05-02-00 05-02-00 Dead 229 lbs n/a 90% Left Cantilever: No Live 329 lbs n/a 100% Right Cantilever. No 3 17602 at bearing Conc.Pt. Right 00-00-00 00-00-00 Dead 229 lbs n/a 90% Live 329lbs n/a 100% Slope: Controls Summary Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 849 ft-lbs 17.1% 100% 14 1 -Internal Disclosure Neg.Moment -934 ft-lbs 18.8% 100% 1 2-Left The completeness and accuracy of End Shear 418 lbs 11.2% 100% 14 1-Left the input must be verged by anyone Cont.Shear 619 lbs 16.6% 100% 1 1-Right who would rely on the output as Total Load Defl. L/1060(0.093") 22.6% 14 1 evidence of suitability for a Live Load Defl. L/1470(0.067") 24.5% 14 1 particular application. The output Total Neg.Defl. -0.018" 3.5% 14 2 above is based upon building Max Defl. 0.093" 12.4% 14 1 code-accepted design properties Span/Depth 18.0 n/a 1 and analysis methods. Installation of BOISE engineered wood Notes products must be in accordance Design meets Code minimum(L/240)Total load deflection criteria. with the current Installation Guide Design meets Code minimum(L/360)Live load deflection criteria. and the applicable building odes. Design meets arbitrary(0.75")Maximum load deflection criteria. To obtain an Installation Guide or if Minimum bearing length for BO is 1-1/2". you have any questions,please call Minimum bearing length for B1 is 3". (800)232-0788 before beginning Minimum bearing length for B2 is 1-1/2". product installation. Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing BC CALC®,BC FRAMER®,BCIO, Connection Diagram BC RIM TM' M Consult project design professional of record or BOISE technical representative for connection design BOARD-,BOISE GLULAMLAM-, Member has no side loads. VERSA-LAM®,VERSA-RIM®,VERSA-RIM PLUS®, Concentrated loads are not considered in side load analysis. VERSA-STRAND- Connectors are:16d Sinker Nails VERSA-STUD®,ALLJOISTO and AJSTm are trademarks of a minimum=2" Boise Cascade Corporation. �� bd b minimum=3" c=1-1/2" a c1=12" • �• • C Page 1 of 1 Z BC CALL®9.1 DESIGN REPORT-US Thursday,June 02,200515:01 Double 1 3/4" x 51/2"VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:FBO4 Job Name: Description: Address: Specifier: City,State,Zip:Barnstable,MA Designer. HBB Customer: Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5612,NER 629 Misc: 1 BO B1 LL 226 Ibs LL 226 Ibs DL 150 Ibs DL 150 Ibs Total of Horizontal Design Spans=05-02-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Right 00-00-00 05-02-00 Live 25 psf 03-06-00 100% Member Type: Floor Beam Dead 15 psf 03-06-00 90% Number of Spans: 1 Left Cantilever: No Controls Summary Right Cantilever. No Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 485 ft-Ibs 9.8% 100% 1 1-Internal Slope: End Shear 298 Ibs 8.0% 100% 1 1 -Left Total Load Defl. L/2581 (0.024") 9.3% 1 1 Live Load Defl. U4289(0.014") 8.4% 1 1 Max Defl. 0.024" 3.2% 1 1 Disclosure Span/Depth 11.3 n/a 1 The completeness and accuracy of the input must be verified by anyone Notes who would rely on the output as Design meets Code minimum(U240)Total load deflection criteria. evidence of suitability for a Design meets Code minimum(U360)Live load deflection criteria. particular application. The output Design meets arbitrary(0.75")Maximum load deflection criteria. above is based upon building Minimum bearing length for BO is 1-1/2". code-accepted design properties Minimum bearing length for B1 is 1-1/2". and analysis methods. Installation Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing of BOISE engineered wood products must be in accordance Connection Diagram with the current Installation Guide Consult project design professional of record or BOISE technical representative for connection design and the applicable building codes. Member has no side loads. To obtain an Installation Guide or if you have any questions,please call Connectors are:16d Sinker Nails (800)232-0788 before beginning product installation. a minimum=2" b minimum=3" � b �—d nimu BC CALCO,BC FRAMERO,BCIV, c= nimu BC RIM BOARD- BC OSB RIM d=12" a BOARD- BOISE GLULAM-, VERSA-LAW,VERSA-RIM®, VERSA-RIM PLUS®, C VERSA-STRAND'TM VERSA-STUD®,ALLJOIST®and AJSTM'are trademarks of Boise Cascade Corporation. G 2 � 28 2 - 2_,- 8 BC CALL®9.1 DESIGN REPORT-US Thursday,June 02,200515:01 Double 1 3/4" x 51/2" VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:FB04a Job Name: Description: Address: Specter: City,State,Zip:Barnstable,MA Designer: HBB Customer. Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: BO B1 LL 75 Ibs LL 75 Ibs DL 53 Ibs DL 53 Ibs Total of Horizontal Design Spans=03-00-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 03-00-00 Live 25 psf 02-00-00 100% Member Type: Floor Beam Dead 15 psf 02-00-00 90% Number of Spans: 1 Left Cantilever: No Controls Summary Right Cantilever: No Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 96 ft-Ibs 1.9% 100% 1 1-Internal Slope: End Shear 83 Ibs 2.2% 100% 1 1-Left Total Load Defl. U22443(0.002") 1.1% 1 1 Live Load Defl. U38339(0.001") 0.9% 1 1 Max Defl. 0.002" 0.2% 1 1 Disclosure Span/Depth 6.5 n/a 1 The completeness and accuracy of the input must be verified by anyone Notes who would rely on the output as Design meets Code minimum(U240)Total load deflection criteria. evidence of suitability for a Design meets Code minimum(U360)Live load deflection criteria. particular application. The output Design meets arbitrary(0.75")Maximum load deflection criteria. above is based upon building Minimum bearing length for BO is 1-1/2". code-accepted design properties Minimum bearing length for 61 is 1-1/2". and analysis methods. Installation Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing of BOISE engineered wood products must be in accordance Connection Diagram with the current Installation Guide Consult project design professional of record or BOISE technical representative for connection design and the applicable building codes. Member has no side loads. To obtain an Installation Guide or if you have any questions,please call Connectors are:16d Sinker Nails (800)232-0788 before beginning product installation. a minimum=2" minimum=3" d b m BC CALCO,BC FRAMER®,BCIO, c=inimu BC RIM BOARD-" BC OSB RIM d=12" a • • • BOARDTm BOISE GLULAMTm, VERSA-LAM®,VERSA-RIM®, VERSA-RIM PLUS®, C VERSA-STRAND- VERSA-STUD®,ALLJOISTO and AJS'rm are trademarks of • • Boise Cascade Corporation. 2- 2x �3 ' BC CALC®9.1 DESIGN REPORT -US Thursday,June 02,200515:01 Double 1 3/4" x 51/2" VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:FBO5 Job Name: Description: Addregs: Specifier: City,State,Zip:Barnstable,MA Designer. HBB Customer: Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: 1 BO 131 LL 75 Ibs LL 75 Ibs DL 53 Ibs DL 53 Ibs Total of Horizontal Design Spans=03-00-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 03-00-00 Live 25 psf 02-00-00 100% Member Type: Floor Beam Dead 15 psf 02-00-00 90% Number of Spans: 1 Left Cantilever. No Controls Summary Right Cantilever. No Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 96 ft-Ibs 1.9% 100% 1 1-Internal Slope: End Shear 83 Ibs 2.2% 100% 1 1 -Left Total Load Defl. U22443(0.002") 1.1% 1 1 Live Load Defl. U38339(0.001") 0.9% 1 1 Max Defl. 0.002" 0.2% 1 1 Disclosure Span/Depth 6.5 n/a 1 The completeness and accuracy of the input must be verified by anyone Notes who would rely on the output as Design meets Code minimum(U240)Total load deflection criteria. evidence of suitability for a Design meets Code minimum(U360)Live load deflection criteria. particular application. The output Design meets arbitrary(0.75')Maximum load deflection criteria. above is based upon building Minimum bearing length for BO is 1-1/2". code-accepted design properties Minimum bearing length for B1 is 1-1/2". and analysis methods. Installation Entered/Displayed Horizontal Span Length(s)=Clear Span+1/2 min.end bearing+1/2 intermediate bearing of BOISE engineered wood products must be in accordance Connection Diagram with the current Installation Guide Consult project design professional of record or BOISE technical representative for connection design and the applicable building codes. Member has no side loads. To obtain an Installation Guide or if you have any questions,please call Connectors are:16d Sinker Nails (800)232-0788 before beginning product installation. a minimum=2" � b d BC CALC®,BC FRAMER®,BCI®, b minimum=3" BC RIM BOARD- BC OSB RIM c=1-1/2' a BOARD- BOISE GLULAM-, d=12' • �• • VERSA-LAW,VERSA-RIM®, VERSA-RIM PLUS®, c VERSA-STRAND- VERSA-STUDS,ALLJOIST®and AJS'rm are trademarks of • • Boise Cascade Corporation. 2 , OS G- Page 1 of 1 S0 BC CALL®9.1 DESIGN REPORT-US Thursday,June 02,200515:01 Double 1 3/4" x 51/2" VERSA-LAM®3100 SP File Name: 0505-EB39 Jonathan Smith Barnstable MA:FBO6 Job Name: Description: Addre$s: Specifier. City,State,Zip:Barnstable,MA Designer. HBB Customer. Jonathan Smith Company: Littleton Lumber Code reports: ICBO 5512,NER 629 Misc: AL BO B1 LL 277 Ibs LL 277 Ibs DL 183 Ibs DL 183 Ibs Total of Horizontal Design Spans=06-04-00 General Data Load Summary Version: US Imperial ID Description Load Type Ref. Start End Type Value Trib. Dur. 1 Standard Load Unf.Area Left 00-00-00 06-04-00 Live 25 psf 03-06-00 100% Member Type: Floor Beam Dead 15 psf 03-06-00 90% Number of Spans: 1 Left Cantilever. No Controls Summary Right Cantilever. No Control Type Value %Allowable Duration Load Case Span Location Pos.Moment 729 ft-lbs 14.7% 100% 1 1-Internal Slope: Neg.Moment -0 ft-Ibs n/a 100% 1 1 -Right End Shear 383 Ibs 10.3% 100% 1 1 -Left Total Load Defl. U1401 (0.054") 17.1% 1 11 Live Load Defl. U2328(0.033") 15.5% 1 1 Disclosure Max Defl. 0.054" 7.2% 1 1 The completeness and accuracy of Span/Depth 13.8 n/a 1 the input must be verified by anyone who would rely on the output as Notes evidence of suitability for a Design meets Code minimum(L/240)Total load deflection criteria. particular application. The output Design meets Code minimum(U360)Live load deflection criteria. above is based upon building Design meets arbitrary(0.75")Maximum load deflection criteria. code-accepted design properties Minimum bearing length for BO is 1-1/2". and analysis methods. Installation Minimum bearing length for B1 is 1-1/2". of BOISE engineered wood Entered/Displayed Horizontal Span Length(s)=Clear Span+112 min.end bearing+1/2 intermediate bearing products must be in accordance with the current Installation Guide Connection Diagram and the applicable building odes. Consult project design professional of record or BOISE technical representative for connection design To obtain an Installation Guide or if you have any questions,please call Member has no side loads. (800)232-0788 before beginning Connectors are:16d Sinker Nails product installation. BC CALC®,BC FRAMER®,BCIO, a minimum=2" b -F—d BC RIM BOARD-,BC OSB RIM b minimum=3" BOARD- BOISE GLULAMM, c=1-1/2" a VERSA-LAM®,VERSA-RIM®, d=12" • T• • VERSA-RIM PLUS®, IT VERSA-STRANDTM''; C VERSA-STUD®,ALLJOISTO and AJS'rm are trademarks of Boise Cascade Corporation. •4 • �� _ 2 LOCATI O N O F - RTY LI Y N O B CC ATE STANDARD LEGEND 0 NOTE:not all symbols will appear on a map 689 _ � - GOLF COURSE FAIRWAY O 7 EDGE OF DECIDUOUS TREES AP 03 6 EDGE OF BRUSH _. /. rl ........ 0 � 2 _ ._ --•� ORCHARD OR NURSERY . 699 --' _- �' 7 EDGE OF CONIFEROUS TREES . . MARSH AREA EDGE OF WATER DIRT ROAD ' 0 1 W .: E DRIVEWAY �-PARKING LOT E�PAVED ROAD ` O ------- DRAINAGE DITCH MAP 03L--�-A ----- PATH/TRAIL 0 PARCEL LINE Y YY '- m MAP 326 �--MAP# 70 AP 03 6 #367 HOUSEPARCEL NUMBER >� � #367 _ HOUSE NUMBER (' 2 FOOT CONTOUR LINE 4~ # 709."-- � E® 10 FOOT CONTOUR LINE I Elevation based on NGVD29 �- 4.9 SPOT ELEVATION c:..x_.z.:D STONE WALL -X—X FENCE _----�� -_--. mAP 03 6 ----Ift—A, RETAINING WALL OO J - 0 0 I RAIL ROAD TRACK 7 �.9 - _.- STONE JETTY 1.Pao SWIMMING POOL 1 PORCH/DECK 0 BUILDING/STRUCFURE -. DOCK/PIER \ HYDRANT 1 \ e VALVE O MANHOLE MAP 036 008 0 POST 0F` FLAG POLE T O W N O F B A R N S T A B L E G E O G R -A P H 1 G 1 N F O R M A T 1 O N S Y S T E M S U N 1 T .a SIGN ® STORM DRAIN M PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of a **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The James "> 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE ❑ TOWER w ° 0 30 60 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and vegetation were mapped to meet National Map Accuracy Standards s 1 INCH=60 FEET* enlarged scale. on the map. at a scale of 1"=100'. Parcel lines were digitized from FY2004 Town of Barnstable Assessor's tax maps. ¢ LIGHT POLE O ELECTRIC BOX Assessor's mop and nn number Smvvoga Permit nu 6er x House number ......../0`yNAM 'TA----------../ ./___` ~1� ^ ������7�� ���� �� � �� ���� r�� � ��'� �� -- �� � � �� |� � �]� ������ |� �� �� �� ������ BUILDING INSPECTOR ��0N N 0-0� N ���� 0 ������ �=0m 0 0N �� �� �� � ���� � �� �� � �� ��� ���� � �� �� APPLICATION FOR PERMIT TO ----.----------------..--.—.--.--------.—.--..---'- TYPE OF CONSTRUCTION -----.---------.—.-----.—.----...-.~_—..—.~---.------. —.—. ..................... | � ' TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for o permit according to the following information: ` Location ...... ^)0..�...... --'S7�./nr�7^--- /~-� ........... __—.,------------ Proposed , ' Use -- ---------------________________________,________. -Zoning District .................� ................................................... / . .Fia District , — .---- . .— .................................. 730/ ' V— r- .NomoofOvne, �« � 77�.h� /2.:r- None of 8vi|6e, — — Al�./6.......................Address —.-------------..,..------.---- Nome of Architect ----------------------AJ6ress --------.'--------...--------' + /��'�° Number of Roomo ----------------------Foundotion —'��---��,)C���=./�'------------. � �~�~~ Exle,ior Roofing —. �J���/��� .� � ---------------------------- '�—.. . .. - Floors ........ ............ ���.�. ---------------]nterio, ------------~--..-----------.. Heating Plumbing-------------------------~—' -------' [7�' Fireplace ---------------------------.ApproximoneCoo ...�f�/��/l.��....------~----^_ � Definitive Plan Approved by Planning 800n6 Area ��0-------. Diagram of � and Building with Dimensions Fee _�����Lot SUBJECT TO APPROVAL OF BOARD OF HEALTH ` u / ��) - ` | � _ . .� V . ` OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS | hereby agree to conform to all the Rules and Regulations of the Town of 8orno*z6le regarding the above construction. Nome - —���..�:������.��--------.—. . Construction Supervisor's License .... JACKSON, DOROTHY /A=36-9 No 2 5 5 3 3 permit for ,.Add Garage ................ Accessory to dwelling ............................................................................... Location ....7.09 Main Street ................................................... Cotuit ............................................................................... Owner D.orothy. . . ...Jackson. . . . ......................... .... .. .... .. .. .. . .. ....... Type of Construction Frame ................................................................................ Plot ............................ Lot ................................ Permit Granted Sept. 14 , 19 83 Date of Inspection, ....................................19 Date Completed � I --------------- i 1 i� Assessor's map'and lot number .... .(a..... •. ..........�. .;II•. . ��THE7-0 Sewage Permit number i 33MSTSH LE i House number. ........70. ..1 ........................:...... ..: ............. V 11ea M �ps�s63q. 9� TOWN OF BARNSTABLE BUILDING -INSPECTOR APPLICATIONFOR PERMIT TO ...........................1.........:..........:........................................................................... _ TYPEOF CONSTRUCTION ............:................:...................................................................................................... ........ y 4. ....................19.13 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ` �- �° ' Location /........ ...:.... ... .r.. . ........��.f S. ............. (� ...rl.r'... ............... .. .5:.,f.s............................................... ProposedUse ...... ...............................................................................:............................... ............................ Zoning District .............................' .............................................Fire District .. [__�./...�l:f.....1 ......................... .... ......... ...... Name of Owner La.r:.a?. ...........k,�.1C.S..G ......Address .....t!tl. , '.�j.i.it��.,uia...f �,;j ..�jlG•Ci,!'" Name of Builder ...�.r4.t1..�...... J!.f._f..l.� ......................Address .................................................................................... Nameof Architect ...................:.:............................................Address .................................................................................... Number of Rooms ..................................................................Foundation .....g.Pf....i•lg.C.4...................................... Exierior .................................:.................................................Roofing ......1/1 .�ca...I T............................................. Floors ........ c,h.C.In.c.�C...............................................Interior ........... ............. Heating Plumbing ..................4/. .. ...../....../..J... ............................. Fireplace ..................................................................................Approximate. Cost ... .D"...................................... Definitive Plan Approved by Planning Board _----------_______-----------19_______. Area ......4.9.....................7 or, A i Diagram of. Lot and Building with Dimensions Fee . f....-7--).0...... SUBJECT TO APPROVAL OF BOARD OF HEALTH v ' 9( 4 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 .................................................. Construction Supervisor's License ....�.. .y�?...c�/. JACKSON, DOROTHY ADD GARAGE No ..... Permit for .................................... Accessory to dwelling .............................................................................. Location 709 Main Street ................................................................ Cotuit ............................................................................... 0,Cvner ....Dorothv Jackson ............................................................. Type of Co" Frame nstruction ............................................ .......................... .......... •...................................... Plot ................................Lot,.:.............................. S . ......... 83P�rmitGranted Pt ...,...........19.... e .. T4 Date of-inspection .............. ...........19 Date Completed .... ............ .......19 of Assessor's map and lot number II&C �oF THE Tod . . . Sewage Permit number ....... "..Y� 9..................... SE!-`-.`11C SYSTEM MU Q a� House number .................................................................... INSTALLED IN COMPL � 9TADLE,� WITH TITLE 5 °o t6 9. �0m ENVIRONMENTAL C0DE T 0 W N ®F CAI NSTTAyBBL)f1EU TIONS oUREN ' D06pEVORM APPLICATION FOR PERMIT TO .......... .... .: i 1. ..............W............................................................ TYPE OF CONSTRUCTION ....... QCz�.....1'` * 4t. '.'t..<................................................................................ ...... . ': , _ -....................191j TO THE INSPECTOR OF BUILDINGS: " The undersigned hereby applies for a permit according to the following information: I Location ...................221..........� ........ �............. Ta.l....Y..t...1.................................................................... Proposed Use Zoning District ...�,. p.T(...1.......; i.. ...... 1............Fire District ......Ga./ � i........... ................................................. Name of Owner a @.p 2_ Name of Builder ..�Q�J.. .....��..... /. . ../..4".l.1...4'........Address ....,�� St.f` �. K.f. ............................. �. .. Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ....... .............................................Foundation ..... ......... G..�.Ic......... .. Exterior ...... bj.04rtyh-,J....................................................Roofing ........ ,' !.s4�/................................................ Floors ::r. a �.4.Y. t. .T.. ., / .:.....................Interior ................-.:.0...............................................:..... • Heating .....�A/ �..?�.....................................Plumbing .................................................................................. . ................ . Fireplace ..................................................................................Approximate Cost .. ....... ..��....................................... Definitive Plan Approved by Planning Board ----------------------_---------19________ . Area ..5 ., ' .�...... Diagram of Lot and Building with Dimensions Fee GJ_ SUBJECT TO APPROVAL OF BOARD OF HEALTH t I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name . . . .... ............................ JACKSON, DOROTHY S . 25278 Addition No .............::.. Permit for .................................... -Single Family Dwelling ............................................................................... Location .....721 Main Street ...........................................................I Cotuit ............................................................................... Owner ... S- Jackson .. ............................................ Type of Construction ....F.r.ame............................ .. ....... ................................................................................. Plot ............................ Lot .................................. 5 83 Permit Granted .............July ,............................19 Date of Inspection ......?_ ....................19 Date Completed ............... ......... 9 PERMIT REFUSED ......................................................... .... 19 ............................................................................... ....................................;.............................................. ............:................................................................... ............................................................................... V Approved ....... ......................................... 19 ............................................................................... ............................................................................ Assessor's map and lot number - 2: +....... ✓�'`�` THE T0� Y C / ? y Sewage Permit number .......:............:...:vl� ...................... Z BAUSTABLE, i House number MAea 90o 1 639 e0A '�E p MAI a TOWN OF BARNSTABLE BUILDING A.INSPECTOR J. APPLICATIONFOR PERMIT TO .......................:..................:............ �.........................................................:.. TYPE OF CONSTRUCTION .......!�2 n,;;n-)......� � !. ...t............................................................................... �•.....5--...................19.'.. 4f TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..................4. /........... ! ✓.y,.:..- ........:. .. ............t...r?. .:... ..........:..............:....................:............... ProposedUse .............. .^ f .......... '��-:- r.:.�................................................................................................................ Zoning District ...I........ ......................... T., - .........Fire District ..... r.. t`r� t..f ........................................... Name of Owner 'i�n y„ �, ,�.....-.............�a.....f � ..Address .................................................................................... Name of Builder .:.?. � ......� t'. ��.!?.... ....Address .... .!. �a ........ ....... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ........ -e.............................................Foundation .....� ,ra ' ../ r r',,'I X,,r' X k r. .�......... ............................... Exterior ....... ....................................................Roofing ........ ...... .J ..1. ........................................... y Floors ...........................7 .......................Interior ................ .:..C.."...................................................... r Heating ...... -' ..T.................../ Plumbing .................................................................................. ..... Fireplace r .................................................p Approximate Cost .............:..:................................................... Definitive Plan Approved by Planning Board ________________________________19________. Area1 � .. -.f ....... Diagram of Lot and Building with Dimensions Fee y.. SUBJECT TO APPROVAL OF BOARD OF HEALTH A I L I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Named.......................... :............................................ JACKSON, DOROTHY S l* A=36-9 7 No 25...78..... Permit for giDDITIOIN Sin" le Family Dwelling............ ....... .............. Main S r Location U.................. ... Q ....................... Cotuit Owner Dorothy..S.e...Jaeks.QZ.................. Type of Construction ...FXaMe.......................... . .......................................................................... Plot ..n.................... Lot ................................ Permit Granted ....JulX 5 ....19 83 Date of Inspection 19 Date Completed ......................................19 r PERMIT REFUSED ....................... ....�..................... 19 ................................. ...... �........................... ................................................................................ ............................................................................... ............................................................................... 1 w-t Approved ................................................ 19 ............................................................................... ............................................................................... Map 6 Parcel OCR ` Permit# 3. S 6 ' House Date Issued Board of H th(3rd floor)(8:15 -'9:30/1:00--��) Fee .5/. � Conservation Office oor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/Scho dmin.-Bldg.) SINE Definitive Plan Approved by Plannin and 19 ; ` BARN STABLE, r MASS. 0 TOWN OFBARNSTABLE f'"`+ All + Building Permit Application Project";Street Address S / r�wtJ S7L Village Owner 5 7i4C kC-S v1, Address Telephone Permit Request First Floor square feet Second Floor t 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: p 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 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 00&v 1 C F✓tCAJ� Telephone Number Address '7! T/9Y?-ct Se^ (?//I License# C6 Home Improvement Contractor# Worker's Compensation# 1 RIS V 51r) 3 i(__5 6 � 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 e i SIGNATURE DATE d G' BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) `� o a _ FOR OFFICIAL USE ONLY _ plh *t l PERMIT NO. DATE ISSUED - MAP/PARCEL NO. + 4 .•r + ADDRESS '` VILLAGE' OWNER DATE OF4INSPECTION: FOUNDATION t a FRAME INSULATION j = FIREPLACE ELECTRICAL: ROUGH FINAL _ PLUMBING: ROUGH FINAL + GAS: ' ROUGH FINAL t FINALBULDING liU ko DATE CLOSED OUT ASSOCIATION PLAN NO. # The Town of Barnstable • a�aivsreei.E. • 9ebA — ,0� Department of Health Safety and Environmental Services TEOMA�� 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 /6 SS , AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: Est. Cost�� � Address of Work: (2 liae� Owner's Name Date of Permit Application: Q 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 of the owner: DA(te Contractor Name Registration No. OR Date Owner's Name The Commonwealth of Massachusetts Department of Industrial Accidents 600 Washington Street F Boston Mass. 02111 Workers' Compensation Insurance Affidavit name: location: 7 Ti4�04So�'i /mil city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole pro netor and have no one workin in any capacity I am an employer providing workers' compensation for my employees working on this job company name•: address city phone#: insurance co. .: ,. olicv# �3�•�` �����d� :> .:::. ❑ I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city:- phone# rnsnrance co. oLcv#.; % company name:'. address: CiW. phone# insurance co. olicv# _. .:.. . . Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification 1 do hereby cerd the airs enalties of perjury that the information provided above is true and correct Signature Date Print name fF✓-C&4W A k-Z,—A,-" Q-�t� Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑checklf immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised 9/95 PJA) \ v. Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 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 who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance 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 required to obtain a workers' compensation policy,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 of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please permit/license number be sure to fill in the P which will be used as a reference number. The affidavits may be retuned io 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 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 Otflce of Inllesugsuons 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 M ctr T GI,STRA rv � z {� 5, •, ACTORS �,RE Y CONTR d Standa r^ a, r o-� p.� .Q 'tIMPRO�EMEN� ul'atj.ons an 1 , �, „ a s HOME' guildin� Res a Room �304 Board` of shbur tc`sn, P 1'ac tt O21Q8, 3 � t 3;` �---- - , T One A Massachuse s, + \ _Q osto n , : ',^� yf"r � ' G✓��o�anw+ .`� ; _•, } r V " : r �� TOR 1. CTOR y 0 BAnM EN0 9 pROVEMENTCONT teo 1T1 2C5O3N6XPa Registralo6253 e9istration TyPe iT, T RsA" C ton 04/06/99 TYPg �,� �OB �#{� �; ,�; , ,��, f ,fit �� .� l ,.,,� ,� ,�^ �,,,�.��� � �. ,_ �� ,�,���• °,�r� E Pira a•. _ . �k > / y {` y�dt '� w • ' d;�-( ,, "rr rt-, r�z ''�r �*4 2`' �� '-q. im i' x t z ; irk i zyF z� rs RUCTION s ONSTRUCTIONI` �RASER.CONST �EZASER C 3£ x ,^5 C ERASER e. F 5ER � y { £ , {: 'pEAN C RA CZ r...k s, G ARRA60H CIR <, r RAG R ^ wM� i 5 TAR.. ON 4 � �• 0263 CO T .MA 02.635 ., °Fl} ,, s _ b TUI s —� t .,- ng e YrTftenng Dept. or) Map 036 " Parcel ©� � � Permit# aA House# M2 Date Issued a..ppr� Board of Health(3rd floor)(8:15 9:30/1:00--4.36) Fee z5z5 Conservation Office(4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin.Bldg.) THE Definitive Plan Approved by Planning Board 19 BARNSTABLE, MASS f TOWN OF BARNSTABLE 'f°"'°"'�� (� Building Permit Application Project Street Address 1�/GU S 7L Village O Owner ae 6117 oi-r l ��/ Address a601V141 C//? Telephone s Ur C/ 79 Permit Request i 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 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 QeGWI Fao a< ) Telephone Number Address-�j ig G q � C F2 License#. CC) _ Home Improvement Contractor# Worker's Compensation# &,V NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �3 N ING PERMIT DENIED FOR TH OLLOWING REASON(S) f � z r FOR OFFICIAL USE ONLY •�, PERMIT NO. DATE ISSUED. - - MAP/PARCEL NO. ADDRESS = I VILLAGE T - OWNER '. DATE OF-INSPECTION: FOUNDATION FRAME N r ? ! INSULATION g - FIREPLACE ELECTRICAL: . ROUGH , FINAL PLUMBING: ROUGH FINAL +' I GAS: ROUGH FINAL ' FINAL BUILDING - f DATE CLOSED OUT ! ASSOCIATION PLAN NO. f P 14 The Town of Barnstable • s�errsrr+atE. • Department of Health Safety and Environmental Services rEOMoc�` 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 yh-,�> I AFFIDAVIT 4 f 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. Type of Work: Est.Cost_�e3_00 Address of Work: Owner's Name t�of2mn, SrY 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 of the owner: Date Contractor'Name Registration No. OR Owner' Date s Name r= -- The Commonwealth of Massachusetts ^< Department of Industrial Accidents -= _ Office 81111Y85 i08affs = t 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: t—Ac,_� location: GLCoV\ / city GA(.0 122 19 phone# C/C9L 0 ` ❑ I am a homeowner performing all work myself. ❑ I am a sole ro rietor and have no one workin in any ca acity % %% Z%Z %%%%��%%%%%%%%%%%%%%%%%%%%%�%%%�%�%%%��%%��%%%// I am an employer providing workers' compensation for my employees working on this job. company name ��. n ... address-. city. phone#. insurance co. RolicV# 5 �� ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: cothpanv name: address: - city: phone# insurance company name: _.. address: ¢ity: phone#: insurance co. "< `olicv# _.... - : Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby ce under he pains and penalti f perjury that the information provided above is truo and correct. signature Date Punt name D>e4K-) ��✓ltAAA'� Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board Cl check if immediate response is required ❑Selectmen's Ofi1ce ❑Health Department contact person: phone#; ❑Other Otmed 9/95 PIA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 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 who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,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 r 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 along with a certificate of insurance 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 required to obtain a workers' compensation policy,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 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 peimit/license number which will be used as a reference number. The affidavits may be returned io 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 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 Me of Inllesdoadons 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 1 77 f /was gy „ Fr7.S Foos ZX , Lj �D gFE04 a BQ4 �Oo raaz • b�L� .. n SCALE: ii APPROVED BY: DRAWN BY DATE: REVISED DRAWING NUMBER /04 . � r �, - sr � APPROVED BY: ' TT SCALE / DRAWN BY DATE:• REVISED DRAWING NUMBER >< 61-vL f � . i. �i 0 D SCALE: APPROVED BY: DRAWN BY 1 ATE: REVISED DRAWING NUMBER • _y , w' I - ior 6xb z II . P r Z -� I I I I t 1 1 1 . i t _ I I ► 1 _ 1 SCALE `� - APPROVED BY: DRAWN BY _/ DATE: REVISED` DRAWING NUMBER